1 | 2022 Health Project Performance Evaluation Report CLAimDev: Monitoring, Evaluation, Research, Learning, and Adapting (MERLA) and Collaboration for the Health Project 2022 Health Project Performance Evaluation Report For the period January – December 2022 Final Report April 20, 2023 DISCLAIMER 2 | 2022 Health Project Performance Evaluation Report The views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or of the U.S. Government. iii This document was produced for review by the United States Agency for International Development. It was prepared by Panagora Group for the USAID/Philippines Collaborating, Learning, and Adapting for Improved Development (CLAimDev) Activity, Contract No. 72049220D00004/72049222F00003 as a Technical Deliverable per Task Order Section F.5 and therefore uses USAID Branding. Recommended citation: USAID/Philippines Collaborating, Learning, and Adapting for Improved Development (CLAimDev) MERLA and Collaboration Activities for the Health Project. 2022 Health Project Performance Evaluation Report (January – December 2022). Silver Spring, Maryland: Panagora Group, Inc. April 20, 2023. Panagora Group Contact: Susan Minushkin Senior Program Director—Monitoring, Evaluation, Research, Learning and Adaptation (MERLA) Lee Plaza 8601 Georgia Avenue, 8th floor Silver Spring, MD 20910 USA iv CONTENTS CONTENTS ...................................................................................................................................................................... iv LIST OF TABLES............................................................................................................................................................... vi LIST OF FIGURES............................................................................................................................................................ vii ACRONYMS.................................................................................................................................................................... viii EXECUTIVE SUMMARY................................................................................................................................................. xi 1. INTRODUCTION........................................................................................................................................................ 1 1.1 Context .................................................................................................................................................................... 1 1.1.1 Policy Environment and Governance................................................................................................... 1 1.1.2 Economic Growth and Budgets............................................................................................................ 4 1.1.3 COVID-19, Natural Disasters, and Disease Outbreaks ................................................................. 6 1.1.4 Key Findings from the 2022 National Demographic and Health Survey ....................................8 1.2 Actions on the Recommendations from the CY 2021 Health Project Performance Evaluation......10 1.3 Health Project Purpose, Sub-Purposes, and Activities................................................................................11 1.4 Theory of Change and Results Framework...................................................................................................14 2. EVALUATION QUESTIONS...................................................................................................................................17 3. EVALUATION DESIGN AND METHODOLOGY............................................................................................21 4. LIMITATIONS OF THE HPPE .................................................................................................................................24 5. FINDINGS .................................................................................................................................................................... 26 5.1 Question 1. How has the USAID HP contributed to improve health outcomes among the underserved?................................................................................................................................................................26 5.1.1 Family Planning and Adolescent Reproductive Health ..................................................................26 5.1.2 Tuberculosis.............................................................................................................................................43 5.1.3 Community-Based Drug Rehabilitation.............................................................................................62 5.1.4 HIV/AIDS..................................................................................................................................................66 5.2 Question 2. How have the USAID Health Project interventions improved social norms and behaviors among the underserved seeking treatment and prevention services?........................................70 5.3 Question 3. How has the USAID Health Project increased client satisfaction?...................................72 5.4 Question 4. How has the USAID Health Project led to continuous quality improvement in care service delivery?...........................................................................................................................................................73 5.5 Question 5. How has the USAID Health Project contributed to improving financial risk protection?....................................................................................................................................................................75 5.6 Question 6. How has the USAID Health Project influenced UHC health systems strengthening efforts for the Philippines? ........................................................................................................................................76 5.7 Question 7. How has the USAID Health Project contributed to greater involvement of the private sector in achieving better health outcomes?........................................................................................................79 5.8 Question 8. How has the USAID Health Project contributed to the greater involvement of civil society in achieving better health outcomes?.......................................................................................................82 5.9 Question 9. How has the USAID Health Project improved male participation in accessing health services?.........................................................................................................................................................................84 5.9.1 HP increased engagement through men-oriented FP messages..................................................84 v 5.9.2 Gender Mainstreaming..........................................................................................................................84 5.10 Question 10. How has the USAID Health Project improved the ability of health service delivery points to mitigate environmental risks and withstand climate risks?..............................................................88 5.11 Question 11. How has the USAID Health Project ensured that interventions for the underserved are sustainable beyond project life?........................................................................................................................89 5.11.1 Family Planning......................................................................................................................................90 5.11.2 Tuberculosis..........................................................................................................................................90 5.11.3 Community-based Drug Rehabilitation...........................................................................................91 5.11.4 Health Systems Strengthening...........................................................................................................91 5.12 Question 12. To what extent are CLA practices integrated in the USAID Health Project? ..........92 5.13 Question 13. What innovative technologies has the USAID Health Project introduced?...............93 6. CONCLUSIONS AND RECOMMENDATIONS ...............................................................................................95 6.1 Overall HP Performance ....................................................................................................................................95 6.2 Overall Recommendations.................................................................................................................................96 ANNEXES ......................................................................................................................................................................... 99 Annex A. Overall Recommendations from the CY 2021 HPPE Report .......................................................99 Annex B. Performance Indicator Reference Sheet: Number of functional adolescent-friendly health service delivery points............................................................................................................................................ 102 vi LIST OF TABLES Table 1. Updated targets and results for selected NOH indicators, 2016 – 2022............................................2 Table 2. DOH NTP budget allocations, obligation rates, and disbursement rates, CYs 2019 – 2022 .........5 Table 3. Results of selected indicators from the NDHS 2022 Key Indicators Report.....................................8 Table 4. USAID Health Project Activities, 2019 – 2024* .......................................................................................12 Table 5. Evaluation / Learning Agenda Questions (as of March 2022)...............................................................17 Table 6. “Traffic Light” System.....................................................................................................................................21 Table 7. Summary of HPPE learning questions and data sources........................................................................23 Table 8. Number of individuals in the target population reporting exposure to U.S. Government–funded FP messages (by channel/no. of channels), CYs 2021 and 2022..................................................................27 Table 9. Number of U.S. Government–assisted CHWs providing FP information, referrals, and/or services during the year in U.S. Government–assisted sites, CYs 2021 and 2022.................................28 Table 10. Percent of U.S. Government–assisted service delivery sites providing FP counseling and/or services, CYs 2021 and 2022...............................................................................................................................29 Table 11. Number of functional adolescent-friendly health SDPs in U.S. Government–assisted sites, CY 2022...........................................................................................................................................................................31 Table 12. Number of adolescents who availed of FP/MCH/SRH services in SDPs in U.S. Government– assisted sites, CY 2022..........................................................................................................................................32 Table 13. FP commodity stockout rates* in U.S. Government–assisted sites, FYs 2021 and 2022 ............34 Table 14. New FP acceptors* in U.S. Government–assisted sites, CYs 2021 and 2022................................38 Table 15. Current FP users in U.S. Government–assisted sites, CYs 2021 and 2022....................................38 Table 16. Couple-years of protection* in U.S. Government–assisted sites, CYs 2021 and 2022 ...............41 Table 17. Number of TB cases notified (all forms), CYs 2021 and 2022...........................................................45 Table 18. Bacteriological diagnosis coverage rate—pulmonary TB, CY 2021 and 2022................................46 Table 19. Childhood TB notifications in the Philippines and by region, CYs 2021 and 2022 .......................48 Table 20. Drug-resistant TB notifications in the Philippines and by region, CY 2021 and 2022..................50 Table 21. Private sector TB notifications in the Philippines and by region, CY 2021 and 2022...................51 Table 22. Contact investigation coverage rate in the Philippines and by region, CYs 2021 and 2022 .......53 Table 23. TB preventive treatment enrollment in the Philippines and by region, CYs 2021 and 2022......55 Table 24. Drug-susceptible TB (DS-TB) treatment success rates in the Philippines and by region, CYs 2020 and 2021 treatment.....................................................................................................................................57 Table 25. Drug-resistant TB (DR-TB) treatment success rates in the Philippines and by region, CYs 2019 and 2020 treatment cohorts................................................................................................................................61 Table 26. Comparison of CBDR accomplishments in FY 2021 vs. FY 2022.....................................................64 Table 27. Highlights of EpiC technical assistance for October 2021 – September 2022...............................67 Table 28. Selected EpiC performance data, October 2021–September 2022..................................................68 Table 29. Overall facility utilization rate in areas implementing QI by USAID, FY 2022...............................75 Table 30. Number of persons trained with U.S. Government assistance to advance outcomes consistent with gender equality or female empowerment through their roles in public or private sector institutions or organizations, FY 2022...............................................................................................................85 vii Table 31. Number of people reached by U.S. Government–funded interventions providing GBV services* (e.g., health, legal, psychosocial counseling, shelters, hotlines, other), FY 2022...................86 Table 32. Selected GEWE initiatives of HP activities, FY 2022 ............................................................................87 Table 33. Selected initiatives on environmental and climate risk management of HP activities, CY 202288 LIST OF FIGURES Figure 1. Reported COVID-19 cases in the Philippines, January 30, 2020 – January 1, 2023.........................7 Figure 2. Framework of the USAID/Philippines Health Project, 2019 – 2024..................................................12 Figure 3. USAID Health Project Results Framework, 2019 – 2024 (with updates to performance indicators as of July 20, 2022)..............................................................................................................................15 Figure 4. Percent of service delivery sites providing family planning counseling and/or services in U.S. Government–assisted sites supported by ReachHealth, by ownership, type of facility and urbanity, CY 2021 vs. CY 2022............................................................................................................................................30 Figure 5. Percent of adolescents who availed of FP/MCH/SRH services in supported SDPs in U.S. Government–assisted sites supported by ReachHealth, by sex, age, type of service, and type of facility, CY 2022......................................................................................................................................................33 Figure 6. Percentage of facilities (public and private*) that experienced stockouts, U.S. Government– assisted sites covered by ReachHealth, by fiscal year, FYs 2019 to 2022 ................................................35 Figure 7. Percentage of facilities that experienced stockouts, U.S. Government–assisted sites supported by ReachHealth, by ownership, October 2021 – September 2022 ...........................................................36 Figure 8. Percentage of facilities that experienced stockouts, U.S. Government–assisted sites supported by BARMMHealth, by fiscal year, FYs 2019 to 2022......................................................................................36 Figure 9. Number of current FP users vs. targets, U.S...........................................................................................39 Figure 10. Number of new FP acceptors, U.S. Government–assisted................................................................40 Figure 11. Couple-years of protection vs. targets in U.S.......................................................................................41 Figure 12. Couple-years of protection by FP method in U.S. Government–assisted sites covered by ReachHealth, public sector only (n= 2,606,712), CY 2022..........................................................................42 Figure 13. CYP performance for FY 2019–Q4 FY 2022 against ..........................................................................43 Figure 14. TB detection rates, CYs 2019 – 2021.....................................................................................................44 Figure 15. Performance vs targets: childhood TB notifications, CYs 2019 – 2022 (results) and CYs 2020 – 2022 (targets).......................................................................................................................................................49 Figure 16. Performance vs. targets: DS-TB treatment success rates, CYs 2019 – 2022 (results) and CYs 2019 – 2022 (targets)............................................................................................................................................57 Figure 17. Preliminary data on DS-TB TSRs: Mandatory notifications vs. DOTS facilities, CY 2021 treatment cohort*..................................................................................................................................................59 Figure 18. Treatment outcomes of mandatory notifications, CY 2022 treatment cohort............................60 Figure 19. Performance vs. targets: DR-TB treatment success rates, CYs 2019 – 2022 (results) and CYs 2019 – 2022 (targets)............................................................................................................................................61 Figure 20. CBDR FY 2022 accomplishments (cumulative) vs. targets (cumulative)* .......................................63 Figure 21. Social media posts from Bawat Simula tungo sa CBDR FB page........................................................65 viii ACRONYMS ACF active case finding AFHF adolescent-friendly health facility ARH adolescent reproductive health ARV antiretroviral ART antiretroviral treatment ASOG Ateneo School of Government BARMM Bangsamoro Autonomous Region in Muslim Mindanao BARMMHealth Bangsamoro Autonomous Region in Muslim Mindanao Health Capacity￾Building BC bacteriologically confirmed (of TB) BJMP Bureau of Jail Management and Penology BPaL bedaquiline-pretomanid-linezolid BPaLM bedaquiline-pretomanid-linezolid-moxifloxacin CALABARZON Cavite, Laguna, Batangas, Rizal, Quezon (provinces) CAR Cordillera Autonomous Region CBDR community-based drug rehabilitation CBO community-based organization CDCS Country Development Cooperation Strategy CHD Center for Health Development (DOH) CiTEC Citywide TB Elimination Campaign (in Cebu City, Philippines) CLA collaborating, learning, and adapting CLEAR Capacitating Local Executives for Agile and Responsive Governance CHW community health worker CQI continuous quality improvement CrCL confirmatory laboratory (for HIV/AIDS) CSE comprehensive sexuality education CSO civil society organization CSS client satisfaction survey (tool) CU current user (of FP method) CY calendar year CYP couple-years of protection DDE drug dependency evaluation DepEd Department of Education DILG Department of the Interior and Local Government DO development objective DOH Department of Health DOTS directly observed therapy short-course DPCB Disease Prevention and Control Bureau (DOH) DRRM-H disaster risk reduction and management in health DR-TB drug-resistant TB DS-TB drug-susceptible TB DSWD Department of Social Welfare and Development DTP Devolution Transition Plan (DOH) ECF enhanced case finding eLMIS electronic Logistics Management Information System EO Executive Order EOP end of project EpiC Meeting Targets and Maintaining Epidemic Control ix e-SBIRT Screening, Brief Intervention, and Referral to Treatment FAST Find Cases, Actively Separate Safely, and Treat Effectively FHSIS Field Health Services Information System FP family planning FPCBT family planning competency-based training FY fiscal year GAA General Appropriations Act GAD Gender and Development GBV gender-based violence GEWE gender equality and women empowerment GINHAWA General Intervention for Health and Wellbeing Awareness Global Fund Global Fund to Fight AIDS, Tuberculosis and Malaria GPH Government of the Philippines HCP health care provider HCPN health care provider network HCW health care worker HCWM health care waste management HP Health Project (USAID) HPDPB Health Policy Development & Planning Bureau (DOH) HPPE Health Project performance evaluation HRH human resources for health HSS health systems strengthening ICF intensified case finding iDOTS Integrated Delivery of TB Services IP implementing partner IPC infection prevention and control ITIS Integrated TB Information System KII key informant interview KonSulTa Konsultasyong Sulit at Tama program KP key population LCE local chief executive LGU local government unit LTAP local technical assistance program MCH maternal and child health MDR-TB multidrug-resistant tuberculosis M&E monitoring and evaluation MIMAROPA Mindoro, Marinduque, Romblon, Palawan (provinces) MN mandatory notification MOH Ministry of Health (in BARMM) MTaPS Medicines, Technologies, and Pharmaceutical Services MTB Mycobacterium tuberculosis NA new acceptor (of FP method) NCR National Capital Region NDHS National Demographic and Health Survey NGO non-governmental organization NOH National Objectives for Health NTP National TB Control Program OH Office of Health, USAID OHAT Outpatient HIV/AIDS Treatment (PhilHealth) PAP Psychological Association of the Philippines x PCPN primary care provider network PDP Philippine Development Plan PEPFAR U.S. President's Emergency Plan for AIDS Relief PHC primary health care PHIC Philippine Health Insurance Corporation PHO provincial health office PhP Philippine peso PhilHealth Philippine Health Insurance Corporation PhilSTEP1 Philippine Strategic TB Elimination Plan, Phase 1 PIRS performance indicator reference sheets PITT performance indicator tracking table PLHIV people living with HIV PMDT Programmatic Management of Drug-resistant TB POPCOM Commission on Population and Development PrEP pre-exposure prophylaxis ProtectHealth Health Equity and Financial Protection Platform PSA Philippine Statistics Authority PSCM procurement and supply chain management PSI progestin subdermal implant PTB pulmonary tuberculosis PWUD people who use drugs QI quality improvement ReachHealth FP/MNH [maternal and neonatal health] Health Innovations and Capacity￾building Platforms RH reproductive health RHU rural health unit RPRH Responsible Parenthood and Reproductive Health SBC social and behavior change SBCC social and behavior change communications SBIRT Screening, Brief Intervention and Referral to Treatment SCM supply chain management SDM standard days method (FP) SDP service delivery point SHF Special Health Fund SOCCSKSARGEN South Cotabato, Cotabato, Sultan Kudarat, Sarangani (provinces), General Santos (city) SRH sexual and reproductive health TB tuberculosis TB Consortium Philippine Private Sector Diagnostics Consortium TBIHSS TB Innovations and Health Systems Strengthening TB Platforms TB Platforms for Sustainable Detection, Care and Treatment TLD tenofovir, lamivudine, dolutegravir (ARV combined drug regimen) ToC Theory of Change TPT TB preventive treatment TSR treatment success rate UHC Universal Health Care USAID U.S. Agency for International Development WHO World Health Organization xi EXECUTIVE SUMMARY This report describes the performance of the USAID/Philippines Health Project (HP) in calendar year (CY) 2022 in achieving its purpose and sub-purposes, and its annual targets for selected indicators. Overall, the HP was able to sustain the momentum from post-pandemic recovery in CY 2021 to stay on track in CY 2022 to attain stated health goals. While lingering effects of the COVID-19 pandemic remain—such as supply constraints affecting availability of selected essential tuberculosis (TB) drugs and family planning (FP) commodities, and limited access to health care services in some areas due to sporadic outbreaks of sub-variants—the “catch up” measures implemented resulted in gains in FP, community-based drug rehabilitation (CBDR) messaging and testing, TB mandatory notification (MN) and treatment success rates, and health systems strengthening through policy development for Universal Health Care (UHC) and primary health care (PHC) implementation. However, challenges limited performance for some key indicators in 2022. One was the national and local elections in May 2022 which led to limited supply due to procurement bans. Moreover, the election of new officials and appointment of new government executives caused shifts in policy directions and program priorities which the HP implementing partners (IP) had to navigate. Three destructive typhoons wreaked havoc on infrastructure and livelihood in many parts of Visayas and Mindanao, disrupting the delivery of services in many health facilities. Outbreaks of other communicable diseases such as measles and dengue further stretched the capacities of health facilities just recovering from the pandemic. Health Systems Strengthening To support the Philippine government and Department of Health (DOH) initiatives on UHC and PHC, the HP collaborated with national and local policy makers and planners on the development of policies and guidelines; trained health human resources on key UHC and PHC functions; and developed new tools to improve governance including on supply chain management (SCM) and financing of programs. Specifically, the HP provided technical inputs to DOH on its Health Care Financing Strategy and continued to help the DOH and the Philippine Health Insurance Corporation (PhilHealth) improve benefits packages (such as Konsultasyong Sulit at Tama, population-based financing programs, Special Health Funds [SHFs]) by estimating costs and funding requirements, designing monitoring and evaluation (M&E) tools, developing a costing calculator and coaching PhilHealth staff on its use, and drafting implementation guidelines. The HP also developed various training modules on procurement and supply chain management (PSCM), continuous quality improvement (CQI), program management, M&E, and gender, most of which were uploaded in the DOH academy for easier and on-demand access. xii At the local level, the HP provided technical assistance to local government units (LGUs) in updating local devolution transition plans, local investment plans for health, and annual operational plans ensuring local investments in health programs. The electronic Logistics Management and Information System (eLMIS) was rolled out in 15 warehouses (seven central and eight regional), and local staff in 12 UHC sites were trained on the use of the system. The eLMIS is a pivotal tool to help the DOH and local governments manage their supply chain of goods and services—an important step for the LGUs as they transition to full devolution and UHC integration. At the program level, the HP supported health facilities sustain the recovery from the impact of the COVID-19 pandemic by technical assistance in the training of health care workers (HCWs), developing and implementing quality improvement tools, and networking with civil society organizations (CSOs) and other stakeholders to participate in health care delivery. The HP expanded the reach of messages on FP, TB, and CBDR and mental health through the use of multiple platforms (e.g., social media apps, radio broadcasts, community dialogues). It continued social and behavior change (SBC) and social and behavior change communications (SBCC) interventions for FP, TB, and CBDR, resulting in improved health￾seeking through in-person attendance in health facilities or teleconsultations. The HP also resumed and expanded in-person training of HCWs, including community health workers (CHWs), on essential skills for PHC, such as family planning competency-based training-1 (FPCBT-1), adolescent services, TB case detection and management, HIV counseling and testing and pre-exposure prophylaxis, CBDR program management, CQI, and M&E. The HP assisted local health facilities in U.S. Government–supported sites on adolescent reproductive health (ARH), resulting in a substantial increase in the number of adolescent-friendly health facilities (AFHFs) (264 AFHFs in 2022). It ramped up TB case finding through active case finding (ACF), enhanced case finding (ECF), and intensified case finding (ICF); enhanced sputum transport mechanisms and rapid molecular diagnostic tests; supported new all-oral regimens for multidrug-resistant TB as well as the new Introducing New Tools Project. Family Planning Performance Indicators The HP exceeded its input targets for FP and ARH. Use of multiple messaging platforms increased exposure to FP/ARH messages—132 million reached, more than double the numbers in 2021, achieving 258 percent its targets for 2022. The HP accomplished 108 percent of its target for the number of U.S. Government–assisted CHWs, and 96 percent of its target number of service delivery sites providing counseling and messages. More than 100 percent of the couple-years of protection target for the U.S. Government–assisted sites was reached. There were slight increases in the numbers of new acceptors (NAs) and current users (CUs) of FP commodities, leading to higher rates of accomplishments relative to 2021. However, the performance in the Bangsamoro Autonomous Region in Muslim Mindanao (BARMM) in these indicators was below par, with a six percent decline in numbers for both NA and CU, reaching less than 70 percent of targets. This underperformance may be due in part to the disruptions caused by the typhoons that hit the region in the latter part of 2022. There was an increase in adolescents who sought FP/ARH services in facilities in HP-supported sites— around 383,000, 43 percent higher than the numbers in 2021, which was 162 percent of HP’s target for 2022. The HP assisted more facilities to become adolescent-friendly, with the number of functional AFHFs increasing by 369 percent from 2021, ensuring the provision of appropriate services to meet the xiii growing needs of adolescents. However, efforts in messaging and counseling must be ramped up to reach the adolescents before they become sexually active to prevent early pregnancy, or to delay subsequent pregnancies. This is where small and quick surveys are important to help identify factors that cause early pregnancy so that the appropriate messages and interventions can be designed and implemented. Coordination with the Department of Education (DepEd) on the comprehensive sexuality education (CSE)-ARH convergence, and with the department of Social Welfare and Development on out-of-school youth programs must be sustained, especially as in-person schooling has resumed. The stockout rates for FP commodities were mostly above the threshold of seven percent. In ReachHealth sites, the stockout rates for all methods, except injectables and progestin subdermal implant (PSI), increased. In Bangsamoro Autonomous Region in Muslim Mindanao Health Capacity￾Building (BARMMHealth)–assisted sites, the stockout rates for injectables, condoms, intrauterine devices (IUDs), and standard days method (SDM) beads were below the threshold at six percent, though the latter two rates rose from zero in 2021. While the stockout rate of PSI was 10 percent in 2022, this was considerably lower than the 47 percent in 2021. Stockouts were more prevalent in private facilities likely because they usually refer clients to public service delivery points (SDPs) where FP commodities are free, or they provide prescriptions for clients to purchase from private pharmacies. The HP facilitated the allocation of commodities among local health facilities to address stockout rates, which remained a problem due to persisting supply and logistics constraints, albeit generally lower compared to baseline years. Tuberculosis Performance Indicators The country posted the highest ever TB case notification rate in 2022 compared to past TB control efforts. Overall, national TB case notification increased by 35 percent, and the TB detection rate rose by 30 percentage points from CY 2021. The HP-supported “Big 3” regions reported an average increase of 28 percent, sustaining the gains in 2021 after the declines in 2020. The National Capital Region (NCR) posted a 44 percent increase, 134 percent of its target for the year. Regions III and IV-A likewise reached more than 90 percent of their target for the year. These achievements resulted from improved reporting from the private sector due to more MNs, and more active/enhanced/intensified case finding (ACF/ECF/ICF) activities. However, more intensive efforts must focus on BARMM, as it continued to lag behind in their case notifications, achieving only 36 percent of target. Drug-resistant TB (DR-TB) notifications in CY 2022 increased by 32 percent from CY 2021. However, only 66 percent of the annual national target was reached. The “Big 3” regions contributed 54 percent to the total DR-TB notifications, attesting to the impact of more focused support from the HP. BARMM reached only 25 percent of its target for 2022, but posted a significant 47 percent gain from 2021. The treatment success rate for DR-TB was 80 percent, which is 94 percent of the target. However, the drug-sensitive-TB treatment success rate remained the same at 77 percent, with both the NCR and Region IV-A posting accomplishment rates of below 75 percent. There was a 54 percent increase in childhood TB case notifications due to intensified ACF campaigns and continued implementation of the Tibay ng Dibdib program in the highly populated “Big 3” regions. However, only 54 percent of the target was reached. Rates of screening of contacts of bacteriologically xiv confirmed TB cases and TB preventive treatment (TPT) remained low and below targets, even as the numbers enrolled to TPT were three times more than reported in 2021. These results are likely affected by under-reporting, as TPT and contact investigation reporting are not yet mandatory. Policy reforms to make contact investigation and TPT mandatory among providers should be explored. Establishment of more TB Contact Centers, intensified SBC for positive health-seeking behavior among the population, additional training of CHWs and health facility staff, and provision of diagnostics and TB drugs should be done in order to achieve TB elimination. Community-based Drug Rehabilitation Indicators The HP’s SBCC campaigns on CBDR reached 230,401 people in the RenewHealth-assisted sites, which is 84 percent of the cumulative target. As of FY 2022, a total of 68,117 people who use drugs (PWUD) had been screened or provided with drug dependency evaluation (DDE), 85 percent of the target. In addition to more training and technical assistance, the HP increased its CBDR sites from 21 to 30 and expanded assistance to workplace, school, and prison settings. Extensive messaging and networking with partners such as the Dangerous Drugs Board, DOH, and selected pilot LGUs have created opportunities for more PWUD screening. Of those screened or provided DDE, 41,747 (61 percent) PWUD were enrolled in appropriate evidence-based CBDR intervention. However, of those PWUDs enrolled, less than a third (19,110) completed treatment, achieving only 53 percent of the target. The treatment completion rate dropped from a high of 88 percent in FY 2021 to only 42 percent in FY 2022. This could be attributed to factors such as national and local elections held in May 2022, which resulted in leadership and personnel transitions in anti-drug abuse councils and CBDR programs in 11 partner LGU sites, low priority given to CBDR by some LGUs, and the dissolution of the Dangerous Drug Abuse Prevention Treatment Program of DOH. Overall Recommendations The following recommendations stem from findings of this evaluation of the HP’s performance in CY 2022. At the health systems level:  Continue to assist LGUs in UHC integration (e.g., establishment of health care provider networks [HCPNs], PSCM, and financial management) and in ensuring quality PHC services. This is particularly important as the Mandanas-Garcia Ruling will take full effect in 2024.  Increase engagement with the new local chief executives (LCEs) while staying engaged with known LCE champions for health. In the face of potential changes in local priorities, it is crucial, to sustain momentum in advancing HCPNs and primary care provider networks as well as FP and TB gains, while increasing advocacy for CBDR interventions.  Evaluate implementation of the eLMIS rollout at the local level to inform adjustments in the system and training of local personnel (especially given the persistently high stockouts). The system can continue to be fine-tuned with data needs of HCPNs and other health data systems.  Continue to support central and local level offices and facilities in the timely collection, accurate xv recording, and comprehensive analyses of disaggregated data. These are the bedrocks of needs￾based and evidence-based planning and policy making. At the Health Project activity level:  Engage with new (or newly assigned) DOH officials and LCEs on integrated PHC and UHC. Demonstrate that tools developed for specific programs can be used for others as well—e.g., tools for rational allocation of TB drugs and FP commodities can also be used for other drugs and commodities; the eLMIS can be applied to all essential goods and services. This will ensure that the HP assistance achieves comprehensive health coverage.  Accelerate scale-up and local buy-in of FP/ARH, TB, and CBDR interventions, especially among new LCEs. For example, investments in TB Contact Centers, which would support increased testing and treatment for TB, or scale-up of the City-wide TB Elimination Campaign model, need to be pushed forward among the new LCEs.  Expand the establishment of matching models for FP and TB among the private sector using CSOs and other private partners. For instance, TB Contact Centers and Move-It Hubs have proven effective in increasing testing and adherence to treatment. LGUs and private firms can be engaged to establish these models to expand the reach of services. The inclusion of FP/ARH and TB testing and treatment services (provided by matched partner facilities) in the benefits packages of employees and their families will increase utilization and improve health outcomes.  Routinely document, disseminate, and institutionalize good practices and promising interventions to inform scale-up and replication. Some key informant interview (KII) respondents, such as LCEs, expressed a desire to learn of the experiences of other LGUs so that they can potentially replicate them in their own localities. For specific health programs: Family planning/adolescent reproductive health:  Utilize data on reach of FP/ARH messages to revise programs and policies (e.g., increase messaging to men; assess reasons for the increase in the number of pregnant adolescents aged 10–14).  Accelerate and scale up the establishment of AFHFs with trained personnel to respond to rising adolescent pregnancy. Follow up with DOH on the proposal to adopt the enhanced HP criteria for accrediting facilities as adolescent-friendly.  Design innovative programs for ARH, especially in pre-pregnancy, given the proposed legislation to allow adolescents to access FP services without parental consent.  As face-to-face schooling resumes, increase efforts to implement the CSE–ARH convergence program with the DepEd. Tuberculosis:  Implement “Catch-up” programs and introduce innovations (e.g., make reporting of contact investigations mandatory similar to TB disease notification) to accelerate contact investigation, TPT, detection, and treatment of childhood TB. Synchronize these with other public programs such as child vaccination drives, enrollment in schools, or as requirements for selected routine government programs (e.g., TB screening for households enrolled in the Pantawid Pamilya Pilipino xvi Program, or issuance of driver’s license, especially for drivers of public utility vehicles, TB testing for incoming and outgoing overseas Filipino workers)  Support the expansion of Xpert testing and establishment of TB Contact Centers among LGUs. Document and demonstrate the benefits to the community when these are included in their own HCPNs.  Strengthen monitoring of MN among providers to improve both disease notification and reporting of treatment outcomes. Community-based drug rehabilitation:  Given the DOH Central Office’s focus on UHC implementation and PHC, escalate advocacy for the adoption of CBDR interventions at the LGU level.  Increase efforts to reach PWUDs, from screening up to aftercare.  Assess the shorter pilot program (General Intervention for Health and Wellbeing Awareness) to reduce dropouts from the CBDR interventions.  Improve M&E of the CBDR program, particularly at the local government level.  Assess use of CBDR IMS and develop plans to ensure long term sustainability of platform use among partners, especially LGUs. For many HP activities, CY 2023 is the last full year in which “catch-up” activities and innovations can be accelerated and scaled up to achieve significant impact. Lessons accumulated over the past four years should continue to inform continuous improvements in HP interventions, while low-yield interventions should be dropped or adjusted. As the HP prepares for an end-of-project evaluation, commitment to HP’s work must remain strong to ensure that its inputs and outputs will translate to visible results for improving the health of the Filipino people. 1 1. INTRODUCTION This report describes and analyzes the performance of the USAID/Philippines Health Project (HP) in the calendar year (CY) 2022 in achieving its purpose and sub-purposes as well as its annual targets for selected indicators. For most of the implementing partners (IPs), this represents the last annual report with an assessment of the yearly performance. While the annual evaluation has allowed HP activities to reflect on their effectiveness in reaching their goals and to adapt where necessary to respond appropriately to program needs and support national and local health systems, this report has been most helpful in designing the next program cycle, building on the lessons learned from program implementation over the past five years. This annual report focuses on program performance for CY 2022 (January to December 2022). Due to fewer cases of COVID-19, restrictions on mobility were lifted in CY 2021 and economic and social activities, fully restored in CY 2022. The initial results of the impact of the catch-up activities that the HP developed and implemented were assessed in the CY 2021 annual performance evaluation. This year’s report shows the ways the HP has sustained the gains made the previous year, and what measures have been put in place to ensure that these are scaled up toward a resilient health system. 1.1 Context 1.1.1 Policy Environment and Governance The USAID/Philippines Country Development Cooperation Strategy (CDCS) provides the overall frame in which the current HP (2018 – 2024) operates. The CDCS 2019 – 2024 focuses on good governance and self-reliance to achieve the goal of the Philippines becoming “A Well-Governed and More Self￾reliant Indo-Pacific Partner.” The three development objectives (DOs) of this CDCS are: DO1: democratic governance strengthened; DO2: inclusive, market-driven growth expanded; and DO3: environmental and community resilience enhanced. There are four cross-cutting strategies: increased private sector engagement; enhanced gender mainstreaming; social inclusion; and strengthened civil society.1 The CDCS goals are consistent with and complement the goals of the Philippine Health Agenda 2016 – 2022, which focuses on financial risk protection, better health outcomes, and a responsive health system that provides access to services.2 The HP is also aligned with the medium-term National Objectives for Health (NOH) 2017 – 20223 of the Philippines’ Department of Health (DOH), which serves as a road map for the Philippines to achieve Universal Health Care (UHC). The NOH is the guidepost for 1 USAID/Philippines. Country Development Cooperation Strategy (CDCS), November 25, 2019 – November 25, 2024. Available at: https://www.usaid.gov/philippines/cdcs 2 Department of Health, Republic of the Philippines. Philippine Health Agenda 2016 – 2022. 3 Department of Health, Republic of the Philippines. National Objectives for Health: Philippines 2017 – 2022. Manila, Philippines: 2018. Available at: https://doh.gov.ph/sites/default/files/health_magazine/NOH-2017-2022-030619-1%281%29_0.pdf 2 implementing FOURmula One Plus (with the tagline “Boosting Universal Health Care”), which provides the medium-term strategic framework for revitalizing the health reform agenda. FOURmula One Plus focuses on the four pillars of health reforms (e.g., service delivery, regulation, financing, and governance), with emphasis on accountability. With the COVID-19 pandemic under control, the DOH developed catch-up plans to get back on track in pursuing its NOH and updated the 2022 targets (see Table 1 for selected NOH indicators relevant to the HP). However, the national achievements were below expectations as reported in the NOH 2017 – 2022 Assessment Report, which was done collaboratively by DOH and the Strategic Engagement for Enabling Development Inc.4 The report coded Indicators 2 and 5 red—i.e., there were very minimal (25% to 49%) or no improvements from the baseline, indicating non-attainment of 2022 targets. The DOH cited several reasons why these targets were not attained: (1) influence of social determinants of health; (2) underinvestment in health; and (3) lingering limitations from the COVID-19 pandemic, specifically access to services (e.g., news of more transmissible COVID-19 variants in other countries, tempering access to services at health facilities). Based on the performance in 2022, the Government of the Philippines (GPH) targets were revised in the updated Philippine Development Plan (PDP 2023 – 2028)—for example, the 2022 target for Indicator 5 (tuberculosis [TB] incidence) is now higher at 510 per 100,000 population, based on the Global TB Report 2021, in contrast to that reported last year (427 per100,000), which was based on the Global TB Report 2020. The DOH also implemented strategic shifts in the structure, functions, and organization of the Public Health Services Team and the Disease Prevention and Control Bureau (DPCB) to accelerate UHC implementation. This had the unintended consequence of posing some challenges in coordination and sustaining momentum in advocacy and project implementation as officers were reassigned and replacements had to be engaged. Table 1. Updated targets and results for selected NOH indicators, 2016 – 2022 Indicator Data Source Baseline 2022 Target Latest Results Strategic Goal 1: Better Health Outcomes Indicator 2: Maternal mortality ratio per 100,000 live births Philippine Statistics Authority (PSA), Civil Registration & Vital Statistics estimates 111 (2015) 108 144* (PSA 2020) Indicator 5: TB incidence per 100,000 population National TB Prevalence Survey; World Health Organization (WHO) annual estimates based on annual country reports 554 (311 – 866 (2016) 510 650 (352 – 1,040) (2021) Strategic Goal 2: Responsive Health System 4 Performance Assessment of the National Objectives for Health 2017 – 2022, Philippines. Department of Health and Strategic Engagement for Enabling Development Inc. (2022). 3 Table 1. Updated targets and results for selected NOH indicators, 2016 – 2022 Indicator Data Source Baseline 2022 Target Latest Results Indicator 8: Provider responsiveness score DOH 93% (2020) To be determined No data Indicator 9: Out-of-pocket health spending as percentage of total health expenditure PSA Philippine National Health Accounts 51.70% (2016) 50 41.49%** (2021) Source: DOH. The New Normal for Health. Manila, Philippines. 2021. Available at: https://doh.gov.ph/sites/default/files/publications/The-New-Normal-for-Health.pdf *Baseline data from the PDP 2023 – 2028 Results Matrices. Available at: https://neda.gov.ph/wp-content/uploads/2023/01/Results-Matrices_Chapter-2.pdf **Reference: Philippine National Health Accounts. 7-9 Current Health Expenditure by Financing Agent, 2014 – 2021. Available at: https://psa.gov.ph/content/health-spending-registered-185-percent-growth-share-health-economy-went-60-percent-2021 The DOH and Centers for Health Development (CHDs) have been preparing their own Devolution Transition Plans (DTPs) as well as those of the local government units (LGUs) to implement the mandates of Executive Order (EO)138 (based on the Mandanas-Garcia ruling) signed on June 1, 2021. There was concern that large gaps in service delivery, including in health, will be experienced during the transition period5 starting in 2022 (full devolution by 2024) since there is a wide variance in the capacities of the LGUs to effectively and efficiently utilize the expected additional income to address their health needs. The Performance Monitoring and Strategy Management Division of the DOH performed an initial assessment of the implementation of EO 138 in the health sector, but it has yet to release the progress report due to concerns about the quality of the data collected. Moreover, in May 2022, with the newly elected legislative officials and local chief executives (LCEs) in place, ideas on how to implement EO 138 could emerge and potentially modify the design of the transition plans. While the new government is not ideologically different from the previous one, the new president, Ferdinand Marcos, Jr., has the mandate and authority to create or amend existing policies, institute reforms, and appoint new cabinet members and other government officials. However, the president has not yet appointed a new secretary of health. The president appointed Undersecretary of the Public Health Services Team, Dr. Maria Rosario Singh-Vergeire, as officer-in-charge (OIC) of the DOH. However, the DOH OIC does not have the same authority as an officially appointed and confirmed health secretary, limiting the ability of the office to execute its functions and ensure continuity of health reforms. Likewise, changes in the leadership of LGUs have caused some shifts in local policies, including 5 Llorito D. Mandanas Ruling Provides Opportunities for Improving Service Delivery Through Enhanced Decentralization. World Bank press release, Philippines, June 10, 2021. Available at: https://www.worldbank.org/en/news/press￾release/2021/06/10/philippines-mandanas-ruling-provides-opportunities-for-improving-service-delivery-through-enhanced￾decentralization 4 on health. For the HP and its IPs, these changes have necessitated modifications in the approaches to coordination, the re-engaging of new LCEs, and the re-introduction of programs. The implementing rules and regulations of Republic Act No. 11596 (also known as An Act Prohibiting the Practice of Child Marriage and Imposing Penalties Thereof, signed by President Duterte on December 10, 20216) was signed only on December 7, 2022. Thus, implementation is expected to be in full swing only in 2023. This landmark law was enacted to address early adolescent pregnancy and child abuse, which became a problem during the pandemic when in-person schooling was suspended and adolescents were susceptible to violence and sexual abuse at home or community. 1.1.2 Economic Growth and Budgets The Philippine economy continued to sustain its recovery and growth momentum in 2022 from the downturn in 2020 caused by the COVID-19 global pandemic. The country posted an annual growth rate of 7.6 percent,7 exceeding the Development Budget Coordination Committee’s 6.5 – 7.5 percent target, and much higher than the full-year 2021 growth rate of 5.7 percent.8 According to the World Bank, this strong recovery can be attributed to the pent-up demand after the COVID-19 pandemic, as well as the reopening of the economy, allowing greater mobility, especially in connection with the elections in May 2022.9 The total adjusted budget appropriated for the DOH for 202210 (from the General Appropriations Act [GAA]) was approximately PhP270 billion, 22 percent higher than the PhP211 billion in 2021. Similar to 2021, the Public Health Program showed a significant increase in budget—from PhP29.93 billion in 2021 to PhP47.86 billion in 2022. The Health Systems Strengthening Program also had a higher budget of PhP41.82 billion in 2022 compared to PhP25.78 billion in 2021. In line with the “Build, Build, Build” initiative of the previous government, the DOH Health Facilities Enhancement Program was granted around PhP23.07 billion in 2022—more than double the PHP7.48 billion in 2021. A new budget line item, COVID-19 human resources for health (HRH) Emergency Hiring and Compensation and Other Benefits for COVID-19 Workers in Health Facilities, was created to address complaints about unpaid allowances of HRH during the height of the pandemic. The total DOH budget (2022 GAA plus Continuing Appropriations from 2021) was around PhP279.2 billion, including special funds to implement the Bayanihan Laws (for COVID-19), the Quick Response Fund for COVID-19 testing, and the Quick Response Fund for National Disaster Risk Reduction and Management Fund. As of December 31, 2022, 6 Philippine News Agency. GDP Expands by 7.2 Percent in the Fourth Quarter of 2022, and by 7.6 Percent in Full-year 2022. Available at: https://www.pna.gov.ph/articles/1164695 7 Philippine Statistics Authority. Press release, January 26, 2023. Available at: https://psa.gov.ph/content/gdp-expands-72-percent￾fourth-quarter-2022-and-76-percent-full-year￾2022#:~:text=The%20Philippine%20Gross%20Domestic%20Product,full%2Dyear%20growth%20in%202022 8 Ordinario C. Full-year 2021 GDP revised to 5-7% on stronger Q4 rebound. Available at: https://businessmirror.com.ph/2022/04/07/full-year-2021-gdp-growth-revised-to-5-7-on-stronger-q4-rebound/ 9 World Bank. Philippines Economic Update December 2022. Available at: https://thedocs.worldbank.org/en/doc/3935c27c779daa684141449c7a70478a-0070062022/original/World-Bank-Philippines￾Economic-Update-December-2022-Web-Version.pdf 10 DOH - Health Policy Development and Planning Bureau. DOH Budget 2022 Brochure. Available at: https://doh.gov.ph/sites/default/files/publications/Budget_2022_brochure_v4_final.pdf 5 the DOH’s obligation rate is at 87.5 percent, with a disbursement rate of 79 percent. In June 2022, the DOH Financial Management Service reported that the election ban in May 2022 affected the implementation of Health Facilities Enhancement Program projects and ongoing procurements and slowed down the utilization of the budget. In line with the DOH thrust of systems integration to implement the UHC law, reorganization of the DOH DPCB began in 2021 and, in 2022, several senior staff were reassigned to new posts outside the bureau. The family planning (FP) program was integrated into the Family Health, Immunization, Nutrition, and Responsible Parenting Unit, which had a budget of ⁓PhP7 billion in 2022—a significant 42 percent reduction from the 2021 budget (⁓PhP12 billion). The 2022 total adjusted allotment for the TB program—also integrated into the total DPCB budget under the Prevention and Control of Communicable Diseases line item—increased by 35 percent (PhP1.7 billion) from the 2021 budget (PhP1.1 billion) and 44 percent more than the 2020 budget (PhP949 million). Table 2 shows that the National TB Control Program (NTP) had 53 percent obligation rate as of September 2022. In the past years (2019 – 2021), the obligation rates were consistently at 99 percent, from 61 percent in 2018. However, there continued to be problems in disbursing the budgets over the past two years, with disbursement rates of only 0.34 percent by the end of CY 2021 and zero as of September 30, 2022. According to the DOH Procurement Service, while the department was able to obligate most of the budget (99 percent in 2021 and 53 percent as of September 2022), funds could not be disbursed—i.e., suppliers could not be paid—due to several factors including inadequate warehouse space for the goods and, because of ongoing reorganization in the department, limited manpower to properly inspect deliveries. Table 2. DOH NTP budget allocations, obligation rates, and disbursement rates, CYs 2019 – 2022 CY Adjusted Allotments (PhP) Obligation Rate (i%) Disbursement Rate (%) 2019 880,129,000 99 51 2020 948,944,000 99 54 2021 1,086,427,606 99 0.34 2022 1,676,309,648 53* 0 *As of September 2022 Sources: (1) DOH. 2019, 2020, 2021 FAR1 Statement of Appropriations, Allotments, Obligations, Disbursements and Balances from https://doh.gov.ph/philippine-transparency-seal; (2) 2022 data from DOH DPCB Financial and Supply Chain Monitoring Division. In 2022, the HP continued to assist the Philippine Health Insurance Corporation (PhilHealth) and the DOH in analyzing the fiscal requirements of the UHC law’s full implementation and, more importantly, the recovery measures from the impact of the COVID-19 pandemic. The GAA of 2022 allocated 6 PhP79.99 billion for PhilHealth premium subsidies, still much less than the PhP172.4 billion first estimated for the full implementation of the UHC law. By September 30, 2022 (based on third-quarter financial statements), PhilHealth had received around PhP145 billion in premium contributions from all sources, an increase of 11 percent from September 30, 2021 (⁓PhP129.5 billion).11 PhilHealth reported benefits expenses of about PhP102 billion, 50 percent for direct contributors. Around PhP269 million (0.3 percent) was paid to the Philippine Red Cross for COVID-19 testing under the Interim Financing Mechanism facility. In CY 2022, PhilHealth paid claims of PhP129.6 billion, 27 percent of which (⁓PhP35.4 billion) was for COVID-19-related cases. Around 22 percent of total claims paid were seniors’ benefits, and 78 percent of total claims payments went to levels 1 – 3 hospitals. Of the critical programs that are the focus of HP, only 0.2 percent (PhP266.1 million) of total claims payments went to FP services. Only 0.35 percent (PhP158.8 million) was paid to TB services.12 It is likely that there was still limited use of health facilities for FP and TB due to patient hesitancy because of the lingering fear of COVID-19 infection, especially since there was still news of more transmissible variants that emerged in other countries in 2022. 1.1.3 COVID-19, Natural Disasters, and Disease Outbreaks Shortly after relaxing mobility restrictions in the country when COVID-19 cases had decreased in December 2021, the Philippines experienced another surge of COVID-19 in January 2022 at 39,004 infections in a day, largely due to the highly transmissible Omicron variant. There was also the usual massive movement of Filipinos during the Christmas and New Year holidays (e.g., congregating at parties, shopping, traveling), and the crowding at the May 2022 election campaign sorties. However, the caseload eased up around March 2022 and continued to decrease until June 2022 (see Figure 1).13 Cases again picked up slightly in July 2022 but remained low throughout the second semester of that year, even as possible spread of other Omicron sub-variants began to emerge. 11 PHIC Financial Statements as of September 30, 2022. Available at: https://www.philhealth.gov.ph/about_us/transparency/ 12 PHIC Stats and Charts 2022. Available at: https://www.philhealtvvh.gov.ph/about_us/statsncharts/ 13 WHO Representative Office for the Philippines. Philippines: Coronavirus Disease 2019 (COVID-19) Situation Report #118. Manila, Philippines. January 2, 2023. Available at: https://reliefweb.int/report/philippines/philippines-coronavirus-disease-covid-19- situation-report-118-2-january-2023 7 Figure 1. Reported COVID-19 cases in the Philippines, January 30, 2020 – January 1, 2023 Source: WHO Representative Office for the Philippines. Philippines: Coronavirus Disease 2019 (COVID-19) Situation Report #118. Manila, Philippines. January 2, 2023. Available at: https://reliefweb.int/report/philippines/philippines-coronavirus-disease￾covid-19-situation-report-118-2-january-2023 In time for the national election on May 9, 2022, the government amplified its COVID-19 vaccination activities and efforts to secure and attain the target of having at least 70 percent of the country’s total eligible population protected against the virus. According to the DOH COVID-19 vaccination dashboard,14 as of January 18, 2023, almost 74 million (~95 percent) Filipinos eligible for vaccination had been fully vaccinated, and ~21.3 million had received their first booster shots. By the end of 2022, 4,064,779 cases and 65,397 deaths had been reported. However, while the COVID-19 cases eventually declined at the latter half of 2023, three typhoons caused severe flooding and landslides in many provinces: Typhoon Agaton/Megi struck the province of Leyte in April 2022; Super Typhoon Karding/Noru slammed Regions III and IV-A in September 2022; and Typhoon Paeng/Nalgae caused widespread flooding in Maguindanao in October 2022. In Northern Philippines, the magnitude 7 earthquake felt in Abra and the Ilocos provinces in late July 2022 caused damage to properties and claimed lives. Aside from a rash of trauma cases from these calamities, the crowding of affected individuals at evacuation centers could have contributed to the surge of COVID-19 cases and other communicable diseases including influenza, measles, dengue, and cholera. For example, as of November 2022, there was a 201 percent increase in the number of measles cases in the country relative to the same period in 2021.15 Region IV-A posted the highest number of cases at 93; followed by Region VII at 67; and the National Capital Region (NCR) at 64. The biggest hikes in cases were 14 DOH. National COVID-19 Vaccination Dashboard. Available at: https://doh.gov.ph/covid19-vaccination-dashboard Accessed January 21, 2023. 15 Jaymalin, Mayen. DOH: Measles cases continue to increase. The Philippine Star, December 9, 2022. Available at https://www.philstar.com/nation/2022/12/09/2229524/doh-measles-cases-continue-increase- 8 recorded in Region VII (from 5 in 2021 to 67 in 2022); Region IV-B (from 2 to 21); and Region III (from 9 to 41). The DOH cited the low vaccination rates among children as one of the reasons for the rise in cases—the slower pace of the DOH expanded program of immunization during the COVID-19 pandemic and the suspension of in-person classes among school children. According to news reports, data from the Disease Surveillance Report of the DOH showed that there were 220,705 dengue cases recorded from January 1 to December 17, 2022,16—182 percent higher than the 78,223 cases reported during the same period in 2021. Region III logged the highest number of dengue cases at 44,030; followed by the NCR at 25,855; and Region IV-A at 19,374 cases. Highest increases relative to 2021 were: Region II—1,168 percent (from 1,428 to 18,107 cases); Region IX—742 percent (from 1,218 to 10,250); and Bangsamoro Autonomous Region in Muslim Mindanao (BARMM)— 630 percent (from 697 to 5,086 cases). These were the same regions that were hit by strong typhoons and suffered the most disruptions in livelihood and severe damage to infrastructure, including those for health care services. 1.1.4 Key Findings from the 2022 National Demographic and Health Survey In mid-2022, the PSA, in cooperation with the Demographic and Health Surveys Program (implemented by ICF in the United States with funding from GPH agencies and USAID), conducted the 2022 National Demographic and Health Survey (NDHS),17 the twelfth of a series conducted every five years. In February 2023, the PSA published the NDHS Key Indicators Report. Key indicators relevant to the HP are provided in Table 3 to provide an updated contextual background on the health status of the country, even as the HP continues to contribute to the 2022 results. At this time, results comparing sites assisted by the U.S. Government against other sites cannot be made because the public use database and full report are not yet available. Table 3 shows that between 2017 and 2022, the Philippines achieved improvements for selected indicators. For instance, there were sharp decreases in the total fertility rate and age-specific fertility rate among women aged 15 to 19, and fewer women reported experiencing any form of violence from their partners. However, NDHS 2022 also shows that after five years, around 30 percent of Filipinos report not being covered by PhilHealth; early childhood mortality rates are virtually the same; and unmet need for FP decreased. Additionally, while there were more women with knowledge about HIV prevention and who were tested for HIV, these are a still a small fraction of the population. Table 3. Results of selected indicators from the NDHS 2022 Key Indicators Report Indicator NDHS 2017 Results NDHS 2022 Results PhilHealth coverage rate (any PhilHealth insurance) 66% 70% 16 Villanueva, Rhodina. Philippines logs 220,705 dengue cases in 2022. The Philippine Star, January 17, 2023. Available at https://www.philstar.com/nation/2023/01/17/2238093/philippines-logs-220705-dengue-cases-2022 17 Philippine Statistics Authority and ICF. 2022 Philippine National Health and Demographic Survey. Key Indicators Report. Quezon City, Philippines, and Rockville, Maryland, USA. February 2023. Available at: https://psa.gov.ph/sites/default/files/2022%20NDHS%20Key%20Indicators%20Report.pdf 9 Table 3. Results of selected indicators from the NDHS 2022 Key Indicators Report Indicator NDHS 2017 Results NDHS 2022 Results Total fertility rate per women aged 15–19 2.7 1.9 Age-specific fertility rate among women aged 15–19 per 1,000 47 25 Fertility preferences of married women aged 15–49 Wants next birth within 2 years 15% 14% Wants to delay next birth for 2 or more years 15% 17% Wants another, undecided when 1% 0% Undecided 6% 8% Want no more 53% 49% Sterilized 8% 9% Infecund 3% 3% Contraceptive use among married women aged 15–49 Any modern method 40% 42% Any traditional method 14% 17% Not using any method 46% 42% Demand for FP methods among currently married women aged 15–49 Total demand for FP methods 70% 71% Unmet need 17% 12% Using traditional methods 14% 17% Using modern methods 40% 42% Early childhood mortality rates (per 1,000) 0–4 years preceding the survey Neonatal mortality 14 15 Post-neonatal mortality 7 7 Infant mortality 21 22 Child mortality 7 5 Under 5 mortality 27 26 Percentage of women aged 15–24 with knowledge about HIV prevention 20% 26% Percentage of women aged 15–49 who were ever tested for HIV 5% 10% Women aged 15–49 who have ever had a husband or intimate partner and who have ever experienced emotional, physical, or sexual violence committed by their current or most recent husband/intimate partner 10 Table 3. Results of selected indicators from the NDHS 2022 Key Indicators Report Indicator NDHS 2017 Results NDHS 2022 Results Emotional violence 20% 15% Physical violence 14% 6% Sexual violence 5% 2% Physical and sexual violence 4% 1% Physical and sexual and emotional violence 3% 1% 1.2 Actions on the Recommendations from the CY 2021 Health Project Performance Evaluation Based on the overall results from the 2021 Health Project performance evaluation (HPPE) report, the HP performed better in CY 2021 compared to CY 2020 in terms of hurdling the setbacks of the COVID-19 pandemic and getting back on track, particularly for meeting the targets for TB and community-based drug rehabilitation (CBDR). The report provided 13 recommendations (See Annex A. Overall Recommendations from the CY 2021 HPPE Report) for the HP to consider. These consisted of five recommendations at the health systems level, three at the activity level for all IPs, five at the program level—one for TB IPs and two each for family planning/adolescent reproductive health (FP/ARH) IPs and for CBDR (RenewHealth). The initial results of the 2021 HPPE were presented to the Development Objective Agreement Management Committee on June 15, 2022. We also integrated the HPPE findings and recommendations with the key results of the HP midterm whole-of-project-evaluation (2018 – 2021) and the FY 2022 HP mid-year report and provided customized presentations during the following meetings: (1) chief of party meeting on July 15, 2022; (2) FP/ARH cluster meeting on July 27, 2022; (3) gender equality and women empowerment (GEWE) meeting on July 28, 2022; and (4) social and behavior change communications (SBCC) thematic meeting on August 5, 2022. These series of meetings were the building blocks of the HP’s stock-taking and strategic planning to guide IPs’ FY 2023 work plans. The USAID/Philippines Office of Health (OH) also integrated the 2021 HPPE findings and recommendations into the HP’s work planning guidance for FY 2023, released by the OH to the HP IPs on August 3, 2022. In developing their FY 2023 work plans, the HP IPs also consulted their respective partners and stakeholders from national government agencies, LGUs, private sector, and civil society organizations (CSOs). In September – October 2022, we assisted OH in reviewing the HP IPs’ draft FY 2023 work plans. From this review, we noted that most of the recommendations from the CY 2021 HPPE have been adopted in varying degrees, except for the following: (1) support the DOH in developing and implementing their DTPs; (2) conduct small surveys via secure digital platforms to identify creative ways to improve TB and CBDR health￾seeking behavior; and (3) advance the disaggregation of performance data. The USAID Agreement Officer’s Representatives communicated our review to their IPs and the IPs considered the recommendations in revising and finalizing their work plans. From our review of the IPs’ progress reports for the first quarter 11 of FY 2023 (covering October to December 2022), we noted that IPs had begun supporting DOH and LGUs in developing DTPs. 1.3 Health Project Purpose, Sub-Purposes, and Activities In line with the CDCS 2019 – 2024, the HP 2019 – 2024 has a specific focus on improving the health of underserved Filipinos. The HP is also aligned with the Philippine Health Agenda (PHA 2016 – 2022)18 and the National Objectives for Health19 of the DOH. In particular, USAID/Philippines and USAID/Washington gave high priority for technical support to TB control, FP/ARH, and CBDR. In the context of the HP, “underserved” refers to people exposed to or people who have TB or multidrug-resistant TB (MDR-TB); youth and adults at risk for unwanted or early pregnancy and childbirth; people who use drugs (PWUD); and populations at risk for HIV.20 Another focus of the HP is geographic areas with the highest burdens. For TB, this includes areas where the TB disease burden is highest. For FP/ARH, this includes areas with the highest unmet need for FP and high teenage pregnancy rates. Also, underserved refers to the poor (given the general association between low income and health concerns, especially TB, inadequate service delivery and sub-optimal adoption of healthy behaviors). “Underserved” also covers poor access to health care, especially those in geographically isolated and disadvantaged areas. In addition, in May 2019, a new HP activity began, providing CBDR services for PWUD. HP health systems strengthening activities at the national level are focused on support for appropriate and relevant policies and health system improvements in health leadership and governance, HRH, health financing, and supply chain management (SCM). At the regional and local levels, the HP provides support in implementing health system improvements, including health information systems, particularly in relation to TB, FP/ARH, and CBDR interventions. Ultimately, fortifying and institutionalizing health systems is expected to support progress toward sustainability and attainment of the Sustainable Development Goals. Three sub-purposes comprise the HP outputs leading to the HP purpose. These sub-purposes are: 1. Healthy Behaviors Strengthened 2. Quality of Services Fortified 3. Key Health Systems Bolstered and Institutionalized Lower-level objectives under each sub-purpose are shown in Figure 2. 18 Department of Health, Republic of the Philippines. Philippine Health Agenda 2016 – 2022. 19 Department of Health, Republic of the Philippines. National Objectives for Health: Philippines 2017 – 2022. Manila, Philippines: 2018. Available at: https://doh.gov.ph/node/16880 20 The HP activity on HIV, Meeting Targets and Maintaining Epidemic Control (EpiC) Project, has a separate monitoring and evaluation framework under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and is not formally covered in this CY 2022 HPPE. However, Section 4.1.4. provides a summary of its accomplishments for the first six months of implementation. 12 Figure 2. Framework of the USAID/Philippines Health Project, 2019 – 2024 Additionally, USAID support has increasingly emphasized the need to capacitate and engage communities, CSOs, and the private sector to contribute as vital partners in pursuing the HP purpose, sub-purposes, and objectives. Capacity-building activities encompass helping these sectors, including community-based organizations (CBOs) and community health volunteers, develop and adhere to established effective delivery networks, transparent information systems, public accountability protocols, and efficient management practices. Strong and independent private institutions are likewise critical in maintaining overall good governance, ensuring sustainable environments, and growing a healthy and educated population. Table 4 shows past and current HP activities for the period 2019 – 2024. Only the HP activities that were fully operational in CY 2022 are covered in this HPPE. The TB Local Organizations Network Project, which started in October 2020, has been included in the performance evaluation since 2021. Table 4. USAID Health Project Activities, 2019 – 2024* Thematic Areas** / Portfolio USAID Health Project Activity Estimated Timeline Status in FY 2022 TB and MDR-TB† Treat TB: Supporting MDR-TB Activities in the Philippines September 2016 – March 2019 Ended TB Innovations and Health Systems Strengthening (TBIHSS)†† February 2018 – February 2023 Current TB Platforms for Sustainable Detection, Care and Treatment (TB Platforms)†† April 2018 – April 2023 Current 13 Table 4. USAID Health Project Activities, 2019 – 2024* Thematic Areas** / Portfolio USAID Health Project Activity Estimated Timeline Status in FY 2022 TB Local Organizations Network†† October 2020 – September 2023 Current FP/maternal, neonatal, child health and nutrition/ARH Community Maternal, Neonatal, Child Health & Nutrition Scale-up August 2016 – December 2019 Ended (Q1 FY 2020) FP/MNH Health Innovations and Capacity Building Platforms (ReachHealth)†† December 2018 – November 2023 Current Bangsamoro Autonomous Region in Muslim Mindanao Health Capacity￾Building (BARMMHealth)†† February 2019 – February 2024 Current Health Systems Strengthening (HSS) Institutionalization of the Health Leadership and Governance Program July 2017 – September 2020 Ended (Q4 FY 2020) Health Equity and Financial Protection Platform (ProtectHealth)†† March 2019 – March 2024 Current Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program†† September 2018 – September 2023 Current Human Resources for Health 2030/Philippines October 2017 – June 2020 Ended (Q3 FY 2020) Drug Demand Reduction Expanding Access to CBDR Program in the Philippines (RenewHealth)†† May 2019 – May 2024 Current Monitoring, Evaluation, & Learning Collaborating, Learning, and Adapting for Improved Health (CLAimHealth)†† March 2018 – March 2022§ Ended (Q2 FY 2022) * USAID/Philippines OH also supports the DOH in controlling the HIV/AIDS epidemic in the country. The EpiC project was launched in March 2021, implemented by FHI360 and funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). It is part of the bilateral Development Objective Agreement but not formally within the HP performance framework, given the PEPFAR monitoring and evaluation (M&E) framework it has adopted. ** Through USAID’s global program for Neglected Tropical Diseases (NTD), the Philippines also receives support to control or eliminate five of the most common NTD infections (lymphatic filariasis, onchocerciasis, soil-transmitted helminthiasis, schistosomiasis, and trachoma) through safe, effective, and cost-efficient treatments via mass drug administration. † USAID/Philippines TB activities are supplemented by a technical assistance support coordinator and the WHO TB technical advisor. †† IPs whose activities are fully operational in Q2 – Q4 FY 2022 and Q1 FY 2023 are included in the CY 2022 HPPE. § Beginning March 30, 2022, collaborating, learning, and adapting support to the OH of USAID/Philippines was delivered by a Health Team under the Mission-wide activity: Collaborating, Learning, and Adapting for Improved Development (CLAimDev), which will end in June 2023. 14 1.4 Theory of Change and Results Framework The underlying Theory of Change (ToC) of the HP 2019 – 2024 is: If key aspects of the health system are strengthened and institutionalized, then the health of underserved Filipinos will improve, and the overall health profile of the country will improve. By addressing the health needs of the individual, the quality and equity of health services, and the sustainability of health services and systems, underserved Filipinos will be able to develop and maintain healthy behaviors and seek and receive quality health care. In line with the CDCS and based on the 2016 Health Portfolio Evaluation21 and the Project Appraisal Document,22 the appropriate strategy to influence desired change is to bolster and institutionalize a system for the GPH health sector, which reinforces healthy behavior, quality services, and agile system functions. This is a significant shift from a strategy of providing technical assistance to fill service and management gaps to a GPH partner that strengthens sustainable systems through evidence-based innovative approaches that deeply engage actors at both national and local levels in the context of an increasingly decentralized governance system.23 The assumptions for positive change through the HP are: ● Reasonable access to the underserved Filipinos (regions/sites with the highest TB burden and unmet need, and low-income groups in these areas). ● Political support to effectively implement the Responsible Parenthood and Reproductive Health (RPRH) law (Republic Act No. 10354), the Comprehensive TB Elimination Plan act of 2016 (TB law, Republic Act No. 10767), and the UHC Law (Republic Act No. 11223). ● Public sector funding levels at the central and regional levels will be at least maintained at current levels and/or increased. ● Services will continue or resume during periods of natural disaster, such as the COVID-19 pandemic or political unrest. ● USAID funding and staffing levels from USAID will be at least maintained at current levels and/or increased. ● For TB, funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) will be, at least, maintained and/or increased until public sector funding can sufficiently fill the funding gap. The change expected from implementing the HP activities is measured through a set of indicators at the level of outcomes and outputs for the three sub-purposes (see Figure 3). 21 USAID Philippines. Health Portfolio Evaluation. August 2016. 22 USAID Philippines. Project Appraisal Document: USAID/Philippines Health Project 2017 – 2022. 23 Ibid. 15 Figure 3. USAID Health Project Results Framework, 2019 – 2024 (with updates to performance indicators as of July 20, 2022) 16 17 2. EVALUATION QUESTIONS The HPPE is a multi-year, cumulative exercise that spans the entire HP cycle and all component activities. In August 2018, the HP activities proposed an indicative and initial list of performance evaluation questions, culled from initial consultations with USAID OH on the learning agenda24 and reviews of the Project Appraisal Document25 and 2016 Health Portfolio Evaluation Report.26 In 2018, the six evaluation questions used to assess performance were: 1) To what extent have targets for HP indicators been achieved in this year and cumulatively? 2) To what extent have the HP component activities contributed to achieving the targets? 3) What are the critical enabling factors associated with achieving HP targets? 4) What are the challenges and barriers to achieving HP targets? 5) How are the HP component activities ensuring that interventions are sustainable beyond project life? 6) To what extent are collaborating, learning, and adapting (CLA) practices being integrated and mainstreamed in and across activities and the USAID/Philippines OH? In 2019, the USAID/Philippines OH and the IPs discussed the HP learning agenda, modifying and expanding the main evaluation questions. The original six evaluation questions above became secondary learning questions for various identified domains. OH and the IPs considered the learning agenda developed as a living document that could be modified or refined over the course of the HP, based on new developments, such as launching new HP activities, significantly altering the assumptions underlying the HP’s ToC, or revising performance indicators, strategies, and interventions. The evaluation questions and learning questions that guided the HP in 2021 and 2022 are listed in Table 5. Table 5. Evaluation / Learning Agenda Questions (as of March 2022)27 Primary Learning Questions Secondary Learning Question 1. How has the USAID HP contributed to improve health outcomes among the underserved? [Improving health outcomes] • To what extent have the HP activities contributed to achieving the targets? • What are the critical enabling factors associated with achievement of HP targets? • What are the challenges and barriers to achieving HP targets? • What high impact interventions and innovations directly contributed to improving health outcomes? Improving health systems? 2. How have the USAID HP interventions improved social norms and behaviors among the underserved seeking treatment and • What demand generation platform and messaging are most effective for: men, adolescent youth, urban poor, women with unmet need for FP, and PWUD? 24 USAID Collaborating Learning and Adapting for Improved Health (CLAimHealth) Activity. July 2018. Health Project Learning Plan. Silver Spring, Maryland: Panagora Group. 25 USAID Philippines. Project Appraisal Document: USAID/Philippines Health Project 2017–2022. 26 USAID Philippines. Health Portfolio Evaluation. August 2016. 27 USAID/Philippines Office of Health. Updated Health Project Learning Plan. 2022. Manila, Philippines. 18 Table 5. Evaluation / Learning Agenda Questions (as of March 2022)27 Primary Learning Questions Secondary Learning Question prevention services? [Improving demand] • What HP interventions have improved health-seeking behavior and treatment adherence? 3. How has the USAID HP increased client satisfaction? [Improving Supply] • How does the HP operationalize people-centered care in delivery of health services? • Are the measures for client satisfaction appropriate and the information gathered accurate?28 • How have USAID health interventions reduced FP and TB treatment and CBDR discontinuation rates? 4. How has the USAID HP led to continuous quality improvement (CQI) in care service delivery? [Improving Supply] Note: No secondary learning questions were formulated for this primary learning question for 2021 and 2022. 5. How has the USAID HP contributed to improving financial risk protection? [Improving Health Systems] • What HP interventions have helped reduce out-of-pocket costs for TB and FP/ARH? • What HP interventions have improved the social and financial benefit packages related to TB and FP/ARH? • What HP interventions have improved uptake of social and financial benefit packages related to TB and FP/ARH? 6. How has the USAID HP influenced UHC HSS efforts for the Philippines? [Improving Health Systems] • [General] What HSS reforms are in place because of USAID interventions? How are these HSS reforms impacting health outcomes? • [Governance and Policy] What HP interventions have improved effectiveness of the DOH DPCB, DOH Health Promotion Bureau, DOH procurement and supply chain management (PSCM) unit, DOH Health Human Resources and Development Bureau, DOH Health Policy Development and Planning Bureau, DOH information systems, the Ministry of Health in the Bangsamoro Autonomous Region in Muslim Mindanao (MOH BARMM), the Commission on Population and Development (POPCOM), and PhilHealth in delivering their mandates? • [Governance and Policy] What HP interventions have improved local health system capacity for policy formulation, budget planning & execution, program implementation and M&E? • [Governance and Policy] What HP interventions have increased national and local capacity in health systems management in sustainably supporting TB and FP/ARH programs? • [HRH] What HP interventions have helped in expanding and building health provider capacity for quality health care delivery for TB and FP/ARH programs? • [Logistics] What HP interventions have helped ensure TB and FP/ARH health commodity security at the national and local levels? • [Information System] How has the HP supported improvement of the TB, FP/ARH, and CBDR information systems? 28 In 2022, this replaced the secondary learning question, “How does the HP measure client satisfaction?” 19 Table 5. Evaluation / Learning Agenda Questions (as of March 2022)27 Primary Learning Questions Secondary Learning Question 7. How has private sector engagement contributed to achieving better health outcomes? [Improving Private Sector Engagement] • How has the USAID HP contributed to the greater involvement of the private sector? • What limits the private sector engagement in effectively contributing to better health outcomes? • What engagement models increased private sector engagement? 8. How has CSO engagement contributed to achieving better health outcomes? [Improving Civil Society Engagement] • How has the USAID HP contributed to the greater involvement of CSOs? • What limits the civil society engagement in effectively contributing to better health outcomes? • What engagement models increased civic participation? 9. How has the USAID HP contributed to addressing GEWE concerns in accessing health services? [GEWE] • How many people were reached and provided with services related to gender-based violence (GBV)? • How many people were trained to advance outcomes consistent with GEWE though their roles in public or private sector institutions or organizations? • How can access of males to TB services be increased? • How can access of men, women, and adolescents to FP services be improved? • How can access of male, female, and adolescent PWUDs to CBDR services be improved? • How did HP activities contribute to the above? 10. How has the USAID HP improved the ability of health service delivery points (SDPs) to mitigate environmental risks and withstand climate risks? [Climate risk management] • What interventions are effective to improving resiliency of service delivery points? 11. How has the USAID HP ensured that interventions for the underserved are sustainable beyond project life? [Journey to Self-Reliance] • What interventions have contributed to the resilience of national and local health systems? • What processes have led to reforms or adoption of high-impact interventions by the GPH at the national and local levels? 12. To what extent are CLA practices integrated in the USAID HP? [CLA mainstreaming] • [Collaboration] How have IP collaboration & coordination improved project performance? • [Learning] What learning platforms were most effective in supporting evidence generation and utilization? • [Adaptive Management] What adaptive management platforms were most effective in supporting decision making and adoption? 13. What innovative technologies are being introduced? [Innovation] Note: No secondary learning questions were formulated for 2021 and 2022. 20 In the annual HPPEs, in addition to reporting on quantitative performance data for indicators against stated targets, we also discuss interventions, initiatives, and systemic changes introduced by the HP activities to achieve HP objectives as well as to respond to the challenges and setbacks encountered. The narratives under each primary learning question in Table 5 also respond to the secondary learning questions without directly listing answers under each one. This approach supports the synthesis of findings and avoids a question-and-answer survey format, thus reducing repetitive replies to related questions. Moreover, the listing of activities and interventions is not exhaustive and instead discusses salient points on whether and how the HP has responded to the learning questions during the year. A more complete and detailed listing and discussion of activities and interventions can be found in the individual IP quarterly and annual reports. 21 3. EVALUATION DESIGN AND METHODOLOGY Similar to the past three HPPEs (2019, 2020, and 2021) this assessment period covers the CY, and specifically, CY 2022 (rather than the fiscal year [FY] October 2021 – September 2022) to correspond to the Philippine reporting period, thus making the report more congruent with local policy and program planning. Overall, this report covers four quarters for the full CY January – December 2022 (i.e., the period covered starts with USAID’s FY 2022 quarter 2 and ends with FY 2023 quarter 1). Specifically, because USAID activities report their performance by FY, we extracted quarters 2 to 4 FY 2022 (January – September 2022) data and quarter 1 FY 2023 (October – December 2022) from the progress reports of IPs to obtain the data for CY 2022. On the other hand, for status indicators such as current FP users, we accessed the most recent data available (i.e., quarter 1 FY 2023). For determining performance targets by CY for comparison against CY performance, we first divided FY targets by four, then multiplied the quartered previous fiscal year (FY 0) by three, and then added the quartered current year target (FY 1). Where CY data are not available, comparisons are made using available data, such as in FY reports, as appropriately explained in the graphs, narratives, and/or footnotes. Due to lags in recording and reporting of routine health data in health facilities through the Field Health Services Information System (FHSIS), the data for the full CY 2022 were sometimes incomplete or absent at the time of the HPPE. In most cases, quantitative performance data are compared to those of the previous year or relevant period. In instances when the data on indicators were not or could not be collected or indicators were changed or modified, the data on these new indicators are reported and discussed in relation to other available data or in the context of current events. Quantitative performance against annual targets used a “traffic light” system,29 with the following parameters: Table 6. “Traffic Light” System Traffic Light Color Interpretation Percent of Target Achieved Green Met or exceeded target 80 to 100% Amber Met at least 50% of the target 50 to less than 80% Red Did not meet the target Below 50% In reporting performance with respect to stated targets, the assessment uses the USAID OH Performance Plan and Report, Performance Indicator Tracking Table (PITT) and special surveys described in IPs’ quarterly and annual reports. Available data from the PSA, DOH, and other government administrative data sources were used to provide context and comparability. 29 This traffic light system was first used in the 2020 HPPE Report and continued in the 2021 HPPE. It was adopted from the traffic light system introduced by the USAID/Philippines Program Resources Management Office in January 2021, which also coincided with the scoring parameters of DOH Bureau of International Health Cooperation’s International Health Partners Scorecard at that time. 22 We also used qualitative information obtained through key informant interviews (KIIs) among selected government officials, service providers, and other partners. These were particularly valuable in measuring the relevance of the HP and the impact of HP activities on local health systems, governance, and sustainability. Table 7 shows a matrix of the HPPE methods and sources of data. 23 Table 7. Summary of HPPE learning questions and data sources Documentary Review & Secondary Data Analyses Context Monitoring GPPI KII OH/IP Meeting Notes OH PPR & IP Reports DOH FHSIS DOH ITIS Remote M&E PSA Reports Other Survey Reports KII Guide Q1. How has the USAID HP contributed to improve health outcomes among the underserved? x x x x x x x x x x x Q2. How has the USAID HP interventions improved social norms and behaviors among the underserved seeking treatment and prevention services? x x x x x x x x Q3. How has the USAID HP increased client satisfaction? x x x x x x x Q4. How has the USAID HP led to continuous quality improvement in care service delivery? x x x x x x Q5. How has the USAID HP contributed to improving financial risk protection? x x x x x x Q6. How has the USAID HP influenced UHC and health systems strengthening (HSS) efforts for the Philippines? x x x x x x x Q7. How has the USAID HP contributed to the greater involvement of the private sector in achieving better health outcomes? x x x x x x Q8. How has the USAID HP contributed to the greater involvement of civil society in achieving better health outcomes? x x x x x Q9. How has the USAID HP improved male participation in accessing health services? x x x x Q10. How has the USAID HP improved the ability of health service delivery points to mitigate environmental risks and w ithstand climate risks? x x x x x Q11. How has the USAID HP ensured that interventions for the underserved are sustainable beyond project life? x x x x Q12. To w hat extent are CLA practices integrated in the USAID HP? x x x x x x x Q13. What innovative technologies have the USAID Health Project introduced? x x x x x x Key Evaluation Questions Evaluation Methods Instruments and Data Sources 24 4. LIMITATIONS OF THE HPPE Before presenting our findings for the primary evaluation and learning questions, it is important to acknowledge at the outset several limitations in this year-end assessment. The 2022 HPPE is a whole-of￾project evaluation, using the HP results framework and learning questions to evaluate performance, and is not a deep dive into the activities of every single IP.30 Complete descriptions and analyses of IP performance and challenges can be found in the individual IP quarterly and annual reports. The HPPE does not perform an evaluation of the impact of any particular activity, intervention, or innovation on the health outcome goals given the limited data and information on the indicators and other parameters and counterfactuals or well-defined comparison groups. While the report discusses selected HP innovations and activities to achieve its activity-level targets, given data limitations, it cannot measure direct impact on overall health outcomes, nor can it compare the effectiveness of one intervention over another. Moreover, the HP undertakes, together with the DOH and other partners, multiple activities in the U.S. Government–assisted sites, making it difficult, without the appropriate impact evaluation methodology, to attribute any change in health outcomes to the specific interventions implemented. Likewise, measuring the impact of social and behavior change (SBC) interventions is not a linear process and generally requires long gestational periods and multiple iterations to permeate the personal and social milieu. Policy instruments and tools that aim to strengthen health systems also require considerable time and effort to be fully and efficiently functional and generally require concomitant actions on other health system building blocks to facilitate change. We used different data sources for some performance indicators for FP/ARH, though most of the data we used were collected by IPs from the FHSIS. However, the FHSIS continues to have data quality issues in terms of timeliness and reliability. The FHSIS reporting is delayed by at least one quarter at the provincial level and delayed by at least one year at the national level. Additionally, health workers also attend to multiple health programs (e.g., childhood immunization) in addition to FP/ARH. Moreover, the reference period for performance targets may vary from indicator to indicator. To align with the annual program evaluation periods of DOH, OH decided to conduct its annual performance evaluations by CY rather than its own FY. However, most performance targets of IPs are estimated by FY, except for the TB indicators, which are aligned with the targets of the NTP. We have indicated in the data tables when FY rather than CY targets were used. 30 USAID Automated Directives System (ADS) definition of whole-of-project evaluations: “Evaluations that examine an entire project, including all its constituent activities and progress toward the achievement of the Project Purpose. Performance evaluations employ many evaluation methods, which often do before-and-after comparisons, but generally lack a rigorously defined counterfactual. As performance evaluations do not contain a rigorously defined counterfactual, they should not answer questions about the amount of change attributable to an intervention, where other factors are likely to have influenced the variable in question.” Sources: (1) USAID ADS Chapter 201. Operational Policy for the Program Cycle. Partial revision date: Oct. 28, 2020. (2) USAID Learning Lab, available at: https://usaidlearninglab.org/sites/default/files/resource/files/whole_of_project_evaluation_10.20.2016.pdf 25 Bangsamoro Autonomous Region in Muslim Mindanao Health Capacity-Building (BARMMHealth) and ReachHealth still have not been able to reliably estimate teenage pregnancies in the U.S. Government– assisted sites. Until the 2022 NDHS public use file and final report is released, this data gap will persist.31 Nevertheless, this HPPE report provides some preliminary and very limited performance data related to ARH—e.g., exposure to FP messages, number of adolescent-friendly health facilities (AFHFs)—and describes several ARH interventions implemented by the IPs. The situation with reporting and recording of TB performance indicators is not as problematic as the FP/ARH data given the existence of the Integrated TB Information System (ITIS) and the support provided by the Global Fund as well as the World Health Organization (WHO) to curate the information. Although there have been increased efforts to encourage private sector practitioners to comply with the TB law that requires mandatory notification (MN) of TB cases, there is a need to encourage reporting of treatment outcomes among MN cases. There are also delays and incomplete data reporting to ITIS because of lack of staff in service delivery points (SDPs) to carry out this regular task. For this particular year, we have observed that there were changes implemented in the ITIS data tables for contact investigation, which affected data consolidation in comparison to the previous year's data. On the other hand, data on CBDR are sourced from the annual progress report of RenewHealth. RenewHealth performance data are cumulative from project inception and follow FY reporting, hence CBDR data do not reflect CY 2022 accomplishments. In the KIIs with HP partners and stakeholders, there were changes in national and local officials and staff following the 2022 national and local elections. The agencies invited for interviews experienced staff reassignments at different levels of the organization, including some of the invited interviewees. Thus, some interviewees either delegated to their staff or program coordinators the task of supplying insights on behalf of the institutions and skipped the meetings altogether or provided a disclaimer that the insights shared referred only to their limited experiences with the IPs. In addition, there were also two invited agencies that declined our invitation for interview citing that there are other divisions/bureaus that are better positioned to comment on the HP. Moreover, the team was not able to receive the responses of some invited interviewees (i.e., representatives from two DOH central office bureaus, one national government agency, and three LGUs) during the HPPE KII timeframe. A couple of interviewees mentioned being preoccupied with rolling out service delivery caravans in their LGUs, which coincided with the Philippine president’s visit, while the others mentioned being preoccupied with other urgent work duties. 31 The NDHS public use file and full report were not yet available as of this writing. 26 5. FINDINGS 5.1 Question 1. How has the USAID HP contributed to improve health outcomes among the underserved? 5.1.1 Family Planning and Adolescent Reproductive Health Consistent with the ToC, the HP approaches the target of better health outcomes among the underserved through ensuring positive impacts on personnel, facilities, and institutions by strengthening technical, organizational, and systemic capacities that are sustained in the long term. One way to establish long-term impact is to promote SBC in FP and ARH. Thus, the HP supports SBC campaigns and direct health messaging conveyed by health service providers and community health workers (CHWs). The HP worked with the DOH, the Commission on Population and Development (POPCOM), provincial health offices (PHOs), and health centers to meet the demand for modern FP methods from FP new acceptors (NAs) and sustain the number of FP current users (CUs) by ensuring the availability of adequate service delivery sites and a steady supply of services and commodities. HP expanded the reach of FP messages through the use of multiple platforms. Table 8 shows that ReachHealth had attained more than twice their CY 2022 target number of individuals exposed to FP messaging, while BARMMHealth achieved around three-fourths of their targets. The table also shows that compared to CYs 2020 and 2021, ReachHealth included television in the platforms used in CY 2022 to disseminate FP messages. While electronic platforms accounted for roughly three-fourths of the total reach in CY 2021, this was reduced to 58 percent in CY 2022, and television and radio accounted for 42 percent of the total reach. It was reported in the CY 2021 HPPE that the DOH, as part of its extensive media campaign, provided funding for a new FP ad aired on national television networks in December 2021. ReachHealth reported in quarter 1 CY 2022 that around 36.6 million exposures could be directly attributed to this ad campaign. BARMMHealth likewise increased the use of electronic platforms (other than radio) as a means to spread messages, increasing the numbers reached by around 51 percent from that reported in 2021. Given the geography of the BARMMHealth sites, radio remains to be the most predominant platform used. It should be noted that the numbers reported here are not counts of unique individuals since there could be multiple exposures of the same individual to the same messages among the various platforms during the reporting period.32 Moreover, there must be more effort at proper intake and recording of data—the number of individuals whose sex was not recorded accounts for almost half of the total reported in ReachHealth sites, and there continues to be no disaggregation by sex in BARMMHealth sites. The effectiveness of SBC campaigns depends on the design and dissemination of appropriate messages to relevant targets and should not be gender-blind. 32 The same is true for the CY 2021 HPPE. 27 ReachHealth partnered with Ease Healthcare Philippines to reach more people and provide alternative service delivery options for those reached by the “It’s OK to Delay” SBC campaign. Through ReachHealth’s partnership with the Department of Education (DepEd), there were also more teens reached (from 864,965 in 2021 to 7.8 million in 2022) by the “I Choose” #MalayaAkongMaging campaign launched in December 2021. ReachHealth improved the Enhanced Usapan curriculum by incorporating SBC materials and linked FP clients with service delivery through multi-sectoral partnerships such as FP Cavite Konek. On the other hand, BARMMHealth reported more people who were reached through community dialogue such as Usapan sessions and “Catch & Change” or during khutba and sermons. With the easing of COVID-19 restrictions, HP was able to facilitate the conduct of more community-based demand-generation activities. However, the percentage of people who were reached through interpersonal approaches (e.g., CHWs and Usapan sessions) remained negligible. Table 8. Number of individuals in the target population reporting exposure to U.S. Government–funded FP messages (by channel/no. of channels), CYs 2021 and 2022 CY 2021 Performance CY 2022 Target* CY 2022 Performance % Change % CY 2022 Target Met ReachHealth 56,830,933 51,250,000 132,044,685 132% 258% By age Adults 55,983,942 117,482,786 Adolescents 846,991 14,561,899 By platform Radio 13,281,773 18,297,255 Television 0 36,932,905 Electronic Platforms 43,070,658 75,981,629 Community Group Dialogue 4,799 16,869 Interpersonal Communication & Counseling 236,335 443,140 In Print 228,436 80,154 Out of Home Media 0 292,400 Others 8,932 333 By sex Male 18,967,577 29,758,239 Female 23,061,471 39,420,972 28 Table 8. Number of individuals in the target population reporting exposure to U.S. Government–funded FP messages (by channel/no. of channels), CYs 2021 and 2022 CY 2021 Performance CY 2022 Target* CY 2022 Performance % Change % CY 2022 Target Met Not Reported 14,819,859 62,865,474 BARMMHealth** 1,151,204 1,666,667 1,034,266 -10% 62% Radio 891,751 322,850 Electronic Platform 43,315 65,256 Community Dialogue 7,098 19,038 *CY 2022 Target = ((FY 2022 target/4)*3)+(FY 2023 target/4). **Because BARMMHealth’s FY 2022 PITT and Quarter 1 FY 2023 PITT do not show the quarterly accomplishments from FY 2019 – FY 2022, CY performance was computed as follows: (a) CY 2021 accomplishment = ((FY 2021 accomplishment/4)*3)+(FY 2022 accomplishment/4); (b) CY 2022 accomplishment = ((FY 2022 accomplishment/4)*3)+(Quarter 1 FY 2023 accomplishment). Table 9 shows that the reported number of U.S. Government–assisted CHWs providing messages and services in HP sites increased by 17 percent from 2021 to 2022, achieving more than 100 percent of its CY 2022 target number of CHWs assisted. By the end of the CY, ReachHealth had already reached 113 percent of its CY 2022 target, while BARMMHealth achieved only 58 percent of its own CY 2022 target even as it increased the number of assisted CHWs in its sites by 10 percent between 2021 to 2022. Table 9. Number of U.S. Government–assisted CHWs providing FP information, referrals, and/or services during the year in U.S. Government–assisted sites, CYs 2021 and 2022 CY 2021 Performance* CY 2022 Target** CY 2022 Performance* % Change % CY 2022 Target Met HP 83,519 90,475 98,121 17% 108% Male 4,948 Female 93,173 ReachHealth 79,498 82,875 93,702 18% 113% Male 811 1,231 Female 78,687 92,471 BARMMHealth 4,021 7,600 4,419 10% 58% Male 3,717 Female 702 *In FY 2022, ReachHealth started collecting from 25% of the facilities in their project sites each quarter. To make the data comparable from earlier years, the CY performance was computed as follows: (a) CY 2021 accomplishment = ((FY 2021 accomplishment/4)*3)+(Quarter 1 FY 2022 accomplishment); (b) CY 2022 accomplishment = (Quarters 2 – 4 FY 2022 Accomplishments)+(Quarter 1 FY 2023 accomplishment). On the other hand, BARMMHealth’s FY 2022 PITT and Quarter 1 FY 2023 PITT do not show the quarterly accomplishments from FY 2019 – FY 2022, CY performance was thus computed as follows: (a) CY 2021 accomplishment = ((FY 2021 accomplishment/4)*3)+(FY 2022 accomplishment/4); (b) CY 2022 29 accomplishment = Quarter 1 FY 2023 accomplishment (note that FY 2022 annual accomplishment is exactly the same as Quarter 1 FY 2023 accomplishment). **CY 2022 Target = ((FY 2022 target/4)*3)+(FY 2023 target/4). Despite the achievements of FP IPs, there remain challenges in spreading FP messages through various platforms and through the work of CHWs.33 ReachHealth noted that POPCOM had difficulty updating SBC campaign materials that are more appropriate for their current activities; there were few local investments in SBC and conduct of demand-generation activities; and the majority of Usapan-trained facilitators were not able to conduct Usapan sessions despite the easing of COVID-19 alert levels. Moreover, BARMMHealth noted that FP radio programs were not consistently aired in their sites. Additionally, face-to-face Usapan sessions and the CHW trainings were limited since PHOs and LGUs still prioritized COVID-19 vaccination campaigns. Likewise, as mentioned in the Introduction section, the national and local elections held in May 2022 involved several months of campaigns and preparations, disrupting delivery of services and implementation of activities, especially in areas where incumbent LCEs were running for office. The percentage of service delivery sites providing FP counseling and services increased in 2022. Table 10 shows that the HP performed better in CY 2022 than in CY 2021 in terms of assisting SDPs in the U.S. Government–assisted sites in providing FP services and counseling, with BARMMHealth posting a 19 percent rise in the number of SDPs. Overall, the HP achieved 96 percent of its CY 2022 target. In U.S. Government–assisted sites supported by ReachHealth, the number of SDPs providing FP services grew by only 8 percent, with the IP achieving 97 percent of its CY 2021 target percentage. BARMMHealth achieved 95 percent of its CY 2022 target percentage. Table 10. Percent of U.S. Government–assisted service delivery sites providing FP counseling and/or services, CYs 2021 and 2022 CY 2021 Performance* FY 2022 Target** CY 2022 Performance* % Change % CY 2022 Target Met HP 78.9% 90.9% 87.5% 11% 96% Numerator 2,199 2,540 2,444 Denominator 2,787 2,793 2,793 ReachHealth† 82.6% 91.6% 88.9% 8% 97% Numerator 1,581 1,754 1,701 Denominator 1,914 1,914 1,914 BARMMHealth 70.8% 89.4% 84.5% 19% 95% Numerator 619 786 743 Denominator 873 879 879 33 Same as CY 2021 HPPE. 30 *In FY 2022, ReachHealth started collecting from 25% of the facilities in their project sites each quarter. To make the data comparable from earlier years, the CY performance was computed as follows: (a) CY 2021 accomplishment = ((FY 2021 accomplishment/4)*3)+(Quarter 1 FY 2022 accomplishment); (b) CY 2022 accomplishment = (Quarter 2 to Quarter 4 FY 2022 Accomplishments)+(Quarter 1 FY 2023 accomplishment)—Quarters 1–3 is subtracted from Quarter 4 since ReachHealth aggregates its annual data in Quarter 4. On the other hand, BARMMHealth’s FY 2022 PITT and Quarter 1 FY 2023 PITT do not show the quarterly accomplishments from FY 2019 – FY 2022, thus CY performance was computed as follows: (a) CY 2021 accomplishment = ((FY 2021 accomplishment/4)*3)+(FY 2022 accomplishment/4); (b) CY 2022 accomplishment = Quarter 1 FY 2023 accomplishment (note that FY 2022 annual accomplishment is exactly the same as Quarter 1 FY 2023 accomplishment). **CY 2022 Target = ((FY 2022 target/4)*3)+(FY 2023 target/4). Figure 4 shows the percentage of SDPs providing FP services and counseling by location and type of facility in ReachHealth sites from 2021 to 2022. The percentage of public SDPs providing FP services and counseling increased by 6 percent, while private SDPs increased by 11 percent. While there was an increase across all types of facilities (a reversal of the slight decline from 2020 to 2021), the most impressive gain was among private hospital SDPs, which increased by more than 300 percent. This could be explained by ReachHealth’s initiative of reaching more private service delivery sites and the increased utilization of private facilities since public facilities and personnel were still being used for COVID-19 pandemic response, including vaccinations. Figure 4. Percent of service delivery sites providing family planning counseling and/or services in U.S. Government–assisted sites supported by ReachHealth, by ownership, type of facility and urbanity, CY 2021 vs. CY 2022 Note: In FY 2022, ReachHealth started collecting from 25% of the facilities in their project sites each quarter. To make the data comparable from earlier years, the CY performance was computed as follows: (a) CY 2021 accomplishment = ((FY 2021 accomplishment/4)*3)+(Q1 FY 2022 accomplishment); (b) CY 2022 accomplishment = (Q2 to Q4 FY 2022 Accomplishments)+(Q1 FY 2023 accomplishment). The HP ensured assisted health facilities are able to provide various FP methods within the facility, are able to refer clients to other SDPs, and have a trained provider in FP competency-based training 1 (FPCBT-1) to conduct FP counseling. In addition to developing the FPCBT-1 blended e-learning manual of operations and uploading it to the DOH academy website, ReachHealth supported the DOH in enhancing the capacity of health workers by conducting training and post-training evaluation and by 31 supporting training institutions.34 Additionally, ReachHealth bolstered FP service delivery in hospitals by assisting in setting up service delivery mechanisms and health care provider network (HCPN) referral systems as part of its support to the UHC implementation sites. To support the MOH BARMM, BARMMHealth conducted an SDP mapping exercise to identify public and private facilities that currently provide FP services and to ensure that these facilities receive the appropriate and necessary support to improve their capacity. Substantial increase in the number of AFHFs to meet the growing demand for services among adolescents. Table 11 shows that the number of AFHFs increased more than three times between 2021 and 2022. This reflects the efforts of the FP IPs and their partners in enhancing the capacities of SDPs and becoming a qualified AFHF based on the HP criteria (Annex A). The performance of the HP for this indicator is quite significant, especially for BARMMHealth, which reported in 2021 that there were no AFHF in its sites that satisfied the enhanced HP performance indicator reference sheets (PIRS) criteria. While the HP achieved only 19.5 percent of its CY 2021 target, it reached 92 percent of its CY 2022 target. Table 11. Number of functional adolescent-friendly health SDPs in U.S. Government–assisted sites, CY 2022 CY 2021 Performance* CY 2022 Target** CY 2022 Performance* % Change % CY 2022 Target Met HP 72 364 335 369% 92% ReachHealth 55 266 251 356% 94% BARMMHealth 17 98 84 409% 86% *In FY 2022, ReachHealth no longer reports this as a status indicator (i.e., mid-year data=Quarter 2, FY annual=Quarter 4). To make the data comparable from earlier years, the CY performance was computed as follows: (a) CY 2021 accomplishment = ((FY 2021 accomplishment/4)*3)+(Quarter 1 FY 2022 accomplishment); (b) CY 2022 accomplishment = (Quarter 2 to Quarter 4 FY 2022 Accomplishments)+( Quarter 1 FY 2023 accomplishment). On the other hand, BARMMHealth’s FY 2022 PITT and Quarter 1 FY 2023 PITT do not show the quarterly accomplishments from FY 2019 – FY 2022. CY performance was computed as follows: (a) CY 2021 accomplishment = ((FY 2021 accomplishment/4)*3)+(FY 2022 accomplishment/4); (b) CY 2022 accomplishment = Quarter 1 FY 2023 accomplishment. **CY 2022 Target = ((FY 2022 target/4)*3)+(FY 2023 target/4). As shown in Table 12, 383,246 adolescents in U.S. Government–assisted sites availed of FP, maternal and child health (MCH), or sexual and reproductive health (SRH) services in CY 2022—12 percent more than the count in CY 2021—suggesting increasing demand for these services. ReachHealth reported almost twice its CY 2022 target, while BARMMHealth achieved 65 percent of its own CY 2022 target. However, it must be noted that the FP IPs collect data from all SDPs in their supported sites, not 34 As recommended in the previous HPPE, ReachHealth provided a grant to the Integrated Midwives Association of the Philippines to organize FP itinerant teams to support LGUs in providing FP services in geographically isolated and disadvantaged areas and underserved urban poor in Negros Occidental and Iloilo. Additionally, ReachHealth provided technical assistance (e.g., training of trainers for FPCBT-1) to potential applicants to become training institutions. 32 only from those classified as AFHF according to the HP PIRS criteria.35 While it is notable that the HP exceeded its targets, the increasing demand from adolescents for services indicates that the HP should ensure that more AFHFs are supplied with the necessary capacities (such as qualifying for the HP PIRS criteria) to provide quality adolescent care. Table 12. Number of adolescents who availed of FP/MCH/SRH services in SDPs in U.S. Government–assisted sites, CY 2022 CY 2021 Performance* CY 2022 Target** CY 2022 Performance* % Change % CY 2022 Target Met HP 268,322 236,578 383,246 43% 162% ReachHealth 245,111 190,387 353,142 44% 185% BARMMHealth 23,211 46,190 30,104 30% 65% * Quarters 1– 3 FY 2022 was subtracted from Quarter 4 FY 2022 because ReachHealth aggregated its annual data in Quarter 4 FY 2022. Then Quarters 2 – 4 FY 2022 was added to Quarter 1 FY 2023. On the other hand, BARMMHealth’s FY 2022 PITT and Quarter 1 FY 2023 PITT do not show the quarterly accomplishments from FY 2019 – FY 2022, CY performance computed as follows: (a) CY 2021 accomplishment = ((FY 2021 accomplishment/4)*3)+(FY 2022 accomplishment/4); (b) CY 2022 accomplishment = ((FY 2022 accomplishment/4)*3)+( Quarter 1 FY 2023 accomplishment). **CY 2022 Target = ((FY 2022 target/4)*3)+(FY 2023 target/4). Figure 5 shows that in the U.S. Government–assisted sites supported by ReachHealth, around 9 percent of the adolescents counted in CY 2022 availed of delivery services, higher than the 7 percent reported in CY 2021. This could mean that many adolescents served by SDPs already have a child or children or are sexually active. As recommended in the HPPE CY 2021, the health workers, with the support of the HP, must exert more effort in counseling adolescents before they become sexually active to avoid early pregnancy, delay repeat pregnancies, and prevent the spread of sexually transmitted infections. Moreover, there was a decrease in the adolescents who are current FP users, from a share of 63 percent in CY 2021 to 37 percent in CY 2022. More than 90 percent of adolescents who availed of services in SDPs were female and were between 15 to 19 years old, but there was an increase from 2.4 to 8 percent in the number of younger adolescents, aged 10 to 14, who availed of AFHF services. Both the lower share of FP CU and increased number of younger adolescents availing of services could help explain the higher share of deliveries in CY 2022 compared to CY 2021. This could be partly explained by the fact that schools started to conduct in-person classes in mid-2022, giving adolescents more opportunities to interact with each other outside the home. This is where the HP must ensure the effective implementation by the DepEd of the comprehensive sexuality education (CSE)—ARH convergence program. However, there were no disaggregation data in the U.S. Government–assisted sites covered by BARMMHealth, making it more challenging to develop age- and sex-appropriate 35 Same as in CY 2021 HPPE. 33 messages and interventions in BARMM. In effect, this limits the ability of the HP to provide targeted support to facilities that provide services to adolescents in the region. Figure 5. Percent of adolescents who availed of FP/MCH/SRH services in supported SDPs in U.S. Government–assisted sites supported by ReachHealth, by sex, age, type of service, and type of facility, CY 2022 Acronyms: 4 ANCs: 4 antenatal care visits FP CUs: FP current users FP-SRH: FP, sexual & reproductive health HEEADDSSS: Home, education, eating, activities, drugs, depression, sexuality, suicide, safety To meet the growing demand of adolescents for FP/MCH/SRH services, ReachHealth continued its support to existing AFHFs, assisting 196 new health facilities to be certified and functional AFHFs and supporting private hospitals integrate FP/ARH in their services. BARMMHealth assisted 68 health facilities become certified AFHFs (see Table 11) and supported MOH BARMM population division develop reporting and recording tools for adolescents. ReachHealth also continued supporting the DOH, DepEd, and POPCOM in implementing the CSE–ARH convergence. Despite the marked improvement in the ARH indicators in CY 2022, the HP and its partners faced challenges that affected the implementation of ARH initiatives. For instance, the coordination mechanisms for CSE–ARH convergence activities still need to be strengthened; engagement of adolescents in AFHF and CSE–ARH convergence remains minimal; and the interpretation of maturity status among CSE–ARH convergence pilot areas is variable. There were also some institutional hurdles in advancing the ARH initiatives, such as DOH and DepEd staff restructuring, including appointment of new agency officials following the national and local elections in May 2022, and continuing adjustments post-COVID-19 pandemic and return to the new normal. 0% 20% 40% 60% 80% 100% RHU/HC Private Hospital FP-SRH information HEEADDSSS Other Risks Counselled FP CU Delivery 10-14 Male Type of Facility Type of Service Age Sex % share of adolescents who of availed services (n=353,142) 34 FP commodity stockouts worsened in 2022. Table 13 shows that the stockout rates for oral contraceptive pill in U.S. Government–assisted sites covered by ReachHealth were still above the 7 percent threshold, increasing from 9 percent in FY 2021 to 11 percent in FY 2022. Stockout rates for injectables and progestin subdermal implants (PSI) were likewise above the threshold but lower than in FY 2021. In U.S. Government–assisted sites covered by BARMMHealth, the stockout rates of most FP commodities were just below the target threshold of 7 percent, but that for pills showed almost a four-fold increase in FY 2022. However, there was a marked improvement in the availability of PSI, with the stockout rates decreasing from 47 percent in FY 2021 to 10 percent in FY 2022. This is likely because the provinces were able to submit the inventory and order reports on time, allowing for the timely distribution of the requested commodities.36 Table 13. FP commodity stockout rates* in U.S. Government–assisted sites, FYs 2021 and 2022 FY 2021** FY 2022*** Target Accomplishment Target Accomplishment ReachHealth <7% 9% <7% 11% Pills 9% 11% Injectables 17% 14% Condoms 16% 16% Intrauterine device 6% 9% PSI 22% 14% SDM beads 17% 23% BARMMHealth <7% 3% <7% 11% Pills 3% 11% Injectables 12% 6% Condoms 26% 6% Intrauterine device 0% 6% PSI 47% 10% SDM beads 0% 6% *Average stockout rate in this report was no longer computed by averaging the percentage of facilities who experienced stockouts from Q1 to Q4 of the entire year. This was no longer feasible because the collection method and interpretation of the indicator were changed in Q1 FY 2022 (October–December 2021). Specifically, ReachHealth collects data only from 25 percent of the facilities in its project sites per quarter. By the end of the FY, ReachHealth is able to obtain data from 100 percent of the facilities in their project sites. On the other hand, stockout rate is a status indicator for BARMMHealth. **Reflects data from October 2020—September 2021. ***Reflects data from October 2021—September 2022. 36 FY 2022 BARMMHealth Annual Report, page 34. 35 Figure 6 shows the stockout rates of different commodities from FYs 2019 to 2022 among public and private facilities in U.S. Government–assisted sites covered by ReachHealth. The stockout rates for pills dropped from 23 percent (baseline) to as low as 3 percent (FY 2020) but then steadily increased, posting 11 percent in FY 2022. The stockout rates for other FP methods also fluctuated between FYs 2019 and 2022, with that for PSI reaching a high 45 percent in mid-2020 due to supply constraints at the height of the COVID-19 pandemic. However, it should be noted that the stockout rates for all FP methods were lower compared to their baseline levels. Figure 6. Percentage of facilities (public and private*) that experienced stockouts, U.S. Government–assisted sites covered by ReachHealth, by fiscal year, FYs 2019 to 2022 *Note: FY 2020 had no private sector data. There were more private health facilities than public facilities in U.S. Government assisted sites supported by ReachHealth that experienced stockouts in all FP commodities during July through September 2022 (Figure 7). This drove the total stockout rates (combined public and private facilities) of FP commodities upward. It is likely that private FP facilities have no incentive to keep stocks of FP commodities since they can refer clients to public SDPs (where commodities are provided free of charge) or simply provide clients with prescriptions to purchase from private pharmacies. To ensure that proper accounting of stockouts is done, the HP FP technical working group agreed in January 2023 to revise the accounting of SDP and stockout indicators in the PIRS. In the updated PIRS, only SDPs that dispense/provide or have pharmacies that supply FP commodities (pills and/or condoms) on-site will be monitored for stockouts. 0% 10% 20% 30% 40% 50% 60% Baseline FY 2019 FY 2020 FY 2021 FY 2022 % of FP SDP who experience stockouts Pills (COC & POP) Injectables Condoms IUD PSI SDM Beads 36 Figure 7. Percentage of facilities that experienced stockouts, U.S. Government–assisted sites supported by ReachHealth, by ownership, October 2021 – September 2022 In U.S. Government–assisted sites covered by BARMMHealth, the stockout rates of different FP methods fluctuated across the years, with the highest rates during the COVID-19 pandemic (Figure 8). The fluctuations suggest systemic resupply issues affecting distribution to SDPs due to lockdowns and logistics constraints. It appears these problems were resolved between FYs 2021 and 2022 as most of the stockout rates have gone down. Figure 8. Percentage of facilities that experienced stockouts, U.S. Government–assisted sites supported by BARMMHealth, by fiscal year, FYs 2019 to 2022 The HP implemented various initiatives as interim and/or part of long-term solutions to the problem of stockouts of FP commodities. At the local level, ReachHealth facilitated the distribution and redistribution of commodities from the 11 DOH CHDs to the 32 LGU priority sites. ReachHealth also 6% 12% 8% 7% 10% 15% 22% 19% 34% 14% 27% 43% 0% 20% 40% 60% 80% 100% Facilities reporting stockouts Pills Injectables Condoms IUD PSI SDM Beads Public Private 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% Baseline FY 2019 FY 2020 FY 2021 FY 2022 % of FP SDP who experience stockouts Pills (COC & POP) Injectables Condoms IUD PSI SDM Beads 37 assisted in the province-wide rollout of the Barcode Track and Trace System in Iloilo and implemented POPCOM’s Supply Management and Recording System in 12 rural health units (RHUs) and four public hospitals in Batangas to monitor FP commodity availability and stockouts.37 On the other hand, BARMMHealth supported integrated PHOs in monitoring the stockouts of RHUs, and facilitated training on the inventory and order report in five BARMM provinces in partnership with MOH, the integrated PHOs, and POPCOM–BARMM.38 Challenges at the DOH Central Office also affected the supply chain. For instance, with the ongoing restructuring in DOH, it was not always clear which bureau one should act on the findings presented by the DOH procurement service on procurement and supply chain management (PSCM). Also, the stockout threshold adopted by DOH is much higher than the USAID threshold target,39 putting the IPs in a challenging situation of convincing and supporting public facilities staff to accomplish more than that required by the DOH. The DOH did not procure combined oral contraceptive pills at the central level in 2022 because it expected LGUs to procure on their own as part of the transition to full devolution. These issues at the central level worsened the existing logistical challenges at the regional and provincial levels, such as the insufficiency and maldistribution of commodities. The increase in the number of new and current FP users suggests signs of recovery from the effects of the COVID-19 pandemic. Table 14 shows that the HP achieved around 82 percent of its CY 2022 target for new FP NAs while ReachHealth achieved 85 percent of its CY 2022 target. However, there continues to be a slowdown in the number of NA reported in U.S. Government–assisted sites supported by BARMMHealth—declining by 17 percent in CY 2021 and by two percent in CY 2022. The mobility restrictions were lifted in almost all areas in CY 2022, which allowed increased access to health facilities, the conducting of counseling, delivery of supplies and services, and the implementation of the various HP initiatives to support the health system. It is important to determine the reasons for the persisting decline so that appropriate adjustments can be made either by redesigning the interventions or refocusing its targets. The recommendation in previous HPPEs to conduct localized simple surveys (such as quick intake data at facilities when patients visit for non-FP services or use of social media platforms) should be pursued. The new bills proposed at the 2023 Philippine Congress to allow younger adults (those aged 15 or less) access to FP commodities and counseling without parental consent are welcome initiatives to fully implement the mandates of the RPRH law. 37 ReachHealth Q3 FY 2022 Report, pages 48 – 50. 38 BARMMHealth Q3 FY 2022 Report, page 22. 39 DOH committed a target of 30 percent or less for stockouts through the Program Expenditure Classification (PrExC) target, which is submitted quarterly to the Dept. of Budget and Management. 38 Table 14. New FP acceptors* in U.S. Government–assisted sites, CYs 2021 and 2022 CY 2021 Performance CY 2022 Target** CY 2022 Performance % Change % CY 2022 Target Met HP 375,448 513,195 421,233 12% 82% ReachHealth 330,209 443,875 378,756 15% 85% BARMMHealth*** 45,239 69,320 42,477 -6% 61% *Data reported were mainly from the public sector. **CY 2022 Target = ((FY 2022 target/4)*3)+(FY 2023 target/4) *** BARMMHealth’s FY 2022 PITT and Quarter 1 FY 2023 PITT do not show the quarterly accomplishments for FY 2019 – FY 2022, hence CY performance was computed as follows: (a) CY 2021 accomplishment = ((FY 2021 accomplishment/4)*3)+(FY 2022 accomplishment/4); (b) CY 2022 accomplishment = ((FY 2022 accomplishment/4)*3)+(Quarter 1 FY 2023 accomplishment). Table 15 shows that the HP and ReachHealth achieved around three-fourths of the CY 2022 targets for FP CUs. While there is hardly any change from the absolute number of CUs in CY 2021, there is some recovery from the previously reported 16 percent decline between CYs 2020 and 2021,40 showing some positive results from the catch-up measures implemented. There was a 6 percent increase in the number of CUs in U.S. Government–assisted sites supported by BARMMHealth, reversing the 5 percent decline in CY 2021. This achievement for BARMMHealth is notable given that it set a target for CY 2022 that was almost 41 percent higher than its CY 2021 target and double its actual performance in CY 2021. Table 15. Current FP users in U.S. Government–assisted sites, CYs 2021 and 2022 CY 2021 Performance CY 2022 Target CY 2022 Performance % Change % CY 2022 Target Met HP 3,100,531 4,265,066 3,154,513 1.7% 74% ReachHealth* 2,875,448 3,858,298 2,943,940 2% 76% BARMMHealth 225,083 406,768 210,573 -6% 52% *Data reported were mainly from the public sector. **CY 2022 Target = ((FY 2022 target/4)*3)+(FY 2023 target/4) *** BARMMHealth’s FY 2022 PITT and Q1 FY 2023 PITT do not show the quarterly accomplishments from FY 2019 – FY 2022, CY performance computed as follows: (a) CY 2021 accomplishment = ((FY 2021 accomplishment/4)*3)+(FY 2022 accomplishment/4); (b) CY 2022 accomplishment = ((FY 2022 accomplishment/4)*3)+((Q1 FY 2023 accomplishment)/4) 40 In the HPPE CY 2021 report, the actual CY 2021 numbers did not include data from the private sector, and not all of the reporting units from the public sector were able to submit data. This may have contributed to the decline of 16 percent in CY 2021. 39 Figure 9 shows that the number of CUs increased by 7 percent between CYs 2019 and 2020 and by 7 percent between CYs 2020 and 2021,41 but the improvement remained marginal until CY 2022. Figure 10 shows some slight recovery in performance in terms of NAs—from the dismal numbers of NAs in CYs 2020 and 2021 to an increase by 12 percent between CYs 2021 and 2022. Figure 9. Number of current FP users vs. targets, U.S. Government–assisted sites, CYs 2019 – 2022 41 Similar to CY 2021 HPPE. 3,611,789 3,682,763 3,648,032 4,265,066 3,045,448 2,691,548 2,890,371 3,100,531 3,154,513 - 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 4,500,000 Baseline CY 2019 CY 2020 CY 2021 CY 2022 No. of Current Users Target Accomplishment 40 Figure 10. Number of new FP acceptors, U.S. Government–assisted sites, CYs 2019 – 2022 However, it should be noted that the actual FP data reported for CY 2022 are incomplete.42 According to ReachHealth’s FY 2022 report covering October 2021 – September 2022, 84 percent of reporting units were able to provide data on NAs, while only 94 percent of the reporting units were able to provide data on CUs. These coverage rates were much higher than the coverage rates reported in quarter 1 FY 2022.43 Nevertheless, despite the improved reported rates for CY 2022 compared to CY 2021 performance, the CY 2022 targets for NA and CU were not met. Table 16 shows that the HP and ReachHealth achieved 105 percent and 109 percent, respectively, of the targets for couple-years of protection (CYP), performing better than for the NA and CU targets This performance is around 14 percent higher than the accomplishments in CY 2021 (see Figure 11). BARMMHealth, on the other hand, achieved three-fourths of its target for the year. One reason for this is because ReachHealth estimated the private sector contribution to CYP44 but not for NAs and CUs.45 Figure 12 shows that pills and injectables have the greatest contribution to the total CYP in ReachHealth sites. 42 The same is true for the CY 2021 HPPE. 43 Based on ReachHealth’s Quarter 1 FY 2022 report, only 60 percent of reporting units were able to provide data on CUs, while only 56 percent of reporting units were able to provide data on NAs. 44 ReachHealth was able to estimate the private sector contribution using the public and private sector CYP distribution reported in the January 2018 – June 2021 CYP study of IQVIA/MTaPS. 45 Similar to CY 2021 HPPE. 778,005 745,906 544,890 513,195 188,668 434,786 413,224 375,448 421,233 - 100,000 200,000 300,000 400,000 500,000 600,000 700,000 800,000 900,000 Baseline CY 2019 CY 2020 CY 2021 CY 2022 No. of New FP Acceptors Target Accomplishment 41 Table 16. Couple-years of protection* in U.S. Government–assisted sites, CYs 2021 and 2022 CY 2021 Performance CY 2022 Target** CY 2022 Performance % Change % CY 2022 Target Met HP 4,183,861 4,540,614 4,781,787 14.3% 105% ReachHealth 3,972,116 4,208,423 4,569,133 15.0% 109% BARMMHealth*** 211,745 332,192 212,654 0.4% 64% *Data reported were mainly from the public sector. **CY 2022 Target = ((FY 2022 target/4)*3)+(FY 2023 target/4). *** BARMMHealth’s FY 2022 PITT and Quarter 1 FY 2023 PITT do not show the quarterly accomplishments from FY 2019 – FY 2022, CY performance computed as follows: (a) CY 2021 accomplishment = ((FY 2021 accomplishment/4)*3)+(FY 2022 accomplishment/4); (b) CY 2022 accomplishment = ((FY 2022 accomplishment/4)*3)+(Quarter 1 FY 2023 accomplishment). Figure 11. Couple-years of protection vs. targets in U.S. Government–assisted sites, CYs 2019 – 2022 2,120,236 3,666,489 4,018,506 4,540,614 2,611,080 3,871,059 3,917,701 4,183,861 4,781,787 - 1,000,000 2,000,000 3,000,000 4,000,000 5,000,000 6,000,000 Baseline CY 2019 CY 2020 CY 2021 CY 2022 Couple years of Protection Target Accomplishment 42 Figure 12. Couple-years of protection by FP method in U.S. Government–assisted sites covered by ReachHealth, public sector only (n= 2,606,712), CY 2022 Acronyms: BTL: bilateral tubal ligation; NSV: non-scalpel vasectomy; IUD: intrauterine device; CM: calendar method; BBT: basal body temperature; STM: symptom-thermal method; SDM: standard days method; LAM: lactational amenorrhea method; PSI: progestin subdermal implant Figure 13 shows that by 2022, the HP had already achieved 91 percent of the end-of-project (EOP) target for CYP, and 68 percent of the EOP target for CU. However, during the same period, the HP reached just half of the EOP target for NA. These are significant accomplishments over a one-year period (CY 2022) since the rates last year were 63 percent for CYP, 27 percent for NA, and 37 percent for CU. During CY 2022, the HP was able to undertake activities to catch up with their targets amid easing up of COVID-19 restrictions and more mobility. However, given the quite low accomplishments during the COVID-19 pandemic years (2020 and 2021) it has been a challenge for the HP to realistically reach EOP targets, particularly for NA. With the FP IPs on their last year of full implementation in 2023, the current HP will need to quickly develop new strategies or refine and intensify current strategies to attain its EOP targets for CU, NA, and CYP. 10.1% 0.2% 36.9% 6.1% 22.2% 0.1% 0.1% 0.0% 0.5% 8.6% 6.0% 9.2% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% % share to total CYP 43 Figure 13. CYP performance for FY 2019–Q4 FY 2022 against EOP targets, U.S. Government–assisted sites Note: Data as of Quarter 1 FY 2023. CU performance per quarter is not summed to obtain annual/midterm/EOP performance. 5.1.2 Tuberculosis TB case detection increased due to intensified, active, and enhanced case finding activities and higher notification rates. Figure 14 shows that the national TB detection rate46 met the Updated Philippine Strategic TB Elimination Plan, Phase 1 (PhilSTEP1) target and rose 30 percentage points between CYs 2021 and 2022, continuing from the gains last year (11 percentage points between CYs 2020 and 2021). The performance in TB detection has recovered sufficiently from the low rates during the COVID-19 pandemic to exceed the baseline rate of 69 percent established in CY 2019—which was the basis for the Updated PhilSTEP1 targets. The improvement in TB detection may be due to: (1) an increase in private sector notification (see Table 21); (2) easing of mobility restrictions following the decrease in COVID￾19 cases, which facilitated the delivery of regular health services and allowed more patients to go to health facilities; (3) improved acceptance and implementation among health providers of TB-related activities; (4) improved TB screening through intensified case finding (ICF), active case finding (ACF), enhanced case finding (ECF), and integration of case finding activities in other health programs (such as child vaccination drives); and (5) improved SBCC initiatives. With this trajectory and barring any major disruptions in the health system, the TB detection target in CY 2023 will likely be achieved, if not exceeded. 46 TB detection rate refers to the ratio of notified new and relapsed TB cases in a specific year to the estimated number of incident TB cases for the same year. 91% (16.9M/18.5M) 52% (1.7M/3.2M) 68% (3.2M/4.6M) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% CYP New Acceptors Current Users % EOP Target Achieved 44 Figure 14. TB detection rates, CYs 2019 – 2021 Source: DOH National TB Control Program. Integrated TB Information System data. Accessed on February 14, 2023. Table 17 shows that TB case notifications have continued to increase across the country, with 89 percent of the Updated PhilSTEPI target for TB case notifications for CY 2022 achieved, higher than the rate of 69 percent reported in CY 2021. Moreover, the country posted the highest ever TB case notification rate compared to past TB control efforts.47 Overall, case notifications increased by 35 percent. Among all regions, Region II registered the highest increase in 2022 at 85 percent, having sufficiently recovered from the decline in the number of cases notified in 2021 (drop of 13 percent from CY 2020). The Cordillera Autonomous Region (CAR) and BARMM continued to lag behind in their case notifications, posting slight increases from CY 2021 but achieving less than half of their targets at 45 percent and 36 percent, respectively. The “Big 3” regions (NCR and Regions III and IV-A) supported by the HP reported almost half of all cases notified and continued to post the better performances in terms of achieving targets. The NCR achieved a 44 percent increase in the number of TB cases notified, building on the recovery efforts since 2021. Moreover, it exceeded its target for the year by 34 percent. Regions III and IV-A likewise showed increases in the number of cases notified, reaching more than 80 percent of their annual targets. 47 World Health Organization. Global TB Report 2022 country database, Philippine data. Available at: https://worldhealthorg.shinyapps.io/tb_pronto/ 69% 44% 55% 85% 75% 80% 85% 90% 0% 20% 40% 60% 80% 100% CY 2019 (baseline) CY 2020 CY 2021 CY 2022 CY 2023 TB Detection Rate National actual National target 45 Table 17. Number of TB cases notified (all forms), CYs 2021 and 2022 TB cases CY 2021* TB cases CY 2022* % Change % CY 2022 Target Met** CY 2022 Updated PhilSTEP1 Target Total notified, Philippines 324,694 438,202 ▲35% 89% 493,325 NCR*** 58,083 83,819 ▲44% 134% 62,427 CAR 2,446 3,682 ▲51% 45% 8,122 Ilocos Region (Region I) 10,896 16,974 ▲56% 72% 23,669 Cagayan Valley (Region II) 6,914 12,820 ▲85% 78% 16,482 Central Luzon (Region III)*** 40,330 50,404 ▲25% 90% 56,183 CALABARZON (Region IV-A)*** 62,131 71,580 ▲15% 97% 73,641 MIMAROPA (Region IV-B) 9,412 14,135 ▲50% 98% 14,360 Bicol Region (Region V) 20,327 28,103 ▲38% 102% 27,630 Western Visayas (Region VI) 29,715 36,430 ▲23% 103% 35,519 Central Visayas (Region VII) 18,016 27,030 ▲50% 75% 36,023 Eastern Visayas (Region VIII) 10,108 14,099 ▲39% 66% 21,512 Zamboanga Peninsula (Region IX) 8,324 12,010 ▲44% 71% 16,956 Northern Mindanao (Region X) 10,316 14,150 ▲37% 62% 22,678 Davao Region (Region XI) 11,686 16,305 ▲40% 68% 24,104 SOCCSKSARGEN (Region XII) 13,962 19,182 ▲37% 86% 22,322 Caraga Region (Region XIII) 8,032 10,529 ▲31% 85% 12,426 BARMM 3,996 6,950 ▲74% 36% 19,273 Acronyms: NCR: National Capital Region; CAR: Cordillera Autonomous Region; CALABARZON: covers the provinces of Cavite, Laguna, Batangas, Rizal, Quezon, and one highly urbanized city—Lucena; MIMAROPA: covers the provinces of Mindoro, Marinduque, Romblon, and Palawan; SOCCSKSARGEN: covers the provinces of South Cotabato, Cotabato, Sultan Kudarat, Sarangani, and one highly urbanized city—General Santos; BARMM: Bangsamoro Autonomous Region of Muslim Mindanao Notes: * CY 2021 and 2022 performance data includes MN and DR-TB notifications data. 46 ** Traffic light color-coding system in this column is based on CY 2022 end-of-year performance data *** Shaded rows are the U.S. Government–assisted sites, i.e., the “Big 3” regions, consisting of the NCR, Central Luzon, and CALABARZON. Sources: (1) DOH NTP. Integrated TB Information System. CY 2021 data as of April 29, 2022, and CY 2022 data as of February 14, 2023; (2) DOH (2020). Updated Philippine Strategic TB Elimination Plan, Phase 1: 2020 –2023. Pulmonary TB bacteriological diagnosis coverage worsened. Table 18 shows that the bacteriological diagnosis coverage rate for pulmonary tuberculosis (PTB) in CY 2022 was 48 percent, lower than the target of 60 percent. However, this accomplishment is 3 percentage points higher than that for CY 2021 (45 percent) and the same as CY 2020. Only 5 out of the 17 regions surpassed the target in CY 2022, a regression from the much better performance in CY 2021 when 11 of the 17 regions did. As in the previous year, the “Big 3” regions performed more poorly than the other regions and did not reach 80 percent of their regional targets. Nevertheless, in absolute numbers, the “Big 3” regions yielded the highest number of bacteriologically confirmed (BC) TB patients, accounting for almost 40 percent of the national total and half of all total cases tested. Several factors could explain the lower BC rate in the “Big 3” regions. A rapid study by TB Platforms of GeneXpert utilization in the “Big 3” regions reported that only around four to six samples were tested per day due to various factors such as inadequate human resources to run the machines, limited number of days allocated to run the testing, and insufficient number of specimens received. The most plausible factor for lower bacteriological confirmation would be the more vigorous ACF, ECF, ICF, Find Cases, Actively Separate Safely, and Treat Effectively (FAST) Plus strategies and private sector engagement implemented in these regions, which casted a wider net for TB screening and thus increased the denominator without a proportional increase in bacteriological testing. It has been shown that the average bacteriological confirmation from ACF and similar TB screening strategies is generally lower than symptomatic patients who seek care in hospitals and other health facilities.48 However, ACF, ECF, and ICF activities are effective screening strategies and should be continued to find more missing people with TB. These initiatives should be complemented with sufficient resources for complete testing and diagnosis. Table 18. Bacteriological diagnosis coverage rate—pulmonary TB, CY 2021 and 2022 CY 2021* CY 2022* % BC PTB (% vs target) Nume￾rator (No. of BC PTB cases) Denomi￾nator (No. of PTB cases) Update d Phil￾STEP1 Target % BC PTB (% vs target) Nume￾rator (No. of BC PTB cases) Denomi￾nator (No. of PTB cases) Updated Phil￾STEP1 Target Total, Philippines 45% (90%) 139,240 309,671 50% 48% (80%) 207,546 429,757 60% NCR** 33% (66%) 18,061 54,698 50% 36% (60%) 29,633 81,743 60% 48 Zhang, G., Zhang, Y., Chen, M. et al. Comparison of different bacteriological testing strategies and factors for bacteriological confirmation among pulmonary TB patients: a retrospective study in Tianjin, China, 2017–2018. BMC Infect Dis 20, 548 (2020). https://doi.org/10.1186/s12879-020-05273-3 47 Table 18. Bacteriological diagnosis coverage rate—pulmonary TB, CY 2021 and 2022 CY 2021* CY 2022* % BC PTB (% vs target) Nume￾rator (No. of BC PTB cases) Denomi￾nator (No. of PTB cases) Update d Phil￾STEP1 Target % BC PTB (% vs target) Nume￾rator (No. of BC PTB cases) Denomi￾nator (No. of PTB cases) Updated Phil￾STEP1 Target CAR 48% (95%) 1,109 2,333 50% 49% (82%) 1,704 3,509 60% Ilocos Region (Region I) 51% (102%) 5,411 10,614 50% 49% (82%) 8,127 16,584 60% Cagayan Valley (Region II) 39% (77%) 2,574 6,670 50% 41% (69%) 5,182 12,579 60% Central Luzon (Region III) ** 39% (77%) 14,511 37,452 50% 44% (73%) 21,822 49,865 60% CALABARZON (Region IV-A) ** 36% (72%) 21,064 58,326 50% 43% (72%) 30,310 70,562 60% MIMAROPA (Region IV-B) 44% (87%) 4,014 9,210 50% 47% (79%) 6,615 13,953 60% Bicol Region (Region V) 56% (111%) 11,092 19,898 50% 57% (94%) 15,597 27,528 60% Western Visayas (Region VI) 50% (100%) 14,294 28,623 50% 53% (88%) 18,903 35,733 60% Central Visayas (Region VII) 54% (109%) 9,373 17,274 50% 53% (88%) 14,126 26,477 60% Eastern Visayas (Region VIII) 63% (126%) 6,167 9,816 50% 62% (104%) 8,577 13,773 60% Zamboanga Peninsula (Region IX) 64% (128%) 5,210 8,120 50% 66% (111%) 7,840 11,818 60% Northern Mindanao (Region X) 57% (113%) 5,602 9,902 50% 60% (100%) 8,318 13,800 60% Davao Region (Region XI) 62% (124%) 7,081 11,448 50% 68% (113%) 10,897 16,062 60% SOCCSKSARGE N (Region XII) 50% (101%) 6,885 13,700 50% 51% (85%) 9,457 18,601 60% Caraga Region (Region XIII) 58% (116%) 4,437 7,648 50% 58% (96%) 5,980 10,348 60% BARMM 60% (120%) 2,355 3,939 50% 65% (109%) 4,458 6,822 60% Acronyms: NCR: National Capital Region; CAR: Cordillera Administrative Region; CALABARZON: covers the provinces of Cavite, Laguna, Batangas, Rizal, Quezon, and one highly urbanized city—Lucena; MIMAROPA: covers the provinces of Mindoro, Marinduque, Romblon, and Palawan; SOCCSKSARGEN: covers the provinces of South Cotabato, Cotabato, Sultan Kudarat, Sarangani, and one highly urbanized city—General Santos; BARMM: Bangsamoro Autonomous Region of Muslim Mindanao. Notes: * Traffic light system for CYs 2021 and 2022 is based on end-of-year performance data. Italicized texts denote the percent of target met. ** Shaded rows are the U.S. Government–assisted sites, i.e., the “Big 3” regions, consisting of the NCR, Central Luzon, and CALABARZON. 48 Sources: (1) DOH NTP. Integrated TB Information System. CY 2021 data as of April 29, 2022, and CY 2022 data as of February 14, 2023; (2) DOH (2020). Updated Philippine Strategic TB Elimination Plan, Phase 1: 2020 – 2023. Better childhood TB notifications, but still below targets. There was a 54 percent increase in childhood TB notifications in CY 2022, doubling the achievement in CY 2021 (19 percent). This is a significant accomplishment attesting to relatively successful catch-up activities, given the increases in targets, and coming from the low performance in CY 2021. However, only 58 percent of the annual national target was reached (compared to 39 percent in CY 2021). Similar to the performance for BC coverage rates, the U.S. Government–assisted “Big 3” regions contributed the bulk (63 percent) of all childhood TB notifications for CY 2022. The NCR, Region 1, Region II, Region V, Region IX, and BARMM reported the most notable gains, while CAR was the only region with a decline in performance. Regions 1 and II reversed the declines in CY 2021, with Region II achieving twice the number notified in CY 2022. While BARMM showed a 173 percent increase from last year, it reached only 12 percent of its target for CY 2022. The NCR and Region III surpassed their targets, likely due to the ACF in these regions and the continued implementation of the Tibay ng Dibdib program launched by TB Platforms in Region III and replicated in NCR. Table 19. Childhood TB notifications in the Philippines and by region, CYs 2021 and 2022 No. of Childhood TB Cases (CY 2021) * No. of Childhood TB Cases (CY 2022) * % Change % CY 2022 Target Met** CY 2022 Updated PhilSTEP1 Target Total, Philippines 22,280 34,344 ▲54% 58% 59,199 NCR*** 5,324 9,235 ▲73% 123% 7,491 CAR 334 363 ▲9% 37% 975 Ilocos Region (Region I) 771 1,479 ▲92% 52% 2,840 Cagayan Valley (Region II) 851 1,604 ▲88% 81% 1,978 Central Luzon (Region III) *** 4,988 7,002 ▲40% 104% 6,742 CALABARZON (Region IV-A) *** 3,791 5,488 ▲45% 62% 8,837 MIMAROPA (Region IV￾B) 802 1,253 ▲56% 73% 1,723 Bicol Region (Region V) 1,030 1,905 ▲85% 57% 3,316 Western Visayas (Region VI) 1,136 1,352 ▲19% 32% 4,262 Central Visayas (Region VII) 449 673 ▲50% 16% 4,323 Eastern Visayas (Region VIII) 462 494 ▲7% 19% 2,581 Zamboanga Peninsula (Region IX) 211 363 ▲72% 18% 2,035 49 Table 19. Childhood TB notifications in the Philippines and by region, CYs 2021 and 2022 No. of Childhood TB Cases (CY 2021) * No. of Childhood TB Cases (CY 2022) * % Change % CY 2022 Target Met** CY 2022 Updated PhilSTEP1 Target Northern Mindanao (Region X) 383 604 ▲58% 22% 2,721 Davao Region (Region XI) 330 487 ▲48% 17% 2,892 SOCCSKSARGEN (Region XII) 789 1,123 ▲42% 42% 2,679 Caraga Region (Region XIII) 526 638 ▲21% 43% 1,491 BARMM 103 281 ▲173% 12% 2,313 Acronyms: NCR: National Capital Region; CAR: Cordillera Administrative Region; CALABARZON: covers the provinces of Cavite, Laguna, Batangas, Rizal, Quezon, and one highly urbanized city—Lucena; MIMAROPA: covers the provinces of Mindoro, Marinduque, Romblon, and Palawan; SOCCSKSARGEN: covers the provinces of South Cotabato, Cotabato, Sultan Kudarat, Sarangani, and one highly urbanized city—General Santos; BARMM: Bangsamoro Autonomous Region of Muslim Mindanao Notes: * Includes drug-resistant childhood TB. ** Traffic light color-coding system in this column is based on CY 2022 end-of-year performance data. *** Shaded rows are the U.S. Government–assisted sites, i.e., the “Big 3” regions, consisting of the NCR, Central Luzon, and CALABARZON. Sources: (1) DOH NTP. Integrated TB Information System. CY 2021 data as of April 29, 2022, and CY 2022 data as of February 14, 2023; (2) DOH (2020). Updated Philippine Strategic TB Elimination Plan, Phase 1: 2020 – 2023. Figure 15. Performance vs targets: childhood TB notifications, CYs 2019 – 2022 (results) and CYs 2020 – 2022 (targets) Notes: (1) “Big 3” targets were computed based on updated PhilSTEP1 sample regional computation, applied to projected annual regional population for 2020–2023. (2) The HP adopted childhood TB notifications as an indicator in 2020, with USAID’s shift to the Global TB Road map process. The HP baseline year is 2019. PhilSTEP1 targets for 2020 – 2023 for this indicator were adopted for the HP. 42,823 18,768 22,280 34,344 28,895 11,265 14,103 21,725 13,928 7,503 8,177 12,619 53,119 56,472 59,199 19,634 21,633 23,070 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 CY 2019 CY 2020 CY 2021 CY 2022 Child TB notified cases National Big 3 Regions Other Regions National target Big 3 Regions' target 50 Sources: (1) DOH NTP. Integrated TB Information System. CY 2020 data as of August 23, 2021, CY 2021 data as of April 29, 2022, and CY 2022 data as of February 14, 2023: (2) DOH (2020). Updated Philippine Strategic TB Elimination Plan, Phase 1: 2020 – 2023. Uneven performance in drug-resistant TB notifications across regions, with the provinces of Mindoro, Marinduque, Romblon, Palawan (MIMAROPA) reporting the biggest gains. Table 20 shows that only 66 percent of the annual national target for drug-resistant TB (DR-TB) notifications was reached in CY 2022. However, there was a 32 percent increase in the national total number of DR-TB notifications between CYs 2021 and 2022. Likewise, BARMM reached only 25 percent of its target in CY 2022 but posted a 47 percent gain from CY 2021. Perhaps the absence of sufficient humanpower and supplies to optimize the use of the 13 Xpert laboratories made functional in BARMM in CY 2021 could explain the decline in numbers. The “Big 3” regions contributed 54 percent to the total DR-TB notifications for 2022, attesting to the impact of more focused support from the HP. Table 20. Drug-resistant TB notifications in the Philippines and by region, CY 2021 and 2022 No. of DR￾TB cases (CY 2021) No. of DR￾TB cases (CY 2022) % Change % CY 2022 Target Met* CY 2022 Updated PhilSTEP1 Target Total, Philippines 5,902 7,764 ▲32% 66% 11,700 NCR** 1,379 1,852 ▲34% 125% 1,481 CAR 45 39 ▼13% 20% 193 Ilocos Region (Region I) 263 346 ▲32% 62% 561 Cagayan Valley (Region II) 104 135 ▲30% 35% 391 Central Luzon (Region III) ** 755 1,077 ▲43% 81% 1,332 CALABARZON (Region IV-A) ** 1,018 1,391 ▲37% 80% 1,747 MIMAROPA (Region IV-B) 149 292 ▲96% 86% 341 Bicol Region (Region V) 423 507 ▲20% 77% 655 Western Visayas (Region VI) 481 530 ▲10% 63% 842 Central Visayas (Region VII) 285 382 ▲34% 45% 854 Eastern Visayas (Region VIII) 190 241 ▲27% 47% 510 Zamboanga Peninsula (Region IX) 114 176 ▲54% 44% 402 Northern Mindanao (Region X) 131 147 ▲12% 27% 538 Davao Region (Region XI) 187 191 ▲2% 33% 572 SOCCSKSARGEN (Region XII) 185 197 ▲6% 37% 529 Caraga Region (Region XIII) 117 149 ▲27% 51% 295 BARMM 76 112 ▲47% 25% 457 Acronyms: NCR: National Capital Region; CAR: Cordillera Administrative Region; CALABARZON: covers the provinces of Cavite, Laguna, Batangas, Rizal, Quezon, and one highly urbanized city—Lucena; MIMAROPA: covers the provinces of Mindoro, Marinduque, Romblon, and Palawan; SOCCSKSARGEN: covers the provinces of South Cotabato, Cotabato, Sultan Kudarat, Sarangani, and one highly urbanized city—General Santos; BARMM: Bangsamoro Autonomous Region of Muslim Mindanao. 51 Notes: * Traffic light system in this column is based on CY 2022 end-of-year performance data. ** Shaded rows are the U.S. Government–assisted sites, i.e., the “Big 3” regions, consisting of the NCR, Central Luzon, and CALABARZON. Sources: (1) DOH NTP. Integrated TB Information System. CY 2021 data as of April 29, 2022, and CY 2022 data as of February 14, 2023; (2) DOH (2020). Updated Philippine Strategic TB Elimination Plan, Phase 1: 2020 – 2023. Improved private sector engagement and more testing through the TB Private Sector Diagnostics Consortium continued to help increase private sector TB case notifications. TB notifications from the private sector in CY 2022 increased by 5 percent from CY 2021, as shown in Table 21. This growth rate is lower than that recorded in CY 2021, and only three regions—NCR, Region IV-A, and Region VI—met or exceeded the target rate for CY 2022. The U.S. Government– supported “Big 3” regions posted the most significant shares and contributed 54 percent to the total private sector notifications for TB. However, Regions III and IV-A reported declines in the absolute numbers from 2021, although they met the 2022 target share. Region IV-A had the most significant share of private sector notifications at 36 percent—but lower than its achievement in 2021 (50 percent). While posting the biggest growth (65 percent) between 2021 and 2022, particular attention must be focused on BARMM to improve case finding, detection, and testing. The sustained increase in performance shows the recovery from the decline in performance during the COVID-19 pandemic. When the mobility restrictions were lifted, small private clinics were able to resume operations to attend to non-COVID cases. Moreover, intensified engagement of the private sector and the continued efforts to make it easier for private providers (i.e., ITIS and ITIS Lite) enabled higher notification rates. The Philippine Private Sector Diagnostics Consortium (TB Consortium) continued to provide access to globally recommended rapid diagnostic tests at a lower cost. As of December 2022, the TB Consortium members had facilitated the conduct of 19,201 Xpert tests, yielding these results: Mycobacterium TB (MTB) detected in 4,185 samples, 502 with trace MTB detected, and 276 found rifampicin-resistant. Table 21. Private sector TB notifications in the Philippines and by region, CY 2021 and 2022 Private sector TB notifications % Change CY 2021: % of TB notifications* CY 2021 Target CY 2022: % of TB notifications* CY 2022 Targe t CY 2021 CY 2022 Total, Philippines 119,075 125,128 ▲5% 37% (147%) 25% 29% (97%) 30% NCR** 25,430 27,355 ▲8% 44% (175%) 25% 33% (109%) 30% CAR 762 1071 ▲41% 31% (125%) 25% 29% (97%) 30% Ilocos Region (Region I) 2,733 3,949 ▲44% 25% (100%) 25% 23% (78%) 30% Cagayan Valley (Region II) 2,471 3,723 ▲51% 36% (143%) 25% 29% (97%) 30% 52 Table 21. Private sector TB notifications in the Philippines and by region, CY 2021 and 2022 Private sector TB notifications % Change CY 2021: % of TB notifications* CY 2021 Target CY 2022: % of TB notifications* CY 2022 Targe t CY 2021 CY 2022 Central Luzon (Region III) ** 17,809 14,418 ▼19% 44% (177%) 25% 29% (97%) 30% CALABARZON (Region IV-A) ** 30,854 25,901 ▼16% 50% (199%) 25% 36% (121%) 30% MIMAROPA (Region IV-B) 1,985 2,867 ▲44% 21% (84%) 25% 20% (67%) 30% Bicol Region (Region V) 3,980 5,847 ▲47% 20% (78%) 25% 21% (70%) 30% Western Visayas (Region VI) 10,394 10,758 ▲4% 35% (140%) 25% 30% (100%) 30% Central Visayas (Region VII) 5,956 7,550 ▲27% 33% (132%) 25% 28% (93%) 30% Eastern Visayas (Region VIII) 2,341 2,802 ▲20% 23% (92%) 25% 20% (67%) 30% Zamboanga Peninsula (Region IX) 1,892 2,284 ▲21% 23% (92%) 25% 19% (63%) 30% Northern Mindanao (Region X) 2,906 4,165 ▲43% 28% (113%) 25% 29% (97%) 30% Davao Region (Region XI) 3,477 4,683 ▲35% 30% (119%) 25% 29% (97%) 30% SOCCSKSARGEN (Region XII) 3,597 4,310 ▲20% 26% (103%) 25% 22% (73%) 30% Caraga Region (Region XIII) 2,036 2,698 ▲33% 25% (101%) 25% 26% (87%) 30% BARMM 452 747 ▲65% 11% (45%) 25% 11% (37%) 30% Acronyms: NCR: National Capital Region; CAR: Cordillera Administrative Region; CALABARZON: covers the provinces of Cavite, Laguna, Batangas, Rizal, Quezon, and one highly urbanized city—Lucena; MIMAROPA: covers the provinces of Mindoro, Marinduque, Romblon, and Palawan; SOCCSKSARGEN: covers the provinces of South Cotabato, Cotabato, Sultan Kudarat, Sarangani, and one highly urbanized city—General Santos; BARMM: Bangsamoro Autonomous Region of Muslim Mindanao Notes: * Denominators include DR-TB notifications from ITIS report 3. The traffic light system in this column is based on end-of-year performance data for CY 2021 and 2022. Italicized texts denote the percent of target met. ** Shaded rows are the U.S. Government–assisted sites, i.e., the “Big 3” regions, consisting of the NCR, Central Luzon, and CALABARZON. Sources: (1) DOH NTP. Integrated TB Information System. CY 2021 data as of April 29, 2022, and CY 2022 data as of February 14, 2023; (2) DOH (2020). Updated Philippine Strategic TB Elimination Plan, Phase 1: 2020 – 2023. 53 Contact investigation of BC PTB patients remains low. Table 22 shows that, overall, the contact investigation coverage49 rates for CY 2022 were lower than those reported in CY 2021, except for four regions: Region V (from 7 percent to 10 percent); Region IX (from 22 percent to 24 percent); Region XII (from 13 percent to 23 percent); and BARMM (from 17 percent to 25 percent). Only 13 percent of the estimated household contacts for TB screening50 were evaluated for TB in CY 2022. Thus, only 17 percent of the national target for the year was achieved. However, the number of contacts investigated in CY 2022 increased by 465 percent from those reported in CY 2021. This figure is likely underreported since ITIS reporting on this indicator started only in CY 2021 and is currently voluntary. However, other factors that could play a role are: lack of human resources to do the contact investigation; lack of reagents for tuberculin skin testing; the need for another visit to read the skin test results; access to chest X-ray services; and low community awareness on the need for TB screening of contacts. The “Big 3” regions accounted for around 85 percent of all estimated household contacts identified and 85 percent of the total contacts evaluated. These three regions showed a combined 14 percent coverage rate and reached 18 percent of their targets. The low accomplishment of Region IV-A should be viewed in the context of the huge increase in the target numbers set for the region for CY 2022, a 587 percent uptick from CY 2021. Likewise, the estimated target number of contacts that should be screened for NCR was increased by 1,084 percent from CY 2021, and that for Region III at a relatively lower hike of 290 percent. TB Platforms reported that it supported screening of 70,458 individuals as of September 2022, which resulted in finding 1,136 active TB cases. Huge increases in the targeted number of contacts to be screened were also noted for the other regions, largely due to the significant increases in CY 2022 of BC PTB cases whose household contacts had to be screened. Nonetheless, we believe the target numbers for contact investigation are hugely underestimated since reporting the identified contacts of BC PTB cases in ITIS (ITIS Report No. 3, Table P) is voluntary (and thus underreported). If we assume an average of four household contacts per BC PTB case, the number of contacts to be investigated would be notably higher than the denominator indicated in Table 22 and would be four times the total number of BC PTB cases reported in CY 2022 (see Table 18). Table 22. Contact investigation coverage rate in the Philippines and by region, CYs 2021 and 2022 CY 2021 % Target Met CY 2021 Updated PhilSTEP 1 Target CY 2022 % Target Met CY 2022 Updated PhilSTEP 1 Target CI Rate Nume￾rator* Denomi￾nator** CI Rate Nume￾rator* Denomi￾nator** Total, Philippines 16% 8,830 55,596 24% 65% 13% 49,885 370,768 17% 80% NCR*** 17% 2,590 14,908 27% 65% 15% 26,074 176,544 18% 80% CAR 24% 60 252 37% 65% 18% 445 2,468 23% 80% Ilocos Region (Region I) 18% 523 2,936 27% 65% 15% 617 4,116 19% 80% 49 Contact investigation rate refers to the percent of contacts of BC PTB patients evaluated for active and latent TB. The trends in this indicator will show the effectiveness of case-finding activities and follow-up measures to prevent TB transmission. 50 The number of contacts of BC PTB patients for TB contact investigation was estimated by assuming that there are four household members for every reported contact identified in ITIS Report No. 3 Table P. 54 Table 22. Contact investigation coverage rate in the Philippines and by region, CYs 2021 and 2022 CY 2021 % Target Met CY 2021 Updated PhilSTEP 1 Target CY 2022 % Target Met CY 2022 Updated PhilSTEP 1 Target CI Rate Nume￾rator* Denomi￾nator** CI Rate Nume￾rator* Denomi￾nator** Cagayan Valley (Region II) 21% 109 512 33% 65% 9% 185 2,008 12% 80% Central Luzon (Region III) *** 14% 3,147 23,308 21% 65% 12% 11,224 90,816 15% 80% CALABARZON (Region IV-A) *** 22% 1,341 6,000 34% 65% 12% 4,904 41,224 15% 80% MIMAROPA (Region IV-B) 24% 36 152 36% 65% 21% 125 604 26% 80% Bicol Region (Region V) 7% 251 3,364 11% 65% 10% 528 5,464 12% 80% Western Visayas (Region VI) 24% 177 740 37% 65% 23% 161 688 29% 80% Central Visayas (Region VII) 16% 256 1,636 24% 65% 11% 3,949 36,440 14% 80% Eastern Visayas (Region VIII) 15% 70 480 22% 65% 7% 258 3,540 9% 80% Zamboanga Peninsula (Region IX) 22% 103 460 34% 65% 24% 391 1,612 30% 80% Northern Mindanao (Region X) 20% 136 664 32% 65% 11% 127 1,156 14% 80% Davao Region (Region XI) 25% 1 4 38% 65% 20% 12 60 25% 80% SOCCSKSARG EN (Region XII) 13% 10 76 20% 65% 23% 28 124 28% 80% Caraga Region (Region XIII) 23% 9 40 35% 65% 18% 311 1,708 23% 80% BARMM 17% 11 64 26% 65% 25% 546 2,196 31% 80% Acronyms: CALABARZON: covers the provinces of Cavite, Laguna, Batangas, Rizal, Quezon, and one highly urbanized city— Lucena; CAR: Cordillera Administrative Region; CI: contact investigation; MIMAROPA: covers the provinces of Mindoro, Marinduque, Romblon, and Palawan; NCR: National Capital Region; SOCCKSARGEN: covers the provinces of South Cotabato, Cotabato, Sultan Kudarat, Sarangani, and one highly urbanized city—General Santos; BARMM: Bangsamoro Autonomous Region of Muslim Mindanao Notes: * The indicator reference sheet for the indicator, contact investigation coverage rate, defined the numerator as "the number of household contacts of bacteriologically-confirmed new & relapse pulmonary TB cases notified in report is year, who have been evaluated for TB.” In ITIS Report No. 3 Table P, the source for contact investigation data, the variable we used as the numerator in CY 2021 HPPE was updated for CY 2022. The "number of contacts tested" was removed and re-labeled as "number of contacts screened." Upon verification, it was confirmed that the DOH refers to “household contacts of bacteriologically-confirmed new & relapse pulmonary TB cases notified in reporting year, who have been evaluated for TB” as “contacts screened.” ** The denominator is estimated by assuming that there are four household members for every reported number of contacts identified. This is an agreement made by the TB cluster during the TB Road map meeting held on March 21, 2022 from the suggestion made by Fidel Bautista of TB Platforms, which was concurred by Dr. Allan Fabella. *** Shaded rows are the U.S. Government–assisted sites, i.e., the “Big 3” regions, consisting of the NCR, Central Luzon, and CALABARZON. 55 Sources: (1) DOH NTP. Integrated TB Information System. CY 2021 data as of April 29, 2022, and CY 2022 data as of February 14, 2023; (2) DOH (2020). Updated Philippine Strategic TB Elimination Plan, Phase 1: 2020 – 2023. Enrollment for TB preventive treatment improved but remains low and below targets. Table 23 shows that TB preventive treatment (TPT) enrollment51 in CY 2022 was three times more than the reported enrollment in CY 2021. TPT coverage rates across all regions were higher than those recorded in the period CYs 2020 – 2021. Similar to that of CY 2021, the total TPT enrollment in CY 2022 was way below the target for the year. Around 53 percent of TPT enrollment was from the “Big 3” regions. Only CAR posted a decline in TPT enrollment, after posting the biggest change (1,963 percent) in the previous period. Region IV-B recorded a 1,979 percent increase in TPT enrollment— after a decline of 55 percent in CY 2021—but achieved only 12 percent of its target for CY 2022. BARMM also recorded a 5,550 percent increase in TPT enrollment, but only reached one percent of its CY 2022 target. TB Platforms noted that there was a low uptake of TPT from contacts investigated for TB. This was exacerbated by a lack of human resources for contact investigation and TPT as well as weak data management systems. Without sufficient contact investigation (see Table 22) and TPT, the number of people with potential latent TB infection will multiply over time and provide a persistent and growing source of TB transmission. The challenges encountered in 2021—such as the optional reporting for TPT and contact investigation, use of old forms, limited knowledge of CHWs on the new requirements for enrollment and investigation—were still observed in CY 2022. To improve contact investigation and TPT enrollment, TB Innovations and Health Systems Strengthening (TBIHSS) provided national-level technical assistance to implement the Contact Investigation and TPT Road Map 2020 – 2023 and implementation of the TPT Field Implementation Guide. Moreover, TB Platforms conducted contact investigation activities and TPT enrollment in the “Big 3” regions. Table 23. TB preventive treatment enrollment in the Philippines and by region, CYs 2021 and 2022 CY 2021 CY 2022 % Change % CY 2022 Target Met** CY 2022 Updated PhilSTEP1 Target Total, Philippines 7,982 33,057 ▲314% 17% 197,330 NCR* 1,473 4,714 ▲220% 19% 24,971 CAR 165 129 ▼22% 4% 3,249 Ilocos Region (Region I) 324 756 ▲133% 8% 9,468 51 Those eligible for treatment include people living with HIV (PLHIV) aged one year and older, all household contacts of BC PTB cases, children less than five years who are household contacts of clinically diagnosed PTB patients, individuals aged five years and older with other TB risk factors (i.e., PLHIV, diabetes mellitus, smoking, those with immunosuppressed medical conditions, malnutrition). Source: DOH. NTP Manual of Procedures. 6th edition. Manila, Philippines. 2020. Available at: http://ntp.doh.gov.ph/downloads/publications/guidelines/NTP_MOP_6th_Edition.pdf 56 Table 23. TB preventive treatment enrollment in the Philippines and by region, CYs 2021 and 2022 CY 2021 CY 2022 % Change % CY 2022 Target Met** CY 2022 Updated PhilSTEP1 Target Cagayan Valley (Region II) 228 2,814 ▲1,134% 43% 6,593 Central Luzon (Region III) * 1,603 5,885 ▲267% 26% 22,473 CALABARZON (Region IV-A) * 1,092 7,027 ▲543% 24% 29,456 MIMAROPA (Region IV-B) 33 686 ▲1,979% 12% 5,744 Bicol Region (Region V) 188 674 ▲259% 6% 11,052 Western Visayas (Region VI) 475 1,534 ▲223% 11% 14,207 Central Visayas (Region VII) 647 2,104 ▲225% 15% 14,409 Eastern Visayas (Region VIII) 92 866 ▲841% 10% 8,605 Zamboanga Peninsula (Region IX) 213 832 ▲291% 12% 6,782 Northern Mindanao (Region X) 486 1,024 ▲111% 11% 9,071 Davao Region (Region XI) 172 1,036 ▲502% 11% 9,642 SOCCSKSARGEN (Region XII) 216 1,175 ▲444% 13% 8,929 Caraga Region (Region XIII) 573 1,688 ▲195% 34% 4,971 BARMM 2 113 ▲5,550% 1% 7,709 Acronyms: NCR: National Capital Region; CAR: Cordillera Administrative Region; CALABARZON: covers the provinces of Cavite, Laguna, Batangas, Rizal, Quezon, and one highly urbanized city—Lucena; MIMAROPA: covers the provinces of Mindoro, Marinduque, Romblon, and Palawan; SOCCSKSARGEN: covers the provinces of South Cotabato, Cotabato, Sultan Kudarat, Sarangani, and one highly urbanized city—General Santos; BARMM: Bangsamoro Autonomous Region of Muslim Mindanao. Notes: * Shaded rows are the U.S. Government–assisted sites, i.e., the “Big 3” regions, consisting of the NCR, Central Luzon, and CALABARZON. * * Traffic light system in this column is based on CY 2022 end-of-year performance data. Sources: (1) DOH NTP. Integrated TB Information System. CY 2021 data as of April 29, 2022, and CY 2022 data as of February 14, 2023; (2) DOH (2020). Updated Philippine Strategic TB Elimination Plan, Phase 1: 2020 – 2023. Treatment success rate for drug-susceptible TB still challenged with increased private sector mandatory notifications, but TSR for DR-TB moving close to target. The national treatment success rate (TSR) for drug-susceptible TB (DS-TB)—which has a six-month treatment period and a 12-month treatment for drug-susceptible-extrapulmonary TB of the central 57 nervous system, bones, and joints—showed similar trends for the CYs 2020 and 2021 treatment cohorts (see Figure 16). Table 23 provides the national DS-TB TSR as well as regional TSRs. The U.S. Government–assisted sites, Regions III and IV-A showed substantially higher TSRs for the CY 2021 cohort, but NCR recorded a lower rate compared to the CY 2020 treatment cohort. Only NCR and Region IV-A among the regions did not meet at least 80 percent of the target. On the other hand, BARMM posted an 11 percent increase in TSR and achieved 100 percent of the target. Figure 16. Performance vs. targets: DS-TB treatment success rates, CYs 2019 – 2022 (results) and CYs 2019 – 2022 (targets) Notes: (1) The HP adopted DS-TB TSR as an indicator in 2020, with USAID’s shift to the Global TB Road Map Process. Thus, while PhilSTEP1 has targets for this indicator from 2017, the applicable targets for the HP for this indicator are only from CY 2020 – 2023; (2) CY 2022 data presented as of February 14, 2023. Sources: (1) DOH NTP. Integrated TB Information System. Data for 2021 cohort DS-TB cohort as of February 14, 2023; (2) DOH (2020). Updated Philippine Strategic TB Elimination Plan, Phase 1: 2020 – 2023. Table 24. Drug-susceptible TB (DS-TB) treatment success rates in the Philippines and by region, CYs 2020 and 2021 treatment DS-TB TSR (CY 2020 Cohort) DS-TB TSR (CY 2020 Cohort)* DS-TB TSR (CY 2021 Cohort) DS-TB TSR (CY 2021 cohort)* % Change % Target Met** CY 2022 Updated PhilSTEP1 Target Nume￾rator Denomi￾nator Nume￾rator Denomi￾nator Total, Philippines 76% 205,782 270,881 77% 241,743 314,330 ▲1% 85% 90% NCR*** 69% 26,564 38,229 65% 37,121 56,776 ▼6% 73% 90% CAR 91% 2,118 2,330 90% 2,136 2,374 ▼1% 100% 90% 58 Table 24. Drug-susceptible TB (DS-TB) treatment success rates in the Philippines and by region, CYs 2020 and 2021 treatment DS-TB TSR (CY 2020 Cohort) DS-TB TSR (CY 2020 Cohort)* DS-TB TSR (CY 2021 Cohort) DS-TB TSR (CY 2021 cohort)* % Change % Target Met** CY 2022 Updated PhilSTEP1 Target Nume￾rator Denomi￾nator Nume￾rator Denomi￾nator Ilocos Region (Region I) 92% 9,335 10,132 91% 9,699 10,653 ▼1% 101% 90% Cagayan Valley (Region II) 86% 7,010 8,133 86% 5,527 6,394 ▲0% 96% 90% Central Luzon (Region III) *** 62% 23,481 37,694 74% 28,389 38,591 ▲18% 82% 90% CALABARZO N (Region IV￾A) *** 57% 28,595 50,591 66% 39,669 59,875 ▲17% 74% 90% MIMAROPA (Region IV-B) 82% 7,341 8,978 86% 8,132 9,504 ▲5% 95% 90% Bicol Region (Region V) 89% 14,390 16,203 89% 17,201 19,392 ▼0% 99% 90% Western Visayas (Region VI) 89% 21,669 24,229 83% 23,998 28,795 ▼7% 93% 90% Central Visayas (Region VII) 86% 13,593 15,755 85% 14,983 17,616 ▼1% 95% 90% Eastern Visayas (Region VIII) 85% 7,718 9,071 85% 8,316 9,752 ▲0% 95% 90% Zamboanga Peninsula (Region IX) 83% 6,713 8,125 85% 6,844 8,018 ▲3% 95% 90% Northern Mindanao (Region X) 91% 8,041 8,866 86% 8,440 9,827 ▼5% 95% 90% Davao Region (Region XI) 90% 8,891 9,926 82% 9,105 11,096 ▼8% 91% 90% SOCCKSARG EN (Region XII) 91% 10,821 11,872 83% 11,301 13,586 ▼9% 92% 90% Caraga Region (Region XIII) 93% 6,320 6,802 90% 7,062 7,831 ▼3% 100% 90% BARMM 81% 3,182 3,945 90% 3,820 4,250 ▲11% 100% 90% Acronyms: NCR: National Capital Region; CAR: Cordillera Administrative Region; CALABARZON: covers the provinces of Cavite, Laguna, Batangas, Rizal, Quezon, and one highly urbanized city—Lucena; MIMAROPA: covers the provinces of Mindoro, Marinduque, Romblon, and Palawan; SOCCKSARGEN: covers the provinces of South Cotabato, Cotabato, Sultan Kudarat, Sarangani, and one highly urbanized city—General Santos; BARMM: Bangsamoro Autonomous Region of Muslim Mindanao. Notes: * Treatment outcome is generated by NTP toward the end of the CY. Data are subjected to de-duplication and validation. CY 2021 cohort data reported in this table are partial and not yet de-duplicated/validated. ** Traffic light color-coding system in this column is based on year-end performance data for the CY 2021 treatment cohort from ITIS version 2. *** Shaded rows are the U.S. Government–assisted sites, i.e., the “Big 3” regions, consisting of the National NCR, Central Luzon, and CALABARZON. 59 The shortfall in achieving the DS-TB TSR targets may be related to TSRs observed from the private sector, who generally report through the MN system. Figure 17 compares preliminary data on TSRs from the MN system compared to TB directly observed therapy short-course (DOTS) facilities, showing significantly higher TSRs in the latter. The very low TSRs from MNs could be due to failure to evaluate and/or report treatment outcomes after initial notification of TB cases or due to high default rates in the private sector given the out-of-pocket costs and possibly lower use of the DOTS approach (Figure 18). Figure 17. Preliminary data on DS-TB TSRs: Mandatory notifications vs. DOTS facilities, CY 2021 treatment cohort* *Data presented for the CY 2021 treatment cohort from DOTS facilities and MN have not yet been de-duplicated as of this writing. The data are usually finalized before official submission to WHO for the Global TB Report sometime in Q3 of each year. Note: According to the NTP Manual of Procedures (6th edition), treatment outcomes for DS-TB should include reported result of the six-month treatment for DS-TB and the 12-month treatment for drug-susceptible if it is of the central nervous system, bones, and joints. In ITIS report 5 Table A, treatment outcomes of new and relapse TB cases from the CY 2021 cohort were categorized as either a reported case from TB DOTS facilities or from MN. Sources: (1) DOH NTP. Integrated TB Information System. Treatment outcome data for CY 2021 cohort as of February 14, 2023; (2) DOH (2020). Updated Philippine Strategic TB Elimination Plan, Phase 1: 2020 – 2023. 60 Figure 18. Treatment outcomes of mandatory notifications, CY 2022 treatment cohort Sources: DOH NTP. Integrated TB Information System. Treatment outcome data for CY 2021 cohort of MN as of February 14, 2023. Figure 19 shows the annual DR-TB TSRs for the treatment cohorts for CY 2019–22, indicating steadily improving TSRs through the years both nationally and in the “Big 3” regions. For DR-TB (which generally has a two-year treatment period except for a few areas where the 9- to12-month all-oral DR￾TB regimen was started), TSR improved by 6 percentage points at the national level and by 8 percentage points in the “Big 3” regions in the CY 2020 treatment cohort compared to the 2019 treatment cohort. Although the TSR of 80 percent for DR-TB is higher than that recorded for the 2019 cohort, only 94 percent of the CY 2022 target was met (see Table 25), lower than the 99 percent achieved last year. Nevertheless, even regions that posted declines in the DR-TB TSR for the CY 2020 cohort (Regions II, IV-B, VI, XI, XII and BARMM) achieved rates more than 80 percent of their regional targets. Sustained implementation of the interventions introduced in CY 2021 helped improve TSR, such as: (1) scale-up of the all-oral regimens for DR-TB, which have fewer side effects and are given for only 9 to 12 months; (2) practice of home-based or community-based treatment; (3) digital adherence technologies; and (4) the rollout of the Integrated Delivery of TB Services (iDOTS) phase 2. 61 Figure 19. Performance vs. targets: DR-TB treatment success rates, CYs 2019 – 2022 (results) and CYs 2019 – 2022 (targets) Notes: (1) The HP adopted DS-TB TSR as an indicator in 2020, with USAID’s shift to the Global TB Road map Process. Thus, while PhilSTEP1 has targets for this indicator from 2017, the applicable targets for the HP for this indicator are only from CYs 2020 – 2023. (2) CY 2022 data presented as of February 14, 2023. Sources: (1) DOH NTP. Integrated TB Information System. Data for DR-TB TSR 2020 cohort as of February 14, 2023; (2) DOH (2020). Updated Philippine Strategic TB Elimination Plan, Phase 1: 2020 – 2023. Table 25. Drug-resistant TB (DR-TB) treatment success rates in the Philippines and by region, CYs 2019 and 2020 treatment cohorts DR-TB TSR (CY 2019 Cohort) DR-TB TSR (CY 2019 cohort)* DR-TB TSR (CY 2020 Cohort) DR-TB TSR (CY 2020 cohort)* % Change % Target Met** CY 2021 Updated PhilSTEP1 Target Nume￾rator Denomi￾nator Nume￾rator Denomi￾nator Total, Philippines 74% 3,904 5,273 80% 4,169 5,217 ▲8% 94% 85% NCR*** 67% 878 1,319 75% 726 963 ▲13% 89% 85% CAR 68% 19 28 82% 27 33 ▲21% 96% 85% Ilocos Region (Region I) 82% 208 254 80% 223 278 ▼2% 94% 85% Cagayan Valley (Region II) 85% 78 92 79% 79 100 ▼7% 93% 85% Central Luzon (Region III) *** 71% 567 799 79% 633 797 ▲12% 93% 85% CALABARZON (Region IV-A) *** 74% 692 931 79% 674 848 ▲7% 94% 85% MIMAROPA (Region IV-B) 82% 162 198 82% 138 169 ▼0% 96% 85% 62 Table 25. Drug-resistant TB (DR-TB) treatment success rates in the Philippines and by region, CYs 2019 and 2020 treatment cohorts DR-TB TSR (CY 2019 Cohort) DR-TB TSR (CY 2019 cohort)* DR-TB TSR (CY 2020 Cohort) DR-TB TSR (CY 2020 cohort)* % Change % Target Met** CY 2021 Updated PhilSTEP1 Target Nume￾rator Denomi￾nator Nume￾rator Denomi￾nator Bicol Region (Region V) 75% 217 291 88% 386 440 ▲18% 103% 85% Western Visayas (Region VI) 85% 307 362 83% 345 415 ▼2% 98% 85% Central Visayas (Region VII) 74% 164 221 76% 210 276 ▲3% 90% 85% Eastern Visayas (Region VIII) 77% 100 130 90% 131 146 ▲17% 106% 85% Zamboanga Peninsula (Region IX) 67% 66 99 83% 84 101 ▲25% 98% 85% Northern Mindanao (Region X) 77% 81 105 81% 112 139 ▲4% 95% 85% Davao Region (Region XI) 88% 126 143 77% 140 183 ▼13% 90% 85% SOCCSKSARGEN (Region XII) 82% 130 158 79% 135 171 ▼4% 93% 85% Caraga Region (Region XIII) 76% 79 104 82% 91 111 ▲8% 96% 85% BARMM 77% 30 39 74% 35 47 ▼3% 88% 85% Acronyms: NCR: National Capital Region; CAR: Cordillera Administrative Region; CALABARZON: covers the provinces of Cavite, Laguna, Batangas, Rizal, Quezon, and one highly urbanized city—Lucena; MIMAROPA: covers the provinces of Mindoro, Marinduque, Romblon, and Palawan; SOCCSKSARGEN: covers the provinces of South Cotabato, Cotabato, Sultan Kudarat, Sarangani, and one highly urbanized city—General Santos; BARMM: Bangsamoro Autonomous Region of Muslim Mindanao. Notes: * Treatment outcome is generated by NTP toward the end of the CY. Data are subjected to deduplication and validation. CY 2020 cohort data reported in this table is partial and not yet de-duplicated/validated. ** Traffic light color-coding system in this column is based on year-end performance data for CY 2020 cohort from ITIS version 2. *** Shaded rows are the U.S. Government–assisted sites, i.e., the “Big 3” regions, consisting of the National Capital Region, Central Luzon, and CALABARZON Sources: (1) DOH NTP. Integrated Information System. Data for CY 2019 cohort are generated from ITIS version 2 (TB Manual of Procedures 6th edition) as of April 29, 2022 and CY 2020 cohort as of February 14, 2023; (2) DOH (2020). Updated Philippine Strategic TB Elimination Plan, Phase 1: 2020 – 2023. 5.1.3 Community-Based Drug Rehabilitation For CBDR, it is important to monitor the achievements across the cascade of care to show that the individuals who seek help and care are attended to, provided with the appropriate interventions, and supported in completing the program. To encourage PWUDs to seek care and complete the intervention program, resources (trained personnel, facilities, goods) must be provided to improve screening rates (catch all that seek help), increase enrolment, and ensure completion of the program for those enrolled. 63 Getting more PWUDs to seek help, get screened, and complete treatment is still a challenge in FY 2022. Figure 20 shows that the HP’s SBC campaigns on CBDR reached a cumulative 230,401 people at U.S. Government project sites as of FY 2022 equivalent to 84 percent of the cumulative target. A cumulative total of 91,163 PWUDs sought help for substance use, amounting to 87 percent of the cumulative target since activity inception (see Figure 20). Moreover, by the end of FY 2022, 68,117 had been screened or provided drug dependency evaluation (DDE), equivalent to 85 percent of the target. Out of those who were screened or provided DDE, 41,747 (61 percent) were enrolled to appropriate evidence-based CBDR interventions, achieving 75 percent of the target. However, among those who were enrolled, less than a third (19,110) PWUDs completed treatment by the end of FY 2022, achieving 53 percent of the target. Figure 20. CBDR FY 2022 accomplishments (cumulative) vs. targets (cumulative)* * RenewHealth performance data are cumulative from project inception and follow FY reporting, hence this section does not report accomplishments by CY. In FY 2022, HP expanded its CBDR assistance to workplace, school, and prison settings. HP entered and sustained partnerships with the LGUs, government agencies (e.g., Department of Social Welfare and Development [DSWD], Dangerous Drugs Board, Bureau of Jail Management and Penology (BJMP), DOH, Department of the Interior and Local Government (DILG), CSOs. and the private sector to ensure continuity of service delivery. RenewHealth enhanced the capacity of focal persons of barangay anti-drug abuse councils and BJMP personnel to deliver CBDR services to voluntary clients and persons deprived of liberty. To date, 303 persons have been trained from the partnership with BJMP. RenewHealth conducted virtual and face-to-face trainings on CBDR, generating an increased number of trained service providers on CBDR and exceeding HP’s life-of-activity target for trained providers (167 percent). To make the training on CBDR more accessible and augment the number of service providers, RenewHealth launched e-SBIRT (Screening, Brief Intervention, and Referral to Treatment) in the DOH academy, an online educational platform. 274,944 105,172 79,995 55,570 35,855 230,401 91,163 68,117 41,747 19,110 Number of people reached through SBCC at the USG project sites Number of PWUD who sought help for substance use at the USG project sites Number of PWUD screened or provided DDE as prescribed in the new client flow in USG-assisted sites Number of PWUD who were enrolled to appropriate evidence￾based CBDR intervention Number of PWUD who completed appropriate evidence-based CBDR interventions FY 2022 HP DASHBOARD: COMMUNITY-BASED DRUG REHABILITATION FY 2022 Target (Cumulative) FY 2022 Accomplishment (Cumulative) 64 In addition to expanded training and CBDR technical assistance in FY 2022, the HP increased its CBDR sites from 21 to 30, and provided technical support to new sites (e.g., municipality of Gerona in Tarlac and municipality of Socorro in Oriental Mindoro) in designing CBDR plans. However, despite the expansion of CBDR sites, Table 26 shows that aside from enrollment to appropriate evidence-based CBDR interventions, the performance for almost all cascade indicators declined between FYs 2021 and 2022. Specifically, there was no improvement in the percentage of PWUDs who sought treatment relative to the number reached through SBCC—14 percent in FY 2021 and 13 percent in FY 2022. On the other hand, in FY 2022 alone, 71 percent of those screened or provided DDE were subsequently enrolled to treatment—an improvement from FY 2021, where only 41 percent were enrolled to treatment. Notable, however, was the low completion rate of 42 percent in FY 2022, compared to the high completion rate of 88 percent in FY 2021. Table 26. Comparison of CBDR accomplishments in FY 2021 vs. FY 2022 Indicator FY 2020 (Baseline) It Is Cumulative For the Year Only FY 2021 Actual (b) FY 2022 Actual (c) FY 2021 Actual (b-a) FY 2022 Actual (c-b) % Change Number of people reached through SBCC at the U.S. Government project sites 78,003 159,482 230,401 81,479 70,919 -13.0% Number of PWUD who sought help for substance use at the U.S. Government project sites 70,608 82,088 91,163 11,480 9,075 -20.9% Number of PWUD screened or provided DDE as prescribed in the new client flow in U.S. Government– assisted sites 48,428 59,616 68,117 11,188 8,501 -24.0% Number of PWUD who were enrolled to appropriate evidence-based CBDR intervention 31,050 35,666 41,747 4,616 6,081 31.7% 65 Table 26. Comparison of CBDR accomplishments in FY 2021 vs. FY 2022 Indicator FY 2020 (Baseline) It Is Cumulative For the Year Only FY 2021 Actual (b) FY 2022 Actual (c) FY 2021 Actual (b-a) FY 2022 Actual (c-b) % Change Number of PWUD who completed appropriate evidence-based CBDR interventions 12,499 16,558 19,110 4,059 2,552 -37.1% Note: FY 2020 baseline and FY 2022 actuals (adjusted) were obtained from RenewHealth’s Quarter 1 FY 2023 PITT while the FY 2021 actuals were obtained from RenewHealth’s Activity Monitoring, Evaluation, and Learning Plan as of January 4, 2023. In general, the HP’s performance was strong in the first stages of the cascade of care. RenewHealth continued to reach PWUDs through incorporating key messages on drug use in training programs, utilizing social media channels (e.g., Facebook), continued utilization of the first self-care mobile app Lusog-Isip, and conducting events such as the “CBDR Works! Stories from the Field” conference, which was attended by LCEs, government agencies, and other stakeholders. While RenewHealth delivered information on mental health, substance abuse, and available CBDR services in several platforms (e.g., social media, Lusog-Isip app, community outreach activities, events, and trainings), the extensive reach does not translate to an increased number of PWUDs seeking and completing treatment. Figure 21. Social media posts from Bawat Simula tungo sa CBDR FB page Factors affecting performance include national and local elections held in May 2022, transition in CBDR personnel in many LGU sites, low priority given to CBDR by some LGUs, and the dissolution of the Dangerous Drug Abuse Prevention Treatment Program of DOH.52 The May 2022 elections resulted in leadership and personnel transitions in anti-drug abuse councils and CBDR programs in 11 partner LGU sites. The treatment of persons deprived of liberty (PDLs), which lasts for six months, has become a 52 RenewHealth FY 2022 Annual Report, page 8. 66 priority for LGUs due to a court order.53 As of September 2022, 90,062 PDLs with drug cases were sentenced, according to the latest data from the BJMP.54 Apart from aforementioned factors on service delivery, the absence of national metrics and an integrated data management system also affects the quality, quantity, and timeliness of data collected from partner sites.55 The HP proposed to continue its technical support on CBDR Integrated Management System and provide capacity-building on data management.56 To facilitate buy-in from new LCEs, the HP conducted courtesy calls, project orientations, and advocacy campaigns. Through a partnership with the Ateneo School of Government (ASOG), modules on CBDR program management were also included in the Capacitating Local Executive for Agile and Responsive Governance (CLEAR) training program for newly elected officials.57 Moving forward, courtesy calls and discussions with new focal persons in the DOH should be done to explore how CBDR interventions can be integrated within DOH’s programs and activities. 5.1.4 HIV/AIDS USAID/Philippines OH also supports the DOH in managing the HIV/AIDS epidemic in the country through funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). With the launch of Meeting Targets and Maintaining Epidemic Control (EpiC) project in March 2021 (implemented by FHI 360), we briefly describe the EpiC project and its accomplishments for FY 2022.58 The Philippines has the fastest growing epidemic in the Asia-Pacific region, with an estimated 158,400 people living with HIV (PLHIV) in 2022, most of whom are men who have sex with men and transgender populations.59 The EpiC project supports the Philippines in achieving the 95-95-95 targets of HIV testing, treatment, and viral suppression rates by 2025. Since March 2021, EpiC has been actively supporting the scale-up of a comprehensive HIV cascade of services—specifically, HIV testing, antiretroviral treatment (ART) initiation, viral load accessibility, and pre-exposure prophylaxis (PrEP) for key populations (KPs)— in the NCR and Regions III and IV-A. The specific objectives of EpiC are to: (1) attain and maintain HIV epidemic control among KPs; and (2) improve program management (including health information systems and HRH) and financial systems to ensure attainment and maintenance of epidemic control. Table 27 outlines selected EpiC activities for the period October 2021 to September 2022. 53 RenewHealth FY 2022 Annual Report, page 15; Dangerous Drugs Board Regulation No. 7, Series of 2019. 54 Bureau of Jail Management and Penology: Data on persons deprived of liberty with drug cases by classification (as of September 30, 2022). Available at: https://www.bjmp.gov.ph/images/data_and_stats/09-30- 22/Data_on_PDL_with_Drug_Cases_by_Classification_-_sep_2022.png on_Number_of_PDL_with_Drug_Cases.jpg. 55 RenewHealth FY 2022 Annual Report, page 9. 56 RenewHealth FY 2022 Annual Report, page 9. 57 RenewHealth FY 2022 Annual Report, page 8. 58 This information on EpiC is drawn mainly from two sources: (1) FHI 360 PEPFAR Oversight and Accountability Results Team (POART) Review; and (2) FHI360. EpiC Philippines Semi-Annual Progress Report (April 1 – September 30, 2022). 58 DOH Epidemiology Bureau AIDS Epidemic Model (AEM)-Spectrum, May 2022 presentation during STIR-UP 2022. 59 DOH Epidemiology Bureau. AIDS Epidemic Model/Spectrum. May 2022 presentation during STIR-UP 2022. 67 Table 27. Highlights of EpiC technical assistance for October 2021 – September 2022 Prevention services for KPs ● Expanded outreach activities through community partners, shifted efforts toward online reach strategies, and engagement of primary care and hospital sites. o Continued conduct of refresher training on PrEP clinical management to clinic staff in Central Luzon PrEP expansion sites. o Expanded QuickRes to 17 HIV and AIDS Support House cloud or virtual clinics and 20 public facilities. HIV testing services ● Initiated physical community-based screening and HIV counseling and testing trainings for NCR, CALABARZON, and newly engaged community partners (Tropical Diseases Foundation, Inc. and Positive Action Foundation Philippines, Inc.). The training covered concepts from identifying risks of clients until helping reactive clients for confirmatory testing by channeling them to certified rapid HIV diagnostic algorithm (rHIVda) confirmatory laboratories (CrCLs). ● Coordinated with the Global Fund to provide blood-based self-test kits to supported SAIL (Save and Improve Lives) clinics for self-testing for monitoring of PrEP clients. ● Continued implementation of Enhanced Peer Outreach Approach (EPOA) with RTHSN-Lakan and commenced a hospital-led EPOA with Laguna Medical Center. ● Conducted multiple HIV proficiency and rHIVda trainings and assisted three new sites to become CrCLs: James L. Gordon Memorial Hospital, Tarlac Provincial Hospital, and Laguna Medical Center. ● Supported laboratory equipment for 23 sites and technical guidance for accreditation of 10 sites. ● Managed a workshop to produce the standardized operating procedure template for sites interested to apply as HIV CrCL. ● Partnered with the TBIHSS project to conduct monitoring visits to the sites and assess level of service delivery to clients in accessing TB medications and X-ray vouchers among PLHIV and for TB clients to have access to HIV testing and care. PrEP ● Supported almost 300 clients with the expanded PrEP baseline laboratory partners for PrEP initiation. ● Continued conduct of the HIV and AIDS Support House community pop-up for PrEP and transition from event-based to monthly conduct. ● Initiated pop-up PrEP and HIV testing activities during Pride events held in June 2022 in which negative clients were initiated on PrEP during the events, contributing to the highest enrollment yield in a month at 849 clients for June 2022. ● Facilitated the inclusion of PrEP into the National Formulary, thereby enabling domestic procurement. ● Supported advocacy for increased domestic PrEP procurement, resulting in DOH commitment. ART ● In an instance of antiretroviral (ARV) shortage, EpiC facilitated the delivery of abacavir from the national warehouse and other overstocked regions to Regions IV-A and III and NCR. 68 Table 27. Highlights of EpiC technical assistance for October 2021 – September 2022 ● Supported the adoption of tenofovir, lamivudine, and dolutegravir (TLD) drug combination as the preferred first-line regimen in the revised treatment guidelines and initiated discussions with the Global Fund and DOH to facilitate rapid access to TLD. ● Aided in hosting several TLD awareness-raising events, which included clinicians, DOH staff, academic leaders, and PLHIV. ● Continued support for baseline testing with partner laboratories to facilitate more rapid enrollment. ● Conducted trainings for motivational counseling to ensure that health staff are knowledgeable on HIV counseling and can easily refer to HIV testing or ART initiation. ● Conducted a series of trainings on client-centered case management, primary HIV care management, comprehensive STI case management, and TPT in partnership with the Global Fund and DOH CHDs. ● Organized multi-month dispensing of ARV drugs; contracted Grab transport services to aid service providers in delivering commodities to clients. ● Facilitated the allocation and distribution list of viral load cartridges with DOH and the Global Fund. ● Supported viral load test training of staff in public and private facilities in preparation for the arrival of the U.S. Government –donated cartridges; includes providing technical guidance on increasing demand generation through social media platforms and CBOs. ● Received and distributed viral load cartridges to different facilities. ● Trained GeneXpert site technicians/operators in EpiC-supported regions on the use of point-of-care viral load cartridges. EpiC also assisted in the conduct of similar training to facilities outside Metro Manila to ensure that all identified GeneXpert sites can conduct GeneXpertVL testing. ● Continuing collaboration to optimize referral systems using GeneXpert machines for viral load testing for uninterrupted access to point-of-care viral load testing. Below is a snapshot of selected EpiC indicators and accomplishments against targets for October 2021 – September 2022. Table 28. Selected EpiC performance data, October 2021–September 2022 Indicators (PEPFAR & Custom) * Men who have Sex with Men Transgender Q1 – Q4 FY 2022 Annual Target % Target Achieved to Date Q1 – Q4 FY 2022 Annual Target % Target Achieved to Date KP_PREV 63,124 14,193 444.8% 26,474 342 7740.9% PREP_NEW 6,199 1,963 315.8% 814 37 2200.0% HTS_TST 59,239 31,666 187.1% 24,721 5,588 442.4% 69 Table 28. Selected EpiC performance data, October 2021–September 2022 Indicators (PEPFAR & Custom) * Men who have Sex with Men Transgender Q1 – Q4 FY 2022 Annual Target % Target Achieved to Date Q1 – Q4 FY 2022 Annual Target % Target Achieved to Date HTS_TST_PO S 3,474 2,546 136.4% 1,534 449 341.6% TX_NEW 3,706 2,291 161.8% 1,366 403 339.0% TX_CURR 26,232 15,680 167.3% 2,938 2,078 141.4% TX_PVLS (N) 8,157 7,840 104.0% 540 1,039 52.0% TX_PVLS (D) 8,385 8,253 101.6% 555 1,094 50.7% TX_PVLS 97% 95% 102% 97% 95% 102% *Acronyms: KP_PREV: No. of KPs reached with individual and/or small group-level HIV prevention interventions designed for the target population. PREP_NEW: No. of individuals who were newly enrolled on oral ARV PrEP to prevent HIV infection in the reporting period. PREP_CURR: No. of individuals, inclusive of those newly enrolled, who received PrEP to prevent HIV during the reporting period. HTS_TST: No. of individuals who received HIV testing services and received their test results. HTS-TST_POS: No. of individuals who received HIV testing services and received a positive test result. TX_NEW: No. of adults and children newly enrolled on ART. TX_CURR: No. of adults and children currently receiving ART. TX_PVLS (N): No. of ART patients with a suppressed viral load result (<1,000 copies/ml) within the past 12 months. TX_PVLS (D): Denominator for TX_PVLS. TX_PVLS: Percentage of ART patients with a suppressed viral load result (<1,000 copies/ml) within the past 12 months. Other HP IPs— Medicines, Technologies, and Pharmaceutical Services (MTaPS) and Health Equity and Financial Protection Platform (ProtectHealth)—have collaborated with EpiC to contribute to the second objective of strengthening health systems. Specifically, in 2021, MTaPS worked with EpiC and the National AIDS & STI Prevention & Control Program to register the antiretroviral (ARV) drug combination, tenofovir, lamivudine, and dolutegravir (TLD), with the Food and Drug Administration, an essential addition to the ART regimens available for PLHIV. MTaPS’s ongoing work on developing and implementing the electronic Logistics Management Information System (eLMIS), as well as training on infection prevention and control (IPC), will also benefit the SCM system for ARVs and quality improvement (QI) in the PEPFAR-supported treatment hubs. MTaPS supported DOH in the development of policies that played a critical role in the availability and safety of lifesaving health products. The team supported the development of “Department Circular 2022-0044: Oral antiretroviral (ARV) medicine, Emtricitabine 200mg + Tenofovir Disoproxil Fumarate 300 mg tablet fixed-dose combination (FDC) as Oral Pre-Exposure Prophylaxis (PrEP) in the Philippines National Formulary.” The signing of this memorandum circular signified the approval of the Health Technology Assessment Council for the ARV to be included in the Philippines National Formulary. This led to the optimization of access to oral PrEP and ensured consistent supply and equitable distribution through all the HIV/AIDS treatment hubs across the country to prevent and control HIV infection. 70 MTaPS conducted site visits of HIV treatment hubs to do pre- and post-assessment of IPC practices. Healthcare waste management is a component added to the IPC assessment tool to ensure a more holistic assessment of the HIV outpatient care sites. After the pre- and post-assessment, the team organized an online feedback forum for stakeholders of HIV treatment hubs visited by the team and provided recommendations on how to improve the IPC measures in all 30 facilities visited. The team also provided a capacity-building session regarding SCM and IPC (including health care waste management) during the forum. Additionally, MTaPS facilitated the importation and release of 25,632 bottles of PrEP tranche 2 in February 2022 and facilitated the documentation for processing the 36,000 bottles of PrEP tranche 3 in November 2022. ProtectHealth, through its work streams related to supporting health policy design and strengthening DOH budget management, conducted several activities contributing to improved HIV financing. These were: ● Completed the HIV financing landscape assessment, which describes HIV resources and how they are utilized. The report served as inputs to the 7th AIDS Medium Term Plan and the country’s funding request to the Global Fund. ● Issued a technical advisory on the devolution of commodities (including those for HIV/AIDS), including a proposal to petition the Department of Budget and Management to provide additional funding for population-based grants to leverage LGU procurement to address equity issues. ● Conducted a social contracting readiness assessment in three sites (one per EpiC-supported region). This assessment currently serves as a foundational platform for current sustainable health financing efforts across stakeholders (e.g., Department of Foreign Affairs and Trade, Australia, the Global Fund). ● Assisted PhilHealth in updating the Outpatient HIV/AIDS Treatment (OHAT) benefits package to allow rHIVda testing to be a basis for enrollment. ● Developed a concept note for conducting a Communication Action Plan workshop for PhilHealth to provide relevant support in communicating the UHC law, focusing on TB, FP, and HIV benefit packages. ● Issued a technical advisory suggesting the recognition of the laboratory results from the rHIVda as a confirmatory test for the diagnosis of HIV, which will facilitate the early enrollment of PLHIV to the OHAT package. ● In collaboration with EpiC and UNAIDS, convened a nationwide consultation with OHAT providers. 5.2 Question 2. How have the USAID Health Project interventions improved social norms and behaviors among the underserved seeking treatment and prevention services? The HP intensified its social media presence and reach through digital advocacy campaigns to improve social norms and behaviors among the underserved. Facebook pages, Facebook groups, YouTube, Twitter, TV broadcasts, and websites have become frequent platforms for the HP to disseminate 71 information on available FP/ARH, TB, and CBDR services. The extensive reach garnered this year was influenced by HP’s strong collaboration with national government agencies such as, but not limited to, the following: DOH, POPCOM, DSWD, DILG, and the Philippine Information Agency. ReachHealth continued its extensive use of social media to reach the underserved and improve social norms and behaviors to increase health care access and utilization. In CY 2022, the four major national campaigns of ReachHealth—namely Usap Tayo sa FP, “It’s OK to Delay,” “I Choose,” and Konektado Tayo—reached 65 million people across the country. ReachHealth also continued its SBC campaigns, reaching over 620,000 people on DOH Healthy Pilipinas LazLive events held on November 11, 2022, and December 12, 2022. In response to one of the recommendations made in previous HPPEs, ReachHealth developed an evaluation protocol to be used in the proposed SBC impact evaluation research to find out if the individuals reached by the SBC campaigns actually access services. Information gathered from this study will help improve the effectiveness of SBC campaigns through the design of more relevant messages, appropriate methods. To date, the impact evaluation protocol has been developed and the data collection activities will commence in quarter 1 2023. TBIHSS produced 35 stories which were published and shared in 30 quad media platforms, garnering a free publicity value of PhP13.1 million. The project’s #TBFreePH website had 34,632 unique visitors, while the online assessment tool “Am I TB-free?” cumulatively reached around 10,500 unique users as of September 2022. As part of their #TBFreePH campaign, TBIHSS produced three advocate survivor videos to share the real-life experiences of TB survivors and disseminate accurate information about TB screening, diagnosis, treatment, and prevention. Furthermore, the TBIHSS’s Healthy Lungs PH website recorded 1,500 unique users during the period October to December 2022, counted 1,266 new followers for the online patient support group, and has recorded a cumulative total of over 5 million organic reaches since July 2021. RenewHealth disseminated information through its Facebook page Bawat Simula tungo sa CBDR. As of December 31, 2022, it has gained 1,123 followers, reached 148,882 people, and accumulated a total number of 4,491 page visits. DOH, DSWD, and DILG shared information on substance use, addiction, and CBDR initiatives and milestones through their respective social media pages. In quarter 4 CY 2022, RenewHealth and the Sangguniang Kabataan of Malabon delivered a workshop to create SBCC campaigns targeting the youth. The DOH, in partnership with the Bonifacio Art Foundation Inc., and Cignal TV developed MindS-Cool TV episodes to tackle mental health and substance use among adolescents. As mobility restrictions were lifted, the number of community-based demand generation activities conducted for FP were relatively higher in CY 2022 than in CY 2021. ReachHealth conducted 1,303 community-based demand generation activities including Enhanced Usapan sessions, outreach, and other mobilization activities. These activities reached 17,857 people, 15,820 (89 percent) of whom became acceptors of FP services and commodities. In collaboration with the Ministry of Social Service and Development of BARMMHealth engaged parent leaders and municipal links in facilitating family development sessions among those with potential unmet need for FP/MCH/ARH. Through the HP’s support, local health facilities provided postpartum women with FP messages during health facility visits for routine immunization, house visits, and Usapan sessions. Likewise, the health facilities mobilized 72 barangay health workers to help provide commodities for supply-based methods. TBIHSS oriented 900 health staff from the “Big 3” regions on the TPT communication package. It tested the inclusion of a TB module in family development sessions. The subnational demonstration started with the orientation of three DSWD Pantawid Pamilya Pilipino program city links and 52 parent leaders on the TB module as part of the Electronic Family Development Session and a draft DSWD family development session guide on TB awareness. TB Platforms conducted two surveys among those who identify as lesbian, gay, bisexual, transgender, queer and the urban poor to gain insights into people’s TB knowledge, attitudes, and practices. The activity developed and disseminated a six-part video series on DR-TB Treatment Orientation for Programmatic Management of Drug-resistant Tuberculosis (PMDT) sites. The video guides are expected to increase patient awareness, address patient expectations and knowledge of a patient’s responsibilities during their DR-TB treatment. Both TB IPs collaborated with the Philippine Information Agency to increase their reach. Our KIIs suggest that the SBCC campaigns have been effective in reaching a wider targeted audience. For instance, the communication strategy to engage #TBFree champions or celebrity ambassadors to pledge support to the campaign of finding and treating Filipinos living with TB has been cited as an effective HP intervention. The active participation of community champions, such as local religious leaders and community leaders, help reach audiences with specific concerns. However, some LGUs still desire more expansive social mobilization in the community to improve health-seeking behavior. The key informants also acknowledged HP support to the development of information, education, and communication (IEC) materials on TB as critical to changing perceptions, behaviors, and attitudes among the underserved. Moreover, they suggested that IEC materials for FP should be localized to appropriately address local needs and issues. To ensure sustainability of interventions, key informants from GPH agencies expressly committed to manage and continue the HP’s digital advocacy campaigns. 5.3 Question 3. How has the USAID Health Project increased client satisfaction? To increase client satisfaction, the HP should more systematically collect feedback from clients and improve the methods of collecting feedback and opinions of clients on the quality and form of services they have received. Nevertheless, our findings from the KIIs suggest an increased community confidence in the HP’s activities, attributed to the support of multiple external stakeholders from the private sector, religious groups, academe, and CSOs. In 2022, ReachHealth installed client satisfaction survey (CSS) kiosks in six “I am very happy and thankful that finally, I can now avail of the family planning services for free without being absent from work. This is such a big help not only to me but to my co-workers as well who have been wanting to space or limit their children.” - FP client, on FP services in the Workplace, ReachHealth Source: USAID’s ReachHealth. Pagadian Workplace Model: Closing the Gap on Family Planning Access in the Workplace. 2022 CLA Awards entry, USAID/Philippines. February 2023. 73 hospitals and trained health care providers (HCPs) in utilizing CSS data for quality improvement. It generated CSS data from 45 facilities providing FP/ARH services that were recipients of the rollout of the CSS tool in CY 2021. So far, a total of 3,274 respondents from ReachHealth sites have participated in the CSS. On the other hand, BARMMHealth collected feedback from clients through random exit interviews from 635 clients in FY 2022, which yielded an average satisfaction score of 4.7 on a five-point scale. In quarter 1 FY 2023, a similar survey yielded a satisfaction score of 4.8, but was only from a small sample of 73 clients. TB Platforms conducted a patient satisfaction survey in its sites between November 2020 and January 2021, and instead of conducting another survey in 2022, it performed a secondary data analysis to determine what services account for the levels of client satisfaction. TB Platforms reported that decentralized protocols through home-based or community-based treatment, adoption of digital adherence technologies, promoting patient welfare through personalized treatment and care planning yielded improvements in client satisfaction, and consequently better treatment outcomes. Home-based or even community-based treatment protocols reduced the expenses shouldered by patients (e.g., reduced transport costs, time away from work) and encouraged treatment adherence. Our findings from the KIIs cite establishment of TB contact centers, which provide teleconsultation services for TB patients, as a good practice to increase client satisfaction. The contact centers address issues of TB patients and their families which includes symptoms, diagnosis, and access to services, treatment, and psychosocial counseling. Through this platform, health workers can also remotely monitor TB patients’ treatment adherence and completion. RenewHealth piloted a CBDR CSS in July 2022 involving a total of 513 respondents from nine partner LGUs sites in the first round of data collection. The average satisfaction rating was 4.68 on a five-point scale or 93 percent satisfaction. 5.4 Question 4. How has the USAID Health Project led to continuous quality improvement in care service delivery? To improve quality of care in service delivery, health care workers (HCWs) must continuously update their skills and knowledge. LGUs and NGAs interviewed for this evaluation report recognized the HP as instrumental in improving service delivery through provision of technical and capacity-building support. Key informants also cited manuals and modules for use of trainers, service providers, and clients themselves as helpful in improving service delivery. But perhaps the most helpful is the systematic integration of continuous learning, pause-and-reflect sessions, and adaptive management into the work of HCWs. ReachHealth assessed the entire e-learning process from recruitment to certification, evaluation of the operational guide, and implementation of the blended learning platform for FPCBT-1. Notably, ReachHealth supported health facilities in installing CQI program components, establishing client feedback mechanisms, and training their personnel on the use of CQI toolkits. As of end of CY 2022, ReachHealth had supported 56 hospitals and 94 primary care facilities implement CQI to improve service delivery. Additionally, ReachHealth did a process documentation of DOH’s CQI framework 74 implementation in Batangas. The documentation aimed to evaluate the process and its effectiveness given the shift to alternative modalities of learning. BARMMHealth organized and oriented CQI teams on the CQI process and conducted coaching on the development of CQI plans and mentoring in the conduct of plan-do-study-act cycles. As of September 2022, BARMMHealth had assisted in organizing 87 facilities (75 RHUs and 12 hospitals) as FP/SRH QI sites. ProtectHealth supported the DOH DPCB in the development of the concept note on supportive supervision. In FY 2022, MTaPS provided training to 7,695 HCWs (just about half of the life-of-activity accomplishment) using non-traditional platforms such as e-learning courses and webinars. On June 2, 2022, the DOH released a memorandum on the rollout of iDOTS Phase 2, and approved the iDOTS mentoring and supervision toolkit, operational plan, and executive brief, which were all developed by TBIHSS. TBIHSS conducted coordination meetings with the National TB Reference Laboratory, DOH, and consultants to develop a compendium of reference standards in establishing TB laboratories. It also conducted TB and TPT 101 orientations of 135 participants to capacitate peer educators, peer navigators, and case managers in the NCR. To improve quality of care in TB service delivery, TB Platforms strengthened and expanded their patient-centered care approach. It conducted a series of CQI orientations for health facilities. As of September 2022, TB Platforms had capacitated 27 hospital and RHU personnel from six PMDT facilities on the use of CQI during service delivery. From October to December 2022, three more facilities in Region IV-A were trained on CQI. To date, almost all PMDT facilities have developed and finalized CQI plans. Other initiatives on CQI include the conduct of supportive supervision training for 29 district doctor and nurse supervisors in Quezon City and an Xpert utilization assessment to evaluate the Xpert MTB/Rif performance in selected facilities (nine rapid TB diagnostic laboratories and 15 referring health facilities) in Regions III, IV-A, and NCR to help identify factors affecting utilization. The Indicator, overall facility utilization rates in areas implementing quarter I, is applicable to both FP and TB activities since they also operate in common sites. Table 29 shows that, as of September 2022 and among areas implementing quarter I measures, ReachHealth reported an overall facility utilization rate of 38 percent, exceeding its FY 2022 by 280 percent. Reporting an overall facility utilization rate of 20 percent, BARMMHealth achieved 100 percent of its FY 2022 target. However, the TB IPs were not able to achieve their FY 2022 targets. Specifically, TB Platforms achieved 81 percent of their FY 2022 target, while TBIHSS achieved only 48 percent of its FY 2022 target. Since the data are largely from How is CQI implemented in your agency? “Monitoring and evaluation are still in the process of adaptation. However, we are now utilizing new monitoring tools like the Client-Exit Interview, ICV Compliance, and checklists for post-evaluation training.” “We are using it as a benchmark/reference to our action/development plans, with an adaptation of the approach, plans and implementations, and monitoring.” “CQI is a tool to improve the quality of services are providing to get more responsive client-centered services. The approach helps us assess our health programs.” — Health facility staff, BARMM Source: USAID’s BARMMHealth. Communicating, Spreading, and Effecting Change through Collaborating, Learning, and Adapting for Continuous Quality Improvement in BARMM. 2022 CLA Awards Entry, USAID/Philippines. February 2023. 75 hospitals60 that have implemented quarter I measures, the overall utilization rate appears low vis-à-vis the larger universe of health facilities. Table 29. Overall facility utilization rate in areas implementing QI by USAID, FY 2022 FY 2022 Target FY 2022 Actual % FY 2022 Target Met ReachHealth* 10% 38% 380% Numerator 737,773 32,953,691 Denominator 7,178,526 86,127,493 BARMMHealth* 20% 20% 100% Numerator 552,087 564,957 Denominator 2,760,435 2,760,435 TB Platforms* 16% 13% 81% Numerator 34,608 22,750 Denominator 216,301 182,004 TBIHSS** 3% 1% 48% Numerator 6,208 Denominator 473,992 *The figures were obtained from the USAID Development Information Solution data provided by USAID’s Program Resources Management Office as of November 25, 2022. **TBIHSS did not have data from the Development Information Solution because the Batangas Medical Center’s TB culture laboratory rerouted all specimens for TB culture to other TB laboratories due to ongoing renovations at the time of the FY 2022 data collection. The data of TBIHSS were obtained from the file submitted to CLAimDev-Health on November 15, 2022. 5.5 Question 5. How has the USAID Health Project contributed to improving financial risk protection? ReachHealth strengthened local health financing through facility and network accreditation—e.g., 218 health facilities were accredited under Konsultasyong Sulit at Tama (KonSulTa; 68 in Luzon, 106 in Visayas, and 44 in Mindanao). ReachHealth also shared with CHDs and LGUs the results of an assessment of the implementation of the PhilHealth KonSulTa program in Cagayan de Oro, Misamis Oriental, and Bukidnon primary care facilities. Moreover, ReachHealth conducted primary care provider network (PCPN) workshops and KonSulTa orientations in 23 LGUs. As a result of the hands-on training of 19 city￾managed KonSulTa-accredited facilities in Davao City on the eKonSulTa system, 35,318 individuals had been registered in these 19 accredited facilities as of September 19, 2022. There were also 46,352 individuals registered in seven accredited facilities in South Cotabato. Four KonSulTa-accredited RHUs (Tupi, Sto. Nino, Polomolok, and Norala) in South Cotabato have already received capitation payments from PhilHealth amounting to PhP95,883, while Howard Hubbard Memorial Hospital received PhP15,876. Moreover, ReachHealth developed an executive online course on local health financing 60 Note: TBIHSS reports data from laboratories. 76 through primary care, which is expected to contribute to the knowledge and skills of LCEs in managing their local health funds. BARMMHealth supported PhilHealth in providing guidelines on KonSulTa accreditation for stand-alone FP clinics and the Maternity Care Package. As a result of this assistance, 68.5 percent (76 out of 111) of RHUs in the assisted sites have been accredited for a PhilHealth Maternity Care Package. Of the many technical advisories and reports developed by ProtectHealth as part of its assistance to Philippine Health Insurance Corporation (PHIC) and DOH, the technical note that suggested a system that checks the financial viability and performance of the National Health Insurance Program demonstrates HP’s strong commitment to improving financial risk protection and ensuring the availability of GPH’s resources to cover health expenses of the marginalized. Such a monitoring system caught the interest of PHIC. Through another technical advisory, ProtectHealth proposed a grant facility whose design is that of a DOH population-based grants mechanism; this facility allows DOH to leverage LGU financing for health. As the implementation of the Mandanas Garcia SC ruling draws near, ProtectHealth assisted GPH with the necessary preparations through a technical advisory on the DTP. This advisory guides local health departments in updating their local DTPs, local investment plan for health, and annual operation plans, together with the IPs. Other sources of funding to reduce costs and cover other finance health care expenditures were also explored in this advisory. On the other hand, a key informant noted that the HP IPs should also pay attention to the political context of technical advisories and help inform and convince high-level officials in PHIC and Congress on the proposed financing mechanisms and models for UHC implementation: “magagaling, binuhos na rin nila pati puso, di lang technical material. . . . Gusto sana76amingn hanggang level ng Board may presentation/workshop, pero hindi. . . . Gagawin na lang76amingn… corporate order hoping it will trickle down to minds of the decision makers.” — Informant from PHIC 5.6 Question 6. How has the USAID Health Project influenced UHC health systems strengthening efforts for the Philippines? HP support to UHC health systems is focused on two fronts—technical assistance in ensuring the sufficiency of and effective management of public health funds including social health insurance and the efficient operation of the supply chain for goods and services. These two support portals entail building the skills and knowledge of public and private HCPs and stakeholders at both national and local levels and the development of systems and tools to support the implementation of policies and developed plans. 77 Over the past four years of HP support, central and regional levels of DOH, PhilHealth, and LGU officials and staff have been trained in service delivery and coached in financial management, costing analysis, local health planning and policy development, procurement, supply chain and warehouse management, and development of provider networks. By 2022, the rollout of the eLMIS (an electronic logistics management and information system that the MTaPS assisted the DOH in developing) had been implemented in 12 warehouses (eight central and four regional warehouses in Regions III, VI, X, and XI). Encoding of inventory is ongoing and this system is expected to facilitate the efficient planning, procurement, and distribution of goods and services that enable the effective operation of the established provider networks (PCPNs/HCPNs). It also complements efforts to mature LGUs in UHC integration and their transition to full devolution of health care services. In CY 2022, the HP continued to support these agencies and their staff in building capacities to ensure seamless transition to full devolution as well as UHC integration at the local levels. For example, ReachHealth coordinated with CHDs and LGUs (e.g., Zamboanga del Norte, Zamboanga City) in providing support in the development of their plans for local health systems integration, including the conduct of baseline assessments, gaps analysis, and identification of investment needs. In the province of Cebu, ReachHealth trained PHO personnel, Development Management Officers, and PhilHealth local health insurance offices on local health systems integration. To support LGUs in UHC integration, ReachHealth assisted in the drafting of catch-up plans of eight Mindanao UHC integration sites. In Butuan City, ReachHealth conducted a PCPN workshop and baseline assessment, which resulted in three PCPNs being identified. Likewise, in Davao City, ReachHealth helped to draft referral protocols to ensure that residents in the catchment population are referred to appropriate facilities. It also developed the referral manual of South Cotabato. In Quezon province, it facilitated a referral expansion workshop for its HCPN, which is interconnected with the Batangas HCPN. In quarter 4 CY 2022, ReachHealth assisted national, regional, and local partners in the implementation of the key reforms in the RPRH and UHC) laws.61 Further, it strengthened the capacity of local actors to achieve LHIS through policy support to help UHC implementation sites progress toward Level 2 maturity, specifically: (1) demonstrating integration though digital solutions in Laguna and Batangas; and (2) commencing policy innovations on PCPNS contracting and Special Health Fund (SHF) implementation in South Cotabato and Laguna.62 BARMMHealth provided similar technical assistance to its supported sites. It conducted a PCPN workshop and assisted the MOH and integrated PHO of Maguindanao and Basilan in establishing PCPNs consisting of municipal health officers, public health nurses, chiefs of hospital at the district and municipal levels, and private hospitals and private lying-in clinics. It also co-facilitated efforts with the MOH and PhilHealth on planning and developing implementation plans to achieve their next UHC maturity-level targets. BARMMHealth also assisted the UHC technical working group of MOH in facilitating the quarterly review of progress under the preparatory level in the two UHC integration sites.63 61 Quarter 1 FY 2023 ReachHealth Quarterly Progress Report, page 10. 62 Ibid. 63 Quarter 1 FY 2023 BARMMHealth Quarterly Progress Report, page 3. 78 In collaboration with MTaPS, MOH BARMM, and integrated PHOs, BARMMHealth oriented PSCM committee members on PSCM and warehouse management to address the region’s fragmented PSCM. It also supported the rollout of the new version of FHSIS. While it can be argued that the TB IPs focus is too program-centric, the tools they developed, and initiatives implemented complement the activities supporting UHC integration in the LGUs. For instance, the citywide TB Elimination Campaign (CiTEC) in Cebu City strengthened the TB/primary care service delivery through the PCPN. TBIHSS assisted the Cebu City Health Office and Central Visayas CHD in the following interventions that support UHC integration: (1) passing of Cebu City Ordinance No. 2646 “An Ordinance Approving the Acceleration of TB Elimination in Cebu City through UHC Reforms and Appropriating Fund for the Purpose Thereof”; (2) annual allocation of PhP5 million for TB elimination through UHC in Cebu City; (3) approval of local health board resolution formalizing PCPN formation and service capacity expansion, including directing the city Health Department (and other relevant units) of Cebu City to appropriate and mobilize resources intended for its operationalization in CiTEC areas. On the other hand, TB Platforms assisted 107 LGUs develop their provincial/local/community investment plans for health and their annual operational plans, and 90 LGUs develop their DTPs. Around 81 policies (e.g., TB ordinances, UHC ordinances, accreditation of facilities as TB DOT centers) have been passed or are awaiting further approval by the LGUs. Between October and December 2022, TB Platforms supported the development of six UHC-related policies in Marikina, Valenzuela, and Paranaque, including local policies institutionalizing SHF and policy framework for establishing a local health information management system. Moreover, because of TB Platfor’'s advocacy and use of TB performance data, 73 LGUs have developed their TB recovery plans, including allocating sufficient budgets and timely procurement of TPT drugs. For example, around PhP11,955,146 additional specific budgets for TB were committed by some LGUs. TB Platforms also advocated for the allocation of an estimated PhP2,162,130,452 for the catch-up plans for TB in the 17 LGUs under the jurisdiction of the NCR and DOH Metro Manila CHD. To ensure that the allocated funds are effectively used, the TB Platform trained or oriented 4,177 doctors, nurses, medical technologists, and CHWs on TB management, program updates, enhanced protocols, or guidelines to implement technical assistance packages. It also piloted the use of the NTP Pooled Procurement model in ten LGUs in Region III and trained 63 HCWs on drug supply management and pooled procurement. This led to local resources being invested by the ten LGUs for the pooled procurement amounting to PhP2.5M for Xpert cartridges and PhP11,700 for purified protein derivative supplies. RenewHealth supported the development of local plans and policies, such as: establishment of Pasig City’s Anti-Drug Abuse Office, establishment of Cagayan de Oro City’s Drug Code, adoption of the General Intervention for Health and Wellbeing Awareness (GINHAWA) program by the City of Lapu￾Lapu Office of Substance Abuse Prevention, and the proposed inclusion of CBDR budget items into the annual investment program of Caloocan City. Additionally, the following national policies were enhanced: Omnibus Health Guidelines for Children, Adolescents, Adults, Elderly, and Managers of Various Settings; Guidelines in the Conduct of SBIRT Using the DOH academy eLearning Platform; and the Dangerous Drugs Board issuance on the adoption of the Yakap Bayan Program as a community- 79 based aftercare and reintegration model. It also assisted the Juvenile Justice Welfare Council and the DSWD in revising the Client Flow for Treatment of Minors, which is now pending board approval. At the local level, RenewHealth assisted the municipality of Socorro, Oriental Mindoro in its first CBDR planning session involving most of the LGU stakeholders from the Philippine national police, health offices, social welfare and development offices, budget and planning offices, the local government operations officer, and selected barangay leaders. RenewHealth assisted the LGUs of Socorro, Oriental Mindoro and Pateros in integrating CBDR in the KonSulTa package of PHIC through the development of a flow chart on the use of KonSulTa in CBDR, and a template ordinance for the inclusion of CBDR program. MTaPS continued to support the DOH and the LGUs in ensuring efficient PSCM by supervising the rollout of eLMIS in their priority UHC integration sites aside from the 12 agreed U.S. Government– supported UHC implementation sites. To help address stockout problems, MTaPS worked with the DOH to develop quantification guidelines for the LGUs as more PSCM functions will be devolved to the LGUs in line with UHC implementation. It continues to work with POPCOM in including standard days method (SDM) cycle beads in the monitoring of FP logistics officers. In the area of pharmacovigilance, the MTaPS conducted a case study to assess current mechanisms in the implementation of active surveillance through Pharmacovigilance Monitoring System. 5.7 Question 7. How has the USAID Health Project contributed to greater involvement of the private sector in achieving better health outcomes? In 2021, the HP initiated the creation of private sector matching models for the program “FP in the Workplace.” This is an initiative that involves engaging and increasing the capacity of partner medical facilities to improve access and to provide FP service delivery to the relevant workforce. In 2022, ReachHealth scaled up the implementation of the program and assisted more medical facilities in Luzon, Visayas, and Mindanao. For instance, through the assistance of ReachHealth, Quest Diagnostics Inc., which was engaged in late 2021, obtained certifications as a FP stand-alone clinic, primary care facility, and ambulatory surgical clinic. Specifically, ReachHealth facilitated a partnership between Quest and the Family Planning Office of the Philippines in Region III to provide FP and HIV/AIDS prevention sessions to 87 employees of Calfurn Philippines Manufacturing Corp. In the Visayas, members of the management staff of 12 companies were given FP orientation through the HP’s partnership with Cebu Light Industrial Park, POPCOM, the Lapu-Lapu LGU, and private midwives. In Mindanao, through the engagement of three medical centers, seven companies implemented FP in the workplace. BARMMHealth engaged the South Upi Rubber Development Cooperative and Malibacao Cooperative to include FP benefits in their respective workplace programs. To date, BARMMHealth has engaged and forged memoranda of understanding with 24 out of the 41 targeted private sector partners. Of the 24, eight were trained on FPCBT-1, one was trained on PSI method, while five routinely submit reports to RHUs or barangay health stations. BARMMHealth conducted capacity-building activities for five private health facilities in Maguindanao and seven private health facilities in Lanao del Sur to provide high quality SRH services. 80 A road map for the introduction of Levoplant®, a new three-year contraceptive implant, was completed by ReachHealth in collaboration with DKT International Philippines. However, there was a delay in the approval of the certificate of product registration. Further, ReachHealth and DKT International Philippines implemented a telemedicine initiative and e-commerce platform called “EasyReach” to improve access to FP services among individuals with unmet need in semi-rural areas in the country. In FY 2022, the platform completed 335 orders of FP commodities from 20 men and 315 women. Products ordered were 378 condoms, 99 pregnancy test kits, 41 birth control pills, and 27 lubricants. In 2022, TBIHSS enhanced the ITIS mobile app by upgrading its features on security, patients’ profiles, patient transfer design, and screening facility drop-downs. This has helped increase notifications from the private sector and is expected to further improve patient compliance with treatments and tracing of contacts. To upgrade skills and knowledge of private providers and stakeholders, TBIHSS: (1) facilitated a forum and orientation on various technical assistance packages, such as FAST Plus, TB Workplace, KonSulTa Plus, and PCPN activation initiative. Eight private hospitals, three large diagnostic networks, local professional societies, and representatives from the Central Visayas CHD and the Cebu CHO participated in this forum; (2) held a program entitled “Engaging Private Providers towards Standardized and Integrated TB Care, Prevention and Notification: Updates from the Adult TB CPG 2021”; and (3) conducted a hybrid training session (online and face-to-face) on the DOH’s Manual of Procedures 2020 Training of Trainers (which was attended by staff from CHDs of Regions VI, VII, X, and XI, and the Philippine Coalition Against TB), and members of specialty societies. TBIHSS also hosted a first climate/environment focused webinar called “Climate and Health Nexus: Breaking Down Silos” attended by 308 participants from USAID (Philippines mission and global), IPs, government agencies, private sector, media, and the academe. Officials from the DOH, the Climate Change Commission, and Philippine Department of Environment and Natural Resources served as presenters and resource persons during the panel discussion and Q&A session. Last, TBIHSS renewed its partnership with Nippon Paint to promote “Para Healthy Lungs” and “KonsulTayo.” TBIHSS continued to support the Philippine Coalition Against TB and the TB Consortium by mapping consortium facilities, organizing knowledge-sharing activities on existing and emerging technologies, and facilitating coordination meetings among consortium members. In November 2022, in an event supported by TBIHSS, the TB Consortium announced the inclusion of GeneXpert Xpress SARS-COV-2 in the consortium platform and additional assays in the pipeline. With technical assistance from TBIHSS, the TB Consortium facilitated the procurement of GeneXpert machines and cartridges—the 13th cycle since its launch in January 2020. In 2022, pooled procurement rounds supported by the TBIHSS resulted in the purchase of one GeneXpert machine for the Cebu Velez Hospital and 13,100 GeneXpert MTB/Rif and Ultra cartridges through concessional pricing for TB Consortium members. Challenges such as inadequate data recording and reporting by private providers, inadequate access to TB diagnostic platforms limiting quality diagnosis remain and require more focused effort to ensure sustainability among the private sector partners. Thus, TB Platforms continued to engage private sector 81 providers to increase access to TB services, improve MN, and participate in referral networks. It conducted two orientation sessions on the TB in the Workplace program for the Central Luzon Occupational Safety and Health Network locators and members, attended by 116 participants from 38 companies. TB Platforms also piloted an LGU-led workplace engagement approach in Calamba City, Laguna, where it trained 80 workplace staff from 39 businesses and establishments and reviewed and updated their workplace policies. It also engaged and oriented 123 representatives (school nurses and school physicians) from the DepEd Division of Batangas on strengthening their TB in the Workplace implementation. During that session, TB Platforms, in partnership with the DepEd Division of Batangas, systematically screened around 7,375 teaching and non-teaching personnel and detected 56 cases that were then started on treatment. During the year, TB Platforms engaged three private health facilities to serve as “Move-it” hubs—a private￾public partnership that addresses the gap of sputum testing in the private sector through improved sputum transport mechanisms and rapid TB diagnostic testing. As of August 2022, 82 private health providers (50 physicians within the hubs and 32 physicians outside the hubs) had participated in the Move-it model implementation and referred patients with presumptive TB for sputum collection and Xpert testing. The private providers notified NTP on 96 TB patients who were started on treatment. TB Platforms also engaged 24 private hospitals to implement FAST Plus, contributing 10 percent (205,108) to the total screening coverage and 705 DS-TB and 34 DR-TB patients. As HP acknowledges the importance of integrating mental health care into the treatment of substance abuse, SBIRT and pilot-test of self-help technology-mediated interventions have expanded beyond community settings and into school and workplace settings. RenewHealth continued utilizing and promoting the Lusog-Isip app launched in 2021. On March 11, 2022, RenewHealth endorsed the app among 1,053 people attending the 35th annual convention of the Psychological Association of the Philippines (PAP)-Junior Affiliates. To facilitate buy-in, ASOG was engaged to collaboratively develop a program for newly elected officials in partner sites—CLEAR training—which tackles CBDR and health governance. RenewHealth also forged partnerships with universities such as the Far Eastern University, Polytechnic University of the Philippines, and Don Honorio Ventura State University to pilot-test self￾help and screening interventions among students and school personnel. It collaborated with PAP and the Ateneo Center for Organization Research and Development in conducting a survey in school and workplace settings on mental health and substance use. RenewHealth partnered with the Bonifacio Arts Foundation, Inc. to develop and produce the six episodes of Mind S-Cool TV. These episodes provide information on the triggers of mental health issues, risks of substance abuse, tips to overcome peer pressure, and stress management techniques tailored for the adolescent audience. In quarter 4 CY 2022, RenewHealth and DILG organized “Ugnayan: Engaging CSO and Private Sector Stakeholders in CBDR” which provided an avenue for HP to secure external support and explore collaboration with civil society and the private sector in conducting CBDR interventions. This was attended by seven LGUs, two non-governmental organizations (NGOs), two civic organizations and one faith-based organization. In the landscape assessment for HIV financing, ProtectHealth included private providers to secure their inputs and define their roles in providing resources to the program. It assisted PhilHealth in expanding 82 the financial and service coverage of the TB-DOTS benefit package which could encourage more HCPs, especially those in the private sector, to engage with the national government’s efforts to eliminate TB cases. MTaPS, ReachHealth, IQVIA, and Reckitt Benckiser worked together to calculate CYP data using an analysis of FP commodity data. To ensure strong and improved PSCM systems are established at the local level through local technical assistance programs (LTAPs), MTaPS engaged with the academe (Cebu Normal University), CSOs, an NGO (i.e., National Pharma Foundation), and the Philippine Institute of Supply Chain Management.64 5.8 Question 8. How has the USAID Health Project contributed to the greater involvement of civil society in achieving better health outcomes? The HP has involved CSOs and NGOs in various capacities: as grantees to model/demonstrate innovations in FP, implementers of community-based FP demand-generation activities and alternative access to service delivery, health advocates, partners in TB case finding, and resource persons/reactors to policy guidelines.65 BARMMHealth continued its support to the four CSOs engaged in 2021 regarding their participation in the local governance mechanism and in providing FP services to address gaps related to the community health of women with unmet needs. ReachHealth monitored the performance of the CSOs/NGOs that received innovation grants, although two of the eight grantees are still implementing interventions. Specifically, ReachHealth worked with The Forum for Family Planning and Development, Inc. support CSE-ARH Convergence through SBC campaigns and materials, community-based ARH providers, and conducted outreach and Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide/Depression, and Safety assessments; concluded the engagement with the Integrated Midwives Association of the Philippines, Inc. that entailed the mobilization of six itinerant teams in Iloilo and Negros Occidental and the conduct of 34 outreach missions; formed, capacitated, and mobilized FP itinerant teams in Caloocan City, Cavite, Davao City, General Santos City, and South Cotabato with The Family Planning Organization of the Philippines, Inc. and the Philippine Society for Responsible Parenthood, Inc.; ReachHealth worked with Wireless Access for Health, Inc. to capacitate 15 personnel from Manila health facilities on health data management; and ReachHealth worked with the Philippine Society of SRH Nurses to introduce improvements on the reference module on providing SRH services for the deaf.66 ReachHealth’s FP Ayuda Express, or more presently known as FP Bicol Konsulta Express, has been integrated with community-based demand generation activities (e.g., Enhanced Usapan) and other mobilization initiatives. Partner academic institutions and concerned city health office PHO have been 64 MTaPs FY 2022 Annual Report, page 22. 65 For purposes of this HPPE, community engagement is subsumed under Learning Question 8 on civil society engagement. This is because many of the strategies for civil society engagement overlap with those for community engagement, particularly people’s organizations. 66 ReachHealth Quarter 1 FY 2023 Quarterly Progress Report, page 97. 83 trained on the updated algorithm of the platform. As of September 30, 2022, the platform has reached117,699 people online. ReachHealth also continues to identify and work with CSOs in their project sites with 9 out of 16 CSOs verified in FY 2022. TBIHSS worked with TB People Philippines, Inc. and USAID’s TB Local Organizations Network Project to co-produce online videos of eight TB survivors—these videos are used in advocacy campaigns to encourage more TB presumptive individuals and their families to get tested and enrolled to treatment. In quarter 4 CY 2022, TBIHSS worked closely with CSOs and CBOs for integrated TB case finding activities in Tondo, Manila, in November 2022. These case finding initiatives resulted in 1,112 people screened, identifying 171 with presumptive TB cases and 31 diagnosed. TB Platforms conducted a workshop for seven CBOs and CSOs to improve their capacity in health advocacy and conduct of self-assessments. In FY 2022, TB Platforms engaged four CSOs through small grant mechanism. It renewed partnership with the Morph Foundation to conduct active case finding activities in Quezon City which commenced in February 2023. This collaboration will involve local NGOs in coordinating the city’s health programs. TB Platforms also conducted coordination meetings and advocacy activities in Regions III and IV-A to solicit civil society engagement and support for local TB program implementation. As an integral part of its main approach to drug rehabilitation, RenewHealth works closely with civil society groups and community organizations in advancing its programs. Thus, to conceptualize CSO Strengthening Program, which intends to improve the organizational and technical capabilities of CSOs to implement and sustain CBDR services, it completed a survey on CSO organizational capacity and CBDR capacity and resources in May 2022. RenewHealth, in partnership with DOH and MentalHealthPH, promoted the Lusog-Isip app in a #UsapTayo Twitter space in March 2022. Through Action for Health Initiatives (ACHIEVE), Inc.—an NGO working on human rights, gender, and other development issues—RenewHealth engaged recovering PWUDs as facilitators in CBDR programs. For example, in Caloocan City, it trained 20 community facilitators and 18 recovering PWUDs as part of the Aftercare Program. The Computer-Assisted Test for Addiction Severity (CATAS) app has helped assess 183 PWUDs (137 men, 46 women). To ensure that the app would be effectively managed and used, ACHIEVE facilitated a sustainability planning session with the Caloocan Anti-Drug Abuse Office (CADAO) to consider allocating a budget for management costs of the app and providing honoraria/compensation for trained and certified community facilitators and peer counselors.67 Fifteen health service providers from CADAO and two of its CSO partners were capacitated on CATAS. In addition to its main work with the DOH and PhilHealth central offices, ProtectHealth has been heavily involved in the conceptualization and implementation of the CiTEC initiative in Cebu City, which is a multilateral program for TB involving the local government, private partners, and civic society groups. ProtectHealth engaged CSOs in community mobilization for ACF, testing, and treatment compliance in priority areas. The CSOs engaged by ProtectHealth include the following: Presentation of 67 RenewHealth FY 2022 Annual Report, page 23. 84 the Blessed Virgin Mary, Central Visayas Network of NGOs, and medical school-based fraternity Asklepian Circle.68 ProtectHealth collaborates with NGOs Epimetrics and Alliance for Improved Health Outcomes, Inc. (AIHO) as its sub-awardees. In partnership with AIHO, ProtectHealth produced a technical report on the Enhancement of PhilHealth OHAT Benefit Package Utilization. This includes a situational analysis of existing policies and other factors that hinder maximized use of OHAT benefit packages among facilities.69 MTaPS engaged DKT International, through IQVIA, for the collection of FP commodity data for CYP analysis. It also met with the National Pharma Foundation and the Philippine Institute of Supply Chain Management to discuss potential collaboration on the implementation of LTAPS. To ensure the efficient utilization of essential drugs and medicines, MTaPS delivered a webinar on PSCM and pharmacovigilance for CBOs providing HIV/AIDS outpatient care. 5.9 Question 9. How has the USAID Health Project improved male participation in accessing health services? 5.9.1 HP increased engagement through men-oriented FP messages. In FY 2022, the HP engaged men on FP through social media and mass media (TV and radio) since they are rarely reached by home visits or seminars in health facilities. Media campaigns, such as Usap Tayo sa FP and “Katropa” highlighted messages geared toward men, especially their role in their family’s journey through FP use. Through the “Ang Salamin” and “Sama-sama Tayo sa FP” videos and the social media posts focused on condoms, the HP generated increased engagement of men. ReachHealth has yet to complete the evaluation study of POPCOM’s implementation of the amended “Katropa”; only an ethics clearance for the evaluation has been secured thus far. BARMMHealth continued to collaborate with Darul Ifta in engaging the indigenous, tribal, and religious leaders who are key allies in championing and promoting modern FP and responsible parenthood. It also supported a series of activities that engaged men in becoming part of the discussions around FP, including mobilizing religious leaders to talk about men’s health during the radio broadcast of the MOH BARMM-sponsored program called “Usapang Kalusugan ni Nanay at Pagpaplano ng Pamilya.” 5.9.2 Gender Mainstreaming The HP not only improved male participation but supported the GPH’s efforts to address gender gaps in service provision through integrated gender sensitivity and women empowerment training. TBIHSS integrated gender sensitivity and women empowerment in the Work TBFree eLearning course by orienting 121 HCPs from the regional, local, and facility levels in both private and public facilities. The IP 68 ProtectHealth FY 2022 Annual Report, page 48. 69 ProtectHealth FY 2022 Annual Report, page 17. 85 also distributed fact sheets on gender and TB to its Level 3 partner hospitals. They also advocated using gender-related messaging during teleconsultations to motivate male and female clients to undergo chest X-ray screening in mobile vans. TB Platforms conducted operations research on gender mainstreaming, which led to the development of a technical advisory on conducting ACF in male-dominated settings. The research report also provided guidelines on how to improve gender sensitivity and gender responsiveness of health care services for TB and HIV. TB Platforms trained 592 health care workers (151 males, 441 females) on gender integration and mainstreaming within TB programming. As a result, 187 TB-gender integration plans for health facilities were developed, each outlining specific gender integration activities with corresponding implementation procedures, timeframe, resources, estimated costs, and designated personnel. Due to TB Platforms’ advocacy, the City of Manila expressed intentions to use its 2023 Gender and Development Fund in implementing their proposed gender integration activities in its TB program. RenewHealth integrated gender-aware programming into CBDR SBCC activities and ensured that gender-sensitive elements were included in the CBDR models and training for facilitators. RenewHealth also conducted formative research on women who use drugs, and results revealed their unique needs that require specific solutions. As an offshoot of this research, RenewHealth collaborated with the DSWD in pilot-testing Yakap Bayan AfterCare, which is a women-only after-care program. The HP continued to integrate gender-sensitivity trainings and messages in its FP, TB, and CBDR interventions. In preparation for UHC implementation, HP bolstered efforts in orienting Gender and Development (GAD) focal persons and providing technical assistance to GPH in developing the GAD agenda to ensure strong gender-responsive health care systems. Table 30 shows that the HP exceeded its target for GEWE indicator by 197 percent, with 2,506 persons trained in FY 2022 through U.S. Government assistance to advance outcomes consistent with GEWE through their roles in public or private sector institutions or organizations. The FY 2022 accomplishment indicates a 361 percent increase from the baseline and 406 percent increase from FY 2021. Data on the number of people trained on GEWE demonstrates HP’s commitment to address gender gaps in FP/ARH, TB, and CBDR programs and deliver specific health needs of women. However, synergies among IPs need to be strengthened to ensure HP’s streamlined assistance to the GPH in implementing a more cohesive UHC GAD agenda. Table 30. Number of persons trained with U.S. Government assistance to advance outcomes consistent with gender equality or female empowerment through their roles in public or private sector institutions or organizations, FY 2022 FY 2020 (Baseline) FY 2022 Target FY 2022 Performance % Change from Baseline % FY 2022 Target Met Total 544 1,274 2,50670 361% 197% Male 105 254 70 FY 2022 OH PPR Narratives: Indicator Report do not have gender-disaggregated data for FY 2022 performance. These are also missing in progress reports of some IPs. 86 Table 30. Number of persons trained with U.S. Government assistance to advance outcomes consistent with gender equality or female empowerment through their roles in public or private sector institutions or organizations, FY 2022 FY 2020 (Baseline) FY 2022 Target FY 2022 Performance % Change from Baseline % FY 2022 Target Met Female 439 1,019 Source: FY 2022 OH Portfolio Plan and Report Narratives: Indicator Report, page 20. On top of GEWE initiatives, HP maintains its support to address gender-based violence (GBV) through counseling services and establishment of GBV helplines and referral systems. The HP provided GBV services to 3,377 people in FY 2022, surpassing the target by 106 percent (see Table 31). The accomplishment indicates a 581 percent increase from the baseline and a 27 percent increase from FY 2021. It should be noted, however, that teenage pregnancy remains a prevalent concern. Though a lack of comprehensive sexual education among the youth could be the primary cause, rape or sex by coercion could also be a possible reason for teenage pregnancy. For example, the PSA reported that 6 to 7 percent of infants born to adolescent girls from 2016 to 2020 were fathered by men who were 10 years older.71 The same report showed that from 2016 to 2020, live births from adolescents aged 10 to 14 years rose by 11 percent, prompting the Philippine senate to call for police investigation and prosecution of these men since sexual relations with adolescents is a crime. This calls for a strong enforcement of laws addressing GBV and effective interventions to help empower and protect young girls. Table 32 provides a summary of IPs’ GEWE efforts in FY 2022. Table 31. Number of people reached by U.S. Government–funded interventions providing GBV services* (e.g., health, legal, psychosocial counseling, shelters, hotlines, other), FY 2022 FY 2020 (Baseline) FY 2022 Target FY 2022 Performance % Change % FY 2022 Target Met Total 496 3,200 3,37772 581% Male 106% 49 Female 447 * Examples of GBV services: health, legal, psychosocial counseling; shelters; hotlines Source: FY 2022 OH PPR Narratives: Indicator Report, page 20. 71 Ramos, Marlon. More teen births involve older fathers—Public Service Announcement. Available at https://newsinfo.inquirer.net/1726758/psa-more-teen-births-involve-older-fathers 72 FY 2022 OH PPR Narratives: Indicator Report does not have gender-disaggregated data for FY 2022 performance. These are also missing in progress reports of some IPs. 87 Table 32. Selected GEWE initiatives of HP activities, FY 2022 HP activity Initiatives ReachHealth ● Secured ethics clearance for the evaluation of the amended “Katropa” program ● Trained 647 health service providers in gender sensitivity trainings and 4Rs (recognizing, recording, reporting, and referring)73 ● Supported the development of a GBV Responders Guide and Directory, which will provide help lines in 188 barangays in Caloocan ● Supported the establishment of Women and Children Protection Units in health facilities ● Continued to integrate gender messages in FP campaigns such as “Usap Tayo sa FP” and “It’s Ok to Delay” ● Engaged men through social media campaigns such as “Ang Salamin” and “Sama-sama Tayo sa FP” that are focused on condom use ● Provided technical assistance to the DOH Health Policy Development & Planning Bureau (HPDPB) and the gender focal point system in developing the 2022 – 2026 GAD Agenda for UHC ● Conducted a GAD orientation for 33 GAD focal persons BARMMHealth ● Trained and mobilized 326 health service providers, emergency responders, barangay health workers, and religious leaders to address GBV ● Supported the Lamitan City Cluster for Abuse and Rape Cases in establishing the inter-agency referral mechanism with Lamitan District Hospital (as an apex referral facility)74 ● Engaged men by mobilizing religious leaders to talk about men’s health during the radio broadcast of the MOH BARMM-sponsored program called “Usapang Kalusugan ni Nanay at Pagpaplano ng Pamilya” TBIHSS ● Developed a module on gender sensitivity and women’s empowerment in the Work TBFree eLearning course ● Integrated gender modules in trainings on the NTP Manual of Procedures, National Adaptive Plan (NAP), and FAST Plus ● Distributed fact sheets on gender and TB to its Level 3 partner hospitals ● Integrated gender messages in teleconsultations to motivate male and female clients to undergo chest X-ray screening in mobile vans TB Platforms ● Trained 277 health care workers on gender integration and mainstreaming within TB programming ● Developed facility-level TB-gender integration plans for 52 LGUs MTaPS ● Collaborated with DOH in developing an eLearning course on sex and gender in PSCM and pharmaceutical services ● Supported the DOH HPDPB in the conduct of the "Planners’ Network Session 8" to orient DOH GAD focal persons ProtectHealth ● Provided technical assistance to the DOH HPDPB in adopting a framework to analyze gender issues on financing by using TB, FP, and HIV as case studies ● Provided inputs to the GAD learning module being developed by DOH and MTaPS ● Conducted a diversity and inclusion orientation on April 25, 2022 73 ReachHealth FY 2022 Annual Report, page 66. 74 BARMMHealth. (2023, January 31). IP Updates and GEWE Best Practices [Presentation]. GEWE Technical Working Group Meeting, Manila City. 88 Table 32. Selected GEWE initiatives of HP activities, FY 2022 HP activity Initiatives RenewHealth ● Conducted formative research on women who use drugs ● Commenced the pilot testing of women-only aftercare groups Source: FY 2022 Annual Reports of IPs. 5.10 Question 10. How has the USAID Health Project improved the ability of health service delivery points to mitigate environmental risks and withstand climate risks? Some of the key informants noted that the IPs helped establish more efficient processes (e.g., eLMIS, policies created from other HPs) to ensure service continuity despite disasters, especially during the COVID-19 pandemic. They also noted that during emergencies, the IPs also provided emergency equipment, materials, and human resources. Table 33 lists environmental and climate risk management-related initiatives of the HP activities, spanning assessment, planning, development of training course, capacity-building/conduct of training, and implementation of specific action plans/measures. Table 33. Selected initiatives on environmental and climate risk management of HP activities, CY 2022 HP activity Initiatives ReachHealth ● Administered climate risk management tools, collected and analyzed data, and documented sharing of results with LGUs and CHDs BARMMHealth ● Developed disaster risk reduction and management in health (DRRM-H) plans and strengthened capacity of program managers and service providers on the Minimum Initial Service Package on SRH in Emergencies TBIHSS ● Organized a three-part webinar series on Climate and Health Nexus: Breaking Down Silos, which aimed to initiate a multisectoral dialogue on air quality and its implications on lung health and TB care services, and served as an interactive platform to share experiences and lessons learned at the global, regional, and local levels ● Continued to implement initiatives like Optimized Specimen Referral System (OSRS) and DataToCare to strengthen specimen transport and referral operations that can minimize lengthy operations, thereby reducing energy consumption and reducing carbon footprint ● Collaborated with DOH-Health Facilities and Services Regulatory Bureau to facilitate an online orientation on Green and Safe Health Facilities attended by 169 participants (i.e., hospital heads and engineering staff) from different hospitals. The orientation provided the attendees with information about health and climate policies, as well as DOH requirements for the green and safe viability assessment tools for hospitals 89 Table 33. Selected initiatives on environmental and climate risk management of HP activities, CY 2022 HP activity Initiatives TB Platforms ● Supported eight LGUs in Aurora province in revising their DRRM-H plans to address TB concerns, and to make them consistent with the requirements of UHC and the DOH’s guidelines for disaster response ● Implemented the Smart (Green and Safe) Hospital Initiative in three public hospitals and one private hospital in Region III, which led to the identification of specific action points to improve water and energy efficiency, and updating of their DRRM-H in hospital plans MTaPS ● Developed training materials and assessment checklists for IPC and health care waste management (HCWM) and conducted training of trainers on IPC and HCWM for regional focal persons to cascade the standards across all regions and their respective catchment areas ● Developed and uploaded an eLearning module on HCWM and SCM at the DOH Academy ● Supported DOH in analyzing quarterly stock data, resulting in the mobilization of DOH resources to address stockout and overstock issues, thus reducing pharmaceutical waste due to expiry ● Trained 22 supply officers on HCWM at health facilities during the training of trainers on PSCM organized by CHD VI for its provinces and highly urbanized cities ● Provided support to DOH in developing the Warehouse Operation Manual ProtectHealth ● Promotes the utilization of climate data to guide policy development and financial risk protection among DOH and other stakeholders RenewHealth ● Assisted partner sites in implementing and evaluating the delivery of virtual CBDR in Caloocan City. The project monitored weather conditions and established protocols and contingency plans during inclement weather, including planned measures to be taken by local health officials and project staff to address gaps in service delivery during natural disasters or calamities. 5.11 Question 11. How has the USAID Health Project ensured that interventions for the underserved are sustainable beyond project life? Sustainability of HP interventions is achieved by maintaining strong partnerships with government agencies, ensuring civil society and private sector participation, and securing buy-in from LCEs. Development of online training courses on FP, CBDR, and TB have helped the HP in expanding access to SDPs and improving health care delivery. Further, integrating project activities into existing government programs and pushing for policy reforms have increased the likelihood of continuity of activities introduced by ensuring funding and mobilizing national and local resources. 90 5.11.1 Family Planning POPCOM has expressed commitment to manage the I Choose and Usap Tayo sa FP websites, which provide access to ready-to-print SBCC materials on FP use. These websites, co-developed with the HP, will also continue to be supported by the CSO partner, Roots of Health. Other SBCC campaigns on FP in traditional media such as the Sama-Sama Tayong mag-Family Planning and Ang Salamin animated postpartum FP video have been endorsed to the POPCOM Knowledge Management and Communications Division for perpetual use and public broadcast.75 POPCOM also pledged support to Konektado Tayo, a campaign that engages the adolescents, youth, and parents through the Facebook app. On the other hand, BARMMHealth facilitated engagements with private stakeholders, civil society leaders and key government officials through BARMM Regional Implementation Team and the technical working group of the Adolescent Health and Development Program. BARMMHealth trained regional supervisors of the MOH Family Health Cluster and Population Division and provided continuous mentorship of HCPs in Basilan and Maguindanao in reaching the preparatory level of maturity for UHC implementation. It also provided a grant to the Mindanao Organization for Social and Economic Progress, a CSO aiming to improve health outcomes in Maguindanao and special geographic areas. To support continuous and cost-effective capacity-building on FP, ReachHealth provided technical support to DOH in developing blended learning and online modules on FPCBT-1 and CQI, which are now accessible in the DOH academy. BARMMHealth extended training and supervision to local HCPs providing FP services. BARMMHealth also enhanced the capacity of MOH BARMM’s UHC team to perform technical review of the Local Health System Integration Maturity Level for UHC implementation in BARMM. The HP offered technical assistance in developing various policies and guidelines in HCPNs, such as the provincial resolutions on referral system establishment and CQI implementation in Batangas; the referral manual in Central Visayas; the Informed Consent and Voluntarism policies in Manila and Caloocan City; and the local policies on FP outreach in Iloilo, Negros Occidental, South Cotabato, and General Santos City.76 5.11.2 Tuberculosis As a result of TBIHSS’s technical support to the TB National Coordinating Committee in the development of TB elimination plans and advocacy agenda for the national and subnational multisectoral response to TB, the Cebu City government issued a local ordinance in Cebu City to secure annual funding of PhP5 million for TB elimination under the UHC program. TB Platforms engaged LCEs through “Usapang Dibdiban” Plus executive sessions, which resulted in 36 LGUs passing local ordinances allocating around USD234,415 for local TB elimination programs.77 75 ReachHealth FY 2022 Annual Report, page 67. 76 ReachHealth FY 2022 Annual Report, page 69. 77 TBP FY 2022 Annual Report, page 41. 91 TBIHSS aided GPH’s communication initiatives by developing and submitting the Electronic Family Development Session communication package78 to the DOH and DSWD to support the TB Elimination Road Map. In addition, TBIHSS facilitated the review of the road map objectives of the Philippine Medical Association and DILG. Further, CiTEC and Introducing New Tools Project implemented in Cebu City, Cebu Province, were also introduced in South Cotabato, showcasing successful prototypes of service delivery approaches useful also in addressing other diseases and contexts.79 TBIHSS also scaled up other successful prototypes like the digital adherence technology and video observed therapy to expand involvement of higher education institutions in CiTEC. TBIHSS, in partnership with the University of Cebu School of Medicine, oriented 88 faculty members, medical students, and health center staff on video observed therapy, and enrolled 48 patients from demonstration sites. TBIHSS lobbied for the issuance of Cebu City Local Health Board Resolution No. 010-2022, which formalizes the PCPN and its protocol for TB care service delivery. This resolution ensures the institutionalization of CiTEC as part of the strategic positioning of PCPN-led primary care service delivery in implementing communities. 5.11.3 Community-based Drug Rehabilitation RenewHealth advocated for the use of CDBR as the most cost-efficient program for drug rehabilitation during a groundbreaking conference hosted by the Quezon City LGU on September 13 – 15, 2022 and participated in by LCEs, government officials, and CBDR stakeholders. Moreover, to ensure sustained use of the CBDR approach in addressing drug dependency, RenewHealth facilitated the inclusion of modules on CBDR program management in the CLEAR training program that the ASOG organized for newly elected officials. Participants in the training program are expected to develop initiatives to establish or improve the implementation of CBDR in their localities. RenewHealth also supported the government of General Santos City by facilitating a strategic planning session to create the City’s Anti￾Drug Abuse Office. 5.11.4 Health Systems Strengthening ProtectHealth provided technical inputs and assistance to DOH in the assessment of the performance of the Health Care Financing (HCF) Strategy 2010 – 2020, which was crucial in the development of the HCF Strategy 2023 – 2030. It assisted in developing the KonSulTa Sandbox operational guidelines, which test network accreditation, contracting, and payment through the SHF.80 In collaboration with DOH, MTaPS facilitated the sub-allotment of USD460,00081 for the implementation of eLMIS. The DOH and CHDs led the co-development and revision of the eLMIS roll￾out plan to ensure sustainability and ownership of responsibility and accountabilities. It assisted in 78 TBIHSS FY 2022 Annual Report, page 13. 79 TBIHSS FY 2022 Annual Report, page 43. 80 ProtectHealth FY 2022 Annual Report, page 13. 81 1 USD = 50 PHP. 92 drafting transition and sustainability plans, which will be presented during the eLMIS consultative workshop scheduled at the end of March 2023. It also conducted a learning session on stock data analysis for the DOH’s Pharmaceutical Division to ensure the continued processing of inventory data for decision-making at the executive level. Likewise, MTaPS continued to capacitate personnel from LGUs on PSCM and PV, reporting a cumulative number of 7,695 people trained in FY 2022.82 It also developed two PSCM training eLearning modules which will be uploaded in the DOH academy to encourage self￾paced learning. Starting in July 2023, the DOH will take over the hosting of the eLMIS website. While the DOH Knowledge Management and Information Management Service (KMITS) proposed budget of PhP10 million to cover the hosting costs from August 2023 to December 2023 was not approved, MTaPS was able to secure a commitment from the Supply Chain Management Service to fund the portion of the hosting costs that the KMITS cannot accommodate. 5.12 Question 12. To what extent are CLA practices integrated in the USAID Health Project? The CLA culture has been adopted and is pervasive across all thematic components of the project. CLA practices were also advocated among the partners to enhance their participation in the co-development of plans and policies, to enrich their coordination and networking with stakeholders and to upgrade their skills and knowledge of adoptable and sustainable best practices in health care planning and delivery. The HP conducted pause-and-reflect sessions with partners as the means to encourage thoughtful planning and sharing of experiences. Some of the CLA practices observed in 2022 are as follows: • ReachHealth, BARMMHealth, ProtectHealth, MTaPS, TBHISS, and TB Platforms collaborated on the development of a joint approach to UHC implementation in eight priority sites for UHC integration. • TB Platforms conducted fidelity assessment and adaptive management, case documentation, assessment of TB awareness and perceptions among urban poor communities, and research on contact investigation and TPT practices in the Philippines. • TBIHSS coordinated with government partners, USAID, and other IPs in identifying challenges, and on brainstorming solutions and plans to synergize interventions from different projects. • RenewHealth documented and presented during a groundbreaking conference various successful CBDR models, good practices, costs, and outcomes of CBDR activities to LCEs, key government stakeholders, and private sector representatives. • ReachHealth completed the design of the midline assessment and the collection of quantitative and qualitative data to identify the conditions for the successful institutionalization of FP interventions. • BARMMHealth and ProtectHealth collaborated on the development of SHF guidelines for BARMM. 82 MTaPS FY 2022 Annual Report, page 6. 93 • BARMMHealth and MTaPS worked together in facilitating an action planning workshop on PSCM. • BARMMHealth and ReachHealth supported the DOH Field Implementation and Coordination Teams Visayas and Mindanao clusters in organizing and facilitating the UHC Pause and Reflect Summit. • ReachHealth and MTaPS worked together in the implementation of Provider Integration and Engagement System in three municipalities in Batangas and four cities in Laguna. • USAID/Philippines OH, MOH BARMM, BARMMHealth, and ReachHealth worked together in establishing AFHFs and strengthening CSE-ARH convergence in Cagayan de Oro City and in Maramag, Bukidnon. Although CLA practices have continued to mature within and among IPs over the years, CLA as it relates with the HP partners should continue to be strengthened. Some key informants observed that co-development of work plans and activities with partners can be improved, i.e., involving more deeply both central and local levels as well as other stakeholders in co-development and adaptive management to ensure a seamless translation and implementation of central office policies and standards on the ground. 5.13 Question 13. What innovative technologies has the USAID Health Project introduced? Following the USAID definition of innovations,83 the HP has the following notable achievements, classified into the four major categories of innovation (offering, delivery, finance, and process): • On Offering: ReachHealth and MTaPS collaborated on the design, development, and implementation of Provider Integration and Engagement System, which integrates private sector service providers into local HCPNs covered by PhilHealth. RenewHealth, in partnership with DOH, developed the Lusog-Isip app, which provides users access to guides, tips, a list of psychosocial services, and exercises to take care of their mental health. ReachHealth supported LGUs in digitizing these referral mechanisms: Wireless Access for Health in Manila; manual of procedures for e-referral system in Central Visayas.84 • On Delivery: The HP continued to communicate information on FP, TB, and CBDR services through community dialogues, traditional media, print, digital, and social media. These campaigns include Usap Tayo sa FP, It’s OK To Delay, I Choose, Konektado Tayo, FamiLigtas, and the Lusog-Isip app. 83 USAID Bureau for Global Health, Center for Innovation, and Impact. Innovation realized: Expanding the path to Health Impact. A guide to amplify global health innovation at USAID. Available at: https://2017- 2020.usaid.gov/sites/default/files/documents/1864/USAID-Innovation-Realized-Guide_web508.pdf 84 ReachHealth FY 2022 Annual Report, page 78. 94 TBIHSS supplemented innovative approaches to TB care by introducing the Health Risk Assessment as a key linking tool between primary care provider—patient relationships and baseline profiling; capacitated HCWs on digital adherence technology utilizing video observed therapy and it utilized ultra-portable chest X-ray for rapid TB screening and diagnosis in demonstration sites nationwide. In addition, TBIHSS developed a concept note on the pilot programmatic introduction of urine lateral flow lipoarabinomannan for the diagnosis of TB among PLHIV, as recommended by WHO. TBIHSS consulted with the DOH DPCB, the ACCESS TB project, and KNCV Philippines on the revised treatment algorithms on the bedaquiline-pretomanid-linezolid (BPaL)85 and the bedaquiline￾pretomanid-linezolid-moxifloxacin (BPaLM)86 regimens for people with DR-TB. • On Finance: ProtectHealth proposed a monitoring mechanism to track the performance of benefit delivery and financial viability of the National Health Insurance Program.87 ProtectHealth also developed sandbox operational guidelines for KonSulTa to test network accreditation, contracting, and payment through the SHF.88 • On Process: MTaPS continued to work with DOH on the implementation of eLMIS in warehouses and SDPs for an improved supply chain data visibility across the country. The HP assisted in developing and uploading technology-mediated modules and online courses on FP, TB, CBDR (e-SBIRT), and PSCM in the DOH academy. These modules help encourage self-paced learning, augment the number of service providers, and sustain HP interventions. 85 BPaL is a six-to-nine month oral DR-TB treatment regimen that replaces the previously recommended 18 – 24 month treatment, including an injectable agent. KNCV Tuberculosis Foundation. BPaL implementation. KNCV website, accessed on March 13, 2023, URL: https://tinyurl.com/4jb9abvm 86 BPaLM is a six-month oral DR-TB regimen based on BPaL, in combination with moxifloxacin. Source: WHO (May 2022). Rapid communication: Key changes to the treatment of drug-resistant tuberculosis. WHO website, accessed on March 13, 2023, https://apps.who.int/iris/rest/bitstreams/1420701/retrieve 87 ProtectHealth FY 2022 Annual Report, page 32. 88 ProtectHealth FY 2022 Annual Report, page 13. 95 6. CONCLUSIONS AND RECOMMENDATIONS 6.1 Overall HP Performance In 2022, the HP continued to ramp up activities that sustained the gains achieved in 2021. To support the GPH and DOH thrusts on UHC and primary health care (PHC), the HP focused on strengthening the health systems through collaborating with national and local policy makers and planners on policies and guidelines; training health human resources on key UHC and PHC functions; and developing new tools to improve SCM. Specifically, the HP:  Provided technical inputs to DOH on its Health Care Financing Strategy.  Continued to assist the DOH and PhilHealth improve the benefits packages (such as KonSulTa, population-based financing programs, SHFs) by estimating costs and funding requirements, designing monitoring and evaluation (M&E) tools, and implementation guidelines.  Provided technical assistance to LGUs in updating local devolution transition plans, local investment plan for health, and annual operational plans.  Rolled out the eLMIS in DOH 12 warehouses (8 central and 4 regional) and trained local staff in 12 UHC sites on the use of the eLMIS. By the end of 2022, the eLMIS had been rolled out in 17 regions except BARMM. The eLMIS is a pivotal tool to help the DOH and local governments manage their supply chain of goods and services—a critically important step for the LGUs as they transition to full devolution and UHC integration.  Facilitated the allocation of commodities among local health facilities to address stockout rates, which remained a problem due to persisting supply and logistics constraints, albeit generally lower compared to baseline years.  Developed various training modules on PSCM, CQI, program management, M&E, and gender, most of which were uploaded in the DOH academy for easier and on-demand access. At the program level, the HP supported health facilities sustain the recovery from the impact of the COVID-19 pandemic by technical assistance in the training of HCWs, development and implementation of quarter I tools, and networking with CSOs and other stakeholders to participate in health care delivery. Specifically, the HP:  Expanded the reach of messages on FP, TB, and CBDR and mental health through the use of multiple platforms (e.g., social media apps, radio broadcasts, community dialogues).  Continued SBC and SBCC interventions for FP, TB, and CBDR, resulting in improved health seeking through in-person attendance in health facilities or teleconsultations.  Resumed and expanded in-person training of HCWs, including CHWs, on essential skills for PHC, such as FPCBT-1, adolescent services, TB case detection and management, HIV counseling and testing and PrEP, CBDR program management, CQI, and M&E.  Assisted local health facilities in U.S. Government–supported sites on ARH, resulting in a substantial increase in the number of AFHFs (264 AFHFs in 2022).  Ramped up TB case finding through ACF, ECF, ICF; enhanced sputum transport mechanisms and rapid molecular diagnostic tests; supported new all-oral regimens for MDR-TB and the new Introducing New Tools Project. 96 The HP efforts in 2022 have led to:  Increased numbers of new FP acceptors and current FP users  Exceeded targets for CYP  Increased TB case notifications—higher than pre-pandemic levels  Higher DR-TB TSR in 2022 compared to 2021 and sustained DS-TB TSR  Increased screening of BC TB contacts and TPT enrollment, although these remain below target and are likely under-reported  Higher enrollment rate of PWUD in evidenced-based CBDR interventions compared to FY 2021, although treatment completion remains a challenge in FY 2022 6.2 Overall Recommendations Based on the evaluation of the performance of the HP in CY 2022, we recommend that the HP consider the following: At the health systems level:  Continue to assist DOH, PHIC, and LGUs in UHC integration (e.g., governance, service delivery (HCPN/PCPN), strategic planning (financing, devolution transition), and in ensuring quality primary health care services. This is particularly important as the Mandanas-Garcia Ruling will take full effect in 2024.  Increase engagement with the new LCEs while staying engaged with known LCE champions for health. In the face of potential changes in local priorities, it is crucial, to sustain momentum in advancing HCPNs and PCPNs as well as FP and TB gains, while increasing the advocacy for CBDR interventions.  Evaluate implementation of the eLMIS rollout at the local level to inform adjustments in the system and training of local personnel (especially with the persistently high stockouts). The system can continue to be fine-tuned with data needs of HCPNs and other health data systems.  Continue to support central and local level offices and facilities in the timely collection, accurate recording, and comprehensive analyses of disaggregated data. These are the bedrocks of needs￾based and evidence-based planning and policy making. At the HP activity level:  Engage with new (or newly assigned) DOH officials and LCEs on the thrust of integrated PHC and UHC. Demonstrate that the tools developed for specific programs can be used for others as well—i.e., tools for rational allocation of TB drugs and FP commodities can also be used for other drugs and commodities; the eLMIS can be applied to all essential goods and services. This will ensure that the HP assistance achieves comprehensive health coverage.  Accelerate scale-up and local “buy-in” of FP/ARH, TB, and CBDR interventions, especially among new LCEs.  Expand the establishment of matching models for FP and TB among the private sector using CSOs and other private partners. For instance, the TB contact centers have proven effective in increasing testing and adherence to treatment. LGUs and private firms can be engaged to establish these models to expand the reach of services. The inclusion of FP/ARH and TB testing 97 and treatment services (provided by matched partner facilities) in the benefits packages of employees and their families will increase utilization and improve health outcomes.  Routinely document, disseminate, and institutionalize good practices and promising interventions to inform scale-up and replication. There were KII respondents, such as LCEs, who expressed a desire to know of the experiences of other LGUs so that they can learn and replicate in their own localities. For specific health programs: FP/ARH:  Utilize data on “reach” of FP/ARH messages to revise programs and policies (e.g., increase messaging to men; assess reasons for the increase in the number of pregnant adolescents aged 10 to 14).  Accelerate and scale up the establishment of AFHFs with trained personnel to respond to rising adolescent pregnancy. Follow up with DOH on the proposal to adopt the enhanced HP criteria for accrediting facilities as adolescent friendly.  Design innovative programs for ARH, especially in pre-pregnancy, given the proposed legislations to allow adolescents to access FP services without the need for parental consent.  As face-to-face schooling resumes in the post-pandemic era, increase efforts to implement the CSE–ARH convergence program with the DepEd. TB:  Implement “catch-up” programs and introduce innovations (e.g., make reporting of contact investigations mandatory similar to TB disease notification) to accelerate contact investigation, TPT, detection, and treatment of childhood TB. Synchronize these with other public programs such as child vaccination drives, enrollment in schools, or as requirements for selected routine government programs (e.g., TB screening for households enrolled in the Pantawid Pamilya Pilipino program or issuance of driver’s license, especially for drivers of public utility vehicles; TB testing for incoming and outgoing overseas Filipino workers).  Support the expansion of Xpert testing and establishment of TB contact centers among LGUs. Document and demonstrate the benefits to the community when these are included in their own HCPNs.  Strengthen monitoring of MN among providers to improve both disease notification and reporting of treatment outcomes. CBDR:  Given the laser focus of the DOH Central Office on UHC implementation and PHC, escalate advocacy for the adoption of CBDR interventions at the LGU levels.  Increase efforts on screening up to after-care of PWUDs.  Assess the shorter pilot program (GINHAWA) to reduce dropouts from the CBDR interventions.  Improve M&E of the CBDR program, particularly at the local government level.  Assess use of CBDR IMS and develop plans to ensure long term sustainability of platform use among partners, especially LGUs. 98 It is important to note that for many HP activities, CY 2023 is the last full year in which “catch-up” activities and innovations can be accelerated and scaled up to achieve significant impact. Rich lessons accumulated from the past four years should continue to inform continuous improvements in HP interventions, while dropping or correcting low-yield interventions. To quote John Maxwell: “Experience is not the best teacher; evaluated experience is the best teacher.” As the HP prepares for an EOP evaluation, there must be a continuous effort in HP’s remaining project life to ensure that HP’s inputs and outputs will translate to visible results for improving the health of the Filipino people. 99 ANNEXES Annex A. Overall Recommendations from the CY 2021 HPPE Report89 At the health systems level: 1. More focused technical assistance to LGUs to support effective UHC implementation. The Health Project should coordinate its support with the DOH and the CHDs. They are the bridges to the DOH Central Office and ensure efficient consolidation and complementarity of support from all international and local partners with the programs of the government. They also ensure more effective and rational use of all available resources. 2. Ensure that the electronic Logistics Management Information System (eLMIS) is institutionalized and fully operational along the supply chain between the DOH Central Office and the LGUs/health facilities. The HP should provide the DOH DPCB and the LGUs with technical assistance and support in the rational allocation and distribution of commodities and other resources using the data generated by the eLMIS. 3. Continue to support the health facilities in providing quality data to the many health information systems of DOH to ensure that all policy makers and planners— national and local, private, and public—are provided with correct, timely, accurate, complete, and relevant data and information. Moreover, the HP should support plans of the DOH for information management systems integration to enhance UHC implementation. 4. Advance the disaggregation of performance data, e.g., by sex, gender, age, location, and other relevant parameters to support appropriate policies and targeted interventions. This is especially relevant to the LGUs for them to fully grasp their health outcomes status to frame their local investment plans for health and ordinances to enforce policies and programs. At the HP activity level: 5. Explore, cooperate, and engage with DOH in its strategic commitment to sectoral and integrated primary health care. This is in line with Recommendation No. 1 to focus support on LGUs in coordination with the DOH Central Office and CHDs. The HP should continue to navigate how to optimally work with the integrated DOH DPCB strategy and structure while adapting to changes at the national and local levels as newly elected officials and appointees assume office in 2022. 6. Secure local “buy-in” of successful FP/ARH, TB, and CBDR interventions. It is crucial that HP routinely documents, immediately disseminates, and supports the implementation among partners of its GPPIs to inform adoption and promote replication. The HP should 89 USAID/Philippines Collaborating, Learning, and Adapting for Improved Development (CLAimDev) Health MERLA and Collaboration Activities. 2021 Health Project Performance Evaluation Report (for January to December 2021). Silver Spring, Maryland: Panagora Group, Inc., June 30, 2022. 100 regularly share information with partners on the progress of these successful interventions. 7. Conduct small surveys via secure digital platforms to identify creative ways to improve FP, TB, and CBDR health-seeking behavior that is particularly relevant to specific target populations. The data from small-scale surveys indicate possible trends or reveal other information that can lead to program modifications. For specific health programs: 8. Connect “reach” of FP/ARH messages with FP outcomes through small surveys and studies. To maximize efficient use of resources and continually adapt to changes in the socio￾behavioral milieu, it is essential to more directly assess the standard metrics of “reach” of the FP/ARH messages and messaging mediums. While direct attribution is difficult to make, small surveys in local communities can provide sufficient data points to determine the influence of multimedia messages on health behavior and support more targeted SBC interventions that can “move the needle” in terms of new FP acceptors and reduce teen pregnancies. 9. Accelerate upgrades to and scale up adolescent-friendly health facilities, especially given the reported high number of adolescents seeking FP/ARH services. For the same reason, HP should support the DOH, POPCOM, DSWD, and DepEd to develop innovative programs for ARH, mainly to prevent first pregnancies and delay repeat pregnancies. 10. Build on the gains of increased mandatory notification of TB cases to improve reporting of treatment outcomes while accelerating efforts toward increased contact investigation, TPT, and detection and treatment of childhood TB. The planned HP innovation of adding alert features in the ITIS Lite can facilitate mandatory notification and improve treatment adherence. Innovations, such as INTP, FAST Plus, and TB contact centers should be accelerated to strengthen lagging performance in childhood TB, contact tracing, and TPT, which can effectively turn off the tap for continuing TB transmission. 11. Improve and expand services to PWUD, especially on aftercare. Data suggest that PWUD who initially participate in screening do not complete the CBDR program reportedly due to lengthy modules and lack of available after-care services. These kinds of feedback counter advocacy efforts and make it more difficult to encourage more PWUDs to participate. The shorter program (GINHAWA), currently being piloted, should be rapidly assessed to provide an alternative program to prevent dropouts and increase CBDR completion rates. 12. Improve the M&E system of the CBDR program to obtain more buy-in and accurate data from LGU reporting units in U.S. Government–assisted sites. This will improve target setting, support evidence-based program modifications, and develop new interventions. Overall, HP will face new challenges in 2022 and beyond. New contexts and complexities should be considered in HP work planning for the remaining two years of the program cycle. In particular, the elections in May 2022 ushered in new national and local executives who needed to be engaged or re￾engaged. This is especially important in light of the mandated assistance to LGUs in their transition to 101 full devolution by 2024. The HP should consider supporting the DOH in developing and implementing their devolution transition plan, which involves arrangements for supplying drugs and commodities, deploying human resources, and providing service. 102 Annex B. Performance Indicator Reference Sheet: Number of functional adolescent-friendly health service delivery points 2022-08-23-Adolesce nt Friendly SDP- Perfo