Indigenous People’s Plan
National Program Support for Kalusugan Pangkalahatan/ Universal Health Care
Revised Draft
November 25, 2011
I.
BACKGROUND
This Indigenous Peoples Plan aims to ensure compliance of the National Program Support for
Kalusugan Pangakalahatan/Universal Health Care with the Philippines Indigenous Peoples
Rights Act (1997) and the World Bank’s OP/BP 4.10 on Indigenous People’s (IPs).
A.
Policy Context
The Project will adopt the definition of indigenous peoples under the Philippines’ Indigenous
People’s Act (Republic Act No. 8371) 1 which states that IPs are: “… a group of people or
homogenous societies identified by self-ascription and ascription by other, who have
continuously lived as organized community on communally bounded and defined territory, and
who have, under claims of ownership since time immemorial, occupied, possessed customs,
tradition and other distinctive cultural traits, or who have, through resistance to political, social
and cultural inroads of colonization, non-indigenous religions and culture, became historically
differentiated from the majority of Filipinos. ICCs/IPs shall likewise include peoples who are
regarded as indigenous on account of their descent from the populations which inhabited the
country, at the time of conquest or colonization, or at the time of inroads of non-indigenous
religions and cultures, or the establishment of present state boundaries, who retain some or all of
their own social, economic, cultural and political institutions, but who may have been displaced
from their traditional domains or who may have resettled outside their ancestral domains”
(Section 3, Article III).
Further, the Project shall contribute to the promotion of the various rights of indigenous people
in the Philippines as provided for in the IPRA. Specifically, Section 25 of Chapter IV of IPRA
guarantees the access of IPs to basic services, including health. Moreover, the project shall be
implemented in a manner that promotes the important rights of IPs to self governance and
empowerment (Chapter IV) and cultural integrity (Chapter VI).
The World Bank’s Indigenous Peoples policy (OP/BP 4.10) contributes to the Bank's mission of
poverty reduction and sustainable development by ensuring that the development process fully
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REPUBLIC ACT NO. 8371 ,The Indigenous Peoples Rights Act of 1997 : An act to recognize, protect and
promote the rights of indigenous cultural communities/indigenous people, creating a national commission of
indigenous people, establishing implementing mechanisms, appropriating funds therefore, and for other purposes,
Chapter II, Section 3 (h)
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respects the dignity, human rights, economies, and cultures of Indigenous Peoples. For all
projects that are proposed for Bank financing and affect Indigenous Peoples, the Bank requires
the borrower to engage in a process of free, prior, and informed consultation. The Bank provides
project financing only where free, prior, and informed consultation results in broad community
support to the project by the affected Indigenous Peoples. Such Bank-financed projects include
measures to (a) avoid potentially adverse effects on the Indigenous Peoples’ communities; or (b)
when avoidance is not feasible, minimize, mitigate, or compensate for such effects. Bankfinanced projects are also designed to ensure that the Indigenous Peoples receive social and
economic benefits that are culturally appropriate and gender and inter-generationally inclusive.
B.
Indigenous Peoples in the Philippines and Their Health Situation
Data from the National Commission on Indigenous People show that there were about 12 million
indigenous peoples in the Philippines. The majority (61%) of the IP are in Mindanao while 33%
reside in Luzon. The remainder 6% are scattered among the Visayan Islands. Historically, the IP
communities resisted assimilation thus, they have been driven to remote rural areas with no or
inadequate access to basic services such as health. Thus, most IP’s are among the indigent
sectors in the country. A large body of research exists in the country on the health of indigents as
well as the problems faced by indigent families in accessing health care. Health outcomes among
indigent families in the Philippines are significantly worse than among non-indigent families.
Access problems relate to: (i) distance to health facilities/services, (ii) lack of medicines, drugs in
facilities, (iii) lack of awareness of PhilHealth benefits and how to access these benefits. Given
that IPs are included in the indigent population, these problems are equally relevant for this
group. In addition, IPs face various cultural, social barriers, although the extent of these barriers
vis-à-vis implementation of universal health care are not well documented. Consultations with
non-governmental organizations indicate that many of these barriers may be related to potential
discrimination faced by IPs when they visit health facilities. Moreover, IPs practice indigenous
medicine, and these practices need to be integrated to the extent possible to make health services
more accessible to IPs. Use of traditional midwives (hilots) is also critical.
There are instances when basic health services reach the IP communities. However, detailed
information on the specific health situation as well as resources of the IPs, including their
indigenous health practices, beliefs and health seeking behavior is limited. Anecdotal stories tell
of IPs’ apprehension in having their children immunized. Consultation with the National
Commission on Indigenous Peoples (NCIP) reveals that some IPs do not even want to go to
hospitals and prefer to deliver their babies at home, as well. Home deliveries have been said to
account for high maternal and neonatal deaths among IPs.
Through the Second Women’s Health and Safe Motherhood Project, IPs in Surigao del Sur have
organized themselves as an initial strategy to enhance their awareness on women’s health and
safe motherhood, which is geared towards eventual representation in the local health board
(LHB).The health sector, in the context of implementation of KP/UHC needs to recognize the
challenges in addressing IP health issues and needs, as well as to understand their health-seeking
behaviors in order to be able to come up with culturally and locally appropriate strategies to
engage them in health activities, and strengthen their awareness. Furthermore, balancing
professional and clinical protocols with respect to the uniqueness and rights of IPs is highly
emphasized.
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C.
Health Policies and Programs for IPs
Health is a priority of the State especially for disadvantaged populations, which includes
indigenous peoples. The 1987 Constitution of the Philippines mandates the protection and
promotion of the right to health of the people and instills health consciousness among them.
This state policy is operationalized through Kalusugan Pangkalahatan (KP), a focused approach
to health reform implementation ensuring that all Filipinos receive the benefits of health reform,
which shall be measured by the progress made in prioritizing the poor and the marginalized, such
as indigenous population, older persons, differently-abled persons, internally-displaced
population (Administrative Order No. 2010-0036 “Achieving Universal Health Care for All
Filipinos”).
As early as 2004, the Department of Health has issued a policy on geographically isolated and
disadvantaged areas (GIDAs), a local health systems development strategy for far-flung areas
and marginalized populations, such as islands, mountainous areas, conflict-affected areas, and
IPs to achieve equity in health and improve access to health resources and services. The GIDA
implementation provides for regular consultations with IPs at the local level. Recently, DOH
directed significant fund allocation for the development of GIDAs, and systems-wide
interventions to increase and extend coverage of health service provision through Department
Memorandum No. 2011-0239 “Prioritization of GIDAs in Province-wide Annual Operations
Plan (AOP) to Support KP Execution Plan.” Specific interventions for IP as identified in
province-wide annual operational plans have previously included:

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MCH – birthing facility at community level – CEMOC/BEMOC to improve access
to FBD by IPs; upgrading of FBD priority on GIDA areas
IP health workers – scholarship for IP midwives;
Program materials/IEC materials – community-health workers’ manual which is
illustrated and localized
An Operations Manual for Community Volunteer Health Workers (CVHWS) has long been in
use in the country to guide volunteer health workers in delivering appropriate and responsive
health services to communities. The Manual provides guidelines, as well as illustrations on
various health care work and services for all members of the community.
II.
The National Program Support for Kalusugan Pangkalahatan/Universal Health Care
Universal Health Care is an approach that seeks to improve, streamline and scale up the reform
strategies in the Health Sector Reform Agenda and Fourmula One for Health in order to address
inequities in health outcomes by ensuring that Filipinos, especially those belonging to the lowest
two income quintiles, have equitable access to quality health care. This approach shall strengthen
the National Health Insurance Program (NHIP) as the prime mover in improving financial risk
protection, generating resources to modernize and sustain health facilities, and improve the
provision of public health services to achieve the Millennium Development Goals (MDG).
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The National Program Support for KP/UHC is fully aligned to the GOP’s agenda of achieving
universal health care, which primarily refers to increasing access of underserved populations,
including the indigenous people, to quality health services. The main project development
objective is to: “increase effective coverage (Health insurance coverage, utilization and financial
protection) under the National Health Insurance Program for households identified through the
National Household Targeting System-Poverty Reduction (NHTS-PR). It is estimated that 16
percent of the 5.2 million households in the NHTS-PR database are identified as IPs (835,000).
In addition to expanding health insurance coverage, the project will also support the Department
of Health and LGUs undertake selected interventions to upgrade the quality of the health
facilities, train health workers, and institute community health team (CHTs) which will have an
outreach function vis-à-vis households, especially IP households that, due to a range of culturally
specific reasons, are more difficult to bring into the health sector. Moreover, the implementation
of KP/UHC is targeting 12 breakthrough regions which are under-performing in the health
sector. These include Geographically Isolated and Disadvantaged (GIDA) provinces as well
where many IPs are residing. At a broad, macro level, KP/UHC is well targeted to IPs.
The aforementioned project development objective (PDO) will be achieved through the
implementation of the following Components:
Component 1: Health Financing: The objective of this Component is to support financial risk
protection for poor Filipino families identified through the NHTS-PR by expanding NHIP
enrollment and benefit delivery. . Poor families are to be protected from the financial impacts of
health care use by improving effective coverage/ the Benefit Delivery Ratio or BDR (enrollment,
utilization and financial protection) of the NHIP. This will be achieved through: (i) expanding
membership coverage into the NHIP, (ii) improving the availment/utilization of PhilHealth
membership services, (iii) improving support value of the NHIP benefits package, (iv)
supporting efficient health spending through risk pooling, fund management and strengthened
strategic purchasing functions. This component would enroll the 835,000 IPs classified as poor
by the NHTS. Moreover, along with the DOH, this component will support the implementation
of Community Health Teams (CHTSs) that will serve as a key interface between the household
and health services. Among other tasks, the CHTs will help enrolled families understand their
PhilHealth benefits, make sure that families are enrolled with a Rural Health Unit and help them
access hospital level services.
Component 2: Health Services Delivery: The objective of this component is to support the
Department of Health (DOH) implement Strategic Thrust 2 of KP/UHC which focuses on
“improved access to quality hospitals and health care facilities2.” The health service delivery
reforms identified under KP/UHC complement the health financing interventions.
Component 3: Building DOH and PhilHealth Capacity in Results-based M&E: The
objective of this component is to support DOH and PhilHealth in the strengthened
implementation of the various scorecards for results-based management of KP/UHC as well as
strengthen systems for monitoring and evaluation of KP/UHC. The DLIs for this component
include:
2
Department Order No. 2011-0188: Kalusugan Pangkalahatan Execution Plan and Implementation Arrangements.
DOH August 3, 2011
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

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III.
Establishment of institutional mechanisms within DOH and PhilHealth for KP/UHC
M&E;
Implementation of revised scorecards (DOH, CHD, LGU, Hospital and PhilHealth)
consistent with the KP/UHC roadmap;
Implementation of a baseline, mid-term and final survey among NHTS-PR families to
measure the impact of KP/UHC in increasing effective coverage/BDR among this target
group;
Strengthening of specific administrative data systems to enable more systematic and
timely reporting on data for tracking KP/UHC (Philippines National Health Accounts,
FHSIS, PhilHealth claims data).
FOCUSED PLAN FOR UNIVERSAL HEALTH CARE FOR IPs
The pursuit of Universal Health Care would inherently improve access of indigenous
people to basic health care services and financing. The following sections defines the
specific strategies, policies and major activities by which the UHC will promote health for
IPs. This plan was informed by the regular consultations with IP groups at the local level,
particularly as experienced suring the implementation of the 2WHSMP and the NHRSP.
Moreover, the NCIP was in agreement with the general design of this project as articulated
during a consultation in November 2011.
A. Strengthening Information base on health of IPs
Prior to the strategy to achieve universal health care, the identification and enrollment of the
indigent in the NHIP was primarily the responsibility of the LGU’s. Under the Aquino Health
Agenda, the identification and enrollment of IP populations has been streamlined through the
adoption of the NHTS-PR of the DSWD to which the DOH has access. With the application of
this instrument, the risk that IP enrollment into PhilHealth’s Sponsored Program will be left to
LGUs is completely mitigated. For IPs that may have been left out during the survey, the DSWD
has a mechanism that allows inclusion and exclusion into the NHTS-PR list whereby such
omissions may be corrected. Constant dialogue with IP groups is being undertaken by DSWD
will facilitate that process.
Establishment of health data on IPs is necessary to build evidence on their real health condition.
This will also be a basis for comparing disparity in health outcomes between IPs and non-IPs in
the country that will support evidence-based prioritization and allocation of resources. The IP
data on health is envisioned to be developed and integrated to the Field Health Service
Information System (FHSIS) or the Unified Management Information System (UMIS) for pilotimplementation.
B. Increasing Access of IPs to Health Services
Since the Universal Health Care Project aims to increase coverage of health services among
underserved population, it is expected to improve the access of indigenous people to health care.
The project will benefit IPs by increasing access of the IP population to quality health services –
both through the expansion of the National Health Insurance Program (NHIP) to reach the
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poorest households in the country, as well as through the upgrading of health facilities.
Currently, PhilHealth has instituted case rate payments and no balance billing in all government
hospitals. This means that any eligible members under the Sponsored Program will have
complete access to hospital services and will not be compelled to pay out of pocket.
Under the project, PhilHealth will also improve health insurance benefits like the Out-Patient
Benefit package. In the improvement of this and other packages, PhilHealth and/or the DOH will
conduct consultations with the IP groups. They will also develop appropriate communication
messages and media that will take into consideration the particular needs of IPs as they access
healthcare. The benefits package and the communication messages shall be evaluated as to
cultural appropriateness for the IP groups. When LGUs update their annual plans for the
implementation of KP/UHC (with technical assistance from DOH), the specific needs of IP
communities will be evaluated (with NGOs working in the area) and adequately reflected.
Through the service delivery component, IPs are expected to have improved access to health
services. The establishment and roll-out of Community Health Team (CHTs), and specific
training provided for CHTs and providers in adopting culturally-appropriate behaviors and
messages towards IPs is expected to enhance IP availment of health services. The CHTs, whose
main task is to serve as an interface between poor households and the health system, will play a
special role in bringing IPs into the NHIP and making sure that they access health services. The
implementation of similar CHT’s (Women’s Health Teams or WHTs) under the ongoing Second
Women’s Health and Safe Motherhood Project has shown that such teams can be highly
effective in improving access of IPs to health services. In the case of the Women’s Health
Teams, the traditional midwives (hilots) who serve IP communities are included. For the CHTs,
a similar practice will be followed by including hilots in the CHTs.
There is, thus, a need to strengthen the capacity of CHTs as facilitators of health service access,
and more importantly as community organizers. Engagement with IPs entails much consultation
and community building. Therefore, the design of CHT trainings incorporates and emphasizes IP
dimensions.
Reaching IPs requires more strengthened local governance whereby the marginalized and the
disadvantaged can participate and their concerns responded to by local institutional structures
and systems. LGUs need to be enjoined to integrate the health agenda of IPs, as embodied in
their Ancestral Domain Sustainable Development Protection Plan (ADSDPP), consistent with
the Province-wide Investment Plans for Health (PIPH).
C. Improving Access of IPs to Health Insurance
The national government had declared that those identified as poor via the NHTS-PR will be
automatically enrolled in PhilHealth’s Sponsored Program. Since the DSWD’s NHTS-PR tool
has already identified the poorest of the poor, including the IPs, one of the impacts of the project
will be enhanced health insurance coverage among poor, including the IP population. The
documentary requirements for enrolment of NHTS-PR identified poor into PhilHealth, which in
the past had been a major stumbling block for the poor especially the IPs, have been waived by
PhilHealth. Currently, the DOH and PhilHealth are constantly undertaking
consultations/dialogues with IP groups and the relevant national agencies in order to find ways to
facilitate the enrolment of the IPs into the Sponsored Program.
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The PHIC is also committed to making the national health insurance program more accessible to
IPs and other poor and marginalized groups and has taken the following steps to achieve this
end:
PHIC translated its IEC materials into many of the minority languages and dialects of the
Philippines, has produced information materials in cartoon form about some of its programs
In order to prevent one of the common cause of exclusion of marginalized groups from formal
social health insurance, PHIC has also adopted rules that allow enrollment of members and their
dependents even if they do not have formal documentation (such as birth certificates, marriage
certificates), by allowing enrollment on the basis of certification by two independent persons or
in accordance with the specific rules set by the National Commission on Indigenous Peoples
(NCIP)
The indicative work plan below provides the major activities and expected outut in pursuit of
the aforementioned strategies for promoting health welfare among IPs under the UHC. These
work plan will be updated annually. In terms of the budget, the total costs of implementing the
IPP for KP/UHC shall be finalized once the KP/UHC Province Wide Investment Plans have
been completed by the provincial LGUs. The PIPHs are expected to be completed by February
2012 and the IPP will be updated to reflect the PIPH, and the associated costs. This revised IPP
(with information from the PIPH) will be shared with NCIP, NGOs and affected communities
during the project launch workshop. Based on consultation during this phase, the IPP will be
revised. The IPP is a dynamic and live document that is expected to be annually monitored and
updated on the basis of the PIPH. Therefore, costs will be estimated and updated on an annual
basis.
Major Activities
Continue/strengthen engagement
with NCIP during UHC
implementation
Strengthening health database on
IPs
 Review of existing data base
 Develop design for
strengthening health
information base on IP
o Evaluate the potential of
utilizing the Community
Expected
output
Working
relationship
between
DOH and
NCIP
established
and
maintained
Strategic
plan for
establishing
health info
base for IPs
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Timeframe
Continuous
Y1
Y2
Responsible
Unit
Bureau of
Local Health
Systems
Development
(BLHD)
Budget
Planning
Bureau (to
coordinate
with the
BLHD and
NCDPC.
BLHD has
Part of
Component
3
(suggested
only)
To be
finalized on
the basis of
the PIPH

Health Teams (CHTs) to
gather IP-related
information
o Incorporate IP-specific
data in the FHSIS
Pilot-testing
Increasing access to basic health
services/facilitites
 Review existing policies
(Department orders, local
policies) related IP health
service delivery
 Develop policy agenda for IP
health
 Policy dialogues and knowledge
sharing
 Review of existing
services/programs/approaches
on IP health service delivery
(including sample local
programs)
o Explore the
development of and
review of an IP-specific
health care delivery
model/s
o Pilot-testing of enhanced
IP health services
o Develop/improve
existing communication
plans for health
advocacy for IP
communities
 Enrolment of IPs in
PhilHealth’s Sponsored
Program
o Identification through
DSWD’s NHTS-PR
o Mobilization of CHTs
o Inclusion of unidentified
IPs into the NHTS-PR
Y3-Y4
Joint
planning
with LGUs
through
provincewide
investment
plans
Y1-4
linkages with
LGUs and the
NCDPC has
oversight on
the CHTs.
BLHD
through the
DOH-CHDs
(regional
offices)
SubComponent
2.2 of
Component
2
DOH BLHD
and NCDPC
with NCIP
DOH Health
Promotion
Bureau and
NCDPC
PhilHealth
RPOs
DSWD
through its
NHTS
validation
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Component
1
mechanism
Consultation
 Issuance of memo for
regular IP consultation at
regional and provincial
levels
 Increased IP/IPO
participation in Local
Health Boards
 Incorporation of IP concerns
in the PIPHs and Annual
Operations Plans
Documentation
 Data banking on “best
practices” on IP health care
delivery
Monitoring and Evaluation
 Annual review of IPP,and
local level plans and
performance indicators
 Review and revision of IP
plan
IV.
Enhanced
IP/IPO
participation
in health
governance
at the LGU
level
Case studies
Y1 onwards
DOH CO
DOH BLHD
Y3 onwards
IPP review
Y1 onwards
and
improvement
LGUs, DOH
CHDs, JAC
review
process
DOH BLHD
and HPDPB
DOH UHC
M&E unit
with NCIP
and IPOs
Project
Supervision
missions
Implementing and Monitoring Compliance to the IP Strategic Plan
The Monitoring Evaluation Component of UHC will include specific monitoring of the impacts
of KP/UHC on IP populations. Such monitoring will occur throughout project implementation. If
gaps are found in the implementation of KP/UHC vis-à-vis IP population, implementation steps
will be revised to proactively address the needs of the IP population.
The DOH and PhilHealth will both establish a KP/UHC monitoring and evaluation unit that
would track the progress of both agencies as they implement KP. The DOH and PhilHealth also
aim to bring down the efforts of KP down to the grassroots level by instituting Community
Health Teams (DOH) and Advocacy and Knowledge Officer (PhilHealth AKO). These teams
will ensure that the PhilHealth beneficiaries are apprised of their benefits, know where they
could access medical care and would not have to pay for any of the services. These same teams
will be able to monitor their respective catchment population including the IPs. The CHTs and
the PhilHealth AKOs may be utilized to engage the IP community in order to address their
specific needs and to generate knowledge on how best they could be served. The regular
interaction of these teams with the poor and the IPs will ensure that the interventions to be
instituted under the KP will be culturally suitable for all targeted populations.
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Part of the monitoring for IPs would be to focus on the status and impact of the project on IP
beneficiaries.
The proposed monitoring and Evaluation arrangements for the project shall be the same
Implementing and Monitoring structure of the National Program Support for Kalusugan
Pangkalahatan/Universal Health Care with the participation of NCIP.
In this organizational chart, the over-all responsibility for tracking UHC implementation would
be lodged with the DOH through the office of the Under-Secretary for Sector Finance and Policy
Technical Cluster. It would gather information from the PHIC and DOH but would do the
consolidation. Compliance to the IP Plan shall monitored by the DOH-BLHD but it will report to
the Under-Secretary’s office. Moreover, NCIP will join health partners meeting where progress
on KP/UHC will be reported and health partners will opportunities to comment on and contribute
to finessing policy and program directions for KP/UHC.
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