Executive Summary
The HIV/AIDS situation in the country can be described as hidden and growing. Based on the HIV/AIDS Registry of the National Epidemiology Center (NEC) of the Department of Health (DOH), the cumulative number of HIV/Ab seropositive cases has reached 2,373 since 1984. Epidemiologists and experts, however, estimate that the actual number of HIV cases is around 10,000. Despite the increasing number of cases, the prevalence rate remains consistently below one percent.
Generally, the policies and programs implemented in the country were in line with the Republic Act (RA) 8504 or the Philippine AIDS Prevention and Control Act of 1998. Various activities on prevention and control, treatment, care and support, including advocacy, training and other management costs were implemented in the last five years.
An examination of the country's total HIV/AIDS spending over the last five years (2000-20004) showed an erratic trend, peaking in 2001, and declining in the years that followed. Notably, a large share of total annual spending came from external sources (at least 75 percent). In terms of type of activities that were financed, these were mostly geared towards prevention given the low prevalence rate. Prevention related activities include: mass media, school-based education programs, condom promotion, STD treatment, among others. Activities related to program management were also financed. These include: surveillance, training, advocacy and communication, among others. A very minimal share of the total spending was used for treatment and care.
The Philippines is committed to halting and reversing the spread of HIV/AIDS. Hence, mobilization of resources is critical in keeping the prevalence of HIV/AIDS low and the rate of transmission slow. It is important, however, to determine the right mix of interventions that must be carried out given the limited and uncertain amount of resources available for HIV/AIDS activities.
Chapter 1 Country Background
Population and Major Demographic Parameters
The Philippine population is currently estimated at 85.2 million spread over a land area of 300,000 square kilometers and is growing annually at 2.05 percent. Males make up about 50.36 percent of the population while females comprise 49.64 percent of the population in 2000. As of 2003 total fertility rate (TFR) per woman is 3.5 For 2000-2005, projected female life expectancy at birth is 70 years, while the projected male life expectancy at birth is to 64 years. In terms of human development index (HDI), the Philippines ranked 84th (or 0.758) in 2003.
Economic Performance
The Philippine economy, despite internal and external challenges and the continued increase in oil prices, grew at a respectable pace over the period 2001-2004. The country's real Gross National Product (GNP) from 2001 to 2004 grew at an expanded average of 5.05 percent while real GDP grew by an average of 4.52 percent. The annual per capita Gross Domestic Product (GDP) was estimated at US$1,025.95 using 2004 nominal prices and exchange rate.
Average unemployment rate in 2004 was 11.8 percent, despite efforts to generate jobs in order to absorb the influx of labor entrants. Underemployment, on the other hand is a more serious problem at 17.6 percent. It must be noted, however, that fiscal deficit remains as the major macroeconomic problem in the country.
As of 2003, 30.4 percent of the Filipinos (about 24.7 percent of Filipino families) are considered income poor. The poor population had income that was below the per capita poverty threshold of Php12,267.
Education Profile
The Philippines has one of the shortest basic education systems in the Asia-Pacific Region-ten years only. Moreover, its quality has also been declining rapidly due to the effects of rapid population growth. Severe budgetary constraints, coupled with the requirements of an expanding student population, have led to under-investment in basic education.
Public and private elementary school enrolment reached 13 million for school year (SY) 2003-2004, up 1.6 percent from the SY 2000-2001 level of 12.8 million. Participation rate at the primary level stood at 90.05 percent for SY 2002-2003. Cohort survival rate (CSR) at the elementary level for SY 2002-2003 was pegged at 69.84 percent. On the other hand, completion rate is about 66.85 percent.
The Philippines' basic literacy rate, at 93.4 percent, is one of the highest in Southeast Asia. Female literacy rate (94.3 percent) slightly edges out male literacy rate (92.6 percent). The 2003 Functional Literacy Education and Mass Media Survey (FLEMMS) also showed that 48.4 million (84.1 percent) of the country's 57.6 million Filipinos aged 10-64 years are functionally literate. The current rate represents a 0.3 percent improvement from 83.8 percent figure posted in 1994.
Health and Health Financing
The Philippine health system has been inadequate in terms of both financing and service delivery arrangements, partly resulting from the devolution of responsibilities for health care provision to local governments with the passage into law of the Local Government Code in 1991. However, slight improvements were achieved in terms of key health indicators. It must be emphasized, however, that there remain large differences across regions and socio-economic status with regard to program coverage, access to health care services and health status in general.
Maternal mortality is considered as one of the most important indicators of a nation's health. In 1998 maternal mortality rate (MMR) was estimated at 172 per 100,000 live births. However, because of large sampling errors associated with this estimate, it is not reflective of the real picture on maternal health. Notably, about 60 percent of births were attended by health professionals for the period 1997-2002.
Infant mortality rate (IMR) is 29 per 1,000 live births and under-five mortality is 40 per 1,000 live births in 2003. About 60 percent of children 12-23 months have been immunized with vaccines against the six preventable childhood diseases-- tuberculosis, diphtheria, pertussis, tetanus, polio, and measles-before one year of age.
In terms of spending for health, the total health expenditure in the Philippines reached Php 136.0 billion in 2003, from Php 117.2 billion in 2002 indicating a 16.0 percent growth at current prices. In real terms, total health expenditure increased to Php 35.5 billion from Php 32.5 billion, which translates to a 9.4 percent growth.
With the total health expenditure growth surpassing the population growth, per capita health spending at current prices registered a Php 200 increase or 13.7 percent from Php 1,462 in 2002 to Php 1,662 in 2003. Health expenditure per capita at constant prices showed a Php 29 increase or 7.2 percent from last year's Php 405 to this year's Php 434.
The share of health expenditure to GNP exhibited an increase from 2.8 percent in 2002 to 2.9 percent in 2003. However, this improvement is still way below the 5 percent standard set by the World Health Organization (WHO) for developing countries.
In terms of sources of fund for health, the government increased its health spending from Php 36.3 billion in 2002 to Php 46.5 billion in 2003, demonstrating a 28.2 percent growth. Likewise, social insurance benefit payments grew from Php 10.6 billion in 2002 to Php 12.9 billion in 2003, translating to a 22.3 percent increase. Although private sources (out of pocket) registered a mere 8.8 percent growth for 2003, it continued to be the highest health spender at Php 74.7 billion from Php 68.6 billion in 2002.
With regard to uses of funds for health, spending for 'personal health care' constitutes 75.7 percent of total spending in 2003. On the other hand, 'public health' spending is only 12.3 percent. 'Other health services' comprised 12.1 percent.
HIV/AIDS Epidemiological data
The HIV/AIDS situation in the country can be described as hidden and growing. Based on the HIV/AIDS Registry of the National Epidemiology Center (NEC) of the Department of Health (DOH), the cumulative number of HIV/Ab seropositive cases since 1984 has reached 2,373 as of October 2005. Epidemiologists and experts, however, estimate that the actual number of HIV cases is around 10,000. Despite the increasing number of cases, the prevalence rate remains consistently below one percent.
Of the total HIV Ab seropositive cases, 1,664 were asymptomatic and 709 were AIDS cases. Sixty-nine percent of the cases belonged to the 20-39 years age group and 63 percent were males. Of the AIDS cases, 275 already died due to AIDS related complications. Sexual intercourse (85%) is still the leading mode of transmission. As of October 2005, there were only 33 reported cases of perinatal transmission. Reported cases from IDU, on the other hand, are seven.
Notably, of the 2,373 HIV seropositive cases, 805 (or 34%) of the cases were overseas Filipino workers (OFWs). These OFWs include seafarers (35%), domestic helpers (17%), employees (9%), health workers (7%), and entertainers (8%). Seventy-five percent of OFWs were males.
The top five common opportunistic infections (OIs) include: tuberculosis (TB), Candidiasis, Pneumocystis Carinii Pneumonia (PCP), Other pneumonias/pulmonary infections, and Cryptosporidiosis.
The conditions that may engender an AIDS epidemic in the country are present. Data with regard to the prevalence of sexually-transmitted infection (STI) on registered female sex workers revealed that Gonorrhea is the most common STI with 24 percent prevalence in sentinel sites based on 2003 data. The top five common STI diagnosis include: Gonorrhea, Chlamydia, Trichomoniasis, Candidiasis, and Syphillis.
HIV/AIDS Interventions in the Country
Generally, the policies and programs implemented in the country were in line with the Republic Act (RA) 8504 or the Philippine AIDS Prevention and Control Act of 1998, and the Third Medium Term Plan (MTP III) on AIDS covering the period 2000-2004. RA 8504 institutionalized the Philippine National AIDS Council (PNAC) which is composed of several government agencies and selected NGOs.
Various prevention and control efforts were undertaken both by government agencies and non-government organizations (NGOs). Mass media activities were implemented by NGOs and LGUs. Condom use promotion was pursued by DKT Philippines and other USAID funded activities.
Efforts to educate workers on HIV/AIDS were carried out by the Occupational Health and Safety Center of the Department of Labor and Employment (OHSC-DOLE), and some NGOs. However, much remains to be done given the large magnitude of workforce in the country. To mainstream knowledge on HIV/AIDS, critical information was incorporated in the curricula of the education system through the School-based AIDS Education Program (SAEP) of the Department of Education (DepEd). The National AIDS/STD Prevention and Control Program (NASPCP) of the DOH, on the other hand, carried out social marketing activities on STI treatment and care, and capacity-building initiatives.
Treatment and care services are being offered by government hospitals, mainly by San Lazaro Hospital, Research Institute for Tropical Medicine and the Philippine General Hospital. All these medical centers are located in the capital city which renders treatment services geographically inaccessible to some persons living with HIV/AIDS (PLHWAs). Non-government institutions are likewise providing support services, such as the Positive Action Foundation Philippines, Inc. (PAFPI), among others. Community support systems were initiated by NGOs and the Department of Social Welfare and Development (DSWD) to a limited extent. It should be noted that anti-retroviral therapy (ART) is an out of pocket expense unless there are sponsors or donations. In addition, there is no program yet focusing on care and support for children orphaned by AIDS.
Surveillance activities were continued through the National HIV Sentinel Surveillance System consisting of both the HIV Serological Surveillance and Behavioral Sentinel Surveillance under the supervision of the NEC of the DOH. Several NGOs and local government units (LGUs) continued to play a major role in some of the surveillance activities. Parallel efforts were previously undertaken to develop the capacity of the STD/AIDS Central Cooperative Laboratory (SACCL) and the Research Institute for Tropical Medicine (RITM) in conducting HIV testing. Presently, HIV testing is being done mainly for employment purposes abroad as a requirement of other countries. Hence, there really is no "voluntary" counseling and testing program in place yet.
Advocacy campaigns, training, and research activities were aggressively done by various NGOs, such as the Health Action Information Network (HAIN), Remedios AIDS Foundation (RAF), Lunduyan, among others. It should be noted that most of PNAC member-agency activities were on AIDS program management, advocacy, and training.
In terms of local responses, local AIDS councils (LACs) have been established in sites previously given foreign assistance. Some of these LACs now have allocated budgets for HIV/AIDS related programs and activities which usually include: IEC, advocacy campaigns, surveillance, and other preventive pursuits.
Currently being developed is the national HIV/AIDS monitoring system. The development and operationalization of this monitoring system aims to institutionalize monitoring and evaluation of all HIV/AIDS activities and to make reporting easier. Just recently, the Fourth Medium Term Plan for AIDS covering the period 2005-2010 was launched. This document contains the strategies that need to be implemented in the next six years, including the estimated cost requirements.
Chapter 2 Objectives and methodology
Objective
The objective of this report is to track HIV/AIDS spending over the last five years (2000-2004) from various sources of financing covering both public and external funds. The aim of this initiative is to inform policy-makers, program managers, and the donor community on the magnitude and profile of HIV/AIDS expenditures in the country and guide them in their planning activities.
Methodology
Primary data collection was undertaken by requesting government agencies, donor agencies and NGOs to fill up dummy matrices which served as data collection tool. Two matrices were distributed to track expenditure flows: by financing source and by financing agents, and by financing agent and by type of activity or function. Donor agencies were requested to provide information on their total spending on AIDS and all their agents, and the activities that were undertaken by each of their agents. On the other hand, NGOs and government agencies were requested to provide all their sources of financing and their activities by source of financing.
Relevant documents (secondary data) were likewise utilized for some of the budget data used in this report in the absence of actual expenditure data. These documents include: project monitoring documents, National Expenditure Program (NEP) publication of the Department of Budget and Management (DBM), General Appropriations Act (GAA), and published project accomplishment report.
Some calculations using assumptions (price-quantity approach, using proportions) with the help of key informant interviews were also made to estimate relevant expenditure items that are difficult to account (treatment for opportunistic infections, prophylaxis).
Detailed methodology is in Annex
Data collection systems
Information systems are apparently not yet in place. Hence, spending data were collected from various sources. Data from public financing agents (national government agencies, local government units) were collected through surveys. However, not all national government agencies were able to complete the survey questionnaire (low response rate) given the difficulty of retrieving historical data (2000-2004). It was for this reason that estimations were made and secondary data were used, such as the General Appropriations Act or the National Expenditure Program document, which contains agency budgets.
For local government spending, the Department of Interior and Local Government (DILG) was requested to collect data from all local government units (LGUs). Unfortunately, not all LGUs were able to provide their AIDS spending data. Data from non-government organizations (NGOs) were likewise collected using survey questionnaire. Again, only a few NGOs were able to comply. NGOs' spending data were, however, validated through the submission of donor agencies' spending data.
The Project Monitoring Staff of the National Economic and Development Authority regularly collects data and monitors the progress of foreign-assisted projects implemented by government agencies (loans and grants covered by Official Development Assistance). It must be noted, however, that it does not cover expenditures of NGOs and data available is oftentimes not disaggregated according to the level of detail required for this report (e.g. health care function).
The tedious data collection process utilized for this report only shows the need for a strong reporting system that must be put in place in order to ensure a systematic monitoring and evaluation of all AIDS-related activities. It is therefore crucial that a strong monitoring and evaluation system be developed which should cover not only activities, outputs and outcomes, but inputs (amount of investments, financing) as well.
Limitations
It should be noted that not all stakeholders were able to provide the required data for this report. Expenditures for orphans and vulnerable children were not included given that there is still no specific program for children orphaned by AIDS. It must be noted, however, that regular programs (protective and rehabilitation services) for orphans and other vulnerable groups are being provided by the DSWD.
Only a few NGOs based in Metro Manila directly provided expenditure information (RAF, HAIN, Lunduyan, and DKT Phils.) on HIV/AIDS. Notably, there are plenty of NGOs all over the country that are actively involved in HIV/AIDS activities. In addition, because of time, financial and geographical constraints, only a few local government units were able to provide expenditure data for some of the years covered in this report. Hence, it can be assumed that the figures provided here may be underestimated.
The expenditures classified in this report under voluntary counseling and testing (as reflected in Table 2 matrices in annex) is not really "voluntary". Most people who go to clinics or hospitals for HIV testing do so mainly for employment purposes abroad as a requirement of the receiving country. Hence, it may not actually be considered "voluntary".
Moreover, with regard to expenditures of public health facilities, only the budgets of San Lazaro Hospital and the RITM were calculated because these two hospitals are considered the major providers of treatment services and given the lack of information on other health facilities that provide these services. It should be noted that ART is usually borne by the AIDS patient. Spending of provincial and local hospitals, including social hygiene clinics for STD management and other prevention activities are not captured in this report.
Also, some of the expenditure items were not broken down into specific functions or activities and some donors (source of financing) were not able to break down their expenditures according to their specific agents. In addition, spending for universal safety precautions and screening for blood transfusion were not included in this report given the lack of information and time constraints although these activities are being undertaken.
Chapter 3 Results
(Refer to Essential Indicators Table)
Financing HIV/AIDS
Total AIDS spending over the last five years (2000-2004) is estimated at Php 1.4 billion. Spending peaked in 2001 largely because of the huge amounts of resources provided by donor agencies--USAID and JICA. During this year, UASID poured its resources with the completion of the AIDS Surveillance Education Project. On the other hand, JICA provided funding assistance for the establishment of the SACCL at the San Lazaro Hospital. Total expenditures slowly declined in the succeeding years.
It can be observed that the share of public sector spending on AIDS in the last five years is relatively small (15.58 percent in 2000, a mere 6.47 percent in 2001 and 21 percent in 2004). It should be noted that in recent years, the Philippines has been experiencing fiscal constraints resulting in limited budget appropriations in nearly all government agencies. A large share of total spending therefore came from external sources (84 percent in 2000, 85 percent in 2002, and 79 percent in 2004).
Public sector sources include National Government agencies and LGUs. National government spending is mainly from the DOH's NASPCP and its Centers for Health Development (CHDs), the PNAC, the DepEd and the DOLE-OHSC, among others. On the other hand, external sources of financing include: USAID, JICA, UNAIDS, UNFPA, Kfw, among others.
It must be noted that NGOs usually get funding from external sources as well. The major NGO players in HIV/AIDS prevention and control activities covered in this report include: RAF, HAIN, Lunduyan, DKT, Philippine NGO Council (PNGOC), among others.
In terms of financing agents, it can be observed that from 2002 onwards, more than half of total financing went to non-public agents or NGOs (71 percent in 2002, 79 percent in 2003, and 57 percent in 2004). The effectiveness of NGOs cannot be denied when it comes to carrying out HIV/AIDS prevention and control activities. This only shows the importance of the NGO community in delivering critical services that are best provided by institutions from the community or grassroots level. On the other hand, this may also connote the weakness in implementation of public agents, or the lack of absorptive capacity.
Nature of HIV/AIDS Program Spending
With regard to specific activities, it can be observed that in the Philippines, resources were poured mostly on prevention activities (77.7 percent in 2000, 65 percent in 2002 and 62 percent in 2004). With the low prevalence in the country, efforts were concentrated on keeping the prevalence low and keeping the rate of transmission slow. Prevention programs in the country include: IEC, condom social marketing, counseling and testing, STD management, among others.
Resources were also spent on program costs, which include: advocacy activities, capability building, monitoring and surveillance, laboratory infrastructure, research and management costs. Notably, a lot of resources were poured on AIDS program cost in 2001 (61 percent) largely by donor agencies (USAID and JICA activities).
Although the share of spending for treatment is very low, it can be seen that from 2002 onwards it is relatively increasing (1 percent in 2002, 1.14 percent in 2003 and 2.4 percent in 2004). These services are limited only to laboratory tests, prophylaxis for OIs and treatment of OIs. Cost of ART is usually borne by the AIDS patient. Efforts are being done, however, to make ART accessible and affordable.
Presently, the government does not have yet a specific program for children orphaned by AIDS. However, regular programs (protective and rehabilitation services) for children and vulnerable groups are being implemented by the DSWD. There is also no policy on providing additional wage benefits for health professionals that cater to persons with HIV/AIDS as in other countries.
Chapter 4 Program and Policy Implications
Generally, more investments are needed in order to halt and reverse the spread of HIV/AIDS given that the total spending on AIDS seems to be decreasing, but the number of cases is increasing. Although the reported cases are relatively low, the disease is deemed "hidden and growing" in the Philippines and the conditions for AIDS to "take off" are present.
Resources are needed for preventive interventions so that these can be improved and scaled up. Prevention activities should be targeted at highly vulnerable groups-sex workers and their clients, males having sex with males (MSM), injecting drug users, and most especially overseas Filipino workers.
Institutional (workplace, school-based) and general public interventions, in particular must be strengthened. Advocacy and IEC activities geared towards encouraging voluntary counseling and testing must be implemented in order to determine the real magnitude of the disease in the country.
Treatment, care and support services for people infected and affected with AIDS must likewise be scaled up and improved. The means of acquiring less expensive ARV treatment must be carefully looked into and institutionalized. Programs specific for children orphaned by AIDS may be developed. Management systems in support of the delivery of HIV/AIDS information and preventive services should be strengthened.
More importantly, resources from public sector must be used effectively and efficiently given financial constraints. Best practice methods in other countries must be examined for possible adoption or replication in the Philippines. Given the volatility in the level of resources, the proper mix of interventions in relation to available resources must be carefully studied so that limited resources are optimized.
Lastly, there is a need to explore the institutionalization of a data collection system so that HIV/AIDS expenditures (among other things) can be regularly monitored and programs and projects can be designed more effectively and efficiently. Although currently in progress is the development of a monitoring and evaluation system, the Philippine National AIDS Council may want to consider adopting the NASA methodology in terms of type of data to be collected and analyzed, standardization of definition, scope of each type of health care function, and ensure compliance of annual reporting of all stakeholders.
Annex
List of Abbreviation
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ART
|
anti-retroviral therapy
|
|
ASP
|
AIDS Society of the Philippines
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ASEP
|
AIDS Surveillance Education Project
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CAFOD
|
Catholic Agency for Overseas Development
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CHD
|
Center for Health Development
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CHED
|
Commission on Higher Education
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CSR
|
Cohort Survival Rate
|
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CWC
|
Council for the Welfare of Children
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DBM
|
Department of Budget and Management
|
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DepEd
|
Department of Education
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DFID
|
Department for International Development
|
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DILG
|
Department of Interior and Local Government
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DOH
|
Department of Health
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DOLE
|
Department of Labor and Employment
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DSWD
|
Department of Social Welfare and Development
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EC
|
European Commission
|
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ERPAT
|
Empowerment and Re-affirmation of Parental Abilities Training
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FHSIS
|
Field Health Service Information System
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FLEMMS
|
Functional Literacy Education and Mass Media Survey
|
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FP
|
family planning
|
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GAA
|
General Appropriations Act
|
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GAD
|
gender and development
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GDP
|
Gross Domestic Product
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GNP
|
Gross National Product
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HAIN
|
Health Action Information Network
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HACT
|
Hospital AIDS Core Teams
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HIV/AIDS
|
Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome
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HDI
|
Human Development Index
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IEC
|
information, education and communication
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IMR
|
infant mortality rate
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ISSA
|
Institute for Social Studies and Action
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JICA
|
Japan International Cooperation Agency
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KFW
|
Kreditanstalt fur Wiederaufbau (German Development Bank)
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LAC
|
Local AIDS Council
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LGC
|
Local Government Code
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LGU
|
Local Government Unit
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MMR
|
maternal mortality ratio
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NASPCP
|
National AIDS/STD Prevention and Control Program
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NDHS
|
National Demographic and Health Survey
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NEC
|
National Epidemiology Center
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NEDA
|
National Economic and Development Authority
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NEP
|
National Expenditure Program
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NG
|
National Government
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NGA
|
National Government Agencies
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NGO
|
Non-Government Organization
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NHSS
|
National HIV/AIDS Sentinel Surveillance
|
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OFWs |
Overseas Filipino Workers
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OHSC
|
Occupational Health and Safety Center
|
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OI
|
opportunistic infection
|
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PAFPI
|
Positive Action Foundation Philippines, Inc.
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PBSP
|
Philippine Business for Social Progress
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PCP
|
Pneumocystis Carinii Pneumonia
|
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PHANSuP
|
Philippine NGO Support Program
|
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PLHWAs
|
people living with HIV/AIDS
|
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PNAC
|
Philippine National AIDS Council
|
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PNGOC
|
Philippine NGO Council for Population, Health and Welfare
|
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PSI
|
Population Services International
|
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RA
|
Republic Act
|
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RAF
|
Remedios AIDS Foundation
|
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RITM
|
Research Institute for Tropical Medicine
|
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SACCL
|
STD/AIDS Central Cooperative Laboratory
|
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SAEP
|
School-based AIDS Education Program
|
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STIs
|
sexually-transmitted infections
|
|
STD
|
sexually-transmitted disease
|
|
TFG
|
The Futures Group
|
|
TFR
|
total fertility rate
|
|
U5MR
|
under-five mortality rate
|
|
UNICEF
|
United Nations Children Fund
|
|
UNDP
|
United Nations Development Programme
|
|
UNFPA
|
United Nations Population Fund
|
|
USAID
|
United States Agency for International Development
|
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WHO
|
World Health Organization
|
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WHCF
|
Women's Health Care Foundation
|
