 My name is Marie Hebert. I work on the Southeast Asia chair here at CSIS. And on behalf of CSIS, it's a pleasure to welcome all of you here to our brand new building. We've only been in here a month, so we're still in the process of breaking it in. So thank you for helping us. This is an event on discussing the health situation in the Philippines. This is co-sponsored by the US Philippine Society, the Embassy of the Philippines, Johns Hopkins Bloomberg School of Public Health Center for Communication Programs, and done in cooperation with the Philippines Department of Health and the Zulig Family Foundation. Just mention that this program is being webcast through the CSIS website, and the Twitter information is at Southeast Asia DC or at CSIS or hash mark CSIS live. Now, we're holding this meeting. It was planned a long time ago. We were holding it at a time of great tragedy in the Philippines. We want to hold the families and people who are suffering immensely in the central Philippines in our prayers. And there's lots of opportunities for donating. The US Philippine Society has information. We also put out some yesterday. The American Red Cross and World Food Program, lots and lots of the NGOs are taking donations. My job here is very simple. I've now performed it, except for turning over the program to Ambassador John Mangio. Monsieur, thank you. Thank you, Murray. Welcome, everybody. Of course, we know it's time for reflection on the impact of the super typhoon Yolanda that struck the central Philippines last week. Those affected included village clinics recently established to provide maternal health services to the rural poor. And you will hear about this this afternoon, because that's what the Zulig Foundation is all about. Now to extend an official welcome on behalf of the US Philippine Society. We have Ambassador John Negroponte, the Society's co-chair. And following Ambassador Negroponte, Mr. William Glass, Director for Strategic Communications of the Center for Communications Programs of the Johns Hopkins University's Bloomberg School of Public Health will join us. But Ambassador Negroponte. Thank you, Ambassador Maisto. Good morning to Secretary Ona, who is joining us from Manila, and I hope he hears this greeting. Good afternoon, Dr. Cabral, Ambassador Romulo, Ambassador Quecia, Professor Gary Lau, Mr. Zulig, Daniel Zulig, Mr. Hebert, representatives from Johns Hopkins, colleagues, and other distinguished participants. Ladies and gentlemen, welcome on behalf of the United States Philippine Society. Super Typhoon Haiyan or Yolanda, as it is known in the Philippines, struck the central Philippines last week with heartbreaking effect. The Philippine government, international and local relief organizations and the international community have launched a massive effort to provide shelter, clean water, food and medicine. Over nine million people are affected with hundreds of thousands in evacuation centers. Reported casualty numbers are growing as communications are reestablished with rural areas. This is one of the strongest tropical cyclones to hit land in history, and its terrifying effects are displayed daily around the world on television and in newspapers. We in the U.S. Philippine Society encourage you to assist by spreading the word about how to provide help. You are health experts, an area of critical need. We have joined with our Philippine partners and co-sponsors of this afternoon's Health Forum to address public health needs in the affected areas where some 70,000 households have been impacted. Our immediate initiative involves an appeal for funding to supply relief kits costing $40. Each kit provides basic supplies to support a family for five days. Let me direct you to the back page of today's program for details on how to contribute. This information is also found on our society's webpage. Our intention to help provide community sustainability first, then to move on to restore health programs so sorely needed over the longer term. You will hear more about those programs this afternoon. So thank you very much for your support and concern, and thank you very much for joining us at this important conference this afternoon. Thank you. Good afternoon, everybody. Representatives of the U.S. Philippine Society, the Philippines Embassy, the Zulig Family Foundation, and the Department of Health of the Government of the Philippines. Panelists and commentators from the Center for Strategic and International Studies, George Washington, and my own colleagues from Johns Hopkins as well as our private sector collaborators in the audience. Given the destruction in the Philippines in the past month with the earthquake and now the typhoon, it's a challenge for those of us at the Center for Communication Programs to focus on longer term development challenges there, such as addressing maternal health. But if even those who are on the front lines responding to these disasters in the Philippines are joining us here today, we can do nothing less than offer them our messages of solidarity. Not only in these challenging days of crisis response, but in their long term efforts to create an enabling environment for sustainable change in key health indicators. We heard overnight that one of our own workshops that was taking place in the Philippines, more than half of the participants can't return home to their hometowns and families. So we're getting some sense of the effects ourselves from our colleagues in country. Despite the destruction brought about by Yolanda or Haiyan, we know that the Filipino spirit of Bayanahan will prevail and that out of this crucible will rise stronger in more productive communities. We at the Center feel a kinship with the work of the Zulig Foundation and the Department of Health in the Philippines. We all understand that key levers of transformative change in the health sector rest beyond the walls of clinics and in the hands of visionary local leaders and enlightened families. For the past 30 years, we at the Center have pursued with passion our belief that putting information in the hands of these actors can trigger broad social movements that move health indicators. And that addressing societal change is a necessary compliment to what happens in clinics. Families are producers of health and inspired local leaders can remove obstacles in their path. In our work in over 30 countries around the world managing 70 grants and contracts, we focus on strategic health communication. Programs that are systematic, evidence based, participatory and capacity strengthening. I'll just mention very briefly three examples of this work. In Pakistan we've worked with our partners to mobilize all sectors of society. Ulamas, men and women, service providers, politicians and the creative classes to take on entrenched maternal neonatal and child health norms. The combined effect has led to increased knowledge of maternal neonatal and child health issues and better health outcomes. One of that program's shining examples of the work was a full length feature film, BOL. It not only spurred national and international dialogue around gender roles and family planning and maternal health issues. It also grossed more at the box office than any other movie in Pakistani history. It's had an impact on national policy as well. There the National Assembly and Senate have unanimously passed two pro women bills aimed at protecting women from negative customs and traditions that seek severe punishments for violators. The second example I'll share with you is from Ghana, our good life campaign. They're working with the National Health Service and the Ministry of Health. The theme of that is life is what you make it. And they're a popular game show, concerts, TV spots, mini docu-dramas and an army of outreach agents at the local level are working to transform norms. The third example I'll give you is from South Africa where our team has been battling the HIV epidemic for 15 years. Their work regularly wins national and international awards and has swept the South African equivalent of the Emmys for two years running and tops the ratings on national TV. Our team's latest, as they call it, adventure in South Africa is ZAZI, a new campaign aimed at women and girls that launched this past May. It encourages women and girls to draw on their inner strength, power and self-confidence to know themselves and what they stand for in order to guide their decisions about the future. I bring up these examples to let you know that our approach to the work resonates quite well with the Zelegs Foundation approach to the work of getting outside of the walls of clinics and outside of the normal health system and trying to inspire broad social change across a wide swath of society. As a body of work, these programs as well as the efforts of the government and NGOs in the Philippines demonstrate that effective health systems require much more than clinics and hospitals. They require enlightened leadership, mobilized communities, and most importantly, empowered families. We're confident that just as the bamboo bends with the wind, the Filipino people will join hands with help and admiration from the international community to forge a more resolute nation committed to the welfare and health of its people. We're proud to be associated with today's event and we look forward to today's discussions. Thank you. It is now my distinct pleasure to introduce Ambassador Jose Cuisia Jr., the Ambassador of the Republic of the Philippines to the United States, to introduce our speaker from Manila, the Secretary of Health, Dr. Nicaona. Ambassador Cuisia. Good morning to Dr. Nicaona in Manila and good afternoon to all our distinguished personalities, speakers, and participants. I've been asked to introduce Dr. Ona, our guest speaker. But before I do so, let me take this opportunity to express my appreciation to the words or expressions of concern, sympathy, and support for the victims as well as families of the victims of the super typhoon. Typhoon Haiyan, more popularly known the Philippines as Typhoon Yolanda. We wish to thank our American friends and the U.S. government, particularly because it was the U.S. government that was among the first to respond to the appeal for assistance when they dispatched C-130 aircraft. Filled with relief supplies as well as Osprey aircraft together with 180 marines were sent immediately to the Philippines to assist in the rescue and relief efforts. Just two days ago, Secretary Hagel dispatched the aircraft carrier, USS George Washington, together with its useful convoy which includes a supply ship and a medical ship that will assist in the rescue and relief efforts. As you know, the carrier also has quite a number of helicopters and other aircraft that would be useful in disaster relief and humanitarian assistance efforts. So we thank the U.S. government and also the American people for their very generous support. Secretary Ona had to say in the Philippines to focus on efforts to respond to the devastating effects of Typhoon Haiyan, or as I said in the Philippines it's known as Typhoon Yolanda. However, he's joining us by video or audio conference to bring the message directly to us. Our guest speakers recognize as one of the top surgeons of the country specializing in the field of vascular and transplant surgery. A graduate of the University of the Philippines, he underwent surgical training in the United States and United Kingdom. He's certified by both the Philippine and American Board of Surgery. Upon his return to the country, he joined the faculty of the University of the Philippines and the Philippine General Hospital. He was professor and vice chair of the Department of Surgery when he was tapped to become the executive director of the National Kidney and Transplant Institute or NKTI, transforming the said institute into the first ISO certified government hospital in the Philippines. Under his leadership, NKTI was recognized as a world-class center of kidney transplantation. He performed the first multi-organ transplants in Southeast Asia, a combined liver and kidney transplant and a combined kidney and pancreas transplant at the National Kidney Transplant Institute. I was privileged to work with Dr. Onam on the board of film care, the largest HMO in the Philippines. At that time, this HMO was jointly owned by AIG and United Health Care. His experience as an expert medical practitioner enriched board deliberations and contributed to the success of the firm. He is a recipient of numerous national and international awards, such as the 10 Outstanding Young Men or TOYM Award in Medicine, 1979, the most outstanding alumnus of the College of Medicine and most distinguished alumnus of the University of the Philippines. He is also the first and only Filipino surgeon to be awarded the Honorary Fellowship of the American College of Surgeons or ACS in 2012, a singular honor for one who is already a fellow of the ACS. As Secretary of Health, he has devoted himself relentlessly to the mission of attaining Kalusugan Pankalahatan or universal health care for Filipinos. Responding to the challenge of his excellency, President Benigno Kino, the third, in his first year, 5.3 million Filipinos or about 25 million Filipinos have been enrolled in field health. During this term, two landmark health reforms have been passed after nearly two decades and five congresses, namely the Responsible Parenthood and Reproductive Health Care or Health Act of 2012, which by the way Dr. Esperanza Cabral was also very much responsible for. And the Tobacco and Alcohol Exercise Tax Reform of 2012. The latter will make it possible to increase the total subsidy for the poor Filipino families, thereby allowing them to increase field health enrollment from 5.3 million families to 14.7 million families or about 45 to 50 million Filipinos starting January 2014. Also just recently, the amendment to the field health law was passed to making coverage compulsory for all Filipinos. Ladies and gentlemen, it's my privilege to send a guest of honor, Health Secretary Dr. Enrique Tiana. Thank you. Thank you very much. You know, I also at this time, with President Benigno Kino, I share a convention that was organized in the state, that is, President Enrique was bringing a level playing field. That is, he was not involved in the same role as we did. That assurance is part of the social contract with our President Benigno Kino, which shared equal access with our members who are actually doing equal access. You know, that was also made in comparison to one of the important or one of the investment you have got, in terms of equal access to one of the investment in the state's field health. Social services. In fact, it is the state of the national address. You know, I was saying, we're going to have a fair amount of time to make sure that by the last, the universe doesn't have to. At first, if you're not involved in the field health law, at least it doesn't have to be. There has to be a federal law in the land area similar to the state of Mississippi. But similar to the state of Ohio, the way Ohio was back in the early 1970s. Why? I mean, if this population between the state and the state of Mississippi, it populates the income lines inside the current population. It's below. There has to be a steady economic growth in 1993. The growth of the national area between 1903 and 1909 is 1,400. There is more than over. It has been well-increased in each other. We have more than 15.5% between 1903 and 1911. 2009. That's about it. Therefore, to make a fair amount of money as the state of Ohio, we have to make a fair amount of money as the state of Mississippi. And according to the Board of Health Organization, we'll have to spend the years in the state of Virginia. We'll be at least 5% of the year to meet the support, the money that has to provide the income of every cent, and for better health outcomes. Why did they have to take this? So, in the meeting testing, we'll have to spend at least 1.4% back in 1995. We're going to have to spend 4.5% life between the two. We're going to have to spend 4.5% life between the two. We're going to have to spend 4.5% life between the two. 53% is still out of pocket, while social insurance covers only 9%. In 1995, the National Health Insurance Act was passed. As you can see, neither government subsidy nor our social insurance have adequately protected the poor from financial risk, despite the fact that Phil Health lo-mandates 100% coverage of all Filipinos within 15 years since 1995. What was the health situation in 2010 before President Aquino was elected? Public health efforts fell short of religion developed with goals especially those related to maternal health. As you can see, it appears that the Philippines will not be able to achieve the MDG target of 52 maternal deaths for every 100,000 live birds. Nothing is done on this. Furthermore, our hospitals are congested and most medical equipment were either outmoded or non-functional. For nearly two decades, the hospitals stayed as they were since they were constructed and did not expand in response to a growing population. What we have is a hospital-bent population ratio that has stagnated for the past three decades. To compound the health infrastructure gap, population growth only made mothers less unreachable. The fertility rate of the Philippines is among the highest in East Asia and average of 3.1 birds per woman of fertile age, especially among the very poor. Our program of universal health care therefore treats us among which are to achieve development goals by 2015, providing financial risk protection for the high cost of catastrophic or serious illnesses, and securing access to quality care at all levels. And the three trusts are being implemented in the continuum of interventions of primary prevention and health promotion, secondary prevention and primary care, and curative health. This is our roadmap to universal health care. The first is the achievement of public health millennium development goals, these strategies such as the reduction of maternal and child mortality, control and elimination of infectious diseases, and the promotion of healthy lifestyle. Second is financial risk protection through the expansion of field health coverage. Third is accessibility of quality care delivery system. And lastly is the improvement of health governance with the strategies of health system development and the maintenance of an effective health regulatory system. As of today, we have accomplished the following. 80% of our children are now fully immunized, 57% of women have delivered in health facilities compared to only 38.8% in 2009. In terms of reproductive health, 2.1 million women of reproductive age were provided with modern family planning commodities last year. And finally, despite significant opposition from various sectors, finally achieved a legislative beat the passage of the responsible parenthood and reproductive health app on December 21, 2012, paying from childbirth from 221 to 50 maternal deaths per 100,000 live births. Our strategy is to increase further facility-based deliveries. Another key accomplishment is the control of infectious diseases including HIV-AIDS, malaria, riases, and others. We have been able to improve the national enrollment rate of field health. This includes 5.2 million poor households of about 20 to 25 million beneficiaries who receive 100% government subsidy for their health insurance premium started in 2011. From a legislative standpoint, the sin tax reform law was signed on December of last year in spite of strong opposition from the tobacco industry. It is estimated that the revenues from the sin tax is projected to generate US $674 million this year and up to US $1.25 billion by 2017. Eighty-five percent of this new source of revenues will be allocated to support universal health care. To enhance financial risk protection, the following benefit packages were institutionalized. This included the no-balance billing policy in September of 2011 from the sponsored program beneficiaries and admitted in the government health facility. The case rate package was adopted a year ago for 23 common diseases, which marked the transition from the traditional people service to a case rate payment system to address diseases which drives families to poverty. The gene benefit package was launched in July of last year. This package included full coverage for breast cancer, prostate cancer, leukemia, and kidney transplantation. We also initiated enrollment at the point of care, which means that poor patients who were not previously identified as poor may be admitted in government hospitals and entitled to the no-balance billing policy. The most visible accomplishment of the Department Health is a health facilities enhancement program which upgraded 1,567 Marangay Health Station, 1,642 rural health units, and 266 total government hospitals since 2010. The Department of Health also upgraded 60 of our national hospitals. Shown here is a small health facility Marangay Health Station, which serves about 3,000 to 5,000 people. This is usually manned by a midwife or an earth. This is a facility tasked with delivery of public health services and primary prevention and health-promoting services. This is a photo of a rural health unit which serves several Marangays or even one whole town and is better staffed and more equipped than a Marangay Health Station. It has a full-time physician, nurses, a midwife, a medical technologist, a sanitary inspector, and even an dentist. Shown is a rural health unit of a third-class municipality in the province of Antique with a population of about 30,000. This picture is a district hospital which may be a 15th to 30th bed hospital which serves a population of as much as 100,000 people. It has doctors, nurses, and other complementary health personnel. This is a picture of a typical department of health hospital with 200 beds or more and serves as the end referral center in a province or a region. To bridge the infrastructure gap is the provision of doctors, nurses, and other health personnel to this help. We have deployed 204 physicians under the doctors to the barriers. 81,952 nurses under the RN Heels program and 2,738 midwives and 40,851 community health teams composed of five members which includes a nurse, a midwife, a leader of the team that is being deployed. We are indeed proud of our Doctors of the Barges program. Shown here on the left is a physician doing a household in a remote village doing preventive and curative care. And the other side shows a doctor giving a public health lecture to an inland community. This year, 22,500 nurses were deployed as part of our registered nurse for health enhancement in local service program. Last July 2012, the Department of Health became the first cabinet department to be fully ISO certified covering both central and regional offices. It has increased its satisfaction rating from good plus 37 in 2009 to very good plus 60 in the latest social weather station survey of last year. In terms of information technology, we have also partially launched a national telehealth service program through the wireless access for health connecting our rural health units to the national health information network. For the first time, Health has formally partnered with the private sector in particular, our program of leadership and health governance with this welling family foundation which will also be presented in this forum today. Other PPPs or public-private partnerships are being initiated into our major Department of Health hospital. Targets by 2016 are to decrease maternal mortality rates of women dying from childbirth, to decrease under five years' mortality, to decrease the prevalence of tuberculosis, to decrease patients getting malaria and maintain the low HIV age prevalence and control its growth. In terms of quality health services, we will complete upgrading and construction of health facilities. We will modernize our equipment and sustain the availability of health human resources and access to drugs. And to minimize financial risk, to also enroll and cover 90% of Filipinos with social health insurance and intend to increase the support value of our health insurance claims. The Department of Health roadmap budget shows our commitment of President Aquino for more investments for health. The budget production shows an increasing trend primary and secondary prevention from 2010 to 2016. However, the Philippines faces unique challenges and gaps with some include among others difficulties to synchronize public health in a devolved, augmented health system. The challenge of bringing health care in geographically isolated areas that involve isolation from medical care and being in conflict areas of enrolling a rapid health insurance coverage to about 40 million Filipinos through our national subsidy or half of the population in three years' time is indeed daunting. We need to reform the governance of public hospitals to make them sustainable financially and not to rely on government subsidy indefinitely. There is a challenge to improve timeliness and accuracy of national data gathering that's as our vital civil registry. There is also resistance to public-private partnerships owing to the misunderstanding of the nature of the relations by the public and opposition from some interest groups. Lastly, the Philippines is within the Pacific Ring of Fire and subject to earthquakes and an average of 20 typhoons every year making it among the most disaster-prone countries in the world. With the most recent one four days ago the Typhoon Highway One or Yolanda Yolk Localic which is considered the most devastating in terms of speed making seven landfalls at 330 to 375 kilometers per hour. The consequence of all these natural and man-made disasters lead to destruction of health facilities that we usually end up repairing or even rebuilding another health facility. This slide shows what happened in Bohol in October 15, 2013 with a 7.2-month-old earthquake that killed more than 200 people and around 597,000 families were affected from six provinces and cities. Quake damaged 57,950 houses, 22 hospitals and 65 other health facilities. This current Typhoon Yolanda that struck the Philippines four days ago has affected an estimated 2 million families or about 9.6 million people in all 41 provinces in the central islands of the Philippines. 615,774 people are displaced and over 433,000 are staying currently inside evaporation centers. The powerful wind of the typhoon which was considered to be as strong as a category 5 hurricane three times the power of hurricane Katrina at 375 kilometers per hour is considered the most powerful typhoon ever recorded in world history and has devastated areas along the central Philippines. On December 16, 2011 this picture shows Typhoon Sendong their national name, Tropical Stone Washi which wrecked havoc on the island of Midanau. The death toll was 1,249 with almost 5,000 injured and 12,000 houses damaged. It is the second highest death toll in Midanau in 35 years. Apart from natural disasters, man-made disasters such as internal conflict, damage health facilities and creates a potential outbreaks in our evacuation areas. Two and a half months ago armed followers of Islamic leader entered the southern city of Sambuanga. The siege which was a result of armed rebellion against the peace process agreement between the Muslim and between the Moro Islamic Liberation Front and the Philippine government state 8,314 families in 27th Equation Center. As a matter of fact, an adjacent government hospital was used as a military staging ground resulting in significant damage to our hospital. On December last year, Eastern Midanau was battered by Typhoon Pablo. More than a thousand people lost their lives and many more were injured. It was also a category 5 Typhoon in reaching as fast as 175 km per hour. Many health facilities were destroyed such as this one. There will be more challenges for the Department of Health but I would like the private sector to partner more with us in the department. Such forms of PPPs are not driven by profit but a desire to assist government in our effort to achieve universal healthcare. On behalf therefore of the President of the Philippines and on a personal note as Secretary of Health I would like to thank the international community for this spontaneous and tremendous outpouring of support and assistance in response to our current crisis. If I ask you to continually support us and for the support that you are giving us I can say thank you and babuhay. We had planned to have some interaction cannot do it for technical reasons but the PowerPoint that the Secretary wanted to accompany this presentation will be on the CSIS website between 24 and 48 hours and it will flesh out what you just heard. So thank you Secretary Ona for that presentation and now we turn to the challenges of reproductive health and for this we have Dr Esperanza Cabral the former Secretary of the Department of Health currently a trustee of the Zulig Family Foundation and Senior Program and Policy Advisor of the United Nations Population Fund. We are indeed privileged to have Dr Cabral here with us today. Thank you very much Ambassador Maisto. Distinguished guests, ladies and gentlemen, friends it is my pleasure to join you at this forum on public health in the Philippines progress and challenges. I wish we could be meeting under less tragic circumstances but I think it will serve to emphasize the challenges of health in general and reproductive health in particular that we have in the Philippines. Thank you. This morning I would like to discuss with you the state of reproductive health in the Philippines as well as the challenges of reproductive health in the country. Just briefly we are talking about a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity in all matters related to the reproductive system and to its functions and processes. In the Philippines, women and young people face huge social and economic barriers to reproductive health. Three million couples do not have access to family planning services and over 5,000 women die from complications of pregnancy and childbirth each year. That comes to 14 mothers every day. Over 33,000 children die in the first month of life. Over 15,000 cases of HIV AIDS have been reported since 1984 and reproductive health problems account for 20% of the burden of health among women of reproductive health and 14% for men. In our country, there are 10.5 million women of reproductive age. 5.9 million of these are at risk of pregnancy at any given time. 3.37 million pregnancies result from this. Out of these 3.37 million pregnancies 1.82 million are unintended and 90% occur in women using no or traditional methods of contraception. For example, natural family planning. Out of the 3.37 million pregnancies, 2.25 million births occur. Almost 1 million of these are unwanted or mistimed. Clearly, unintended pregnancy is a major public health problem that affects not just individuals but the whole of Philippine society. Having babies is not necessarily more fun in the Philippines. We direct our attention to two of the millennium development goals this afternoon and these are MDG goal number 4 and number 5 which are reducing child mortality and improving maternal health. Under 5 mortality in the Philippines is improving and we are scheduled to meet our MDG target of 26.7 per thousand live births under 5 mortality by 2015. We also are not doing so badly in infant mortality rate and while infant mortality rates plateaued in the last 10 years we are probably also going to meet our MDG target of 19 per thousand live births by 2015. However, there is very little progress to speak of as far as MDG goal number 5 is concerned and we are not likely to meet this particular goal. You can see that as a baseline sometime in the 1990s the maternal mortality ratio was 209 per 100,000 live births and our target is to bring this down to about 52 per 100,000 live births by 2015. But in the last survey conducted in 2011 it was found that our maternal mortality ratio is about the same as it was in the 1990s. It is currently at 222 per 100,000 live births. This is mostly due to the fact that contraceptive prevalence rate and therefore unintended pregnancies that result in many complications and deaths for both mothers and infants is quite low. You can see that our prevalence rate for the use of modern methods of contraception is merely 34%. Natural family planning made use of by one out of 200 women of reproductive age even though for the past nine years during the Arroyo administration this was the method of contraception that was advocated by the administration. This slide shows you the percent of currently married women with unmet needs for family planning by economic indicator. And you can see that the unmet need for family planning of poor women is much greater than the unmet need for family planning of rich women. This unmet need for family planning results in a rise in unintended pregnancy risk which has been observed to rise from about 33% of unintended pregnancy risk to about 39%. But the averages tell only part of the story as far as reproductive health in the Philippines is concerned. The poor always have a difficulty accessing health services compared to the rich. This is not something that is new even in biblical times. It was like that so that Matthew says in general for unto everyone that has shall be given and he shall have abundance but from him that has not taken away even that which he has. Inequity is nowhere more evident than in reproductive health care and this shows you some of the indicators of reproductive health in the Philippines. The actual fertility or birth for per women in her reproductive cycle is 1.3 children per woman. But if you divide people into wealth quintile you can see that the actual fertility of women in the poorest quintile is 5.2 children whereas it is 1.9 for the richest women. The wanted fertility is 3.1 among the poor and 1.6 children among the rich. Here you can see that there is an excess of about 2 children per woman if you belong to the poorest quintile whereas the women in the richest quintile have exactly the number of children that they want. The birth interval among women who are poor is shorter than it is among women who are rich and more poor women are child bearing at an early age than rich women. As we mentioned contraceptive use is greater among rich women than among the poor which results in a greater unmet need among poor married women of reproductive age and by the way also non-married women of reproductive age. But I can tell you that it is very difficult to get data on unmarried women of reproductive age in the Philippines they are an invisible group as far as government and society is concerned. Here are a few other reproductive health indicators by wealth quintile. The number of women who deliver their babies with skilled health personnel in attendance is much greater among the rich than it is among the poor. The same with the number of women who deliver in health facilities. The percentage of cesarean section also differs between the poor and the rich. You might recall that in general about 10 to 15% of pregnancies need to be delivered by cesarean section. What you can see here is that only 1.7% of deliveries among poor women is done by cesarean section but 20.3% of all deliveries by rich women is done by cesarean section. The poor, whether they need a cesarean section or not will generally not get it. The rich, whether they need a cesarean section or not will get it. Of interest particularly these days when the rate of teenage pregnancy has been rising is the percentage of young women have started childbearing. Among the poor 44% of women have started childbearing between the ages of 15 to 24 and only 13% among the rich have started childbearing between the ages of 15 and 24. I think that we discussed this inequity in fertility rate. Other consequences of poor women's inability to access modern family planning methods are about 800,000 unintended births, 560,000 abortions, 5100 maternal deaths per year and many other health, economic and social costs. About a decade back the government instituted its contraceptive self-reliance strategy and the national government obligated itself to act as guarantor of last resort assuring that contraceptives remain available for current users who depend on donated supplies. This policy of course failed and from 1998 when 0.1% of women used natural family planning methods the use of natural family planning methods only increased to 0.5% leaving a lot of women with no means of family planning during those years. We know about the three prong strategy to prevent mothers and babies from dying and these are planned families, facility-based delivery by skilled health personnel and access to emergency obstetric and neonatal care. The government all these years have been trying to improve our facility-based delivery rate and the access to emergency obstetric and neonatal care. There have been improvements in these things however there has been no improvement in maternal mortality. The reason being we had not paid any attention or inadequate attention to family planning. When it comes to reproductive health we don't know everything but we know quite a bit. The bigger challenge is applying the solutions we already know to the problems at hand. The gap between what we know and what we do in the Philippines is fundamentally political. There is at the moment general ignorance on reproductive health issues. Poverty impacts a lot on reproductive health care and services and a big part of the reason why we have a poor reproductive health profile is objections from the Catholic Church. In addition and this will be discussed further by Secretary Garilao there is poor leadership and governance not just for reproductive health but for health in general. We have weak health systems weak development activities we implement our signed conventions very poorly our local chief executives and even national chief executives do not recognize that we have a major problem that puts us out of sync with development and finally our leaders are intimidated by the Catholic Church. Such that in some communities there are ordinances that are past banning contraceptives except for natural family planning. Resulting in an increase in the number of unintended pregnancies and births in these localities. One important thing that has occurred in our country is the final passage of the Reproductive Health and Responsible Parenthood Act but it went through a 17-year struggle before it finally became a law and while we need to credit our legislators for pushing this thing for 17 years even though the chances of passing it was very minimal we need to credit our president at present for finally getting the Reproductive Health Bill passed into a law. The Reproductive Health Bill is keynoted by the right to inform choice by the public and the duty of government to provide Reproductive Health information and services particularly to the poor because as you can see we don't need to take care of the rich as far as Reproductive Health is concerned they can take care of themselves it is the poor who actually need Reproductive Health services and they are the ones who are deprived of it. The Reproductive Health Bill therefore aimed to achieve good Reproductive Health outcomes equitably there were many objections to the Reproductive Health Bill but basically it is because it is part of what is known as the death to the family bills in the Philippines and death includes divorce, euthanasia, abortion total population control, homosexuality and same-sex marriage. The philosopher said those who in principle oppose birth control are either incapable of arithmetic or else in favor of war pestilence and famine as permanent features of human life we needed to go through a lot of struggle just as many other Catholic countries needed to go through this kind of struggle before finally getting some amount of empowerment for our women and here are just a few pictures of the people who advocated for Reproductive Health rights and services in the country I was telling you that the Reproductive Health Act was pushed primarily in Congress by three people Congressman Edselagman Senator Pio Cayetano and Senator Miriam Defensor Santiago but finally together with the public that had an 80% approval rate for the Reproductive Health Law the president was able to pass this bill into a law the Reproductive Health Bill is rights-based health-oriented and sustainable development driven it provides for all of these things and many others besides but threats continue there are with the Supreme Court 13 petitions against the law and it went through three months of oral arguments that finished sometime in August the petitioners and on both sides were given 60 days which ended on October 25 to file their final memoranda on the law and now it is entirely up to the Supreme Court not only is the Reproductive Health Law threatened in the Supreme Court there are already anti-Reproductive Health bills refiled in the 13th Congress and the budget for Reproductive Health services will always be a matter of negotiations apart from that there are still very many areas in the Philippines where anti-Reproductive Health local government units have been influenced strongly by the Catholic Church we however hope that eventually the Reproductive Health Law will be declared constitutional by the Supreme Court and we can move to its implementation during which time there will be many more challenges including education adoption implementation and suspension of the activities related to Reproductive Health nobody can argue with this slogan of every woman being empowered every pregnancy being safe and wanted and every child being provided for and loved but still we do face a lot of challenges that would deny Reproductive Health rights and the duty of the state to work for all as far as Reproductive Health is concerned I only wish it gets easier the second time because there will be not just a second time there will be many other times we all have to fight for the Reproductive Health rights of Filipino women as well as women all over the world thank you very much thank you so much Dr. Cabral and now we move to the open forum and I would like at this moment to ask Ambassador Roberto Romulo Chairman of the Zulig Family Foundation to come up to the stage where he will be joined by our two panelists Dr. Rajiv Rimal Chair of Prevention and Public Health of the George Washington University and Ms. Anne Hershey who is a hands on health official from the US Agency for International Development who has just completed a four year assignment in Manila so she should know something of what she's doing Ambassador Romulo as soon as you get seated it's all yours I will have to also be a policeman I have to manage time may I suggest that for three minutes each of our reactors can react and after that they can continue to ask questions and I also ask regarding Secretary Ona those who want to have questions you may want to write it down and give it to Ernie to Faye where is Faye there and we will post it in the web and get answers accordingly if there isn't enough time Dr. Rimal may I ask you first to give any reactions to either Secretary Ona's comments or to Dr. Cabral's remarks Thank you very much dear friends, distinguished guests I am honored to be here to express some thoughts and I guess opinions on what is transpiring this afternoon which I think is very informative as we gather under some very trying circumstances in the Philippines two thoughts before I react directly two thoughts come to mind in this very challenging times in terms of just what has happened when I think about the millions in the larger literature on how people perceive disasters there is a very interesting phenomenon and that is that if you are in the business of asking people to donate time, money and their dedication to a cause like this one you can show people pictures of millions of people being devastated or you can show pictures to people of one single family being devastated and it turns out that when you show people the stories the narratives behind that one family donations increase many fold than when you show them pictures of homes being devastated now why would that be and I would argue that it is a question of how people feel human agency the extent to which they feel that their efforts can make a difference that is responsible for that effect and when we see millions of people being devastated it is far easier to sit back a bit and say someone else will help because after all what could I do to help this huge calamity and so I urge everybody here not to think like that but think about particular children particular women, particular men who have been devastated in what just happened and the two things that spring to mind for me at a time like this are first the natural human aspiration dreams that children have dreams that you and I have dreams that all of us have can very easily be shattered at a time like this and secondly we tap into or we wish to tap into human resilience that will very much that will sorely be needed in the days ahead and I believe the two Filipino words for that are hangad for aspiration and matibay for resilience matibay matibay so I wanted to put that out there as a frame with which to think about and react to the discussion that we have just heard and I guess I would say that the theme that permeated both the talks that we heard this afternoon was one of disparities that yes we know that times are very challenging the mortality rate so many other indicators give us pause about what's happening but there is no denying that the disparity that exists between the haves and the have nots whether it is in the Philippines or whether it is right here in Washington DC have exacerbated in the last 15 years in the last 20 years and unless we do something to address those disparities then the disparities in access to care to treatment will continue to be exacerbated over the years and I would assume that in the talk that we heard earlier the theme of universal health care which we know has its own story in this country and its own set of challenges in a country as prosperous as ours is a wonderfully noble desire in the Philippines and the reproductive health bill certainly can go a long way in meeting those universal needs so let me just stop you for a second and then I'll turn the mic over and I can certainly talk in Iran Thank you very much Dr. Rimal I would like to make a correction on my announcement if you do give the questions to Faye now for Secretary Ona we will send that via email and he will answer accordingly Ms. Hershey would you like to say a few words? I would like to thank you for inviting me to join the panel today I was the health officer of USAID Philippines for four years in Manila and just returned in June and it was one of the best four years of my life and as my family says we're still in Philippines withdrawal and my eight year old says every day I want to go back to Manila so anyway it was a joy to work there and I was honored to be able to work with the staff of the Department of Health with Secretary Ona and with Secretary Cabral and others what I wanted to do is just run through briefly our the USAID program in the Philippines and as I do I can respond to some of the comments that were made by both Secretary Cabral and Secretary Ona USAID's health assistance in the health sector in the Philippines goes back decades and we've worked closely with the Department of Health in introducing child survival interventions such as ORS routine immunization, vitamin A supplementation and others and as we heard in Secretary Cabral's presentation and former Secretary Cabral's presentation that really they're on track to achieve the reduction of under five mortality and I think that's a major achievement and I think one of the challenges going forward is just to sustain in child survival interventions such as maintaining that immunization rate we also help create fill health introduce the field epidemiology training program and have supported the development of health reform agendas and policies throughout the years the program today focuses on supporting the Department of Health's universal health care strategy or call a sugam pangalahatan and I think it's a testament to the leadership of the DOH that all the donors can know about KP and most of them can pronounce it and we're really all on board in terms of supporting the government the three thrusts of universal health care improving health infrastructure financial risk protection and the achievement of the MDGs so it's an example of a clear strategy put forth by the government to really improve the health of the Filipino people and also the emphasis on improving equity so everyone does talk about the lack of access for the poor and we're all donors included and civil society and non-governmental organizations looking at how we can go that last mile to really reach the vulnerable to reach the JEDAs which is one of my favorite acronyms, geographically isolated and depressed areas really trying to get to people who haven't had services and need services so what we do is we under this overarching under this overarching strategy of universal health care we provide technical assistance training, materials and supplies really working with the Department of Health and not parallel but working through the existing structures to strengthen maternal and newborn health family planning, tuberculosis and HIV AIDS supporting the Department of Health in terms of health care finance particularly fill health enrollment accreditation and utilization local government leadership and management and improved health data it was the USAID with the Department of Health and I believe the World Bank that supported the family health survey of 2011 which showed that we really hadn't made the gains that we thought we were going to had that we should have made in reducing maternal mortality so that was really an eye-opener I think that helped, even helped advocate for the passage of the RH Bill and we work in 40 provinces closely with all levels central, regional and local I think one of the most important things that the government has done is promoted a protocol essential interpartum newborn care and we are promoting the scale up of that it really looks at preventing postpartum hemorrhage cases of death during the delivery and also providing a key set of newborn interventions so I think again one of the challenges going forward is we have a good protocol we have good policies but we really need to scale them up and make sure that they're implemented in the way they were intended and of course in family planning we support the DOH and its goal to increase access to quality family planning information services and products at the national level because there wasn't there was a focus on just natural family planning at the national level but I think there's a real opportunity with the current administration and we're really taking advantage and working closely with the Department of Health to scale up access to FP and one of our strategies is to look at counseling, integrating FP into maternal and child care maternal and you know we're also looking at the program of counseling and we're also looking at the academic and maternal services oh I'm sorry okay so that's it I just think it was a great summary by doctor Govral and secretary Ona I completely agree with the challenges and I think it's really equity and quality that we have to look at going forward thank you My name is Vicky Navarro, I'm the President of the Philippine Nurses Association of America. And Dr. Cabral, thank you so much for that presentation. We actually have a demonstration project that we are starting in Bacolod. And what we would like to do is to actually educate more RN midwives. Because the RN midwife is actually a very important role in the UK and in the Middle East. And with maternal and child health and the Planned Parenthood, a nurse is actually a lot more critical thinking than the midwives. I'm not saying that they're not qualified, but the education and training of a nurse allows her to do much more better assessment. And gestational diabetes and preeclampsia, polyhydramnios, those are the causes of maternal mortality. And so in addition to that, these RN midwives will actually train the midwives and the helots. And the helots. And for sustainability, we know that RN midwives, they will go somewhere after a while because the salary is not competitive. So we will need to go to the midwives, train the midwives on how to do screening for diabetes. How to take blood pressures. The helots as well. Our challenge is to get a grant for this program. So thank you so much. So your statement basically is midwives should be better trained in this area. And the question is how can we find appropriate funds to do this? Because we are partnering actually with a school in Bacolod. In an NGO and the barangays. You're preaching to the converted and what we need is people to support that endeavor. Because first of all, we don't even have enough midwives. We have too many helots. And actually it's 17 midwives for 42,000 barangays in 2011. That was the number in 2011. And the midwives should get along with each other by the way. So thank you. I hope that this forum will actually help us get grant funding because PNAA unfortunately we don't have a track record for having grants. So we are actually struggling to get grants. But it's a good program. Thank you very much indeed. Another question? Yes, ma'am. I'm Gloria Federigan from McLean, Virginia. I'm Gloria Federigan from McLean, Virginia. I have a brief question to Dr. Cabral. Thank you for the presentation. But I don't see any aspect in the presentation regarding the negative aspects of having this RH. As we know, a lot of people are practicing liberal sex. Many people also are irresponsible in having sex. They are unmarried or unmarried. I think that kind of thinking and behavior should be also addressed when we have this RH bill discussion. Thank you very much. The reproductive health law in the Philippines addresses risky sexual behavior, if you will, as well as values. These are all aspects of reproductive health. And in the Philippines, there is no argument about all the other aspects of reproductive health except for contraception. And that's the reason why that was the focus of my discussion. I don't think anybody can argue with prevention of sexually transmitted illnesses. I don't think anybody can argue about breastfeeding for infants. Nobody can argue that there should be male involvement in reproductive health. All of those things, the church and the people who are advocating reproductive health agree on those things. It's only on contraception that they don't agree. Thank you very much, Dr. Cabral. Yes, ma'am. I'm Nina Reynoso-Ray and I'm a case manager and a member of the BNA. I work with Children's National Medical Center. And my focus of interest is the RH. Does it cover sex education? And have you included that in the school curriculum? Because I see 15 to 24 as one of the highest, the ages where there's a very high unwanted pregnancies. Now, with that being said, I'm a product of a Catholic school. I graduated. And I don't think taking OBGYN nursing. I don't think that was at all discussed during the time I was taking up nursing. So that being said, faith-based Catholic schools would be a challenge for you to include that in the curriculum. How would you handle this? Well, a lot of debate occurred on age and development appropriate sex education. And what happened was age and development, sexuality education, as far as the RH law is concerned, is compulsory for public schools, but optional for private schools. We couldn't pass the reproductive health law if we did not make that compromise. But I agree with you that sexuality education is important and should start when children start thinking about the birds and the bees, so to speak. I think there's time for one more question. Yes, sir. Dr. Junasula, UPD, Medical Alumni. Well, back in the Philippines, we have cultural and religious differences. Up north, it's more Catholic predominance. But how do you deal down south when they're non-Catholics, when they're wary of government attempts to control population? So one program we did was we tried to involve the female religious leaders, teach them proper birth control and hygiene. But in terms of government program, how do you deal with those non-Catholics? You will be glad to know that there were no objections from the Muslim area as far as reproductive health is concerned. In fact, the armed region, the autonomous region of Muslim Indenal passed their own reproductive health law ahead of the Philippines. I'd like to thank Dr. Rimal and Anne Hershey for participating in this, and of course I'd like to thank Dr. Cabral once again. She is certainly the strongest advocate of reproductive health in the Philippines, and I hope she continues to fight and maybe beat up some of those Supreme Court people. So thank you very much indeed. Fifteen minutes for a coffee break. But if we come together, there is some hope for our mothers. And so it is with that mindset that we are approaching that. And the reason we have taken on this problem, maternal mortality, is very clearly that if we do nothing in the next decade, it's estimated that nearly three million women will die from complications of pregnancy and childbirth. And please remember that most, if not all of the causes that are killing these women, are preventable. In this side of the world, decisions on whether to paint the room pink or blue, where to deliver, what kind of a party to have, those are the questions that surround a childbirth, the happiness around a childbirth. Whereas in many parts of the world, they send their daughters and their wives and their sisters without knowing whether they'll see them again. So it's preventable. And yet this tragedy occurs. So the issue is, can we come together and do something about this? The reason a maternal death is devastating is because when a mother dies prematurely, it is not just her death. Very often, the children at home suffer. The child in the womb dies. The family dies. The community dies. The nation dies. They say when a mother bleeds to death, so does the nation. And even economically, women account for one third of the GNP of a nation. All the work they do in the house and in the farms, and if you were to add all that up. So it's not just the right thing to do. It's also the smart thing to do. Without a strong mother in the house, there is no strong community or nation, both physically, mentally and economically. Merck made a commitment two years ago that we would bring all of MSD to this problem. In addition, we pledged $500 million over the next 10 years. And we have pledged to work in partnership. And our partnership in the Philippines is a good example, and I've come here to represent that partnership. But basically, what my company has said is that we will approach this problem bringing in all what Merck can do. And for a company like MSD Merck to be a successful farmer company, we need to know from end to end, we need to know consumers, how to change behavior, we need to know supply chains, we need to know pricing, we need to know policy, we need to know how does the drug get from the bench of the scientist to the bedside of the patient. We know that. We do that for a living. The idea is can we bring this kind of mindset to a public health problem and join in partnership. We don't want to believe we can do it. So that is what we're trying to establish here. We are approaching it by focusing on the two big killers. And the two big killers worldwide is postpartum hemorrhage and preeclamps here. Again, we know why they're dying and we know how to save them. And Dr. Cabral, you'll be happy to know the third pillar is family planning and reproductive health. Because if you don't get pregnant, you won't die from it. So we are focusing on those three big targets. And the way we're doing it is through innovation. This is what MSD knows best. How can we bring the next game-changing innovation solutions? We also know that it's not enough to bring out an innovation. We need to make sure the woman has the access to that at the time she needs it, where she needs it, when she needs it, at a price she can afford. And that is our access activity. And we also know the importance of advocacy. That 16 years of languishing of the reproductive health bill passed only because of the advocacy efforts that was done to make it come through. So advocacy is important. It's slow. It's a slow burn, but it's important to amplify what you're doing. So those are the ways we're doing it. We also are evaluating our programs in real time. London School is working with us to evaluate the programs in real time. And we believe 80,000 Merck employees all over the world can bring a lot to bear on this. So that's what we're doing is all of Merck is coming in. So far, it's been two years since we've taken off. And we are in 20 countries, including the Philippines, I'm proud to say. This is my last slide. I am not going to get into the details of the program and the partnership because I understand Ernesto Garila will now follow me and will give you an overview. But basically, we are partnering with the Zulik Foundation and the Zulik Foundation strongly believes that if you have empowered and engaged local leaders who are technically and technologically supported and who themselves take ownership and that we take the effort to train them and make them owners of this, that is how you shift the needle. And we truly believe and we are partnering with the Zulik Foundation in this kind of training of the local governments and local leaders. And we've chosen a particularly difficult area in the Philippines. And Ernesto will talk about that also, I'm sure. And I'm happy to say we are getting some initial good read and some good results. I look forward to working on this project and I will leave it for Ernesto to talk about it. But I was hoping to bring to this group, my closing remark would be the importance of making sure that the private sector joins that triangle in these kind of efforts because there is something we can bring to the table. And in this instance I think it's working well. Time will tell. Thank you. Thank you so much, Dr. Rao. And now we have Ambassador Romulo coming to the table who is going to tell us about the Zulik family. And this is a story, a short story that must be told in order to understand why all of this is going on. Let me use it. And we'll continue to be of our government. But I think part and parcel of that in terms of response. You need the private sector to be very much involved. I would suggest that what Merck has done is just the beginning, together with the Zulik family foundation. You need more public, private partnerships. And I want to discuss that. And public-private partnerships goes beyond just infrastructure. And what we're doing, the Zulik family foundation of which, as you may have heard, I'm also the chair, although I'm known for other things. And it's extremely important. For me who did come originally from the private sector, in many ways, the way I feel is government must enable. And it's the private sector that should implement it. And I think my country is starting to understand that situation. So thank you very much, Dr. Rao. We really appreciate that. And before I, and I have 10 minutes, I will do a lot less, John, I promise you. The second point I wanted to emphasize is because of this regrettable disaster that we have today, we can go on and tell you everything about it. But the truth is, CNN and NBC and ABC is covering it better than any of us could do it. However, within the context of our little portion of the Zulik family foundation, where we have adopted multiple municipalities, and now we're going to work with the Secretary of Health for another 609 municipalities, our feedback so far, although there's portions where we have no feedback. At least 10 municipalities that we deal with have been substantially affected and they need help in terms of rehabilitation and in terms of relief, meaning ability to feed and feed their families. So in that context, and Professor Gary Lau will cover this more, I just wanted to say I hope you listen to this presentation on that part also because we're talking about 40,000 households and 240,000 people. So in that alone will require a substantial amount of money of something like $2 million just in that portion. So you multiply that with what you read in the newspapers, you can see the kind of challenges we have in that respect. Now, you've heard the name Zulik multiple times during this presentation and it's a Zulik family foundation and many of you may wonder what is a foreign name like Zulik doing in the Philippines to begin with and what on earth are they doing supporting a foundation? First things is the Zulik family started sometime at the beginning of the 20th century and the Zulik Foundation or rather the Zulik FE Zulik Groups effectively had its beginnings in 1901 and Dr. Steven Zulik and Danielle Zulik you'll hear from later his father Gilbert grew up and were born into Philippines and been doing business there even during the war. So many may think they're these foreigners, they're not just foreigners. They're Philippine born, they're Philippine citizens and they're also switched by blood and citizenship. In this day of dual citizenship let me just say they've been very pertinent in the livelihood and in the Philippine society and I'm personally involved with his uncle Dr. Steven Zulik who interestingly enough is a very young 96 years old and let me just suggest that he has done wondrous things for our country in many ways. So now in terms of the Zulik Group without belaboring the point the reality is they are now a multinational corporation all over from Australia and New Zealand all the way to India and they have their worth in that respect. But in the context of the Zulik Family Foundation they have multiple corporations they have their own corporate and social responsibilities but Dr. Steven Zulik and Mr. Gilbert Zulik said we owe a lot to the Philippines and we want to personally give our funds to support this family foundation. So it's separate and distinct from the CSR works of the various corporations. Again thank you for joining us but now let me give you a very brief video of what the Zulik Family Foundation is doing followed by a very interesting presentation of Professor Ernesto Garilao. Thank you. I just imagined in 2009 Ang Lapuyan and Merong 6 deaths which is equivalent to 1600 maternal mortality ratio. I don't know if this will happen to my child. This is starting from the reality that I should own the problem and we need to work together to answer what we can do with our help here in our city. There's not much to learn in the program because we don't have personal insurance. Sometimes we don't have medicine to give. I'm not sure if my budget for health is really enough for the whole year that I will be pregnant. Because of my engagement with the Zulik Family Foundation we initiated the Barangay Health Board. They are also learning about data-based collections and what problems regarding health in their Barangay. I have a lot of children. I hear other voices. She's a good mother. She's a good friend. She's good for the whole family. I thought that I would have a check-up. I'm sure everyone is aware that they should seek the health services given to them by our health personnel. If you're okay, I'll be okay. One of our supporters here is to help them and be a good friend of their child. They need to get these services because we give these services to them as basic services to all the local officials. Our Archeopo is a fell-health accredited. It's a blessing to you. If you're willing to live my life, we'll be able to do this. I always take vitamins so that you're strong and not sick. My budget for health increases almost every year before we started with 7% to 13%. We have three big groups. One is the RHU, who catered for service delivery and two are in Tiguwa and Marwing. They serve cluster barangays. The three big groups of service delivery have a maternal shelter that we provide to them. And the shelter, expectant mothers could stay before and after delivery for a day or two. We formulate the ordinance. The children are free at home and the children are at the facilities. From health workers to barangays, to the mayor and their families. I feel like I have a lot to do. Because my partner, Zwelli, has the capability of building modules that we do, workshops, and an eye-opener for all health concerns that we need to do in our country. All training is a big help for us to focus on the Millennium Development Goal. I have a son in a month. He told me that if I can go, we'll be close to him. I have a lot to learn. As a person, I know that we can do what we have to do if we are able to work and we can do everything in unity with Stan and we can solve our problems. Just imagine, in 2009, Lapuyan alone has six deaths, which is 1,600 maternal mortality ratio. And in 2011, we reduced it to zero maternal death. So it can be done, pa la. Inaya natin, anak. Sekita din tayo sa wakas. Now we have, as he comes to the podium, Ernesto Garilao, who is going to elaborate. Thank you very much. The video you just saw gives you a clearer picture of what we at the Zwillig Family Foundation, or ZFF, do for, do in rural health. And the Zwillig initiatives in this area are guided by its firm belief that the key to improving the health situation among the poor is the local chief executive. That is the mayor. The mayor must be transformed into a health champion, one who fixes the system and makes health programs accessible to the poor and responsive to their needs. Only then can health outcomes improve. First, a brief background on ZFF. As Chairman Romulo said, it started as a corporate foundation in 1997. In 2002, it focused on policy advocacy and training of health professionals. And sometime in 2008, the foundation became the Zwillig Family's vehicle for philanthropy. And as such, it had to settle the question of relevance and impact. Where could its resources be placed to ensure a critical point of leverage? Simply put, how can the work of the foundation make a real difference and lasting national impact? The family decided that it was in the health sector where its resources could best make a relevant and strategic contribution. For after all, the family's strength was clearly in the health sector where it had been in business for several decades. This was in 2008. And at that time, the evolution of health services from the national to the local government has been in effect for over a decade and a half. While well-intentioned, the devolution produced a fragmented health system. Municipal governments were in charge of primary health care. The provincial governments looked after curative hospital care, and the national government took charge of tertiary care and specialized hospitals. When the devolution took place, many local governments, especially those in poverty areas, were unprepared to take on the responsibilities. Mayors failed or simply did not know how to wield their authority and use their resources to create responsive health programs and services. And this led to health inequities that had dire consequences on the poor. And I think the past speakers, in fact, mentioned that. The 2008 numbers noted the late former secretary, Alberto Romualdes, underscored the serious disparities between the health outcomes of the rich and the poor. Those in high-income urban areas, like Metro Manila, Cebu, and Davao, had outcomes comparable to those in developed countries while those in low-income rural areas had numbers closer to those in the least developed countries. For example, life expectancy at birth among people in rich areas was over 80 years. It was less than 60 in poor areas. Infants in poor areas were nine times more likely to die than those in rich areas. Likewise, maternal mortality, or MMR, was at least 150 per 100,000 live birds in poor rural areas, and it was less than 15 in rich areas. And those in the richest quintile have the option of giving birth in a private facility while 87% of the poor have only one option. In 2008, to deliver at home, assisted primarily by a traditional birth attendant, making the mother at risk. Data in 2008 also showed that when seeking health care, 48% of the richest quintile went to private hospitals, 31% to private clinics. In contrast, over half or 53% of those in the poorest quintile went to either the village health center or the rural health units of their municipalities. So essentially, the poor just went to the rural health unit, not to any private facility. These health inequities led the Zwillig Family Foundation to focus on the health of the rural poor, where relevant contributions can have strategic impact in terms of improvement of health outcomes across the country. It began formulating a strategy that was also aligned with the Millennium Development Goals on Health. What the Zwillig Family Foundation plan to do can be best summed up by what it calls the Health Change Model, which is heavily influenced by a marchesense development as freedom. Health outcome is a function of people's access to health services. Just how responsive health services are is largely determined by existing institutional arrangements that in turn are made possible by a responsible leadership. Responsible leaders craft policies that make health services more accessible to the poor. The thesis of this Health Change Model is that a transformed leadership would reform the existing health systems to address health inequities and produce better health outcomes of the poor. In building the capacities of health leaders, the Foundation adopted the bridging leadership approach specifically designed to address social inequities. At the core of this approach is the personal transformation of the mayor. The goal is for mayors to learn to connect their life's purpose to the quality of life indicators of their constituents. This interior transformation is deeper, more personal, and has a more lasting impact. Personal ownership or owning the problem is therefore a necessary prerequisite before mayors can convince other health stakeholders of the need to address existing inequities. The Foundation's intervention involved a two-year, four-module training with six months of practicum in between. During the training, the mayors and the municipal health officers are given structured learning exercises to help them become bridging leaders. During this practicum, they are given coaching and monitoring advice so that they can apply their competencies in bridging leadership to develop their local health systems. It is during this practicum when local governments work on reducing inequities. Here, they are guided by the municipal health system Technical Roadmap, which was developed by ZFF based on the world's WHO's Organization Six Building Blocks of Health Systems Development. Each building block has a system of indicators, the status of which serves as the basis for coaching and mentoring, sessions of municipal health leaders. Between 2009 and 2012, ZFF piloted its health change model in three types of municipalities which we organized as cohorts. The first type consists of low-income municipalities with high health burdens, characterized as cohort one, two, and four. The second type are municipalities in the autonomous region in Muslim Indirao, which are also low-income, have a non-devolved setup, occasionally suffer from security disruptions, and whose moral populations strongly adhere to traditional beliefs, cohort three. And the third type consists of municipalities located in geographically isolated and disadvantaged areas. Given its geography, there is very little access to health services. This type also has a high poverty rate with poor health-seeking behavior among its population. It also has security concerns. Building on the health change model, the ZFF was able to adjust its strategy based on insights called from the experience in working with these municipalities, assessing those that produced positive incomes and were cost-efficient. In the case of Lapuyan, the video that you just saw, an initial assessment based on the roadmap showed the majority of its health indicators were below the national standard. And this is it. I think one of the things that we asked the mayors to do is to really learn what the health system is all about, what are the different components of that system, health and leadership, financing, access to medicines, delivery of health services, et cetera, et cetera. And here they take a look at their health system. They make an assessment of where they are in terms of the indicators. And in the case of Lapuyan, when she did her assessment, it was basically all red. And that, in fact, was resulted in six maternal deaths when she first started out. By the time she finished the course, her scorecard looked something like this. So essentially, they're now all green. She still has some reds to attend to. But this is the result of a two-year practicum program wherein they have a better appreciation of the components of the health system and start working on the indicators. And we always tell them, you have to take a look at health as a system because if you want to see to it that it's going to be sustainable, then you have to address a lot of the indicators there. Specifically, health leadership and governance, information systems, health financing and the program, especially on maternal health. Results like this have been encouraging. And the ZFF3 cohorts that completed the two-year program, these are our graduates, have shown significant reduction in the MMR. And basically, this is a Sentinel indicator of the quality of health system. So the next one, when you take a look at, when we looked at their MMR, starting 165 in 2010, really dropped to 58 in 2011. By 2012, it's already below the target of 52. And so far, in 2013, it is 49. And this is really the intervention in terms of health leadership and facilities-based delivery. What is not imputed here is the intervention on family planning because we feel that if we improve the contraceptive prevalence rate, you will have the possibility that the MMR would even go down. But the objective here is not really below 52, as Dr. Lozare was telling us. It is really zero. We always tell the governors, the mayors, that their target was that there should be no mother, no mother should die in my municipality as far as maternal deaths are concerned. Now, what accounts for the good results? One factor that contributed to the good results is the foundation's practice of choosing municipalities with high health burdens but whose leaders are committed to improving health systems. If you're not committed to improving your health system, you're not part of this particular cohort because we feel that if the person is not committed, then no matter what interventions you will give him, he's not really going to work out. The other factor was that we ensured the delivery of effective training plus practical. You train but you have to do your deliverables during the practical period. That's when you do the indicators. We continue to monitor the performance and provide coaching and mentoring. The foundation's approach is therefore not transactional. It is not a one-time engagement similar to implementing a specific project. Rather, it is transformational. A long-term relationship because what needs to be fixed is a system and that it takes time. MMR in cohort municipalities that have yet to complete the program remain high. If you take a look at cohort four and five, they're still working out. Cohort five on the right-hand side is interesting because these are mostly in summer. These are the MMR of our partnership with Merck for Mothers. As a matter of fact, we were thinking because of the recent typhoon, unless interventions are done, you really would see the spiking of MMR. Primarily because you see the breakdown of health systems, the loss of income sources, malnutrition for children, infection deaths. And with loss of income, mothers don't anymore go to the rural health units. They just remain in their homes. The next step is we learn to simplify our approach. In 2010, we began to see improvements in the health system and an opportunity was to develop a shorter and less expensive approach to our change model. And this was done through an agreement with the University of Makati or UMAC, which piloted a simplified approach in an initial target of 20 out of the 300 sister cities of the city of Makati. And the results of the UMAC, first two cohorts showed that MMR in batch one had fallen to zero as of end of September of this year, but the batch two increase can be explained by the decrease in the number of live birds despite the drop in death cases. Aside from the health outcomes, this program gave us valuable insights on how to simplify the approach without sacrificing the quality of training and outcomes. And based on these insights, the two-year program was reduced to one year. And unless absolutely necessary, ZFF staff did not conduct field visits. The coaching of mayors was done in Manila and frequently they were in the area and the monthly coaching of the municipal health officers was done over the phone. And these changes dramatically reduced the intervention costs. The foundation's experience with UMAC led to further adjustments and the use of the model resulting modified approach for expansion and replication of the model. The expansion of the scope of the health change model is done through partnerships with UNFPA in nine provinces, zeroing in on family planning, with Merck Mothers for Health in 21 municipalities in summer, focusing on maternal health, with USAID in five provinces, including health plus tuberculosis. And discussions are ongoing on the United Nations Children's Fund for 36 municipalities. And I think when you take a look at it, a lot of these partners really looked at the role of local chief executives, the mayors and provincial governors, in fact to own the health issues in their community. And once they own it, then they can modify their system accordingly and produce better health outcomes. In December 2012, the opportunity to reach the critical point of leverage came when Secretary of Health Enrique Ona invited us to replicate the model in 609 poorest cities and municipalities in the Philippines. While there is top leadership support for this program, the replication strategy still faces some formidable challenges. And I think this is true for in development areas. When you start doing replication, where in the mainstream institution, now that's the replication of an approach proven effective in its pilot stage, then there are replication issues that have to be addressed. And the first is scale. The leap from 94 municipalities to 609 requires a different implementation modality. Ownership by the DOH bureaucracy requires institutionalization of the health and leadership governance program. And its central and regional offices and this program must be seen as an enhancer and not a competitor of existing programs. In other words, the bureaucracy itself must own the different approach. And if they own it, then what institutional arrangements can be worked within the program. The new arrangements also have to be accompanied by new skills in handling health and leadership. The DOH field personnel will serve as coaches. And the academic partners, regional academic partners, will now serve as training providers. So whereas before we were doing the training, now we move the training technology to the regional academic partners. So they themselves will do the training with the regional DOH. Incidentally, in this model, the DOH raised almost 800 million pesos for this program. None of the resources go to us. It goes directly to cover the cost of the training and to cover their cost as well as the cost of the academic partners. And the last factor to consider here is our own capacity to transfer the capacity-building program and the training and the coaching competencies to both DOH and academic partners. And I think here it's really a great opportunity because you have a private sector that has proven a method that is accepted by the top leadership of DOH. And now the challenge is how do we now get the bureaucracy to do the new institutional arrangements that in fact would address that. The next slide that I will give you is that we started 81 municipalities this year that have undergone the first training. Their collective MMR is 95. And we were telling Secretary Orna that he should be able to see changes in the movements by the second half of 2014. Everything considered. I mean, if the assumptions hold, the rate will drop. And if the rate does not drop or does not drop accordingly, then you go back and take a look at the interventions and what should that be? So that is the first 609 municipalities and that essentially largely will depend on the DOH capacity to provide coaching during the practicum. As we told the Secretary, in areas where DOH is prepared, the program will go fast and the converse is true. Looking ahead, the next step that he asked us to do is to do the next set of 624 municipalities. And that is the original reason why we're having this forum. You have a briefer there that gives you an idea of the funding requirements for which 8.4 million will be raised for the program. And we hope that you will consider this. The relationship between DOH, CFF, and the academic institutions show how existing challenges can be addressed by public-private partnerships co-owning the issues and co-creating the strategic interventions in the spirit of trust and collaboration. And these new arrangements will result in better health outcomes and we have no doubt that it will. My last slide is really about the Typhoon. I think you've seen this. We took this from Washington Post. You see the band, the dark band there, which is really where the Typhoon went through. And we have proponents, 14 municipalities in summer, two municipalities, zero maternal mortality for the past four years. But with that, you just have to... What would be the interventions that would prevent the spike? Because in a disaster situation, you would really know that the maternal mortality was spiked. We have not heard from Romblon. We have not heard from Asbate down there. And I think two municipalities will be affected somewhere here because that's Agutaya and Magsaysay. And if there was a storm surge, they would have been quenched. But the more problematic area is really summer. And I think the major ones there are really at south of summer, three in eastern Visayas because that was the first landfall before it moved over to Tacloban. And then it went through western summer, you have here. And the thing about western summer is that the health system is not in place. Western summer is notorious for bad governance. And really did not take care of its referral hospitals. And the referral hospitals, since the referral hospitals were not in order, they in fact went to Tacloban for emergency obstetrics care. And the facility in Tacloban in fact was destroyed. So in a sense you have to take a look at that area and you say, all right, if Tacloban is no longer operable, where do the mothers go? And unless those interventions are going to be attended to, then you will see the spike. And I think our challenge really is to see to it that the interventions is done and to see to it that the system is taken care of. So with that, thank you very much. Thank you, Professor Garilao. Everyone can see how what Zulig Family Foundation does and ties into what the typhoon rendered. The second open forum will now begin. Ambassador Ramalo, will you come up please? And he will be joined by our second set of panelists, Mr. Basel Safi, Head for Asia, and Mr. Matthew Lynch, Director for Global Program on Malaria with the Center for Communication Programs of the Johns Hopkins Bloomberg School of Public Health. And Dr. Rao and Professor Garilao will also join the panel. So this is a rich panel. And Ambassador Ramalo, as soon as you get your people seated, we will begin. Ambassador Quezier, you. I was going to make further comments, but we'd go over time. So let me just keep my mouth shut and turn over, begin with comments from my right, was from Dr. Lynch. And then after that, I'll ask for comments from Mr. Safi. And then questions will follow. Thank you very much. And thank you all for being here. So I will keep my comments very, very brief. It's really a pleasure to follow a talk as comprehensive as Professor Garilao's because really he covered it all. And there's not a whole lot else that needs to be said. I did just want to emphasize a couple of points that he made that I think have broad applicability across the developing world as well as in the Philippines. I think the importance of private sector partnership, public private partnerships is hard to overemphasize. It really is an incredible confluence of capacities, merging what the private sector can do in terms of supply chains and planning with the public sector responsibilities and ability to direct subsidies and civil society's ability to mediate that role with the general public. It's very, very powerful. One key point that I wanted to make that is a key issue right now in the malaria world is the importance of local level data. I cannot say how important it is in empowering these local level government officials with not only the ability to collect data, but the capacity to analyze that data and use it for planning. It's incredibly powerful. I think we will see that in terms not only of the maternal mortality and some of the other indicators, but I also think we'll see that in terms of the impact of the typhoon because local mayors who are used to looking at the situation, analyzing it in a rational manner, and then using that data to make decisions are going to deal with the impact of the catastrophe much more effectively than those who are not. My congratulations to all involved. This is a remarkable program. Thank you, Dr. Lynch. Mr. Batsafi. I'd like to thank everybody for inviting me today. I've enjoyed this afternoon's sessions and in some ways I think I represent the multiculturalism of the Zulig Foundation as a passport holder from three different places. So I welcome this international group. When Dr. Rao was speaking about the golden triangle, I think implicit to what he was stating is that the mother who's pregnant, the mother we've all been talking about today, really sits at the center of the golden triangle. And when we talk about innovation, access, advocacy, and the context of what President Ernesto mentioned in the health change model, really what we're talking about is capacity. Capacity for change. And I think when we think about that individual level change, a lot of emphasis is put on the system around that individual, that system around that mother. But really the first line of defense in many cases is changing health behavior at the household level. Because health seeking behavior is often the first pivot point through which all these things are possible. So when we think about capacity, we must think about at an individual level for those household members, for that woman and the people who surround her at the organizational level and helping leadership to pursue sometimes unpopular agendas, as we heard with the reproductive health agenda and the Philippines today, and also to encourage lawmakers and citizens to see the value of that change within the system. And certainly when you look at the interaction of the public sector, the private sector, and civil society, we see that at the heart of this lies an ability to rally around a key issue and keep that pregnant woman in our hearts and minds throughout this. And I think a good example of that capacity is actually a project that Johns Hopkins Center for Communication Programs is engaged in now in the Philippines with the generous support of USAID and the Ministry of Health, where we're really looking at capacity across these various systems. And Anne and I were just speaking during the break and come to know that we are a subcontractor to a private sector firm in the Philippines called Campaigns in Gray, which in the 90s actually served as a subcontractor to Johns Hopkins CCP. Now we're working with them on this multi-year USAID project to build capacity among the local health workforce at all levels of government. So I'd like to applaud the group today and the efforts towards maternal and child health in Philippines, and thank you for your time. Thank you, Mr. Safi. I think both our commentators have given us a little more food for thought. But I think at this point, perhaps, there would be questions from the audience for the two main speakers here. Please. Professor, thank you for this great forum. I am Dr. Cabellon of the University of the Philippines Medical Alumni Society. We do some help also in the Philippines, but the big question that I have for Dr. Garland, I believe, is that how much of an additional investment in terms of money, in terms of personnel, in terms of knowledge that you have to invest in the one factor of trying to make a dent on maternal mortality. Health is not just maternal mortality. There is dengue. There is malaria. There is cancer. There is cardiovascular disease. So this is one aspect, and if I were the mayor of a town in the Philippines, this is a big headache. The intervention that we have, our direct cost goes around half a million pesos, including the training and the modules. When we did the University of Makati, the intervention cost actually went down to around 75,000 because other institutions pick up the costs. But I think the pay off there is that, in fact, they will put in more resources, more local resources for health. For instance, in the case of Lapuyan, she moved from 6% to 13%. And we really want to move them to 13% to 15%. And when they have that kind of expenditures, basically they would cover the basics. One thing that we also knew was that when you try to get them to concentrate on all the facets, it's too much for them to handle at one time. So in other words, do MMR, IMR, TB, Dengue, Malaria, et cetera, et cetera. They get overwhelmed. But in a sense, you ask them to do what goes first. And the first really goes maternal, MMR and IMR. And once they have gone through that system, then they take a closer look at infectious diseases, and even now they are looking at non-infectious diseases. So when you take a look at costs, and I think that's why in my presentation I said,