IAG WEBINAR SERIES O2: Policy & Program Considerations for COVID-19 Response in BARMM
This is the second of a series of webinars that the IAG is running on COVID-19 and the BARMM. Last week (April 3), we had BARMM Local Government Minister and Spokesperson Atty. Naguib Sinarimbo giving us a situation in the region and the responses to the COVID-19 pandemic that are being undertaken by the Regional Government and the implications on the Bangsamoro transition.
In the second episode of our webinar series (April 7), we will explore recommended policies and programs to strengthen COVID-19 response in the BARMM. Our guest is BTA Member Atty. Laisa Alamia whose minority block submitted to the BARMM Chief Minister recommendations for responding to the COVID-19 pandemic in the Bangsamoro region. Atty. Alamia currently sits in the Bangsamoro Parliament as Minority Leader. She is a human rights lawyer with over fourteen years of experience in civil service. She is also a registered nurse and a women and children rights advocate.
I’m here to present some proposals that we have come up with in addition to the BARMM Inter-Agency Task Force (IATF) on COVID-19 at the regional level. Some of these proposals have already been taken on or implemented by the regional government and by the local government units (LGUs). Some are still to be implemented, so I would like to immediately present to you what these proposals are.
I'll be focusing more on the health aspect. If you look at the public health emergency in the Philippines, you will find that public health in the Philippines is decentralized, meaning it's at the level of the local government managed by the LGUs with the Department of Health (DOH) as the lead agency at the national level.
If you look at the structure of the National Disaster Risk Reduction and Management Council (NDRRMC), there is a sub-structure there under DOH wherein we have what we call Centers for Health Development (CHDs). These are the regional offices of the DOH. Within these CHDs, we have what we call the Health Emergency Management Staff or the HEMS, the office that addresses health concerns of emergency services in the context of emergencies and disasters. They go down to the provincial health offices, city health offices and municipal health offices. The LGUs play a big role in the whole structure when it comes to a health emergency. BARMM comes in at that level. The regional level, while there is a separate Ministry of Health (MOH), the MOH is under the structure of the autonomous region of the BARMM.
Under Section 22, Article IX of the BOL, it says, “The Bangsamoro Government shall assist and cooperate with the NG in the provision of quarantine services for the prevention and control of epidemic and other communicable diseases.” That means the Bangsamoro has the authority to help the national government in times of health emergency cases. Under the Bangsamoro government, looking at the structure again, we have the MOH, BARMM Disaster Risk Reduction and Management Council (BDRRMC) – because the BARMM is new it was created recently through Executive Order No. 12 series of 2019. At the same time there is what we call the BARMM Rapid Emergency Action on Disaster Incidence (READI-BARMM) – this used to be the ARMM Humanitarian Response Team. Under the BARMM, READI-BARMM is now managed by the Ministry of Interior and Local Government (MILG). For now there is no policy framework yet on disaster and emergency management including public health emergency because BARMM is just starting when this pandemic occurred.
If you look at BARMM, it's special in the sense that it is a different structure compared to the national government and to the other regions in the country. It's divided into two: you have legislative and the executive that are fused into one. The executive is composed of the interim Chief Minister plus his cabinet and they are at the forefront of emergency response. They are the managers and implementers of the programs using the emergency funds. On the other hand, the legislative or the parliament is the policymaking body in the region. It also rallies support for the region’s response to the crisis and it enacts laws or initiatives relative to the emergencies. For example, if there is a need for us to realign the budget to provide a supplemental budget to counter the effects of COVID-19, the parliament is able to do that.
This is the overall proposal. Although this is also – if we look at other countries, this has been the goal of all of the responses and interventions that have been done by governments across different countries.
Initially, there was just one objective and that’s to flatten to the curve. Why is there a need to flatten the curve? If there are no protective measures then the number of people who will be afflcited with COVID-19 will rise, the peak would be very high compared to the healthcare system capacity. But if you put in protective measures, then the curve will lower and flatten eventually.
There is a second objective considering that in the Philippines and in particular, in the BARMM, we have a problem on our healthcare system capacity. So we need to also look at setting up interventions, putting in facilities that would raise the line, raise the bar, that means raising the capacity of the BARMM healthcare system.
If the objective is to flatten the curve, the proposal is for strict enforcement of containment measures. This is already being done – you can see that in NCR, you can see that also in local government units across the region in the Bangsamoro. When you talk about containment measures, this include social distancing, quarantine, home quarantine, self quarantine, self isolation, enhanced community quarantine or lockdown. That should be strictly enforced, otherwise we will not be able to flatten the curve and more people will get the disease.
The other intervention is for increased testing and contact tracing. There is where right now, we are having some challenges and difficulty. We need to increase testing and contact tracing, otherwise we won't know who among the population are actually afflicited with coronavirus, who among them are carriers except when they go to the hospital and they come in manifesting moderate to severe symptoms.
We have been advocating for increased testing and I think that DOH at the national level has already responded to this already. There is already an expanded list of testing laboratories across the country.
I have seen that list and the Cotabato Regional Medical Center (CRMC) in Cotabato City is included, still at stage 2; there’s also one in Zamboanga City and then other parts of the country. In particluar, in Mindanao we have already a testing center, and that’s the Southern Philippines Medical Center (SPMC) in Davao City.
But it's not just about putting up these laboratories. We need to also determine who will be tested. The DOH protocol or algorithm for testing would require only testing if there is a patient that would go to the hospital and exhibiting mild to moderate symptoms. That’s the time the patient is tested. PUMs and PUIs who are asymptomatic are not tested.
We would like to really push for increased testing – first and foremost of all the PUIs and the PUMs so that we can pinpoint and stop the virus in its track, pinpoint who are carriers even if they are asymptomatic so that immediate treatment can be provided and they can do strict isolation or home quarantine.
Aside from increased testing, we also proposed provision of various economic support to ensure and enhance compliance of citizens. If we do enhanced community quarantine, if we expand the period for the lockdown because we have not yet flattened the curve, we would expect a lot of negative effects as a result of people who rely on daily wages who wouldn't be able to work. Those who are living under the poverty line would suffer more and so the government, and in this case, the Bangsamoro government, should be able to provide sufficient social economic support to all the households in the region. This will also ensure compliance of citizens with strict enforcement of containment measures.
The next objective is to raise the line. This was one of the first proposals that we have submitted. If we do an inventory of the identified hospitals that will become COVID-19 centers or facilities in the BARMM, we need to look at the number of ICU beds that are there: how many are ICU beds, how many are ventilators, or respirators that are present right now in these hospitals. We found out that there is not a single respirator or ventiltor, for example in BASULTA hospitals. Before we try to increase the capacity of the regional healthcare system we need to do an inventory of all of these hospitals.
In increasing the capacity of the region’s health system, these are our proposals. We need to free up more beds in public and private hospitals. Because there is a shortage of ICU beds, we need to work with other hospitals that are present or the hospital itself, which has been identified as COVID-19 center or facility should be solely devoted to handling cases of COVID-19. We need to free up more beds just in case the number of cases increases, those with moderate to severe symptoms.
We also need to identify non-hospital settings for self-isolation of mild cases. How is this done? For example, in Zamboanga City, the city government has partnered with the private sector, with the academe, with Ateneo de Zamboanga City, for the use of one of its campuses for self-isolation or quarantine area for those who are PUIs with mild symptoms – and even now there is a clamor to include also PUIs who are asymptomatic.
The mass testing should also include mass testing of medical frontliners. Why? Because if all of the medical front liners would be considered as PUIs, for example in particular hospital, and no one is left to take care of the patients because everyone will be undergoing self isolation, but if we're able to test and the results would come out immediately then we would be able to determine who among the medical front liners are actually positive. This is for practical reasons, it would be really helpful.
Going back to the non-hospital setting, aside from the example I’ve given, local government units can look at other hotels, hostels or gyms in their own locality and transform that into a COVID-19 facility or center where they can put the mild cases. Just be ready with it – set it up, put all the requirements that are needed, the beds, if there’s a necessity to expand the ICU unit in the existing hospital to this extended area like in a gym or a hotel. If funding is the problem, this can be done in coordination with the Ministry of Health, the Office of the Chief Minister in the Bangsamoro, and the Department of Health at the national level. There are also those in the private sector and national officials who are providing help.
We need to increase the number of ICU beds, ventilators and respirators. The other thing is we have to ensure that there is sufficient PPEs and medical grade masks for our medical frontliners. In the BARMM, for example, in BASULTA, that is a major problem because there is a lack of PPEs, masks that can be worn by our medical frontliners. If this will continue and we are not able to provide that immediately to them, the medical frontliners will suffer first, especially if the people could not be contained and would not follow the rules, the guidelines on enhanced community quarantine.
The other proposal which is more on the medical side is to set up negative pressure rooms within the hospital. That means if an ICU is already identified as a COVID-19 unit, that room should have negative pressure. What are negative pressure rooms? These are rooms where the air that’s inside doesn’t get out and so it lessens the possibility of the spread of the contagion.That is a bit difficult. Usually this is done in tertiary hospitals in first-world countries. For example in Saudi Arabia, all of the tertiary hospitals, their ICUs are using negative pressure rooms to protect the medical frontliners and to protect the other people working in the hospital and the other patients who do not have COVID-19.
The other thing that can be done, if you look at the screen, that's a picture of a patient being intubated by a doctor within or inside an aerosol box. This one is an improvisation, instead of negative pressure room they can use aerosol boxes. There is a DIY in the internet that you can look up on how to come up with aerosol boxes. The purpose of this is to make sure that the virus does not spread and medical frontliners are protected whenever they provide care to the COVID-19 positive patients.
The other thing we need is to also look at the wages and incentives of the medical frontliners. We know that the medical frontliners have one of the lowest salaries in the entire country. In the BARMM, a lot of them are not permanent employees, they work based on a contract and they receive only a very small wage compared to what they could receive if they work abroad. I think it is high time that the country, and the BARMM because it has a block grant – it is autonomous, it has a better structure at least on paper, a bigger budget compared to the previous autonomous region – would be able to focus a big percentage of it’s budget and resources to increasing the wages and incentives of frontliners, to redesigning the current health services, improving the facilities, making the hospitals, especially in the island provinces of Basilan, Sulu and Tawi-Tawi because they are too far from Cotabato City where the seat of the Bangsamoro government is situated.
We need to strengthen, redesign and capacitate the medical frontliners who are in these hospitals. We also have to strengthen the treatment protocol by ensuring sufficient medication. The question is, if a COVID-19 patient in an island, for example in Sulu, and not in the mainland Sulu, would be afflicted with COVID-19 and would have to be brought by boat to Jolo, Sulu so that the patient can be attended to at the hospital there, at the COVID-19 center, would there be sufficient medication that can be provided? What kind of medication can be provided? Is there a DOH algorithm on treatment protocol for COVID-9 patients? That is a question that I have also asked our doctors particularly those working in the BARMM. Is there an algorithm for a treatment protocol of COVID-19 coming from DOH? Because right what we have – these doctors, these hospitals, public and private, are doing their very best, responding and intervening or providing medical intervention to patients with COVID-19, with whatever facility that they have, whatever medication that they have, whatever machines that they have just to save the lives of these positive COVID-19 patients. I think there has to be an algorithm for treatment already at the national level. We can look at the experiences of other countries, like Taiwan for example, even Singapore, China and some other countries that have been successful -- that there's a lot of recovery in this country, what kind of treatment protocol was used there and then we need to initiate training programs for health professionals in urban and rural settings in the Bangsamoro.
We’ve submitted three proposals. The first one was an economic response plan of COVID-19, and then the regional diagnostics facilities and the third one, supplemental guidelines of COVID-19 response. I’d like to go through these proposals one by one.
When we submitted the first proposal prior to the coming up with a contingency plan by the BARMM IATF – I have not seen yet the contingency plan – but we proposed that there should be a series of protective interventions and social amelioration programs for the Bangsamoro community on health, emergency relief and aid that includes food and non-food, livelihoods, for example wage subsidies, financial support, also crisis recovery and that would include, for example, the banks within the BARMM providing incentives, providing loans with very small interests to businesses that have closed. These are very, very important and then subsidies to those who don't have work right now. Those who are working the government will continue to have salaries, but those in the private sector, they don't have any salaries for now, they don't have any income, so it’s very important that we put a budget on these protective interventions and social amelioration programs.
After we submitted this proposal – it's a good thing that Congress has passed the Bayanihan To Heal As One Act – where it is provided that there is a social amelioration program that will be implemented by the DSWD. The president said that they need more funds because if this will extend, then we have to get more funds to be able to provide for everyone including the BARMM.
Within the BARMM, under the fiscal year 2020 Bangsamoro budget, we can activate fund approrpriations that are already there. The block grant is between 60 to 65 billion pesos. Under the Office of Chief Minister, we have allocations for project Tabang and Ambag. Ambag is a program under the Office of the Chief Minister and it’s earmarked currently for hospital expenses of COVID-19 patients.
It’s a very good thing, what the Office of the Chief Minister has done so anyone who would be COVID-19 positive and would need hospital care would be taken care of through the Ambag program.
Then there's the emergency assistance program or EAP under the Minisry of Social Services and Development (MSSD) and then the MILG under the internal affairs program where the BARMM READI is being managed, they also have a budget of almost one billion pesos. As for the Ministry of Agriculture, Fisheries and Agrarian Reform (MAFAR) you can look at the production support service sub-program, they can utilize that. Under the Ministry of Labor and Employment (MOLE), there is also a workers welfare program. So this one is on top of what the national government will provide under the Bayanihan Act. Under the Ministry of Trade, Investment and Tourism (MTIT), there is a budget there for the promotion and development of trade and industry including SMEs, plus there’s a contingent fund under the Office of the Chief Minister.
The second proposal which I am very happy to note that the Minister of Health, Dr. Saffrullah Dipatuan, in a press conference, said that the MOH is going to pursue this. Prior to that we proposed the activation of the provincial diagnostic facilities through the GeneXpert SARS-CoV-2 testing. This was found out that the GeneXpert SARS-CoV-2 testing – there are already machines for this. These machines have been donated to the hospitals in the BARMM in the previous administration and they are being utilized to test tuberculosis. But what is needed are the new cartridges on the GeneXpert. We can also look at what the University of the Philippines has done, that can also be utilized in the meantime there are no cartridges for the GeneXpert SARS-CoV-2 testing.
The other thing is, because this one is not just for this particular emergency, is that we can set up mobile diagnostic facilities for free COVID-19 testing in areas that need diagnostic capacity. If you look at the geographical location of the provinces of the BARMM, this would really be helpful for Basilan, Sulu and Tawi-Tawi.
The third proposal, and this is the last one, is to scale up the current guidelines in the management of response operations and – this one we introduced a categorized multi-layered approach in managing the outbreak prevention and containment. Why multi-layer? Because the whole issue of COVID-19 is also multi-layered. We looked at the population, we grouped them and do contingency planning and do interventions based on this particular classification.
Group A can be those persons who are unrestricted, not positive, not PUI, not PUM. Group B are the persons who are under monitoring. Group C are persons who are under investigation, the results of the test have not yet come out; they are asymptomatic but they are considered PUIs because they must have traveled to an area where there’s a lot of cases, or they are a member of a family wherein one member is positive for COVID-19. Group D are those who are confirmed cases with mild symptoms. Group E are confirmed cases with severe symptoms.
If we go back to the objective of flattening the curve, how do we handle Group A? These are persons who are unrestricted, healthy and not infected, so again, we have to reiterate social distancing. I think all of local government units should enforce protective measures such as self-quarantine, regular washing of hands, wearing of masks when going out. In fact in some LGUs, if you go out, it is now required to wear a mask. Our local governments – we extend lockdowns with community quarantines, prohibit mass gatherings, ensure continuous disinfection in health facilities, markets and other public structures and then continue relief operations that are being done now.
The relief operations should be rationalized so not all groups, for example, if you look at the particular situation happening now, several groups, several layers of the government are providing relief operations to the same community. We need to maximize resources. I would like to cite an example, a very good practice of the Maguindanao Provincial Government. They have scheduled the relief operations, so the first week it will be the barangays, second week will be the municipality, third week will be the provincial government and the fourth week, it's the regional government that will conduct the relief operations.
I hope that is being implemented and respected by all the layers of government. That maximizes resources just in case we will continue with the community quarantines for up to two months.
We also need to pursue partnerships with both the public and private institutions to impose moratorium on loan, rents and mortgage payments. This involves everything. I hope the private sector would be cooperating.
The second group, the PUMs. The PUMs have history of travel and exposure to a confirmed case of COVID-19. They do not have any sign or symptom then they should undertake strict home quarantine for at least 14 days. But considering the latest data of who are dying, I think we should extend the 14 days to 21 days just to be very sure. The government should put into regular monitoring these PUMs by concerned Barangay Health Response Emergency Teams (BHRETs). The BHRET is a very important component of the entire health response emergency system. It's at the barangay level. The BHRET has already been set up by the DOH, and now by the MOH – they are there set up by the local government units in all of the LGUs in the entire Bangsamoro region. They should be made use of by the LGUs and MOH in the continued relief operations for the PUMs.
For the PUIs, they exhibit symptoms but these are very mild. There are two things that can be done. The first one is for them to observe strict home quarantine through isolation in a separate room if possible, so that the PUI, if ever he is positive, will not infect the other members of the family. But considering that we are targeting lowering and flattening the curve and the way we see it, it’s very difficult for people to follow this rule, the other thing that can be done is to set up isolation areas with partner hotels, gyms and other buildings to house the PUIs. If they are considered PUIs with symptoms but very mild, take them out of the family and put them in an isolation area, provide all the care, provide food for them and if there’s a need for treatment, treat them. That would stop the transfer and spread of the virus to the other members of the family. Then activate the public health system for the treatment, test the PUIs, and the caregivers in the family under home quarantine. This one I’m really advocating, it’s not just the PUIs that should be tested but include the caregivers under home quarantine if we really want to stop the spread of the contagion. Then BHRETs will do regular monitoring, the government should provide relief and medical assistance.
For those confirmed cases with mild symptoms, they should be placed in an isolation areas with complete set-up. That means there are beds that can be transformed into ICU beds, there’s medicine, there are caregivers with PPEs, and then conduct regular tests for the patients including the caregivers and the family who are at home undergoing strict home quarantine. For those undergoing strict quarantine at home, they should be provided relief and medical assistance.
For those confirmed cases with severe symptoms, they should immediately be brought to a COVID-19 health facility. That is where I think there has to be somehow the medical association of doctors in the country together with the Department of Health coming up with options for treatment protocol and algorithm that can be utilized.
For our doctors, they should be equipped with ICU beds, ventilators. Hopefully the BARMM government would procure ventilators for the hospitals in the five provinces of the Bangsamoro region, aerosol box, and at least one internal medicine expert – pulmonologist, respiratory therapist and ICU nurse. Critical care is a special field, we cannot just put anyone there. They have to be trained. We can do very quick capacity building on the existing medical personnel right now in hospitals and then provide them with sufficient PPEs and other support such as interim housing for the medical personnel, meals, even transport assistance and prepare to expand the isolation area if the hospital will not be sufficient if the number of patients continues to increase.
Those are some of the proposals that we have made and and I think it's very important that everyone will cooperate, that we put out any politics. Let's work together, both the private sector and the government and the community, so that we can heal as one.