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INTRODUCTIONBACKGROUND OF THE STUDY The Eastern Visayas region in the Philippines composed of six provinces was once considered as endemic for Filariasis and Malaria several years ago. The parameters such as baseline survey, clinical and diagnostics, mid- sentinel surveillance, active case detection, Mass Drug Administration (MDA), post- MDA survey and dossier was conducted and implemented to attain the very high target of filariasis and malaria program which is the elimination of the disease. There are two pillars in the National Filariasis Elimination Program of the Department of Health, one is the Mass Drug Administration (MDA) which is to cut the transmission of the disease and two is to halt the progression of the disease through Morbidity Management and Disability Control (MMDP).Southern Leyte, Biliran, and Eastern Samar Province attained the target of MDA coverages above the benchmark of 85% from the time of its MDA implementation until its declaration as Filariasis-free. The remaining provinces such as Western Samar, Leyte, and Northern Samar, hit the target in its late years of MDA’s implementation. In the epidemiological assessment through mid-sentinel and spot check evaluations, cluster survey and final evaluation of the six provinces, it established favorable results which led to the official declaration of the first Filariasis- Free region in the Philippines. Southern Leyte province, the first province declared in the country in 2008, followed by Biliran Province in 2010, as the third, Eastern Samar province, rank eleventh of the Filariasis- Free province in 2011, Western Samar and Leyte, rank 13th and 14th, respectively in 2013 and in 2014 Northern Samar province rank 20th filariasis- free provinces of the country.

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The strategies brought by the national government such as technical assistance on leadership management, networking, collaboration, advocacy, integration, capability building, monitoring and partnership and collaboration with non-governmental organization yield to an explicit and creditably good Mid- sentinel survey, final evaluation, border operation surveillance, post- MDA result and report in the six (6) previously declared filariasis endemic provinces in Eastern Visayas Region. Filariasis, according to the World Health Organization (WHO) is a disease of the poor. The disease is usually seen in areas with low visibility and low political voice which is common in remote and rural areas. It primarily affects the poor communities in developing countries. The shame and stigma are common in Filariasis and is most often “covered-up,” wherein the principal clinical manifestations of enlargement of the extremities are imminent eventually results to avoidance in coming to seek help in the health facility. This gives a picture of the scope and the impact of the disease, which mainly affects the economic and social burden in the endemic areas. Since the disease is not fatal, it ranks low on the health priority agenda, and the disability it causes is greatly underestimatedThe global data shows that filariasis affects more than a billion of people in 83 countries who are living in areas endemic for lymphatic filariasis, which makes them at risk.

Eight hundred seventy-three (873) millions of it resides in the South-East Asia Region, which the Philippines is part of it.Based on WHO, filariasis is otherwise known as Elephantiasis, because of its recognizable sign of swelling of either one or both legs which looks like an elephant’s leg. It is one of the oldest and most neglected tropical diseases in the world, second from Leprosy, a mosquito-borne parasitic disease, which in the very late stage is painful and very disfiguring.

Figure SEQ Figure * ARABIC 1 Distribution and status of MDA for lymphatic filariasis worldwide, 2011 Source: WHO. (2013). A handbook for National Elimination Programmes. WHO Lymphatic Filariasis.

p4According to the LF manual of the WHO, filariasis resembles a thread-like filarial worm under the microscope. There are three filarial parasite that affects human which are : Wuchereria bancrofti, Brugia malayi and B. timori: Wuchereria bancrofti or Bancroftian Filariasis, is most common parasite in the tropics and sub- tropical areas, Brugia malayi parasite is usually present in the Southeast and Eastern Asia, while Brugia timori is common Indonesia and Timor- Leste.

Figure 1, gives a picture of the worldwide data of filariasis in terms of endemicity and MDA.”According to the WHO, worldwide data shows an estimated 120 million cases of lymphatic filariasis, wherein there are about 40 million people disfigured and incapacitated by the disease. When the male and female filarial worms together form “nests” in the human lymphatic system, the human lymphatic system which is responsible for the network of nodes and vessels that maintain the delicate fluid balance between blood and body tissues is affected.”The CDC describes the life cycle of filariasis starts firstly with a bite by a mosquito of an infected human. While in the mosquito, the parasite goes through different stages while developing, of which only the third stage is infective. When an infected mosquito bites a human, the parasites are deposited on the person’s skin, the entry point to the body. From this, the parasites will migrate to the lymphatic vessels and eventually developed into an adult worm over a period of 6-12 months causing damage and enlargement of the lymphatic vessels.

The adult filariae live for several years in the human host. During this time, they produce millions of immature microfilariae that circulate in the blood. The larvae further develop inside the mosquito before becoming infectious to man When a mosquito bites an infected person the microfilaria are then ingested. Thus, a cycle of transmission is established. Its acute local inflammation, involves the skin, lymph nodes, and lymphatic vessels and often accompanied by chronic lymphoedema, the swelling of the lymph nodes. The painful swelling of the limbs is caused by fluid retention.

The genital disease which is the collection of fluid and swelling of the scrotum and penis is sometimes accompanied by high fever. Most of the population infected with filariasis are asymptomatic and do not have obvious symptoms in its early infection, although virtually all of them have subclinical lymphatic damage. And these infected people have 40% kidney damage, with proteinuria and haematuria (protein and blood in the urine, which is not normally found in healthy people).

After the death of the adult worms which usually takes place for about 10-15 year, is the start of the overreaction of the disease which is the enlargement of the upper and lower extremities, and some affect also the human organs such us scrotum and vagina, the breast will be visible. The most common disabilities of filariasis are lymphoedema, particularly of extremities (hands and feet) and hydrocele (scrotal swelling). Figure SEQ Figure * ARABIC 2Filariasis life cycle: Wuchereria bancroftiSource: WHO. (2013). A handbook for National Elimination Programmes. WHO Lymphatic Filariasis. p17 Based on the history, LF is among the most neglected tropical disease in the world One the obstacles is the lack of diagnostic and investigative tools and is largely underestimated by the government and the implementers.

The following paragraphs will describe the reasons why LF is part of NTD.In Figure 2, it describes the life cycle of filaria in the vector and in the human host. It shows that after copulation, the adult worms release their young or microfilaria (MF) into the blood. Not all infected individuals are infested with MF, many have active infection with living adult parasites but with no MF circulating in the blood, some MF only circulate in the blood during the few hours on either side of midnight, thus making the diagnosis difficult. It, therefore, needs a lot of time and involves manpower and support. Among the reasons why Filariasis is part of NTD is due to its nocturnal character periodicity which contributes enormous practical barrier for diagnosing lymphatic filariasis and understanding its distribution. The blood collection and examination should be at night because of its nocturnal periodicity.

A blood collection is made wherein thick blood smear should be made and stained with Giemsa or hematoxylin and eosin. In endemic regions like the Philippines, blood smear method is the most practical and affordable method of examination. Other serological test and technique such as concentration are tedious, difficult, expensive and requires technical expertise, therefore it is not recommended for field implementation. Moreover based on a study it is notable that the laboratory test for patients in its very late stage is more likely result in negative in the blood test. Hence, patients with enlarging extremities are oftentimes negative in laboratory examinationThe technical aspect of LF program like understanding its cycle is important for its diagnosis. Without knowing the periodicity of the parasite will likely give a false result in laboratory examination.

The difficulty in diagnosis of LF as discussed in the previous paragraph leads to mass drug administration (MDA) as the main intervention for the filarial program. The use of this strategy results in the reduction of the transmission of filarial infection resulting to decrease of transmission that it is not any more sustainableThe drugs of choice for filariasis in the Philippines are Diethylcarbamazine Citrate (DEC) and Albendazole. Albendazole has a synergistic effect in combination with and is effective at reducing microfilaraemia for up to 12 months. It is significantly more effective than any drug alone.MDA is implemented and treated on an outpatient basis, whether through a house to house technique or conducted in an affixed site by the health workers in the community. Overseeing and supervision by the local health implementers in the conduct of MDA is recommended for community member’s compliance with therapy and for the management of febrile reactions in heavily infected patients.

The first pillar of LF which is MDA is explained and elaborated in the preceding chapter, which purpose is to progressively reduce and interrupt transmission. The following paragraphs will discuss on the second pillar of the program which is disability management or MMDS of patients with overt reaction to halt the progress of the disease and to alleviate the suffering in which is conducted by educating the patient through home disability management to effectively manage lymphedema and avoid secondary infection. Figure SEQ Figure * ARABIC 3 Overall framework of GPELF and sequential programme steps recommended by WHOSource: WHO.

(2013). A handbook for National Elimination Programmes. WHO Lymphatic Filariasis. p3In the process of eliminating the disease in areas endemic for filariasis, as shown in Figure 3 the initial activity of the health department in every region is to conduct a mapping through blood examination in the entire area to evaluate the endemicity. Once the smallest administrative unit which is known as the “barangay” has >1MFR, the entire municipality/city and eventually the entire province is declared endemic for LF. In this case, the recommendation of the WHO is to conduct MDA in declared endemic areas for at least 5 years targeting an 85% MDA coverage or until the MFR is <1.

High MDA coverage will reduce microfilaria to a level that it will not sustain transmission and for a period long enough to exceed the fertile lifespan of adult worms. That is why it is very important to achieve high coverage of MDA in all endemic and at-risk communities. Moreover, according to the WHO to implement vector-control techniques is an adjunct activity to MDA. Therefore education such as the use of personal protective measures like using mosquito repellents, bed nets and insecticides prevents mosquito bites. Furthermore, the conduct of search and destroy activities is essential to reduce mosquito breeding places. Integrated vector management and personal protection measures are useful complements to MDA.In the previous paragraph, it is learned that filariasis is transmitted by a mosquito.

Based on the study there are various species of mosquitoes that can transmit a parasite, depending on the geographic area. In the Philippines, the vector of filaria is Aedes, Culex and Anopheles mosquitoes. To get infected with filariasis you have to be bitten thousand times repeatedly over several months to years. Since there is a number of different species of mosquitoes which is responsible for transmitting lymphatic filariasis, it, therefore, adds to the challenge of developing effective vector control strategies to eliminate the spread of these infections.The Department of Health (DOH), in 1998 eyed on the global call for the elimination of lymphatic filariasis. Based on the baseline survey conducted the national microfilaria prevalence rate was 9.7 per 1000 population.

The program started with National Filariasis Control Program (NFCP) which later shifted the strategy from control to elimination. This was pressed and pointed out during the drafting of the National Filariasis Elimination Plan, the signing of the Administrative Order No. 25-A by the Secretary of Health which formally started the National Filariasis Elimination Program (NFEP). This creates the formulation of the NFEP Guidelines and the conduct of the first Training of Trainers in 1999. Immunochromatographic Test (ICT) was introduced at this time to the different filariasis team formed by the central government in the different endemic areas of the country. ICT is a rapid detection which can be conducted any time of the day compared to the standard method of testing which is nocturnal blood examination which can be done only at night time. The purpose of which is to fast-track the mapping of endemic communities in establishing filariasis infection.

While baseline survey is conducted in some undetermined areas to rapidly plot endemic provinces, Mass Drug Administration (MDA) with combination of DEC and Albendazole as the main strategy for filariasis elimination was piloted in five (5) selected municipalities for each region belonging to Category 1 or regions with municipalities in provinces established as endemic areas for filariasis in the Philippines. This was implemented from December 1999 to 2000 incorporating different strategies such as fixed site and launching through a Filaria Health Fair. One of the piloted municipalities was Maasin, now a city in the Southern Leyte Province of Eastern Visayas where MDA was widely accepted by the targeted population. After careful analysis of the issues and concerns that were raised during the pilot MDA campaigns, the department started the nationwide MDA which begun in 2001. The administrative order (AO) states that the MDA must be executed in established endemic provinces for a minimum of than five (5) years or until its declared filariasis-free. Today, different regions extended beyond the elimination period targeted by the Global Alliance to Eliminate Lymphatic Filariasis (GAELF) due to the different factors such as poor implementation of MDA, lack of support, failure to collaborate, inefficiency in setting target of the national and local implementers and scantiness of support from the local chief executive.Meanwhile, community diagnosis through subset sampling of the total population to identify which barangays were endemic continued in different regions and in 2002, the national prevalence rate went down to 7.

7 per 1000 population. The endemic mapping concluded in 2004, the NFEP identified 189 municipalities in 39 provinces in 10 regions considered to be endemic for this disease. The distribution showed that 19% of the cases were from the Visayas group of provinces, 25% from Luzon provinces and 56% from the Mindanao provinces. Unfortunately, these affected communities were represented by the poor and marginalized sectors in the Philippines society as shown by the 76% endemicity from the 4th- 6th economic class municipalities.In Eastern Visayas Region, however, all the six (6) provinces were categorized as endemic with a regional microfilaria prevalence of 5.

3 per 1000 population in 2004. Therefore annual MDA was implemented in these provinces including all the cities in the area. The pilot MDA successfully kicked-off in Maasin City in Southern Leyte in 2000, the health sector embarked on a simultaneous province-wide MDA campaign using a combined regimen of (DEC) and Albendazole in 18 municipalities and 1 city in Southern Leyte and only 2 of the 8 endemic municipalities in Biliran province. Capability building activities were first carried out to equip local implementers with the technical know-how and increase their competence in handling the responsibilities. This activity cascaded smoothly in Southern Leyte and Biliran Province where key personnel at the municipal and barangay levels have been identified and trained to motivate and solicit the support of their respective Local Government Units. Hence, their respective LGUs committed to providing transportation expenditures, support drugs for the program and continuous advocacy to and among communities on the need to eliminate lymphatic filariasis.

This LGU support was legalized through a local ordinance as mandated in the Administrative Order 369 developed by the DOH for the National Filariasis Elimination ProgramPROBLEM STATEMENTThe significance of sustainability for attaining the First Filariasis-free region in the Philippines which was made possible through the concerted effort, participation and agreements by other government institution, non-government agencies, and civil society spearheaded by the Department of Health is important to protect the health of the community and promote economic stability to realign funds of the national government to other significant national projects. The good practices and experiences can also be shared, practiced and replicated in other filariasis-endemic areas in the local and in other developing countries to attain filariasis-free as well. More so, this good practices may also be applied by other programs on the communicable disease which can be avoided, managed and treated with knowledge power to achieve the goal of the global community on health agenda.In the above statements, the impact of the capacity building, advocacy, collaboration, and networking showed a concrete result of attaining the target, however, the sustainability of its status by the local government is more important.

With this, there is a need to empower local government units, equipping them the know-how to contribute for the sustainability of the program which should be well thought and implemented and that the impact to the Sustainable Development Goal set by the global community will be sustained.Policy implementation, regulation, and enforcement will contribute enormously to the sustainability of the status and aid the economic development of the national government. The need to learn the tools and mechanism to efficiently and effectively implement the empowerment of the local government units and to include identification of intervention on the gaps and barriers that halt empowerment is also necessary to achieve the common goal of the health department.HYPOTHESIS1.If the local government guarantee good service through adequate planning and implementation of the program, the sustainability of filariasis-free is assured.2.If the local government takes initiative and the central government support it adequately, the sustainability of filariasis- free is ensured.

OBJECTIVE OF THE STUDYGeneral Objective: To determine the strategies and activities of the local government in sustaining filariasis-free provinces.Specific Objectives: To describe the role of the central government and local government units in maintaining the filarial-free statusTo determine the support needed by the local health workers from the central and local health governmentTo determine the impact of the technical know-how of the health implementers in attaining filariasis-free provincesRESEARCH QUESTIONWhat is the responsibility for planning and management needed by the local government to ensure the sustainability of the filariasis-free program? What are the technical capabilities needed by the local health implementers to sustain the filariasis-free status? What is the support given by the central government to the local government? Is there any support initiated by the local chief executive for the local health implementers.SIGNIFICANCE OF THE STUDYThe challenge of sustainability in Eastern Visayas as the first region in the country declared Filariasis-free is important. There is a need to assess and evaluate the impact of empowerment of the local officials and workers in achieving its target. This study is also beneficial to the following:Community. Local Government Unit. Department of Health Program Coordinators.

RHU Health Personnel/Health Care Providers. The Researcher. Future Researchers. RESEARCH FRAMEWORK AND METHODSCHAPTER II:THE NATIONAL FILARIASIS ELIMINATION PROGRAM AND EASTERN VISAYAS PROFILEAs we look at the objectives of this study, among those is describing the role of the Central and the Local government and determining the support that the local health implementers need in order to achieve its target of maintaining the filariasis-free status.

This chapter will describe the organizational framework of the country, how it works, its roles and function of the health sector, the support that it is shared and the profile of the region which is the subject of the study. The purpose of which is to appreciate the picture of the Philippine government, the health department and the Eastern Visayas region, According to the constitution of the Philippines, our country is a unitary, presidential, constitutional, republic form of government. The decentralization was introduced and promoted during the advent of the 1987 Constitution, wherein the executive branch headed by the president has direct relation and control over central government agencies but has limited powers over local government which is through supervision only, as shown in Figure 4. It is further enshrined in RA 7160 or otherwise known as the Local Government Code of 1991, eventually preserving a highly decentralized form system of government which guarantees the local government autonomy.

Local government is political units compose of province which is the highest tier, and is made up of a cluster of municipalities and/or cities. Figure SEQ Figure * ARABIC 4 The government structure of the PhilippinesSource: Miclat E.F. (2012), Local Governance in the Philippines Leadership, Structure, and Process and Political System (2014) Available at Accessed 22 January 2016The Department of Health (DOH) is the agency primarily in-charge in health concern and expected to discharge duties to maintain a healthy status of the community. The chief responsibility of this office is to ensure that the basic public health services to all Filipinos are delivered, it is accessible through the provision of quality healthcare, affordable in terms hospitalization, purchase of drugs and medicines in times of sickness and that the regulation of providers of health goods and services is strictly implemented and conducted. “The vision of the department by 2030 is to become a global leader for attaining health outcomes, competitive and responsive health care system, and equitable health financing.

And the mission is to guarantee equitable, sustainable and quality health for all Filipinos especially the poor, and to lead the quest for excellence in health.”The local government unit (LGU)is the forerunner and the front liners in government services as embodied in the Constitution. They are primary responsibility is the provision of basic public services for the community. The provinces are mostly responsible for competences that imply inter-municipal services provision,e.g. tertiary healthcare services and maintenance of hospital covering several municipalities in terms of health. The Eastern Visayas region is among three regions situated in the Visayas, the second major island of the country.

It is the gateway to the other major islands of the north which is Luzon and Mindanao in the south. It has a total land area of 1690403 hectares with six provinces and 7 cities. Eastern Visayas economy improved by 4.

6 percent in 2015. It contributed 2.00 percent to the country’s Gross Domestic Product. About 16.6 percent of the region’s output came from the Agriculture, Hunting, Forestry and Fishing sector which recorded a 3.5 percent drop in 2015.In discharge of its duty in terms of health the entire region is technically assisted by the central government through the Department of Health-Regional Office VIII, following the framework of the World Health Organization that describes health systems in terms of six core components or “building blocks”: (i) service delivery, (ii) health workforce, (iii) health information systems, (iv) access to essential medicines, (v) financing, and (vi) leadership/governance.

The six health components are cascaded by the department to the local government units as their guide for the full implementation of the national program. Among the programs of the DOH is the National Filariasis Elimination Program otherwise known as Lymphatic Filariasis Program. The disease was first discovered in the Philippines in the year 1907 by some foreign workers. Figure 5 describes the areas in the country endemic for filariasis, and as it is shown Visayas and Mindanao regiona are highly endemic of the disease.In Eastern Visayas, Lymphatic Filariasis has been endemic since the first survey in 1959. Vectors for filaria such as Aedes poicilius and Anopheles flavirostris are always present in the area as it thrives in the base of the leaf axils of abacá and banana plant which are the prime commercial crops in the Philippines.

Textiles, banknotes, furniture and other handicrafts are the most common export products of abacá to other countries which brought US$76 million a year in the Philippines’ coffer.Figure SEQ Figure * ARABIC 5 The geographic data of filariasis cases in the PhilippinesSource: DOH. National Filariasis Elimination Program (1998)The filariasis program of the department provided technical assistance by organizing a yearly consultative meeting to discuss program updates especially on the importance of sustaining the 85% benchmark for MDA, provision of non-stop capability building and advocacy awareness campaign. Issues and concerns raised in the previous MDA and a planning workshop prior to the conduct of mass drug administration in November which was identified as Filariasis Awareness Month in the health calendar are identified, analyzed and intervened. The drugs such as DEC and Albendazole drugs were allocated to the different implementing units.

DEC is purchased by the central government represented by the DOH and the Albendazole is donated by the GlaxoSmithKline. To monitor the progress of MDA in different LGUs, the DOH Program Manager together with the DOH Representatives were mobilized to provide technical inputs and assist the health workers in the Rural Health Units on the preparation, collection and submission of reports. Although regional consultative meetings and conferences were organized by the DOH, these were reinforced by quarterly district meetings especially in the first two declared filariasis-free provinces, Southern Leyte and Biliran. Stakeholders take an active role in empowering their respective communities to foster ownership of the Filariasis Program and focusing their collective efforts in reaching the 85% benchmark for MDA every year.

The meetings also served as an avenue for them to discuss challenges and victories as well as updates related to the program. Institutionalization of the Inter-Local Health Zones (ILHZ) in Southern Leyte and Biliran Province became a major opportunity to sustain the good annual MDA coverage that exceeded beyond the 85% benchmark for MDA after subjecting the program to Strengths, Weaknesses, Opportunities, and Threats (SWOT) Analysis. As early as 2003, four (4) ILHZs were organized in Southern Leyte and one (1) in Biliran with the support of the DOH Eastern Visayas and German Technical Cooperation (GTZ). The program’s monitoring even became more rigorous and systematic with the development of the health systems. In 2003, Southern Leyte boasted with the awarding of Pacific ILHZ as the jewel in governance nationwide.

The implementation of Formula-One framework of the DOH was well coordinated. When these 2 provinces started to establish their respective Province-Wide Investment Plan for Health (PIPH), they became more conscious in achieving the disease-free zones which were replicated by the four other provinces, thereby achieving the target of MDA. In addition the department initiated activities such as consultation with LCE through signing of pledge of commitment, collaboration with other government agencies such as Department of Interior and Local Government (DILG), Department of Education (DepEd), Department of Social and Welfare (DSWD), non-government organization, private companies and MEDIA to solicit support especially in strengthening advocacy campaign to scale-up the MDA coverage.To determine the impact of the MDA that is implemented by the local health units/ implementers, epidemiological assessment or monitoring and evaluation was conducted by the filariasis team of the regional office.

The result carried out a good result which ultimately in years of conducting MDA, consultation networking and collaboration resulted in the declaration of the provinces filariasis-free. While MDA was progressing in its nationwide implementation especially in Eastern Visayas and attaining impressive gains to interrupt transmission of lymphatic filariasis in established endemic areas, the second pillar in the elimination campaign on disability management to reduce the suffering among chronic cases with lymphedema and hydrocoele was promoted and implemented through “self-help” and “support groups.” In 2010 the Department of Health in the region initiated the conduct of Home- Based Disability Management Training among rural health implementers integrating Leprosy as among the disease that causes disability to increase effort on disability prevention, piloting Eastern Visayas. Eventually, Eastern Visayas culminates the declaration of filariasis-free after the success in the final evaluation of the last province to be declared which is Northern Samar in 2014, making the region the first filariasis-free region in the Philippines. The declaration of making it the first in the Philippines is a challenge to the regional and the local government units.

The WHO guideline states that the program does not stop there, a greater challenge is awaiting since every after 2-3 years from the time of its declaration, there will 2 post- MDA evaluation that will be conducted until its fourth to the fifth year. In 2008 Southern Leyte was declared free and post-MDA evaluation was conducted in 2011 and 2014. Biliran was declared in 2010, and post- MDA evaluation was conducted in 2012 and 2015, Eastern Samar was declared filariasis-free in 2011, and post- MDA was conducted in 2013 and 2015, Leyte and Samar were declared filariasis- free in 2013, post-MDA was implemented in 2015 and 2017.Northern Samar the last province declared filariasis-free had its first post-MDA evaluation in 2016 which will be followed-up in 2018.

All of the foregoing post-MDA evaluations conducted resulted in less than the cut-off rate of 16-18 ICT positive thus achieving the criteria of sustained filariasis-free.The six provinces declared filariasis-free received a grant and mobilization fund support from the central government represented by the regional office. This fund is dedicated to sustainability activities which at the moment is not supported by the guideline of activities from the central office.

The challenge of maintaining its disease-free status and the absence of the sustainability guideline the regional office of Eastern Visayas proactively initiated the conduct of border operation in between the years of post- MDA evaluation to gear the provinces for the post- MDA evaluation. The border operation includes NBE of 500 samples ideally in border areas of the provinces to include the sentinel sites or the municipalities with a history of a very high MFR (at least 5 municipalities in 2 years), training of local health implementers on home-based disability management and entomological activities.CHAPTER III.

LITERATURE REVIEW3.1.1 Objectives of Literature ReviewThis chapter will provide the reader a guide on the elimination and sustainability of Filariasis-free which will present a history of the need to rest on the assessment of the previous and current literature. At its most basic, this literature review will give an overview of the technical capabilities that are required by the local health workers, its theories if there is any, the support that is given by the central and local government including the initiatives implemented by the local government through their local chief executive. This significant literature currently published will aid this research based on the study.

The following presentation will not simply summarize the prior research but will critically review the research related to Filariasis- free zone then present the researchers perspective on the research field as a means for establishing the credibility as a scholar. It will be structured, and the ideas will flow logically from one point to the next.3.2 Literature Reviews related to Filariasis-free3.2.1 The study of Dr. Poonam Khetrapal Singh WHO Regional Director for South-East Asia; the Maldives and Sri Lanka have eliminated lymphatic filariasis express that geographical status and political will contributes to a stunning success that should inspire other South-East Asia Region countries, this supports the statement in the research objective that technical know-how of the implementers contribute to the success of the program.

It is noted in this study that despite its unique geography and scattered population, Maldives was able to attain first in the Region to be certified as having eliminated the disease as a public health problem. And to do so a sustained a mass drug administration campaign that provided at-risk communities several rounds of preventive drugs annually, wherein it was made possible through capacity building conducted to the health workers. This occurred alongside mosquito control efforts, as well as a greater emphasis on case identification and treatment. A robust surveillance system is also necessary, monitoring progress which provided authorities the information to better target their interventions. In this study, it also demonstrates that technical capabilities are crucial in attaining the elimination and eventually sustaining the status filariasis-freeDespite the country’s geographic archipelagic picture with a scattered population, it was not an obstacle in reaching in its goal to attain its target of eliminating the disease and the country was even certified as the first in the Region as having eliminated the disease as a public health problem. It is described in this article that a good planning on elimination activities like sustained mass drug administration campaign which was implemented in providing at-risk communities several rounds of preventive drugs annually.

This was conducted alongside with mosquito control efforts, as well as a greater emphasis on detection of the case through identification and treatment of those who are found to be positive. A robust activity like surveillance system is also important, wherein the disease is listed as among the notifiable diseases to alerts the surveillance unit in case of reported positive cases and monitoring progress which provided the local authorities the information to better target their interventions.The article states that commendably the country also developed a plan to provide disability prevention services (MMDP) to halt the progression of the disease and ease the suffering of more than 200 people that remain chronically affected. With this, it helped eased the suffering and burden of disability by those with overt reaction.

Hence, in 2008 not a single new case of the disease has been reported across the country’s entire archipelago of nearly 2000 islands.Apart from the Maldives, Sri Lanka, too, has demonstrated crucial key strategies in deploying to tackle lymphatic filariasis, such as capacity building of the local implementers. After the country launched its most recent elimination program in 2002, mosquito control efforts were scaled up; case finding and treatment were intensified; surveillance was strengthened; a mass drug administration campaign was rolled out.

The combination of strategies proved remarkably successful: Surveys conducted in 2008 and 2011 among school children in endemic districts confirmed the country’s progress, culminating in the recent WHO certification of the country’s ‘filariasis-free’ status. Hence, this literature supports that the need to capacitate the front liners is necessary to eliminate and eventually sustain filariasis-free status.The Maldives and Sri Lanka both demonstrated a commendable performance in their campaign to combat filariasis. It explains the importance of political will and unrelenting commitment of the health authorities and political leaders at the highest levels which resulted in a ripple effect of achievement in the local level which leads them in the certification of filariasis-free countries four years before the deadline. This is remarkable achievement demonstrated how firm leadership makes real change possible. Although the literature statement is so vague this anchors to the research objective of this paper with regard to the role of the local government in the fight against filariasis.

(WHO Regional Office SEA, 2017)3.2.2. In this study, it substantiates the assumption that adequate planning and implementation are necessary for achieving the target of elimination and sustainability. The article on Winning the battle against Filariasis, there are so many challenges that are so much related to environmental conditions, like the existence of areas conducive to vector breeding, unplanned urbanization, and a high population density which are factors in the spread of LF.With the above-mentioned issues, an economic development through improved infrastructure operations, well-planned urbanization, and population control were considered in the planning. It was determined that intervention like environmental care, population control, and urbanization planning are elements in accomplishing the target of a disease-free zone.

Moreover, according Dr. Mendis that the stringent control strategies leading to successful elimination, have been parasitological surveillance and control (night blood surveys for case detection and treatment) or blood examination; MDA or mass treatment entomological or vector surveillance and control to assess the disease transmission, eliminating the breeding places and using integrated vector control method; and disability management or MMDP. Therefore, a good urbanization planning intervention by the government, whether it be of the central and the local, are factors that are crucial to attaining the target of the program. (2016)3.

2.3 As part of the objective of this study in determining the strategies conducted by the government both in the local and the central government, the study on “Facts influencing sustained transmission of lymphatic filariasis in school children after eight rounds of mass drug administration will be partly described in this article: In the village of Mafuriko village in north-eastern Tanzania. Muhimbili University of Health and Allied Sciences: Dar es Salaam by Charles L. discussed and emphasized on three main parts, such as entomological component that included collection and determination of infection and infectivity rates in vectors, parasitological component that involved night blood examination for microfilaria detection and quantitative studies to assess community knowledge and awareness of the LF elimination program, determines that the proportion of individuals who took drugs during the last round of MDA vis a vi assess the rate of insecticide-treated bed net utilization. Which explains that the presence of infected individuals, infected mosquitoes, poor compliance to treatment, low levels of knowledge on LF elimination program, transmission and prevention are the main factors that may influence the high prevalence of CFA in school children.

Therefore, poor implementation of planning in the major component and pillar of the program will result in poor compliance with the community (Charles L.,2013)3.2.

4 The technical capabilities required for empowering the local health implementers by the central government is supported by this literature review. It spells out the necessary activities that are useful to capacitate the local health implementers in leading the community to achieve its target. Based on the study of Family Health International 360 on its topic on Philippine Neglected Tropical Medicine case studies, LF elimination success is attributed to the task commenced with a series of consultative workshops and conferences involving all the stakeholders concerned with the technical expertise provided by the DOH. The goal setting, as well as the determination of strategies and methodologies, which is done by using pertinent and validated data from the mapping/case finding activities.

It also included that the roll-out strategy of orientation and capability- building is important, wherein the DOH regional staff trained the technical section of the PHO, which in turn conducted roll-out activities to the RHU and city health unit workers. Partnership building also with other agencies such as DepEd personnel was also pivotal through the conduct of orientation and training, as they were also responsible for the MDA target population. In those seminars and workshops, exhaustive information or facts about filariasis were discussed, including its pathophysiology, vector mosquito, its transmission, treatment, prevention and control measures; as well as the risk factors present in the communities. With this collaboration with all stakeholders was enhanced and built thereby resulting in the filariasis- free elimination of Southern Leyte in 2008.

(Villarosa M.E.J., Olobia L., & Balila A., 2015) 3.2.

5In this literature, it is demonstrated that roadmap which serves as the guide by the central office improves the status of the local government in terms of economy. “The health and economic benefits of the global programme, according to Hugo C. Turner et al explains that there is cost-benefit if the pillars of filariasis program set by the central government will be implemented. It states that those protected from acquiring the infection, those with subclinical morbidity prevented from progressing and those with clinical disease alleviated will provide an impact on the economic savings.”It was then analyzed in the context of prevented medical expenses incurred versus LF clinical patients, wherein there is potential income loss through lost-labor, and there is increase costs to the health system to care for affected individuals. This is calculated vis a vi the indirect cost estimates using the human capital approach.

” Therefore, it proves that the value and highlights of the investment in MDA identify substantial health and economic benefits. The importance of continued investment in the GPELF for the elimination of the disease is important. (Turner, H.

C., Bettis, A. A., Chu, B. K.

, McFarland, D. A., Hooper, P. J., Ottesen, E.

A., & Bradley, M. H.

, 2016)3.2.6″This article is technical in nature, but it somehow supports the objective of this study that in terms of good planning by the government to combat filariasis against the reintroduction of the disease will eventually aid and result to the economic growth of the country, lack of planning will result to otherwise. The literature on “Morbidity management in the Global Programme to Eliminate Lymphatic Filariasis which discusses MMDP by David G Addiss and Molly A Brady favors that there is the Economic and psychosocial impact on the elimination of Filariasis. The studies in India, Ghana, and Haiti indicate that ADLA treatment costs to patients range from US$ 0.

25 to US$ 1.62 per episode, as much as two days’ wages. In Sri Lanka, Chandrasena reported costs of US$ 7.38 per episode for care from private practitioners, although most patients received free treatment at government clinics. The inclusion of the costing are the costs direct costs of treatment, which includes self-medication and travel. There are also two studies which include costs of food and accommodation. In Haiti, patients seeking care from health centers or private providers spent more money than those seeking care from traditional practitioners, primarily because these providers had higher consultation charges, this covers all cases, except for consultations with herbalists.

Apart from it, payment was most often provided in-kind when care was given by members of the extended family or traditional practitioners. According to Kron et al, that at the upper end of the spectrum, the calculated costs for personal expenses in the Philippines reaches as high as US$ 25 per ADLA episode, with the exclusion of lost wages.The productivity study indicates that there is a reduction of potential community labor supply in case of ADLA episodes.” In Ghana, for example, there is a reduction by 0.79% and in Indian communities by approximately 0.1%. However, they do not adequately capture the impact of ADLA at the level of the household he although the figures show and represent a much smaller loss than that from a chronic filarial disease of 7% of potential labor lost.

This result gives an idea that there are household-level effects in terms of psychology, which includes the time lost from work and school for caregivers, thereby affecting individual and the country’s economy.(Addis D.G. & Brady M.A. (2007))3.2.

7In NTDs the key roles like the partnership, coalition and alliances are crucial in advocacy campaign and resource mobilization as demonstrated in the literature on “Preventive chemotherapy as a strategy for elimination of neglected tropical parasitic diseases: endgame challenges” by Moses J. Bockarie. Thus, the question on the need of a capacity building for health implementers and the local initiatives such as the formulation of resolution aids in the achieving the target of elimination and sustainability. Inevitably, programmes for elimination or control by PC at either global or regional scales have historically proceeded at different rates driven usually by resource availability and country commitment. The following activities are all essential components if the endgame is wanting to achieve: the target. The availability of resolutions, the development of a constituency of partners, the definition of the problem through mapping of the disease burden, establishment of financing options, development of drug management processes, identification of implementing partners like the ministries of health, stakeholders, international organization are essential in the maintenance of implementation over several years.

It also noted that the undertaking of evaluation and monitoring, and finally post-intervention surveillance and verification of interruption of transmission or absence of morbidity are important activities for elimination and sustainability. (Bockarie M.J., Kelly-Hope L.A., Rebollo M. & Molyneux D.

H.,2013)3.2.8The study on Lymphatic Filariasis Elimination, Department of Control of Neglected Tropical Diseases, World Health Organization 2) Current address: Institute of Tropical Medicine (NEKKEN) of Nagasaki University J-STAGE demonstrates that the challenge in the global level is to develop the global policies and international standard guidelines for everybody in the world.

It’s not only the Pacific areas but also any other areas we have to cover. Therefore, it should make very clear and core policies and basic guidelines which can be used by many countries, that all guidelines are based on the evidence including country’s experiences and research evidence, which will involve the statisticians or epidemiologist ideas too. Hence, awareness on the guideline, will not be focused only on the certain region but globally. Working together to develop the guidelines using their evidence is salient. (Ichimori K.

,2014) 3.2.9To establish the objective of this study, this article describes that support such as a capacity building which includes supervision and monitoring that is necessary. The literature on the “Impact of the Lymphatic Filariasis Control Program towards elimination of filariasis in Vanuatu, 1997-2006” by Tammy Allen explains that the supervision which was led by the province level malaria supervisors and other public health provincial level managers is very important The supervisor’s role on checking with each MDA team every 2-3 days, the carrying of extra registration books and medicines, follow-up on any refusals, and comparing the numbers treated versus the target population were all crucial factors that influence the high level of MDA coverage in Vanuatu.

Furthermore, it was also described that increasing awareness is best strategies that are used before MDA, which is also a role by the supervisors as an advocate. This advocacy campaign involves the distribution of posters and leaflets with clear, visual messages on the need to take medicine, its side effects, the transmission of the disease, the ways to improve the MDA coverage. Therefore, to establish a relationship with the community and the assurance of follow-up on cases not treated, supervision is necessary. The engagement of community leaders will guarantee culturally appropriate strategies wherein compliance to challenging preventive chemotherapy will be supported by the community through a good leadership by supervisor. To warrant that the skills in terms of treatment, supervision, and monitoring are practiced, technical capabilities must be cascaded to the local health unit. This will aid to improve implementation of the strategies in the program.

(Allen, T., Taleo, F., Graves, P.

M., Wood, P., Taleo, G., Baker, M. C.

& Ichimori, K., 2017)3.2.

10The study on “Policy and, technical topics on selected neglected tropical diseases targeted for elimination: kala-azar, leprosy, yaws, filariasis and schistosomiasis; by the Regional Committee SEA, states that there are respective actions to be taken by each member state and the WHO which are the following; sustain strong political commitment and programmatic activities to accelerate progress in eliminating the targeted diseases, strengthen monitoring and evaluation and improve reporting to WHO and sharing of experiences on the part of the member state. And for the part of the WHO, continuous provision of technical support to the member states to eliminate targeted diseases, organizing an experience-sharing meeting in the region, and documentation on the progress, in order to achieve the NTD targeted for elimination. However, the study pictured challenges that though the region is making good progress and meeting most of the milestones on the elimination of these diseases, the following are still to be addressed to accelerate and sustain the progress. Some of the recognized challenges include: weakness in programme management; delay in reporting and poor data management; cross-border surveillance and information-sharing; weak procurement issues on supply chain management.

Furthermore, difficulties like multi-sectoral collaboration, the dilemma in engaging with non-health sectors also exist. There are questions also on low priority and resource allocation in decentralized settings to include sustaining political commitment after attaining elimination target; and inadequate capacity in vector expertise resulting to poor vector. It is therefore noted in this literature that a need to strengthen programme management, especially at the subnational level, data management; monitoring and evaluation; and cross-border collaboration is crucial in attaining elimination and sustainability. (WHO, Regional SEA, 2015) 3.3.

1Conclusion:With the abovementioned literature reviews, it elucidates that the realization of the health sector’s goal to attain better health outcome through elimination of lymphatic filariasis which is illustrated through technical capabilities by the central government and in the local level, the political leadership through administrative support of drugs and other logistics to include collective sectoral participation with stakeholders. The collected literature review construed and support certain aspects of the objectives of this study in terms of determining the role, the support of the government and the impact of the technical know-how in the program.According to authority, health sector reforms are anchored on the goals reflected in the international organizations millennium development goals for the Filariasis Elimination Program such as the Global Alliance for the Elimination of Lymphatic Filariasis (GAELF). Although devolved health setting was demonstrated in regional aspect it did not impede to achieve the elimination of country’s declared filariasis-free in the case of Sri Lanka and Maldives. This was developed through sound health systems by technical guidance and consultations by the central government together with stakeholders based in the locality which in turn provides technical leadership through the regular conduct of meetings and institutionalization of the program. Moreover, this initiative involves the participation of other agencies in terms of the advocacy campaign, mass treatment, response to an adverse reaction and halting the progress of the disease through disability management.

It is therefore realized that transfer of the abovementioned capabilities to local health implementers will eventually meet the target and fast-track the millennium development goal. Moreover, the lead team such as the local government keeps track of the disease-free zone initiatives for the elimination of LF with the consciousness of the need to sustain a steadily good coverage for annual MDA above the benchmark set by the WHO in the targeted population within the period set. Therefore, although empowerment and technology are transferred to the local level monitoring and supervision is necessary to look into and observe whether the guidelines are seriously and religiously followed.Based on guideline and history of filariasis program the health sector through its Filariasis Elimination Program and Local Health leaders and technical staff conducts endemic mapping and provides a continuous supply of Mass Drug Administration drugs to these implementing unit while at the same time harmonizing the national and domestic priority to eliminate LF through effective and efficient governance and service delivery efforts.

Backed by strong political commitment, the Local Chief Executives and lawmakers made a counterpart to allocate fund for support drugs and traveling expenses and invite more filariasis elimination volunteers to distribute MDA drugs. The study of the different researchers demonstrated how strong multi-sectoral cooperation and agreements of various stakeholders became the key success factor in eliminating the transmission of lymphatic filariasis in the at-risk population. Thus, achieving elimination of Lymphatic Filariasis with leadership and cooperation is workable. To further the information gathered by the researcher with the existing works of literatures and elaborate on the role clarification of each sector the research will, therefore, undergo a process of data collection in the study site. The results will be analyzed and each outcome will eventually determine the significance of the entire study. Likewise, the respondent’s comments and findings will now trigger future strategies that will answer current issues and gaps in sustaining the program implementation at the local level.

CHAPTER IV.DATA GATHERING AND ANALYSISIn order to increase the scope of the data provided in the previous studies and several literatures, the researcher sees its best to gather first -hand information from the implementers itself. The process involved focus group discussions (FGD), distribution of questionnaires and data analysis using existing dossiers. Literature reviews are also limited as it only mentioned few studies which do not represent the entirety of the filariasis elimination program. Each study has its distinct characteristics based on its geography, political structure and government strategy. Though there are some of the findings has similarities in the previous literature reviews, the researcher would like to further explore other practices in relation to filariasis elimination, in case of Eastern Visayas, Philippines.

The research questions were answered elaborately and solely based on their actual experiences in the field.As a guide to finally achieved the objective of this study, questions were formulated in the primary data gathering, which involved the distribution of questionnaires and KII. The discussion was focused on the initiatives initiated by the LGU, the activities and measures conducted by LGU in response to filariasis-free status in terms of technical and financial factors and other activities that the LGU will recommend for technical capacity and enhancement.

To carry through to completion, an FGD was conducted. The motivation was based on the following key questions: (1) Whether the new thrust of the central government on integration effective and practical; (2) Is good governance and strong political will in the local level, enough; (3) Is there any existing multi-sectoral collaboration, participation and engagement at the local level; (4) Was the decentralized allocation of fund by the central government effective; (5) The weaknesses encountered in program managementThe data gathering conducted was participated by the provincial and city National Filariasis Elimination Program (NFEP) coordinators, provincial and city health officers as well as some local health workers in the municipality level. The role of the provincial and city NFEP coordinators manages both the financial and technical aspects of the program. They are tasked to make work and financial plan annually, provides direct supervision among other health workers in the ground (municipal level), conducts trainings, seminars and the likes after which they have been trained at the regional level. Conduct of health promotion activities up to drug administration to the community were also part of their concern. Provincial and City health officers on the other hand, provides supervisory level support to their respective program coordinators and indorses activities of the NFEP to their local chief executives for funding support and all other kinds of support needed by the program. Thus, the chosen respondents were found to be the key informants that will help the researcher in solving the problem and support its hypothesis.

The documents review – Records of the National Filariasis Elimination Program in the DOH- RO8 and the Provincial Health Offices of the six provinces were reviewed highlighting the conceptualization of the elimination strategies for NFEP, the implementation of MDA, the planning and management of the central and local government, the strategies and epidemiological assessment to evaluate the impact in sustaining the filariasis free and the subsequent sustainability activities of the LF-free provinces. Records revealed the strategic plans and steps taken in the sustainability of LF-free. The Key Informants Interview were conducted to Provincial Health Officers, Provincial Coordinators, some official of the Department of Education, and Provincial and Rural Health Unit Staff to obtain first-hand information on their actual participation and experience in the elimination and maintaining LF-free status. During the FGD, it was conducted in a venue suitable for a meeting. It was in a closed-door room wherein the group were divided into two in order to facilitate the questions more progressively.

Through the research questions used, the data presented and shared testimonies of the respondents during the data gathering were found to be significant and somehow related to those literature reviews and case studies presented in the previous chapter. However, it is too early to say that the strategies used in the previous studies and the findings of this current study are absolute and yet purely empirical. In this data gathering, the uniqueness of the road to success of every local government units (LGU) and the challenges they hurdled was expressed in different manners but were collectively effective and worth duplicating. All information found were verified and concurred by their respective offices for the benefit of this study.The data gathering was done in a form of a meeting conducted in series, wherein the respondents were invited in a certain venue and was facilitated through program support of the DOH regional office. Likewise, actual visit to the LGUs were also made for the researcher to explore other potential source of information that will help the study.

The future of this study will not only benefit the Eastern Visayas region but also the entire country, for there is none, so far, other regions in the Philippines has achieved the goal of elimination for filariasis.4.1SOUTHERN LEYTEWho:Dr. Noel P. Lumen- Provincial Health Officer, Dr. Judecita Pineda- Develooment Manement Officer IV, Ms.

Eunice Aida Batalon- Provincial Filaria Coordinator, Engr Joyce Banzon,- Development Management Officer IVWhen:Primary Data Gathering: Feb 27- March 2, 2017; Secondary Data Gathering: September 13-29, 2017Where:Maasin, S. Leyte and Tacloban CityHow: Documents and Records, Questionnaires, KII and FGDDiscussion:During the conduct of interview with the key players of the Filariasis Program which was held in Southern Leyte Provincial Health Office in Maasin City last February 27- March 2, 2017, Ms. Eunice Aida Batalon, the Provincial Filariasis Elimination Program Coordinator, shared to us their feats and plights in getting the beacon as the first Filaris-free Province in the country.

According to her, Southern Leyte is located in the tip south of Eastern Visayas and the gateway in going to Mindanao. It has eighteen municipalities and one city and most of its barangays are located in coastal area. Agriculture is the major source of living in the province in which they grow rice, coconut abaca, banana and corn, as well fishing, raising poultry and livestock. She added that all municipalities in Southern Leyte is accessible by land except for some of its barangays and sitios which are located in high terrain upland and islets in the Pacific Ocean. In the interview, Ms. Batalon told us that when Southern Leyte was declared in 2008, the grant was released almost a year from the declaration, which causes the delay in their implementation. But despite of this, the she did even more from what is being expected.

They conducted advocacy campaign whenever the other program will conduct on their own. Lobbying for transportation allowance from the management so that the health workers will have their mobilization fund during transmission assessment surveys. Under the leadership of Dr. Noel Lumen, Provincial Health Officer, due to the late release of grant, the LGU try to look for alternative fund source, utilized its linkages with other sectors and do all other cost-efficient measures just to sustain its filariasis- free status.

Based on guidelines, whenever a province is declared Filariasis- Free, a One Million Pesos grant is given to the Local Government Units (LGU) to fund their sustainability activities. The LGUs were given the leeway to conduct its own initiatives to protect their borders from re- infection. Part of the initiatives initiated by the LGU was to continue its information dissemination drive in the barangay level prior to any filarisis activities. By this means, the people in the community were given time to prepare themselves physically and psychologically. They also involve them in case- finding of persons with deformities due to filaria. This has been part of the routine in the LGU for nine years, and they find this effective and significant. Seven years after the province of Southern Leyte was declared as the First- Filariasis- Free province in the entire country, the provincial health office headed by Dr.

Noel P. Lumen and Ms. Celestial Plateros, who already retired from service, as NFEP program coordinator they both agreed and recommends program integration. According to them, this strategy will maximize their efforts as well as with their limited resources. It may also create a great impact to communities specially that there are communities that are rarely being visited by health care workers. Furthermore, with presence of human resource for health (HRH) deployed in every municipality, they can now maximize their deliverables to the community, improve monitoring and evaluation of the program and establish a good surveillance mechanism in sustaining filarisias-free status.

Dr. Judecita Pineda, a long-time DOH representative in Southern Leyte, affirmed that the presence of HRH in the field will help the LGU conduct filarisis- related activities in aid of the local health workers. She mentioned this during the secondary data gathering in September 2017. For her, the LGU should make use most of the presence of the nurses deployed in their area, for during the time when the province was not yet filarial- free, manpower were one of their weaknesses.

Engr. Joyce Banzon, also a DOH representative in Southern Leyte, suggests that as to its sustenance of the program, the LGU should allocate a specific budget for the conduct of filariasis activity. She even recommends the inclusion of filaria activity in the common health trust fund (CHTF) of each inter local health zone of the province. Ms. Batalon again reiterates their need for financial and logistic support coming from the regional office and the provision of hazard pay to health workers conducting border operations, especially in Geographically Isolated and Disadvantaged Areas (GIDA). Ms. Batalon, who acts as the present program coordinator also expresses the need to continue advocacy activity even though they’ve already achieved the goal of elimination.

“People are mobile, we don’t have control over them, that’s why we still need to continue our health education”, as verbalized by Ms. Batalon during FGD session last September 2017. The Southern Leyte filariasis team also conducts cross-border surveillance to their border municipalities to ensure that no new infection will cross to their area. Early detection of case is subjected for treatment, while patient with disability are given psychosocial intervention and provided with disability kits for proper care and management of the affected part of the filarial patient. In addition, an orientation for local chief executives to be conducted every three years is also necessary. Local election is scheduled every three years, while presidential election happens every six years. Documents were also reviewed through the existing dossiers which the program coordinators kept for years that will tell all their efforts in the next generation.

4.2BILIRAN4.2BILIRANWho: Ms. Salita Montejo- Development Management Officer IV, Mr. Von Wendell Ampong- Provincial Filaria CoordinatorWhen:Primary Data Gathering: March 3- March 5, 2017; Secondary Data Gathering: September 30- October 16, 2017Where:Naval, Biliran, DOH- Palo and Tacloban CityHow: Documents and Records, Questionnaires, KII and FGDDiscussion:With the technical leadership coming from the DOH, a systematic and structured program of activities was steered. Series of meetings and orientations were performed which they considered effective.

Being the smallest province in the region, the conduct of filarisis activities was less challenging. People in the community are very cooperative and the LCEs of the eight municipalities were very supportive. Policy institutionalization, continuous research and program monitoring and evaluation were recommended by Ms.

Montejo and Mr. Ampong to bolster their filarial-free status and preserve their declaration. Biliran is situated in the northwest of Leyte Island and southwest of the Samar Island. Before it became a province, Biliran was them part of the Leyte Province. At It consistent of eight municipalities and 132 barangays, which consist of flat and rough terrains.

The people’s source of livelihood are agriculture, forestry and fishery with distinct characteristic in terms of language as they speak both Cebuano and Waray. When Biliran Province declared filariasis- free in 2010, the access to the One Million Pesos grant was not easy. The LGU received the money several months after its declaration. Like in Southern Leyte, they share the responsibility with other stakeholders and to the Local Chief Executives (LCE) and co-own the problem. Ms. Salita Montejo, the Provincial NFEP Coordinator and at the same time the provincial DOH Representative in the area, share their journey in the attainment of Filarisis- Free Province eight years ago.

For Ms. Montejo, Biliranon (the people in Biliran), are easy to manage, as they were cooperative and participative as well. “We don’t have so far, problem with the people, they participate in MDA and attends community assembly whenever we are in the field.” In that event, we input our advocacy on Filarisis and even other health programs to maximize there (the people) presence”, she further added. Though the program is co-managed by the region and provincial personnel, the sustainability plan was successfully carried out.

In the FGD session, Ms. Montejo said that one of their strategy that was found effective was when they build allies who could help them in their journey. According to Mr. Von Wendell Ampong, the current NFEP coordinator in Biliran, he added that their advocacy was conducted in a province-wide scale where the information dissemination campaigns was channeled thru local TV network, in schools, Day Care Centers and even in barangay assemblies. “We orient the local officials and lobby for the passage of ordinance, a simple but steady steps for us to be able to sustain the filariasis-free status of our province,” he emphasized.

Based on the documents reviewed among the 6 provinces, Biliran has the lowest micro filarial rate of less than 1%. However, their border control remains a challenge, the province is both accessible by land and by sea both from Leyte, Samar and even provinces of Bicol regions, hence MDA was still implemented to guard the province from the disease to spread.With the technical leadership coming from the DOH, a systematic and structured program of activities was steered. Series of meetings and orientations were performed which they considered effective.

Being the smallest province in the region, the conduct of filarisis activities was less challenging. People in the community are very cooperative and the LCEs of the eight municipalities were very supportive. Policy institutionalization, continuous research and program monitoring and evaluation were recommended by Ms. Montejo and Mr. Ampong to bolster their filarial-free status and preserve their declaration4.

3EASTERN SAMARWho: Dr. Jean Egargo- Development Management Officer V, Dr. Chicano- Development Management Officer IV, Ms. Divina Grace Salas- Provincial Filaria Coordinator, Ma.

Gina Marasigan- Development Management OfficerWhen:Primary Data Gathering: March 6-March 7, 2017, Secondary Data Gathering: October 17- November 1, 2017Where: Borongan, Eastern Samar , DOH- Palo and Tacloban CityHow: Documents and Records, Questionnaires, KII and FGDDiscussion:Eastern Samar was the third province declared as Filariasis- Free in the region in the year 2011. In the interview conducted last March 6-7, 2017 at the Provincial Health Office Borongan City, Eastern Samar, Ms. Divina Grace Salas, the Provincial NFEP Coordinator, told us that before they attain the goal of filaria elimination, ten years of non-stop mass drug administration was conducted.

Every year was a challenge because of the strong political factors which most of the time constraint the activity. Their area was also comprised by GIDA municipality and barangays. The province is located in the eastern part of the region and has 597 barangays, 22 municipalities and a component city which is under the administration of a governor.

Like other provinces, farming and fishing serves were the primary economic activity in the province. In addition, Ms. Salas told us that they’ve got a total of three Midterm Surveys and two Transmission Assessment Surveys conducted in span of ten years. “We conducted (surveys) in different areas in the province, for us to detect if there are still cases of filariasis happening in our place. Though it was a bit challenging, the terrains and rough seas, still its fulfilling in our part.

” she acclaimed. She continued sharing their experiences until they were able to complete the three rounds of TAS that is currently rolling every two consecutive years.On the other hand, after the province was being declared, access to sustainability fund was not smoothly carried out. Several revisions were made due to lost Service Level Agreements (SLA) and difficulties in securing signatories of the revised SLA. Because of the persistent attitude of Ms.

Salas, several activities were initiated like continuous capacity building to health workers, intensive surveillance and border control operations, vector control measures, continuous information- education campaigns and recognition of best performing LGUs in Filarisis Program.For them to achieve the goal, multi-sectoral approach was instituted, provision of incentives to health workers conducting nocturnal blood examination (NBE), incessant consultative meetings with the local implementers and the overwhelming support of the Regional Filariasis Program Coordinator were found significant. Continuous fund assistance from the regional office was stressed out in support to border operation activities which for them was a big factor. With limited allotted budget from the LGU, continued assistance is not only limited to grants provided but as well as capacity building and logistics support.

To Dr. Jean Marie Egargo, DOH Provincial Health Team Leader , program integration has already been the practice of the province since 2010, they even tag their strategy as “Zero-bites” initiative that was implemented in the entire province. It has a positive outcome, in which the success of filaria elimination was credited to this strategy. “The Zero-bites initiative in Eastern Samar has been instrumental in the high compliance of the people to filari mass drug administration (MDA)”, said Dr.

Egargo. In addition, it also lowers their rabies incidence as the initiative does not limit only to mosquito-borne diseases but also cover other diseases that requires other vector to infect a human being. Ms. Gina Marasigan, DMO of East Samar, had share during the FGD in Tacloban City last October 17- November 1, 2017, that the success of a program does not only rely on how much resources the program has, but on the concerted efforts of the program managers involved and their motivation to succeed the program they are re handling. However, she also put emphasis on the re-orientation of the LCEs as election happens every three years and this to facilitate continued support to the program.

Also in the FGD conducted, Dr. Mimi Chicano, DMO of East Samar, also higlighted the need for them to conduct cross-border surveillance, as it was not a practice in their province. She wanted it to be in place since we cannot control the movement of the people in the community. Data sharing and enhanced information collection were considered important since the success in filaria elimination still needs further study for the program to improve in the next future, she added which was also agreed by Ms.

Salas. Furthermore, Ms. Gina Marasigan honestly brought up the absence of monitoring system in their area. No monitoring tool is being followed that’s why the LGUs are given the liberty on how are they going to conduct their monitoring and evaluation of the program, making it more complicated for the provincial coordinator to collate and analyze the data. Ms. Marasigan re-enforces the recommendation of Ms.

Salas that a strong partnership with other stakeholders are indeed necessary in attaining Filariasis-Free status. For them, having been declared as “Filariasis-Free” is just a beginning of a very long journey. There are a lot more things to do and establish so that this long-term disability won’t anymore affect the future generation of Eastern Samar. That is why during discussions, Ms. Grace Salas acknowledge the overwhelming support of the DOH regional office even if they were already able to received their 1 Million grant. For them, the LGU cannot do it alone, they still need the technical expertise and financial assistance of the national government for the program to flourish. The devolution of health services from the national government had been a long-time challenge of the health sector, making it part of the reasons why health programs had a hard time penetrating up to the grassroots.

All decisions should come from the Local Chief Executive, which still depends on the his/her priority project for his/her term; lucky for those who supports health, but how about for those who prioritize infrastructures and the like? However, the provincial coordinator is still positive that in no time, they will succeed in all their undertakings. They drew strength from the regional coordinator’s positivity and is optimistic that with their continuous advocacy to LCEs, provision of trainings to RHU staff and enhancement of their information system, they can sustain their Filariasis-Free status.4.4SAMARWho: Dr. Dulce Cernal- Provincial Health Officer, Ms.

Evelyn Domingo- Provincial Filaria Coordinator, Mr.Domingo Vecina- Calbayog City Filaria Coordinator, Ms. Deogenes Daradal, Marita Carpuente- Development Management Officer IV, Ms. Luchie Abantao- Development Management Officer IV, Mr.

Santiago Gloria- Development Management Officer IVWhen:Primary Data Gathering: March 8-11, 2017, Secondary Data Gathering; November 18, 2017Where: Catbalogan, Samar , DOH- Palo and Tacloban CityHow: Documents and Records, Questionnaires, KII and FGDDiscussion:The largest among the two other provinces of Samar Island, Western Samar Province or most commonly known as ‘Samar’ alone has served as the access point to any part of the region. It has two component cities, Catbalogan and Calbayog City, and 24 other municipalities both island and mainland. Fishing, farming and tricycle driving were the major source of livelihood in the province. Among all the six provinces of Eastern Visayas, Samar has the most complex expanse and diversified culture in terms political and socio-economic viewpoint.Among the provinces, Samar has the highest micro-filaria rate and took them more than 10 years of mass drug administration.

In the documents review and interview conducted, Ms. Evelyn Domingo, the Provincial NFEP Coordinator,and Dr. Dulce Cernal, Provincial Health Officer, for them, having that status will only be in their wildest dream as they banked on lack of a strong and powerful political influence among all health services at their locality.

Samar has been known for politically challenged ever since. The presence of armed conflicts is also their and being the largest among the two other provinces of Samar Island. They also added that among all the six provinces of Eastern Visayas, Samar has the most complex expanse and diversified culture in terms political, as mentioned earlier, and socio-economic viewpoint.”The province of Samar was declared in year 2013 together with the Province of Leyte. A grant of one million was transferred immediately with less hustle. During the implementation phase, I’d had a hard time in the access of funds.” Ms.

Domingo shared. Issues on the political side was identified which hurdles the implementation process. “It’s very hard for us to access the funds even if we already have the approved Work and Financial Plan (WFP), Ms. Evelyn Domingo, said.

“What we do instead is lobby support from the councilors in the municipality just for us to conduct the activity in the field,” she further discuss. There was even a time when the DOH regional office facilitates the processing of all activities until such time they (Leyte and Samar) will be able to resolve their financial and administrative issues. Samar and Leyte province was both declared in the same year, 2013. With that transitory arrangement, the PHO-Samar felt resurrected somehow. She also mentioned, that they are also experiencing constant change of leadership depending on the disposition of their provincial governor.

For her, this hampers the implementation of the program, which is far beyond their control as health workers. However, with the support coming from the regional office, they were able to conduct Program Implementation Review (PIR), consultative workshop, etc. During PIR, issues and concerns were brought up and with technical assistance coming from the DOH regional office, an agreement was reconciled with the province in the financial management aspect. Ms.

Genie Daradal, DMO of our office, suggested during the FGD sessions that for the province to be able to start doing their (own) activities, the regional office should help them initially so the province can take off in their sustainability plan. The current administrative set-up had made Samar province delivers their planned activities on time and even fast track their border control operations. Among the provinces, Samar has the highest micro-filaria rate and took them more than 10 years of mass drug administration. During this years, health workers encountered several bad weathers, life-threatening scenarios- armed conflicts and difficult terrains, hesitance of the community in taking the drug due to fear of its adverse effects and the like. It was not a walk in park, according to Ms. Domingo which was affirmed by Mr.

Domingo Vecina, NFEP coordinator of Calbayog City who also took share during the conduct of border operations and transmission assessment surveys. “Even availing our travelling expenses vouchers (TEVs) were not possible; but because of the health worker’s commitment they still pursue in going to areas just to achieve the target”, Ms. Domingo shared. Most of their activities were focused on the advocacy campaigns, capacity building of local health workers and treatment assessment surveys. Mostly, same with other provinces, technical support, multi-sectoral collaboration and provision of financial and logistics support from the regional office were find to be significant and a plus factor in the sustainability phase of filarial elimination. In one of the FGDs, Ms. Domingo admitted that they don’t have an existing monitoring and evaluation mechanism yet in their area.

She identifies the difficulties if there is no M;E is established; first, health workers will not be guided especially during conduct of surveillance and cross border operations as to no tool is available; second, they won’t be able to measure the extent of efforts the LGUs are doing for the program; and third is that, it would be hard for them to identify LGUs what needs to be improved. Ms. Genie Daradal, DMO in Samar province, recommends to the regional office that the provision of financial support be continued and to include study grants if possible for the health workers. Mr. Santiago Gloria, Ms.

Luchie Abantao and Ms. Marieta Carpuente DMOs of Samar Province also suggests the same during the primary data gathering. They also stressed the need for a program integration to maximize the resources, both human resource and financial resources. They also see the need to improve the conduct of advocacy campaigns in the field using testimonials from the patients who were treated and seen their lives improved with the aid of the filariasis drug and other interventions.4.5.LEYTEWho: Ms.

Joline Ariza- Provincial Filaria Coordinator, Dr. Vilma Estorba- Development Management Officer IV, Ms, Mae Analyne Marquez- Development Management Officer IV, Mr. Marvin Allen Guy-joco- Development Management Officer IV, Ma. Suzette Arcillas- Development Management Officer IV, Ms.

Delvin Aresgado- City Sanitary InspectorWhen:Primary Data Gathering:February23-26. 2017; Secondary Data Gathering:Where:Naval, Biliran, DOH- Palo and Tacloban CityHow: Documents and Records, Questionnaires, KII and FGDDiscussion:Joined with Samar in 2013, the Province of Leyte was also declared as the 5th Filariasis-Free Province in the region. Leyte has the most unique implementation of the program.

They had their MDA first implemented in 15 municipalities in 2002 due to the presence of micro-filarial rate in this areas as evidence in the baseline survey conducted in 1997. These municipalities were, Hindang, Mahaplag, Mayorga, La Paz, Tabon-Tabon, Capoocan, Tunga, Tolosa, Babatngon, Leyte-Leyte, Albuera, Matg-ob, Merida and Baybay. During the interview with Ms. Joline Ariza, NFEP Provincial Coordinator of Leyte, she said that this kind of implementation was not favorable since Leyte Province has 43 local government units, two of which are major cities of the region. “It was hard at the beginning of the implementation (of the program), since there are 43 LGUs and only 15 of them are said to be endemic.

How can we be able to convince other LGUs to join the MDA, where in fact they don’t have filariasis circulating their area?” one of the apprehensions of Ms. Ariza when she started handling the program. She also emphasized the geographical constraints they encountered during the implementation. ” There are instances that we need to travel by “habal-“habal” just to cross to the next school due for TAS,” she exclaimed. Ms.

Ariza also said that the timing of MDA is not conducive for them (health workers) to do it, since November is already a season for typhoon to visit our place. In the said interview, Ms. Helen Cabugwang, a DMO assigned in Leyte affirmed the testimonies of Ms.

Ariza. She also emphasized, “Leyte being one of the biggest province in Eastern Visayas, covers nearly half of its population and a major producer of abaca in the country.that is why it’s really hard for our health workers combat this disease.” Abaca plant is one of the major breeding site by the filaria-carrying mosquito and mostly the main source of livelihood in the area. On the other hand, during the focused group discussion conducted between December 6-8, 2018, three DMOs of Leyte province were present. Mr. Marvin Allen Guy-Joco, Ms.

Mae Analyn Marquez and Ms. Suzette Arcillas also shared to the group the difficulties they (Leyte Province) encountered before and after Leyte was declared Filarisis-Free in 2011. First issue was on the political aspect.

Most of the LCEs do not prioritize ‘health’ as part of their agenda, instead they focused on the infrastructure as was easily seen by his/her constituents. Second, most of the health workers are not provided with their LGU travelling expenses in going to conduct monitoring activities in their locality. And lastly, the lack of health work force in the grassroots because most LGUs does not fill in vacancies for health personnel. According to Ms. Ariza, those mentioned difficulties are really happening even up to present. She said that if they only dwell on these difficulties and frailties of their LGU, nothing will happen to their province, the efforts of the health workers who worked hard just to eliminate filariasis will be put to side and the risk of acquiring the infection for the future generation will re-emerge.

From that scenario, the regional office together with the team of PHO Leyte, initiated a forum with all the LCEs in Leyte Province in which the goal is for them be aware and get involved in the implementation of the program. The said activity was successfully done with the presence of the Leyte Governor, who encourages the LCEs to work together and help the program sustain its achievements. Ms. Ariza further expands the activity through duplicating the best practices of the one LGU to the other. Mr.

Delvin Aresgado, a City Sanitary Inspector of Tacloban City, do their share in the sustainability though the conduct of vector-mapping and vector-control activities. Among all other provinces, Leyte received a total grant of 1.5 million to support all their sustainability activities.

Ms. Ariza who is handling other programs aside from NFEP is in favor of program integration. She said that it will maximize the resources at hand and the people themselves will benefit most as they are less often visited by health workers due to tough roads. She also suggested that program coordinators like them, will also be given the opportunity to enhance their capability through study grant, so that they can improve their program implementation performances. To date, they are conducting border control operations to monitor and evaluate the programs sustainability roadmap.4.5NORTHERN SAMARWho: Dr.

Rommel Francisco- Development Management Officer IV, Dr. Warren Agapito Otadoy- Provincial Health Supervisor of the Department of Education , Ms. Sellah Tomol Balanyos- Medical Technologist, Ms. Lenette Lapara- Provincial Filaria Coordinator, Ms. Sonia Margallo- Development Management Officer IV, Ms. Jeanisan Olimba- Development Management Officer IVWhen:Primary Data Gathering: March 12- March 15, 2017; Secondary Data Gathering: December 6, 2018Where:DOH- Palo and Tacloban CityHow: Documents and Records, Questionnaires, KII and FGDDiscussion:Situated in the tip north of Eastern Visayas that serves as the entry point of travelers from Luzon going to Mindanao. Agriculture and fishing are the primary source of living in Northern Samar.

Composed of largely of low and extremely rugged hills and small lowlands areas. The geographic location of the province makes it more challenging for some health workers as some would need to travel six hours boat ride and two hours hike before you can reach a certain municipality not to mention the existing armed conflict that has been sitting in the area decades already which made their road to Filaria-Free more challenging.From March 12-15, 2017, a data gathering was conducted in the province of North Samar thorugh data review and interview of the key informants involved in the filarisis elimination program.

It was Ms. Lenette Lapara, Provincial NFEP Coordinator of North Samar, who shared that being the last remaining province yet to become a filaria-free province was really a test of leadership and commitment. Their implementation of MDA was not as satisfactory compared with other provinces. It took them ten years in conducting MDA having below par of the 85% target. “When I came to the program in the year 2009, reaching the target is really a struggle, the highest so far MDA coverage we got was only 48%,” she stressed. “Honestly, I don’t know where to start,” she added.

Ms. Lapara tried to seek assistance from the regional office on how will they improve their coverage and what possible strategies will they follow. When North Samar was declared in 2013, the access to one million grant to fund their sustainability activities was done in less hassle. One of the facilitating factors identified by Ms.

Lapara was the dedicated attitude of the health workers, which for her, had contributed a lot in the success of the program. “Good thing that most of our health workers are committed, if not for them, I don’t think we can make it.”, she emphasized.

Dr. Rommel Francisco, Provincial Team Leader of DOH North Samar, shared his experience on the implementation of the program during the FGD conducted last December 6, 2017. He said, “Filaria program is very challenging. Even if we are already filarial-free, we still need to strengthen our advocacy and border operation, especially that our MDA coverage is not that good.” Dr.

Warren Otadoy, a DepEd Medical Officer, also advocates the need to integrate filarial program in schools to improve awareness. At present, a non-stop advocacy campaign was done in schools, community level and even to the LCEs to solicit support along the way. In the first session, Ms. Sellah Balanyos, a Medical technologist, who also took part during the border operation shared that the community still needs to be reminded all the time through advocacy whenever possible. During their Nocturnal Blood Examination (NBE) in border municipalities, the difficulties they encountered were unfathomable. The GIDA barangays were extremely hard to reach and issue on security were also at risk. The measures implemented at their level to sustain their status were vector control, surveillance and reporting for patients having lymphedema and conducting entomological surveys.

With the aid coming from the regional office, mobilization fund in support to their activities were provided. These were seen effective and motivating for the health workers they said.Ms.

Lapara also believes that multi-sectoral approach could be one of the many strategies in sustaining their filarial-free status. Considering mass media as an avenue for wider scope of promotion and continuous program monitoring and evaluation to the different municipalities. Their third Transmission Assessment Survey (TAS) is yet to be scheduled this year, while a selective mass treatment is done for those areas with positive of microfilaria during the conduct of NBE in the border operation.SUMMARY:Since the first province in Eastern Visayas was declared filariasis- free in 2010, several practices were documented, both positive and negative. During consultative meetings, good practices and issues were tackled which paved the way in improving program implementation. After fourteen years of hard labor, the entire region was placed first in the country’s map that was declared filariasis- free.

During the focus group discussion with the program implementers and DOH representatives in the LGU, several observations were made. Likewise, they also provided their self- assessment and personal rating on how their LGUs will take part in sustaining filarias- free status. Most of the respondents in the FGD were confident in providing their observations that our local health workers were already capacitated and empowered in terms of skills, technical know-how and case management. They also conducted advocacy campaigns and social mobilization activities in the community to aid them (health workers) in detecting filarisis cases in the event of re-emergence. Having reached the goal of elimination it also helped them in maximizing their resources as it opens the gate towards integration. For example, when local health workers conduct a community visit, they don’t just advocate for filaria alone but tackles as well other programs.

Before, their approach was programmatic to which they give priority to those most dreaded and has enough funding support leaving out other programs which has of equal importance.Continuous funding support and well-provided logistics were also seen as good points of the program and are major factors to which the filarial-free status can flourish. Although the political aspects are usually perceived as negative, to some it was positive and is because of their shown support through manpower and logistics provision. This may not generalize the whole situation but most of them gave their thumbs up that political support is less challenging.

On the other side, there were three responders who had their own apprehensions since never they attain the MDA coverage target of 80% due to Geographically Isolated and Disadvantage Areas (GIDA) in their province and with the existence of insurgencies. “Our local health workers had a hard time in reaching these areas; before you can reach the site, we need to hire motorcycles from the town proper and travel for two hours to reach the nearest point. Then we need to hike for an hour since the roads are not passable for any type of vehicle” as articulated by Ms. Evelyn Domingo (Provincial Filariasis Coordinator in Samar Province).

While in Northern Samar, they (health workers) cannot just go to a certain barangay without the knowledge of the Philippine Army. “Sometimes we just left the medicines (DEC) to the army and teach them how to administer and how to observe for any reactions” says Ms. Lenette Lapara (Provincial Filariasis Coordinator of Northern Samar) She also added that the presence of vectors in their area warrants the possible re-entry of the disease if not being prevented. Attitude and culture in the region also varies.

The coordinators were insistent of this aspect as it this is not achieved over time. Furthermore, another major negative finding was the financial capability of the Local Government Units. Though it was written in the law for the full financial support of the program, still LGUs are having hard time where to source out funds for support. Majority of the LGUs in Eastern Visayas belongs to the 5th and 6th class municipality, in which their IRA are not enough to support all the programs of the national government being implemented at the local level.

And to add insult to the injury, the fast turnover of local officials is seen as part of the notable challenges in sustaining filariasis-free. Every three years, local election took place which means that our health workers need to lobby ‘again’ for program support and all others to the newly elected officials. The sustenance of the program still relies on the support coming from the national government.

With the new thrust of the government toward integration, during the earlier discussion, it was noted that it was good move as it maximizes the resources of the government and others. However, in the later part, 50% of the responders expressed the not so good side of this. Overlapping of schedules of different programs with one and the same coordinator at the local level. The result was, the local coordinator needs to pick to which program will he/she will attend to.

Lack of coordination at the national and regional level was perceived. To some point, local health workers will tend to prioritize the program that gives additional incentives rather than perform their routine work.Considering that it is only nine years from the first filaria- free province was declared and some of its province are still on their transmission assessment survey, the local government units are still in their early stage to be claimed as independent. They are still dependent on the support being provided by the regional office and some were not aggressive enough in the implementation. Though they have the technical know-how on the implementation of the program, it is hampered by issues which are out of their control.The release and process of grants for the declared provinces has far improved.

Well-coordinated mechanisms have been established at the regional office and the involvement of management committee in the program had played a vital role. Multi-sectoral coordination and linkages were seen effective and powerful specially in the community level.Provincial program coordinators commitment and attitude towards work has surfaced and considered a great factor in the contribution of success, despite of financial struggles and political issues. Indeed, if there’s a will there’s a way. The need to have a permanent provincial filaria coordinator is deemed necessary. The province should take the fully responsibility in the program. The DOH regional office are mandated to provide only technical assistance and policy support in all other programs.Program monitoring and evaluation process needs to improve as it will determine the effectiveness of the strategies being implemented. It must focus holistically and should involve other sectors, so that if there’s a need to change or improve a certain policy in other agencies, which does not a concern of health, it can be addressed properly as it may affect our health endeavors. These occurrences had flagged the researcher to conduct an evaluation study on the empowerment of local government units to sustain the filariasis-free status of Eastern Visayas.Both health and economy are now in picture. A good economy may indicate a healthy community as more people are disease-free and can now contribute their share in lifting the socio-economic status. But according to the Family Income and Expenditure Survey (FIES) conducted by Philippine Statistics Authority (PSA) last March, four out of six provinces in Eastern Visayas were among the poorest provinces in the country. Eastern Samar the 2nd poorest province in the country has the poverty incidence of 55.4%, while Northern Samar and Western Samar tied on the 9th rank which had remained 43.5% poverty incidence despite of the latter’s booming tourism industry, and Leyte placed on the 17th with 46.7% poverty incidence rate. Southern Leyte being the first declared filariasis- free province in the entire Philippines in 2008 and Biliran follows in 2010, the said provinces were no longer among the poorest provinces in the country. CHAPTER V.CASE STUDY OF MALDIVES FILARIASIS-FREEThe previous chapters discussed the importance of sustainability and the strategies conducted to sustain the filariasis-free status. It tackles and encompasses the planning and implementation implemented by the local government to include the initiative and support for the success of the programme. It is also noted that there is a concrete outcome from the technical assistance by the central government which is in nature necessary incapacitating the local health workers in attaining the target.To support and supplement the objective of this study possessing the result of capacitated, empowered local health implementers and strong political will of local leaders in the local community, a case study of Maldives as among the countries in Asia declared as Filariasis-free country will be propounded and discussed. It will journey us on the activities conducted by the Maldives government in combatting the disease, achieving the filariasis-free status and eventually attaining its sustainability.5.1 AnalysisThe structure of the government and the filariasis program of Maldives will be discussed in this subchapter. The outline will focus on the following pillars (1) The country, the government and the health ministry of Maldives (2) Background of the program.(3) The manner and courses of implementation and action-taken by the government to sustain the disease-free status. (4) The pathway to success and the model in addressing issues and gaps by the LGU. (5) The best practices and pillars of Maldives in terms of sustaining the filariasis-free will serve as a guide for empowering local government health workers which are focused on this research. 5.1.1 The country the MaldivesThe Maldives like the Philippines is a unitary, presidential, constitutional and republican country, which is a south Asian country found in the Indian Ocean of the Arabian Sea. It is located southeast of Sri Lanka and India. Like our country, it is among the most geographically dispersed however it is the smallest Asian country in terms of land and population.The World Bank classifies the country as having an upper middle-income economy. Fishing, based on history is the dominant economic activity and remains the largest sector at present, followed by the rapidly growing tourism industry. Along with Sri Lanka, it is among the two Asian countries with a high Human Development Index with its per capita income the highest in the SAARC.Between 2008 and 2013, Maldives experienced a significant change in governance when their constitution was ratified in August 2008. In the year 2009, seven provincial administration was formed and the heads of this administration were appointed by the President. “Under this provincial system, seven health ownership and seven utility corporations were formed. These corporations were given assets to perform their functions. The health corporations took over the assets that were previously belonged to the Ministry of Health and this goes the same among other ministries.”In 2010, the parliament of Maldives passed the decentralization act. This systematized the roles and responsibilities of Atoll and Island Councils and its democratic election. The first decentralized function and even the primary mandate of the decentralization Act are to deliver a primary health care services for the community.However, even though the decentralization act mandates island councils to provide the basic primary services these continued by the utility corporations who also continued to control the assets of the Atolls and islands. 5.1.2 Maldives Ministry of Health The vision of Ministry of Health To have a nation with a healthy population which is health literate and practice healthy lifestyles, and have easy and effective access to quality health services in the region where they reside which is covered by a health care financing mechanism. The mission of Ministry of Health Protect and promote the health of the population with enabling policies, relevant modern ICT and healthy environments; provide social health insurance; develop an efficient, sustainable health system and provide need-based, accessible, affordable and quality health services in partnership with private sector and community. The vision and mission of the health department of this country resemble that of the Philippines except in some instances which is specific and it is not limited only to health but includes advancement of technology and covers other sectors like the healthy environment which is a pillar to promoting a healthy community. Moreover, it is said also that partnership with private sectors is also a fragment of the mission which is in terms of the health system, the quality, accessibility, and affordability is more achievable.5.1.3BackgroundIn the Maldives, the access to good quality healthcare is anchored to primary health care approach, which is evident in achieving the targets of the health ministry. It is therefore obvious that our front liners, empowered primary health care providers are the main actors in attaining the development goals in terms of health. Furthermore, the high priority on protective and promotional health is also an important factor in maintaining health status like high levels of literacy and improvements in the socio-economic situation of the people which is manifested in the achievements gained over the past few decades. With the abovementioned factors, the improvement in health targets like reducing Infant Mortality Rates, Maternal Mortality Rates and increased life expectancy was achieved. And with regard to disease-free zone, most of the communicable diseases were either eradicated or controlled. The country was even certified by World Health Organization as a “Malaria Free Country” in 2015. Which includes, control of vaccine-preventable diseases to such an extent that diseases like polio, neonatal tetanus, whooping cough and diphtheria which are non-existent anymore in the country. The communicable disease like Leprosy and Filaria have reached to zero transmission levels and elimination targets. Among others such as tuberculosis and HIV prevalence was maintained at very low levels. But despite the achievement in communicable disease programs there still a potential public health threat since there is a debilitating situation of drug abuse and the high-risk behaviors of the key affected populations. 5.1.4 Overview of Filariasis program in the MaldivesIt was noted that there is continued improvement and scaling up of the situation in terms of communicable diseases, but with regard to Malaria and Filaria a most remarkable achievements in the past 2 years was achieved by the Maldives being declared Malaria free and the submission and approval of dossier for Lymphatic Filariasis elimination, which is the major step in the process to certify the Maldives as having eliminated lymphatic Filariasis.Based on WHO the National Filaria Control programme in the Maldives was launched with WHO collaboration. Activities included: passive case detection and treatment; larvicide-based (Abate 500EC) vector control; and treatment of all positive cases of LF with a weekly dose of diethylcarbamazine (DEC) for 12 weeks. A night blood survey conducted in Male in 1968 showed a Microfilaria (Mf) rate of 5.5%. A further 9 islands in 5 atolls surveyed in 1969 recorded an Mf prevalence greater than 1% in only one atoll. And according to the ministry, a support from WHO, 34 islands were surveyed for lymphatic filariasis (LF). 37% of the population were found either infected with W. Bancrofti or showing clinical manifestations of LF. With the above result of the MFR, it shows that the Maldives is a country endemic for Filariasis, hence MDA is necessary to halt the transmission of the disease. Apart from MDA activities conducted, entomological activities such as larviciding were also implemented as an adjunct to the program. There are Filaria cases in the Maldives which is seen both to be symptomatic and asymptomatic, which like the Philippines the causative agent is W. bancrofti, which is usually common in tropical countries.However, according to the health ministry of Maldives that during the initial years of finding and management activities there was an enormous problem, like the lack of health facilities and staffing across the islands, lack of systematic mapping of endemic areas. The location of patients was also a barrier to service outreach activities, treatment completion. This also includes the issue of the guarantee to access the support for disability management or MMDP services to all LF patients with overt reaction or with manifestation across the Maldives. In terms of maintaining a healthy environment, multiple vector breeding sites was an issue in the country due to poor and lack of advocacy campaign in environmental sanitation. Today, the great challenge of Maldives is the socio-cultural and livelihood practices, the continuous risk of migrants and the neighboring countries which are still endemic for LF. The Maldives is expecting tourists because of their wonderful beaches and is among the bucket list of tourist destination in Asia.However, the above-mentioned barriers did not hinder the Maldives, instead, it channels them from achieving its target based on MDG that by 2020, Filariasis must be controlled and eliminated in their country.5.1.5 Roadmap to Elimination of Filariasis in Maldives Figure SEQ Figure * ARABIC 6 The pathway to elimination of filariasis in MaldivesSource: World Health Organization. (2017). A nation unburdened-elimination of Lymphatic Filariasis in MaldivesFigure 6 showed us the journey of Filariasis program in the Maldives from endemicity to elimination. In 1950, baseline mapping was conducted in all areas in collaboration with the WHO. The result showed that Maldives has a ;1 MFR prevalence rate hence considered endemic for Filariasis resulting to the conduct MDA to cut the transmission of the disease as one pillar of the program. Through the years of MDA an initiative of integrating Malaria and Filaria program eventually forming Vector-Borne Control unit in 2000. In the advent of the GAELF from 2002-2007, Maldives was programmed to follow the plan of the GAELF to eliminate Filariasis in 5-year time, targeting elimination from 2004-2008. To determine the impact of MDA, TAS was conducted in all islands rolled -out endemic for Filaria from 2008-2005 and it showed a conclusive zero MFR. It was validated and confirmed by the WHO and based on the result of the verification Maldives was declared Filariasis-free in 2016. With this story of Maldives, the following sub-chapters will aid this research the important factors and elements that make the country a disease- free of filariasis. 5.1.6 The plan for success in eliminating Filariasis in Maldives and best practices.According to the ministry, political leadership, support, and commitment of the health ministry with the aid of other support agencies like WHO, Red Crescent and other stakeholders across the country are factors that will contribute to the control and elimination of the disease. Planning was crucial to the country as an initial step to elimination, like launching, capacitating, ensuring availability of drugs and services in case of MMDP in all regions and inclusion of filariasis as among the notifiable diseases.For technical capacity, the health implementers are compelling in the implementation of the program. Highly trained health workers are part of the surveillance system and warrants in stimulating case-finding activities and treatment services in the country. More so, part of the border operation is regulating all recruits in the armed forces, sailors, exchange students where blood screening was required for mF. Besides blood testing of foreign and domestic migrant population, entomological activities such as vector control were also implemented.In terms of financial aspect, the elimination of the disease was strongly supported by the government through domestic resources ensuring that implementation truly conducted,To resolve the issue on stigma, according to the ministry, isolation, segregation, and relegation is prohibited. This was made possible through intensified advocacy and awareness campaign.6. Next Steps of MaldivesAccording to the WHO and the Ministry of Health of Maldives, there is continued post validation surveillance to ensure that no new instances of the disease emerge. The international visitors in the country will be screened for LF, which is an important activity to prevent reintroduction of the disease. As an adjunct to parasite control through MDA a regular entomological monitoring, including search, reduction and destroying of breeding and the use of self-protection measures sites will be implemented. With this, it is required the constant involvement of capacitated health workers and strong community participation. With surgery in case of hydrocele, the health facilities whether it be regional or local is equipped to accept and admit patients. And for MMDP, a preparedness plan to assess the quality of care for lymphedema, acute dermatolymphangioadenitis (ADLA), and hydrocele surgery. These will ensure that post validation, chronic LF patients will continue to receive high-quality care in the Maldives8. ConclusionThe story of Maldives in their combat towards the elimination of LF has proven the impact of empowerment which was initially addressed with planning anchored to MDG including integration of programs related to each other to mitigate resources and to implement the program effectively, efficiently and within the time frame. With regard to the capacity building of health implementers, it encourages the community to participate in the implementation of mass treatment, MMDP and adapt the entomological intervention. It is also noted that resource mobilization to public health delivering basic primary services was supported and backed up with policy and resolution. Those strategies were implemented by the government lead by the central and were cascaded to the local unit wherein planning management, political will and leadership style and the opportunity for implementation of an empowerment strategy was replicated. The elimination and sustainability of filariasis in the Maldives support the assumption that an empowered and empowering workforce can contribute to service improvement. That political will, style of leadership, training, resources for the implementation of the activities are necessary for the success of the program. It also supports the assumptions the levels of and opportunities for innovation will contribute to the performance level of the program. CHAPTER VI. CONCLUSION, SUMMARY AND RECOMMENDATION6.1ConclusionIn this study, the following research questions therefore were answered:What is the responsibility for planning and management needed by the local government to ensure the sustainability of filariasis-free status?Based on the discussion on the previous chapters, it is concluded that the responsibility for the planning and management needed by the LGU in order to attain the sustainability is the capacity enhancement through technical assistance wherein there is the investment of knowledge, the provision of a firm, stable and cohesive policy and framework support. With this, the sustenance of the filariasis-free is concrete and achievable.What are the technical capabilities needed by the local health implementers to sustain the filariasis-free status?The specialized technical skills on border operation like the conduct of Nocturnal Blood Examination, case finding for deformity survey, capability to conduct MDA/ selective treatment and case and morbidity management and disability preventionEntomological activities such as mosquito sampling, collection, identification and vector controlSkills on surveillance and information systemTechnical capacity on health leadership and governanceAnd the enhancement of the following skills, communication, networking , collaboration, evaluation and monitoring of the local health implementers through mentoring and coaching by the central government in order to scale up and encourage community to proactively participate and clients with overt reaction in the sustainability activities and programs of filariasisWhat is the support given by the central government to the local government?It is academic based on the discussion in Chapters 2 and 4 that the following support were provided by the central government.Funding through the provision of grant and mobilization supportTrainings to improve technical capabilityCollaterals such as advocacy materials and diability kitsLogistics like MDA drugs (DEC and Albendazole) and support drugsSupport to border operation: Slides, lancet, alcohol, cotton.Is there any support initiated by the local chief executive for the local health implementers?It is noted that most of the LGU’s provides manpower, allocate funds and purchase support drugs in the conduct of sustainability activities. With limited financial capability, still, most of the logistics were provided by the Central Government. 6.2 SUMMARYThe study exemplifies some of the good practices in health service delivery evolving in Eastern Visayas particularly in eliminating a major tropical disease like lymphatic filariasis which was realized through collective efforts from different sectors sustained for quite a long time. It was said that filariasis is part of NTD, a vector-borne and it is the second most debilitating disease in the world. To fight against the disease there was a call for elimination globally. As discussed in the previous chapters, the battle started from baseline survey to MDA, to sentinel and spot-check sites survey, to transmission assessment survey up until the border operation for sustainability of filariasis-free status. And to implement the previously mentioned activities and strategies the central and the local government must work hand together with the other stakeholders in scaling-up technical capabilities of the LGU by giving technical assistance through trainings, networking, collaboration, advocacy campaign and logistics and fund assistance in order to capacitate and empower the local implementers, thereby achieving the target of the program and sustain the filariasis-free status.Furthermore, in Chapter 2, it was learned that the Philippine is a unitary type of government and has a decentralized set-up or otherwise known as Anglo- American type of government. Thus, the Central government under law has its limitation in terms of control over LGU. Its power which is limited only to supervision. Hence, in order to equip, empower the local implementers and scale up the capability of the LGU and for them to be guided with the roadmap to elimination and sustainability, a thorough program management training should be conducted. In this way, there will be an assurance that the sustainability plan of the program will be cascaded down to the local level regardless of the limitation of power by the central government.In the literature review, it was further discussed that to attain the better health outcome on health particularly the elimination and sustainability of the filariasis- free it is illustrated through technical assistance. Nonetheless, this will be achievable if the primary ingredient of empowerment in the local level which is political will and leadership of the LGU through administrative support and logistics assistance with collective participation is existing and in progress. In the data gathering, it was described and explained that the technical capabilities needed by the health implementers was the technical know-how on to guard and fight re-infection against filariasis in their respective areas and the specific tasks that the local health implementers must do in case an imported case will exist in their locality again. On the central government side, aside from technical assistance, they also provides financial assistance; a one million peso grant. This kind of support given by the national government to the LGU is an augmentation to fund their filariasis sustainability activities. The LGUs who were given the said assistance has the privilege to conduct their sustainability activities in whatever they want to do it as long as it can protect their boundaries from re-infection of the disease. In some cases, the release of this grant would take a long time before the LGU could enjoy it. This remains a major concern as it poses delays in the program implementation and give off the feeling of disappointment to the local implementers In this case, the LGU would try to find other alternative fund source just to conduct the activities that are expected from them to do even if is par below from their actual target. LGUs would also utilized its linkages with other sectors and do collaborative efforts at low cost just to conduct sustainability activities. From that point, the commitment and dedication of the health workers comes in, which is considered as one of the good practice of the LGU has. Activities initiated by the LGU were the conduct of information dissemination drive in the barangay level through integration of filaria activities with the other program that has the same target population and area. Other activities that the LGU initiates were the conduct of deformity survey to which its involves the case- finding if there are still persons with deformities due to filaria and morbidity management disability prevention. This has been the routine activities that the LGUs is doing, despite of limited access to financial resources, both local and national support. The LGU wishes to let not the national government renounce their support as they still can’t handle the full implementation of the program, since resources at their level are not enough to support the numerous health programs of the Department of Health (DOH). As of now, the DOH is investing on the health leadership and governance program for local chief executives, for them to fully understand and embrace the health burdens of their locality, that as a leader they are part of the problem and the solution as well. Issues on the provision of hazard pay to the local implementers are out of control of the national government. The LCEs has the capacity to implement the need, thus, the need for them to involve in the program. More so, it was mentioned that LGUs are aware of their responsibilities in implementing the program, only that they have limited resources available, both human and financial, to include the political factors which greatly affects the entire program. Therefore , the LGUs in general shall empower local leaders and make them embark on the sustainability activities of NFEP like initiating surveillance activities, intensified advocacy campaigns and vector control management to cut the transmission.In the story of Maldives a filariasis- free country, showed that in their combat towards elimination, it has proven the impact that empowered LGU contributes service improvement and that political will, manner of leadership, training, resources for the implementation are necessary and important for the success of the program.Furthermore, in relation to one of the literatures reviewed in Chapter 3, Maldives and Sri Lanka, factored out the importance of political will and strong commitment of health leaders which created a ripple effect in the local level that made them finish their target four years ahead of the expected date of elimination. Their Central government spearhead all the initiatives and strategies that will be cascaded to their administrative islands or local government units. The strategies listed were: sustained mass drug administration to high-risk communities annually, mosquito control and a robust surveillance system. In the previous chapters, it was described and explained that the technical capabilities needed by the health implementers are the technical aspect that guard and fight re-infection against filariasis in their respective areas. Other technical capabilities which the LGU also needs are health leadership and governance, health financing and service delivery through border operation activities, advocacy campaigns and the various entomological activities.Theoretically, the LGUs are well-capacitated in terms of program implementation of the NFEP. However, it was not enough for them. In the FGDs and interviews conducted, most if not all program coordinators admit that they can manage the program as long as both financial and political support are present. RECOMMENDATION:The study demonstrated that empowering LGU is necessary in order to sustain the filariasis-free status of Easter Visayas.The following advice and suggestion are recommended for improvement:The central government should establish a sustainability roadmap/ guidelines.The clamor for NFEP sustainability roadmap is still in the pipeline since only Eastern Visayas region has been declared as Filarisis-Free in the entire country. That is why Eastern Visayas is eager in aiming to produce a sustainability roadmap as soon as possible so that local health implementers will be guided in implementing the program. The concept of the roadmap that was mentioned will serve as their bible in providing technical assistance that are focused on the six core components on health which involves service delivery, health workforce, health information system, access to essential medicine, financing and governance or leadership. Among the six building blocks, health leadership should be put on priority. It should be considered that the LGU has full responsibility for the provision of basic public service and that the powers of the central government is limited only to supervision. Undoubtedly, the LGU should be the one to initiate and strategize planning and management for sustainability activities that will ensure disease-free status and eventually prevent re-infection of the disease. In addition, the central government also assist the LGUs in crafting program roadmap that will serve as their guide throughout the implementation. On top of that, financial assistance is ready whenever a province is able to achieve filarial elimination. In the proposed roadmap, the six building blocks for health should serve as their guide.The incorporation of the sustainability roadmap/guideline to NFEP MOPThe sustainability roadmap for Filarisis-free area should be incorporated the existing Manual of Procedures (MOP) of the National Filariasis Elimination Program (NFEP) that would indicate all the necessary tasks the LGUs should follow and must note that the LGU should be the one to have the full responsibility for the provision of basic public service and that the powers of the national government is limited only to supervision as stated in the in the constitution. Indeed, the need to strategize planning and management of sustainability activities to ensure disease-free status and eventually prevent re-infection of the disease and for them to fully recover their economic status and alleviate the burden should be contemplated by both the national and the local government.The technical assistance should invest and focus on leadership coaching and mentoring.In the same manner, the local implementers, during the interview, also stressed out the need to improve health leadership as it greatly affects in the sustenance of the program. One Provincial NFEP Coordinator had expressed the importance of program orientation to elected officials as they change every three years; the program is left again in the cupboard. It is really hard to establish a concrete activity without direction to follow. In Chapter 4, it was discussed that the challenge therefore by the central government is how to capacitate and empower Local Government Unit (LGU) in terms of risk-based planning and management suited with the kind of government we have.The LGU should promote and adapt comprehensive health services based on the mandate of RA 7160. With the current structure of government the Philippines has, LGU’s are supposed to be independent by nature since they were devolved from the national government through the Local Government Code of 1991 or the RA 7160. The national government limits it capability to supervisory power over the LGUs but as it is always being emphasized, there should be a shared responsibility among all programs and projects being implemented in every LGU. The LGU’s should take their counterpart as they benefit it most. But in reality, one program coordinator mentioned that it is their current challenge, less efforts were seen from the LGU’s though the central government has been providing a lot for them. Sustainability activities not only deals with service delivery alone but more so with governance, health financing, health human resource and others. According to some program coordinators, issues on the provision of hazard pay (Magna Carta for Health Workers) and access to financial resources are in scarce in most of the LGUs in the region. Even the implementation of the former and the latter vary from one LGU to the other which most of the time causes some health workers felt they are demoralized; overburdened with work and yet under payed.Strengthen the surveillance system in case of parasitological and entomological survey.On the same weighing, the program should also invest on the vector and parasitological control to fully eradicate the disease in the community even if the area has been declared as filariasis- free. It has to be remembered that vectors and parasites are present in our ecosystem that they need also to be controlled to lessen the infection in the event that an imported cases enter the community. People are mobile, there’s no other way we can control their traffic. Moreover, a robust surveillance system is must needed for the program to established a good quality of data at the local level. From early detection to decision- making, the program should have a readily available data, especially with the government structure and political challenges our country has. First, the policy makers need a concrete figures before they invest their support to the program. It should be noted that not all public officials has the knowledge and is aware of the wide array of health indices unless the health sector would translate the health data into its economic impact. The data collected through the surveillance system can now generate data-cost analysis that will be used by the lawmakers to decide on what better strategies will their LGU would take into action. The burden of lymphatic filariasis in the community is felt only when they have value for money and is affecting the economic and social development of their locality. LGU’s rely mostly on the aid coming from the national government, from technical to financial assistance. This may not be true to all LGU’s, but majority of them are like those.Increase the awareness campaign on economic impact if re-infection may occurAs it was discussed it in the first chapter, the local economy is dependent on the people and the products they produced like abaca- one of the major commodity for textiles and banknotes, which is also the primary breeding site of the filaria-infecting mosquito. Health service providers have to be aware of the extent of the economic impact if re-infection occurs.Establishment of local TWG for MMDP and Psychosocial program.The NFEP should also consider those filarisis patients manifesting elephantiasis. Because of their incapability to perform their routine tasks, like farming, teaching and some other decent jobs, filaria patients are prone to emotional and mental stress which affects their psychological and sociological being. The program should establish support that will address these problems, all the more that there is still a stigma for this kind of patients. The program has the leeway to capacitate this patients for them to continue being productive in their lives and contribute in the local economy. The health sector is not a stand-alone agency for this program. As it has been mentioned in Chapter 4, that a good networking and collaboration with other stakeholders contributes a lot in the success of the program. The national government should take a look into this aspect as this may become a potential investment opportunity. And also for the program, especially the health sector which has all the resources, to go outside of the box and extend its capability to co-create initiatives with other sectors that would help not only the patients but the entire community as well through engaging in livelihood projects with persons with disability offered by other government agencies and will soon create a stigma-free community as they were given again the chance to become productive and be able to help their local economy. Sometimes we need to capitalize on the challenges we are facing for us to be able to think brighter ideas and better solution to the existing problem. In no time soon, all the struggles that the program is dealing with right now will turn out to be the strength of the NFEP if all sectors will work together for the betterment of the people.

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