Annex C.

AOP Form 1. Summary of Investment Cost by Health Systems Building Block and Fund Source

Region: REGION A
Province/HUC/ICC: PROVINCE Y
Municipality/Component City: _______________
AOP CY: 2023

Fund Sources (PhP)

Total per Building
Health Systems Building Blocks LOCAL GOVERNMENT UNITS (LGU) DOH
Unfunded Block (including % of Building Block
Province/HUC/ICC LGU Mun/CC LGU Remarks
(PhP) Unfunded) to Grand Total
Trust Fund for Trust Fund for BLGU Central Office CHD Others (PhP)
General Fund Total General Fund Total
Health/SHF Health
1. Health Service Delivery
2. Health Workforce
3. Health Information System
4. Supply Chain & Logistics Management
and Health Regulation
5. Financing
6. Leadership and Governance
Total per Fund Source (including Unfunded)
(PhP)
As a Percentage of Total

(1) Health Systems Building Blocks:

§  Health Service Delivery; Health Workforce; Health Information System; Supply Chain & Logistics Mgt and Health Regulation (Medical products, vaccines and technology); Financing; Leadership and Governance
(2)  Fund Sources – Which/what office will be able to fund the investment:
§   LGU – Local Government Units: Province/HUC/ICC LGU (General Fund and Trust Fund for Health/Special Health Fund); Municipality/Component City LGU (General Fund and Trust Fund for Health); Barangay LGU
Trust Fund - Fund which accounts for the receipts by any agency of government or by a public officer acting as a trustee, agent, or administrator for the fulfillment of some obligations
General Fund - Fund which is available for any purpose and is composed of all receipts and revenues which are not otherwise accruing to other funds
Special Health Fund - pool of financial resources at the P/CWHS intended to finance population-based and individual health services, health system operating costs, capital investments, and remuneration of additional health workers and incentives for all health workers
§   DOH – Central Office or Centers for Health Development;
§   Others - Other Fund Sources, such as Official Development Assistance (eg. UN Agencies, development partners); other national agencies; NGOs/CSOs; private and other sectors
(3)   Unfunded - No funding source has been identified
(4) Total per Building Block - Sum of all funding sources for a particular Building Block including Unfunded
(5) % of Building Block to the Grand Total
(6) Remarks - Notes or comments; may specify Other fund sources
Annex C.3
AOP Form 2. Cost Assumption by HS Building Block, PPAs, Quarter and Fund Source (AOP Mother Plan)

Region: REGION A
Province/HUC/ICC: PROVINCE Y
Municipality/Component ____________
City: ___
AOP CY: 2023
Target Resource Requirements (PhP) Fund Source (PhP)

Program/Project/ Municipality/ Name of Province/HUC/ICC LGU Mun/CC LGU

Performance
Activities (PPA) District Component Health Total
Indicator Q1 Q2 Q3 Q4 Unit Cost Quantity BLGU CO CHD Others Unfunded Remarks
(Building Block) City/ Barangay Facility Target Trust Fund for Trust Fund
General Fund Total General Fund Total
Health/SHF for Health

Major/Sub-Program 1
Strategy 1 _______
Activity 1
Activity 2
Activity 3
Sub-total
Strategy 2 _______
Activity 1
Activity 2
Activity 3
Sub-total
Strategy 3_______
Activity 1
Activity 2
Activity 3
Sub-total
Sub-total for Major/
Sub-Program 1
II. Major/Sub-Program 2
Strategy 1 _______
Activity 1
Activity 2
Activity 3
Sub-total
Strategy 2 _______
Activity 1
Activity 2
Activity 3
Sub-total

Strategy 3_______
Activity 1
Activity 2
Activity 3
Sub-total
Sub-total for Major/
Sub-Program 2
Total for (Building Block

(1) Health Systems Building Block: Service Delivery; Health Workforce; Health Information Systems; Supply Chain & Logistics Mgt and Health Regulation (Medical products, vaccines and technology); Financing; Leadership & Governance
▪ Strategies - Identified priority interventions that address health needs and health inequities, such as:
▪ Construction; Repair/renovation/expansion of health facilities; Procurement/repair of equipment; Hiring of health workforce; Retention of health workforce; Capacity building/development; Procurement/provision of commodities, medical supplies;
 Target Resource Requirements (PhP) Fund Source (PhP)

Program/Project/ Municipality/ Name of Province/HUC/ICC LGU Mun/CC LGU

Performance
Activities (PPA) District Component Health Total
Indicator Q1 Q2 Q3 Q4 Unit Cost Quantity BLGU CO CHD Others Unfunded Remarks
(Building Block) City/ Barangay Facility Target Trust Fund for Trust Fund
General Fund Total General Fund Total
Health/SHF for Health

▪ Establishing systems; Monitoring; Policy development; Sectoral collaboration/partnerships; Advocacy/awareness/health promotion campaigns; Research and development; Others
▪ Objective – Desired outcome in 3 years for the Strategy
(2) Performance Indicator for the Strategy - Measurable value/performance measurement to evaluate the success of a strategy/intervention
(3) District - The legislative district where the Strategy will be applied/conducted. In a province, this excludes the legislative districts covered by the HUC/ICC which will be reflected in the HUC/ICC’s respective plans
(4) Municipality/Component City/Barangay - Specific area where the Strategy will be applied/conducted, indicate if area covers GIDA/IP/Urban poor and other vulnerable population
(5)  Name of Health Facility - The exact name of the facility where the Strategy will be applied/conducted
(6) Target - Quantifiable physical target/goal/objective in relation to the performance indicator of a particular strategy
(7)  Resource Requirement – Inputs needed to conduct/produce the PPA
§  Items Description - specific description of the items/units to be costed (eg. Capsules, tablets, meals, activity cost etc)
§  Expense Category: PS, MOOE, CO (Infrastructure, Equipment, Motor Vehicle, Others)
§  Unit Cost - Estimated Cost to produce/conduct the P/P/A
§  Quantity - Total Number of the Units to be costed
(8) Fund Source – Which/what office will be able to fund the Strategy output:
§   LGU – Local Government Units: Province/HUC/ICC LGU (General Fund and Trust Fund for Health/Special Health Fund), Municipality/Component City LGU (General Fund and Trust Fund for Health); Barangay LGU
Trust Fund - Fund which accounts for the receipts by any agency of government or by a public officer acting as a trustee, agent, or administrator for the fulfillment of some obligations
General Fund - Fund which is available for any purpose and is composed of all receipts and revenues which are not otherwise accruing to other funds
Special Health Fund - pool of financial resources at the P/CWHS intended to finance population-based and individual health services, health system operating costs, capital investments, and remuneration of additional health workers and incentives for all health workers
§   DOH – Central Office or Centers for Health Development;
§   Others - Other Fund, Sources such as Official Development Assistance (eg. UN Agencies, development partners); other national agencies; NGOs/CSOs; private and other sectors
(9)  Unfunded - No funding source has been identified
(10) Remarks - Notes or comments; may specify Other fund sources
Annex C.4

AOP Form 3. SUMMARY OF LGU INVESTMENT NEEDS

Region: REGION A
Province/HUC/ICC: PROVINCE Y
Municipality/Component City: ____________
AOP Year: 2023

Cost per Fund Source (PhP)

LOCAL GOVERNMENT UNITS (LGU) DOH
Categories of Investment Needs Province/HUC/ICC LGU Mun/CC LGU
Unfunded Total Remarks
Others
Trust Fund for Trust Fund for Barangay Central Office CHD
General Fund Total General Fund Total
Health/SHF Health

1. Health Facility Development

New Construction
a. LGU Hospital
b. RHU
c. BHS
d. Other facilities (please specify)
Repair/Improvement/Upgrading
a. LGU Hospital
b. RHU
c. BHS
d. Other facilities (please specify)
Equipment
a. LGU Hospital
b. RHU
c. BHS
d. Other facilities (please specify)
Motor Vehicle
a. LGU Hospital
 Cost per Fund Source (PhP)
LOCAL GOVERNMENT UNITS (LGU) DOH
Categories of Investment Needs Province/HUC/ICC LGU Mun/CC LGU
Unfunded Total Remarks
Others
Trust Fund for Trust Fund for Barangay Central Office CHD
General Fund Total General Fund Total
Health/SHF Health

b. RHU
c. BHS
d. Other facilities (please specify)
MOOE (including operations cost)
a. LGU Hospital
b. RHU
c. BHS
d. Other facilities (please specify)
2. Information & Communication
Technology
a. LGU Hospital
b. RHU
c. BHS
d. Other facilities (please specify)
Sub-Total

3.*Human Resource for Health

I. HRH Deployment
Please indicate the quantity and
amount per cadre.
a. Physician (specify)
b. Nurse
c. Midwife
d. Medical Technologist
e. Dentist
f. Pharmacist
g. Nutritionist-Dietician
h. Physical Therapist
i. Other HRH, please specify
II. LGU employment
a. Need for New Plantilla Items
(itemized)
b. Existing Plantilla Items
(Lumped)
 Cost per Fund Source (PhP)
LOCAL GOVERNMENT UNITS (LGU) DOH
Categories of Investment Needs Province/HUC/ICC LGU Mun/CC LGU
Unfunded Total Remarks
Others
Trust Fund for Trust Fund for Barangay Central Office CHD
General Fund Total General Fund Total
Health/SHF Health

c. Request for New Job

Order/Casual (Lumped
d. Existing Job Order/Casual
(Lumped)
Sub-Total
 Cost per Fund Source (PhP)
LOCAL GOVERNMENT UNITS (LGU) DOH
Categories of Investment Needs Province/HUC/ICC LGU Mun/CC LGU
Unfunded Total Remarks
Others
Trust Fund for Trust Fund for Barangay Central Office CHD
General Fund Total General Fund Total
Health/SHF Health

4. Commodities
(Drugs/Vaccines/Med. Supplies)
Please indicate commodities/
drugs/ vaccine under each
program Commodities
cited in this template are
EXAMPLES only.
Family Health, Nutrition and
Responsible Parenting
Family Planning & Reproductive
Health
a. DMPA
b. Pills
c. Condoms
d. Sub-dermal Implant
Oral Health
a. Flouride
b. Lidocaine
Nutrition
a. Micronutrient powder
b. Vitamin A
c. Iron
Others
National Immunization
a. IPV
b. OPV
c. DPT-HEPB-HIB
d. MR
Elimination of Infectious Diseases
Malaria Control and Elimination
Schistosomiasis
Leprosy
 Cost per Fund Source (PhP)
LOCAL GOVERNMENT UNITS (LGU) DOH
Categories of Investment Needs Province/HUC/ICC LGU Mun/CC LGU
Unfunded Total Remarks
Others
Trust Fund for Trust Fund for Barangay Central Office CHD
General Fund Total General Fund Total
Health/SHF Health

Filariasis
Rabies Prevention and Control
Prevention and Control of
infectious Diseases
TB
Dengue Prevention and Control
HIV/STI Prevention and Control
Other Infectious Diseases
Non-communicable Diseases
Hypertension
Diabetes
Mental Health
CVD
Cancer
Environmental and Occupational
Health

Health Emergency Management

Other Commodities

Sub-total

5. Other Technical Assistance

A. Leadership and Governance

Local Health Systems integration
activities
LIPH/AOP development and
monitoring
 Cost per Fund Source (PhP)
LOCAL GOVERNMENT UNITS (LGU) DOH
Categories of Investment Needs Province/HUC/ICC LGU Mun/CC LGU
Unfunded Total Remarks
Others
Trust Fund for Trust Fund for Barangay Central Office CHD
General Fund Total General Fund Total
Health/SHF Health

GIDA, ICC/IPS, Urban Poor

activities/projects
LGU Health Scorecard activities
including advocacy and recognition
of those with exemplary practices
Leadership and Governance
strengthening activities
Data collection for health equity
assessment, measurement and
intervention for HUCs/ICCs
Barangay Health Workers (BHWs)
activities
Documentation of best practices
Others

B.  Financing
C.  Health Workforce
D.  Information
E.  Supply Chain and Logistics
Management & Health
Regulation

F.  Service Delivery (Programs

indicated are not exhaustive)
Family Health, Nutrition and
Responsible Parenting
National Immunization
Elimination of Infectious Diseases
Rabies Prevention and Control
Prevention and control of Infectious
Diseases
 Cost per Fund Source (PhP)
LOCAL GOVERNMENT UNITS (LGU) DOH
Categories of Investment Needs Province/HUC/ICC LGU Mun/CC LGU
Unfunded Total Remarks
Others
Trust Fund for Trust Fund for Barangay Central Office CHD
General Fund Total General Fund Total
Health/SHF Health

TB
Dengue Prevention and Control
HIV/STI Prevention and Control
Other Infectious Diseases
Non-communicable Diseases
Environmental and Occupational
Health
Health Emergency Management
Others (specify)

Sub-total

Total
Annex C.5

AOP Form 3.1. LGU Investment Need for Health Facility Development, Information & Communication
Technology and Operations Cost

Region: REGION A
Province/
Municipality/ PROVINCE Y
HUC/ICC:
Component _______________
City:
AOP CY: 2023

Facility Investment Need (PhP) Cost per Fund Source (PhP)

LOCAL GOVERNMENT UNITS (LGU) DOH
Municipality/
District Name of Project Province/HUC/ICC LGU Mun/CC LGU
Component City/ Category Medical Motor Total Cost/
Health Facility Description Infrastructure ICT Others Central Others Unfunded Remarks
Barangay Equipment Vehicle Facility Barangay CHD
Trust Fund for General Trust Fund for Office
General Fund Total Total
Health/SHF Fund Health

I. Health Facility Development

A. Construction/ Completion/ Repair/ Upgrading/ Equipping

B. Maintenance and Other Operating Expenses (including operations cost)

Sub-total

II. Information and Communication Technology

Sub-total
Total

Operations Cost - costs to to cover day-to-day requirements of facilities to carry out their regular operationssuch as water utilities, electricity, regular office supplies, rents, gasoline, other maintenance and operating expenses
Annex C.6

AOP Form 3.2. LGU Investment Need for Human Resource for Health

Region: REGION A
Province/HUC/
PROVINCE Y
ICC:
Municipality/ ______________
Component City: _
AOP CY: 2023

Cost per Fund Source (PhP)

LOCAL GOVERNMENT UNITS (LGU) DOH

Municipality/ Province/HUC/ICC LGU Mun/CC LGU

Name of Health Salary Total Salaries
District Component City/ HRH/ Cadre Number Unfunded Remarks
Facility Grade and Benefits Others
Barangay Trust Fund Barangay CO CHD (PhP)
General General Trust Fund
for Health/ Total Total
Fund Fund for Health
SHF

I. HRH Deployment
a. Physician
(specify)
b. Nurse
c. Midwife
d. Medical
Technologist
e. Dentist
f. Pharmacist
g. Nutritionist-
Dietician
h. Physical
Therapist

i. Other HRH,
please specify
Sub-total
II. LGU Employment
a. Need for New Plantilla Items* (summary per facility)

b. Existing Plantilla Items

c. Request for New Job Order/Casual

d. Existing Job Order/Casual

Sub-total
Total

NOTES
Column S to include Unfunded
Annex C.7

AOP Form 3.3. LGU Investment Need for Commodities

Region: REGION A
Province/HUC/ICC: PROVINCE Y
Municipality/
____________
Component City:
AOP CY: 2023

Cost per Fund Source (PhP)

LOCAL GOVERNMENT UNITS (LGU) DOH
Municipality/ Total Cost
Commodities Name of Target Estimated Unit Province/HUC/ICC LGU Mun/CC LGU
District Component Items/ Description Quantity (Unit Cost x Quantity) Remarks
Health Facility Population Cost (PhP) Others Unfunded
City/ Barangay (PhP) Trust Fund for Trust Fund for Barangay Central Office CHD
General Fund Total General Fund Total
Health/SHF Health

Major Program 1
Sub Program 1
Commodities 1
Commodities 2
Sub-Total

Sub Program 2
Commodities 1
Commodities 2
Sub-Total

Sub-total Major Program 1

Major Program 2
Sub Program 1
Commodities 1
Commodities 2
Sub-Total

Sub Program 2
Commodities 1
Commodities 2
Sub-Total

Sub-total Major Program 2

Total
Annex C.8

AOP Form 3.4. LGU Investment Need for Other Technical Assistance

Region: REGION A
Province/HUC/ICC: PROVINCE Y

Municipality/ ______________
Component City: _
AOP CY: 2023

Resource Requirements (PhP) Fund Source (PhP)

Target
LOCAL GOVERNMENT UNITS (LGU) DOH
Municipality/ Total Cost
Activities Province/HUC/ICC LGU Mun/CC LGU
Component City/ (Unit Cost x Unfunded Remarks
Barangay Items Description Unit Cost Quantity Quantity) Trust Fund Central Others (PhP)
Q1 Q2 Q3 Q4 Total Target Trust Fund Barangay CHD
(PhP) General Fund for Total General Fund Total Office
for Health
Health/SHF
A. Leadership and
Governance
Major Program 1
Sub-Program 1
Activity 1
Activity 2

Sub-Program 2
Activity 1
Activity 2
Sub-total Leadership and Governance
B. Financing
Major Program 1
Activity 1
Activity 2
Sub-total Financing
C. Health Worksforce
Major Program 1
Sub-Program 1
Activity 1
Activity 2

Sub-Program 2
Activity 1
Activity 2
Sub-total Health Workforce
D. Information
Major Program 1 `
Sub-Program 1
Activity 1
Activity 2

Sub-Program 2
Activity 1
Activity 2
Sub-total Information
E. Supply Chain & Logistics
Management (Health
Regulation)
Major/Sub-Program 1
Activity 1
Activity 2
Sub-total Supply Chain & Logistics Management (Health Regulation)
F. Service Delivery
Major Program 1
Sub-Program 1
Activity 1
Activity 2

Sub-Program 2
Activity 1
Activity 2

Major Program 2
Sub-Program 1
Activity 1
Activity 2

Sub-Program 2
Activity 1
Activity 2
Sub-total Service Delivery
Total
Annex C.9

AOP Form 4. REGIONAL SUMMARY OF LGU INVESTMENT NEEDS

Consolidation of AOP Form 3 of Provinces, HUC, ICC in the Region.

For details, please refer to Form 3 of Provinces, HUCs, ICCs.

Region: REGION A
AOP Year: 2023

Cost per Fund Source (PhP)

LOCAL GOVERNMENT UNITS (LGU) DOH
Provinces/HUCs/ICCs LGU Mun/CC LGU
Categories of Investment Needs GRAND TOTAL
Unfunded REMARKS
Trust Fund for Others (PhP)
Trust Fund for Barangay Central Office CHD (PhP)
General Fund Health/ Total General Fund Total
Health
SHF

1.       Health Facility Development

New Construction
a. LGU Hospital
b. RHU
c. BHS
d. Other facilities (please specify)

Repair/Improvement/Upgrading
a. LGU Hospital
b. RHU
c. BHS
d. Other facilities (please specify)

Equipment
a. LGU Hospital
b. RHU
c. BHS
d. Other facilities (please specify)

Motor Vehicle
a. LGU Hospital
b. RHU
c. BHS
d. Other facilities (please specify)

MOOE (including operations cost)

a. LGU Hospital
b. RHU
c. BHS
 Cost per Fund Source (PhP)
LOCAL GOVERNMENT UNITS (LGU) DOH
Provinces/HUCs/ICCs LGU Mun/CC LGU
Categories of Investment Needs GRAND TOTAL
Unfunded REMARKS
Trust Fund for Others (PhP)
Trust Fund for Barangay Central Office CHD (PhP)
General Fund Health/ Total General Fund Total
Health
SHF

d. Other facilities (please specify)

 Cost per Fund Source (PhP)
LOCAL GOVERNMENT UNITS (LGU) DOH
Provinces/HUCs/ICCs LGU Mun/CC LGU
Categories of Investment Needs GRAND TOTAL
Unfunded REMARKS
Trust Fund for Others (PhP)
Trust Fund for Barangay Central Office CHD (PhP)
General Fund Health/ Total General Fund Total
Health
SHF

Sub-Total

2.       ICT Equipment

a. LGU Hospital
b. RHU
c. BHS
d. Other facilities (please specify)

Sub-Total

3.      Human Resource for Health

Physician (specify)

Nurse
Midwife
Medical Technologist
Dentist
Pharmacist
Nutritionist-Dietician
Physical Therapist
Other HRH, please specify

II. LGU employment

a. New positions (itemized)
b. Existing (Lumped)
c. JO new (Lumped
d. JO existing (Lumped)

Sub-Total
 Cost per Fund Source (PhP)
LOCAL GOVERNMENT UNITS (LGU) DOH
Provinces/HUCs/ICCs LGU Mun/CC LGU
Categories of Investment Needs GRAND TOTAL
Unfunded REMARKS
Trust Fund for Others (PhP)
Trust Fund for Barangay Central Office CHD (PhP)
General Fund Health/ Total General Fund Total
Health
SHF

4. Commodities (Drugs/Vaccines/Med. Supplies)

Family Health, Nutrition and Responsible Parenting

Family Planning & Reproductive Health

a. DMPA
b. Pills
c. Condoms
d. Sub-dermal Implant
Oral Health
a. flouride
b. Lidocaine
Nutrition
a. Micronutrient powder
b. Vitamin A
c. Iron
Others

National Immunization
a. IPV
b. OPV
c. DPT-HEPB-HIB
d. MR
e. Others

Elimination of Infectious Diseases

Malaria Control and Elimination
Schistosomiasis
Leprosy
Filariasis
Rabies Prevention and Control
Prevention and Control of Infectious Diseases
TB
 Cost per Fund Source (PhP)
LOCAL GOVERNMENT UNITS (LGU) DOH
Provinces/HUCs/ICCs LGU Mun/CC LGU
Categories of Investment Needs GRAND TOTAL
Unfunded REMARKS
Trust Fund for Others (PhP)
Trust Fund for Barangay Central Office CHD (PhP)
General Fund Health/ Total General Fund Total
Health
SHF

Dengue Prevention and Control

HIV/STI Prevention and Control
Other Infectious Diseases
Non-communicable Diseases
Hypertension
Diabetes
Mental Health
CVD
Cancer

Environmental and Occupational Health

Health Emergency Management
Other Commodities

Sub-Total

5. Other Technical Assistance

A.  Leadership and Governance
Local Health Systems integration activities

LIPH/AOP development, planning and

monitoring, advocacy to/ consultation with key
stakeholders, program implementation review
GIDA, ICC/IPS, Urban Poor activities/projects
LGU Health Scorecard activities including
advocacy and recognition of those with
exemplary practices
 Cost per Fund Source (PhP)
LOCAL GOVERNMENT UNITS (LGU) DOH
Provinces/HUCs/ICCs LGU Mun/CC LGU
Categories of Investment Needs GRAND TOTAL
Unfunded REMARKS
Trust Fund for Others (PhP)
Trust Fund for Barangay Central Office CHD (PhP)
General Fund Health/ Total General Fund Total
Health
SHF

Leadership and Governance strengthening activities

Data collection for health equity assessment,

measurement and intervention for HUCs/ICCs
Barangay Health Workers (BHWs) activities
Documentation of best practices
Others

B.  Financing

C.  Health Workforce

D.  Information

E.  Supply Chain and Logistics Management &

Health Regulation

F.  Service Delivery

Family Health, Nutrition and Responsible
Parenting
National Immunization
Elimination of Infectious Diseases
Rabies Prevention and Control
Prevention and control of Infectious Diseases
TB
Dengue Prevention and Control
HIV/STI Prevention and Control
Other Infectious Diseases
Non-communicable Diseases
Environmental and Occupational Health
Health Emergency Management
Others (specify)

Sub-Total
Total