Institutionalizing LGBTQI+ Health: A deeper embedding through capacity-building and behavior change

Martha de la Paz


When I first thought of pursuing LGBTQI+ health, a colleague once asked me how I can pursue such a career path if the health sector’s direction is to integrate vertical programs. Three years later, the question remains in my head.

According to WHO researchers, vertical programs, also known as stand-alone, disease management, or disease control programs, are interventions provided through delivery systems with separate administrations and budgets, as well as varied structural, funding, and operational integration with the wider health system. Before the Universal Health Care (UHC) Law in the Philippines, health problems were addressed and reforms were spearheaded through the establishment of vertical programs. For example, after World War II, it was estimated that there were at least 500,000 tuberculosis cases among the 18,000,000 citizens of the Philippines. In 1978, the National Tuberculosis Control Program was established. In another case, according to the Philippines Department of Health, since 1999, cancer has been the third leading cause of morbidity and mortality in the country. In 2019, the Philippine Congress enacted the National Integrated Cancer Control Act.

But now, with the UHC Act, the Department of Health (DOH) leads the horizontal integration of these vertical programs. Instead of managing multiple siloed health programs, the DOH is shifting towards integrated health care management throughout the lifetime. This approach promotes a healthy start to life while also addressing the needs of individuals at critical periods of their life. Diseases, both communicable and non-communicable, and injuries are addressed in a holistic and efficient manner. As such, the million-dollar question for me is, how can I institutionalize LGBTQI+ health without creating a program or a specific unit for it?

Implementing Institutional, Sectoral, and Societal SOGIESC Education

During my interviews with LGBTQI+ individuals and civil society organizations, their stories unveiled various gaps in our health system that facilitate the inaccessibility of health services for LGBTQI+ patients, as well as poor health outcomes. A common theme emerging from the experiences of different members of the community is the lack of health worker knowledge on LGBTQI+ health needs, which translates to unmet needs and/or discrimination. While it can be frustrating as a trans public health professional, I cannot entirely blame individual health workers. Centuries of erasure and disregard of LGBTQI+ rights translated to generations of health professionals who are ignorant on how to take care of our health.

That is why I believe in the power of education. Institutionalizing LGBTQI+ health in UHC requires continuous capacity-building of health workers, program managers, and policy makers. This I realized during our first co-creation seminar with the Policy, Planning, Standards and Research Division of the Health Promotion Bureau. From being the only one in the room knowledgeable about the realities faced by the LGBTQI+ community relative to negative health outcomes, health system gaps, and multisectoral forms of discrimination, we left with an additional five people more aware of LGBTQI+ health issues. Now, the goal is to educate and bring on board the whole bureau and eventually the whole DOH.

A critical strategy I propose is to implement gender sensitivity training on sexual orientation, gender identity, expression, and sex characteristics (SOGIESC) for program managers and policy-makers at the DOH. As stewards of health, it is imperative for the DOH to be abreast of emerging SOGIESC concepts. This, I believe, will give a new perspective about how SOGIESC affects health and wellbeing as a social determinant of health. Understanding health disparities experienced by LGBTQI+ patients allows the institution to recalibrate its existing strategies towards addressing common health issues relative to mental health, sexual health, and NCDs that disproportionately affect LGBTQI+ Filipinos. Furthermore, it raises the attention of policy makers on specific services needed by the transgender and intersex communities.

Aside from policy makers and program managers, it is also equally important to increase the capacity of frontline health care workers. As it is their responsibility to care for LGBTQI+ Filipinos’ health, frontline health care workers must understand SOGIESC and LGBTQI+ health disparities to provide responsive services. Thus, it is crucial for current health care workers to receive and participate in training activities on SOGIESC and LGBTQI+ health. In the long term, the DOH, the Commission on Higher Education, and, academics should pursue embedding LGBTQI+ Health in health and allied health curricula. As Wahlen et al. (2020) discovered, a one-hour lecture on sexual orientation and LGBTQI+ health issues has the potential to increase medical students’ knowledge and ultimately improve LGBTQI+ health outcomes.

Stretching this further, eliminating LGBTQI+ issues that translate to negative health outcomes requires changing multiple generations’ perception of the community. As such, it is important to embed SOGIESC in the education sector. Teaching LGBTQI+ youth SOGIESC concepts will promote a greater understanding of their bodies, experiences, and relationships, while increasing the awareness of non-LGBTQI+ youth on their LGBTQI+ peers’ realities. Just imagine the power and impact of normalizing LGBTQI+ experiences towards achieving gender equality!

Embedding in Existing Initiatives and Systems

With the enactment of the UHC Act, the sector is moving towards ensuring that all Filipinos have access to quality and affordable health services. Now, the challenge is making sure that existing initiatives and systems catalyze LGBTQI+ health. In fact, there are various initiatives in the DOH that I see which have great potential in promoting LGBTQI+ health. One of which is the development of clinical practice guidelines (CPG) for trans and intersex health. This is one of the salient reforms of the UHC Act, wherein the DOH shall develop CPGs to ensure the safety and quality of health services. In our interviews, most trans and intersex patients feel that they are more knowledgeable about the respective health services that they need compared to the current cadre of health professionals. They also communicated the lack of local standards of care that should provide information on gender-affirming hormone treatments and surgeries for trans people, and appropriate diagnosis and management of intersex individuals, as well as access points. The development of CPGs will not only provide standards to health professionals and patients, but also advance the clinical practice of trans and intersex health in the country like more established systems such as Canada, USA, and UK.

To ensure that frontline health care workers are inclusive towards LGBTQI+ patients and knowledgeable of their health needs, as emphasized previously, SOGIESC and LGBTQI+ health modules for frontline health workers can be rolled-out through the DOH academy. Currently, modules on UHC are cascaded at all levels of the health system through this platform. LGBTQI+ health can even be integrated in primary care modules to communicate the critical role of primary care providers in helping LGBTQI+ patients navigate the health system and fostering an inclusive health environment where they trust their health providers.

Other than the UHC Act, the establishment of the Gender and Development Focal Point System (GFPS), institutionalized through the Magna Carta of Women, can be utilized to push for LGBTQI+ health. Given that both LGBTQI+ health and GFPS’ objective is to promote gender equality, GFPS can be utilized to create a cadre of LGBTQI+ health advocates. Increasing the knowledge of program implementers on LGBTQI+ health will catalyze the recalibration of existing UHC initiatives for the benefit of the LGBTQI+ community. Lastly, to transform the DOH into a champion of LGBTQI+ rights, inclusive human resource programs can be implemented through GFPS, including the use of lived names and pronouns in communications and human resource database, and reporting and management of SOGIESC-based discriminatory acts in the workplace. In reckoning my personal experience of discrimination related to HR. Faith, my immediate supervisor, said that these simple initiatives make life less difficult for us who continue to suffer discrimination, exclusion, and other gender-based inequities.

As my mentor would always say, my biggest challenge is changing the habitus of my fellow policy makers in order to move LGBTQI+ health forward. I know it will take years of continuous education and repeated convincing. It may even remain as a challenge of future generations after mine. But as I watch my project unfold and meet like-minded individuals inside and outside the bureaucracy who are as passionate as I am to take this work forward, I know we are taking the right steps. These are the people who will help us ensure that existing initiatives and their respective health cadre continuously find solutions and treat LGBTQI+ health with utmost importance.