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July 7, 2010

The Priorities of The New Administration On Health

New administration, new chances. Now that we have a new Administration, I am hopeful that now we can start introducing the changes we wanted for our country. I am no politician. I am just a medical doctor who had 3 years of public health experience and 2 years of teaching experience as well. Within this short span, I was exposed to our health care system and had the opportunity to also be exposed to other health care systems beyond our borders and was able to compare our system with theirs. Of course there are differences and these differences are brought about by the disparity in resources and the variation in cultures. However, we both face the same illnesses and public health concerns. Now that President Aquino has appointed a new health minister, I am hopeful that under the leadership of the new Health Secretary, we can start introducing the changes we wanted for our own health care system, reforming it so that it can be responsive to the needs of the Filipino people. If I were the Health Minister, I would focus on the following priorities:

1. Reformation of the Primary Health Care System - the Primary Health Care is the bedrock of Public Health. Without the strong Primary health care, our entire health care system will crumble. Presently, our primary health care system is left to the hands of local government units to manage, considering that we are a devolved system. While this may be no issue to relatively richer LGU's, the task maybe almost impossible for poorer LGU's. The success therefore of a strong Primary Health Care system relies also on the strength of the LGU and the leadership of its Local Chief Executive.

A strong LGU implies that it must have the financial capacity to sustain its locally initiated programs including those vertical programs from the National Government. In all things, it is money that makes everything functional. In other words, the LGU, in order to sustain its health programs, must practice a sound fiscal management, with health getting the larger chunk of the local budget.

Unfortunately, not all LGUs think that health is a priority. There are still many LGU's which have poor infrastructures for health services, with dilapidated Rural health units or insufficient medical supplies that can at least sustain primary health care services. Some of these Local Chief Executives have been in power (or at least their political dynasty) for many years but it would seem as if the construction or renovation of a health unit would take them forever to do so.

Infrastructure is just the other side of the coin. Human resource is as vital as the infrastructure. There are still many LGU's who cannot afford to hire enough doctors, nurses and midwives to run their Rural Health Unit. Even if they cannot afford, some of these LGU's do not even bother to hire medical professionals to serve their RHU for a myriad of reasons. Others are just too far-flung for even a willing doctor to go and serve. In some cases, Local Chief Executives would use to their political ends these health workers.

So, with a derelict health unit and a poor health workforce, what can you expect of the health outcomes of their communities? People tend to get even sicker and since they do not have a strong Primary Health Care System, these sick constituents of the politicians would go to their Mayors or Vice Mayors or Congressmen, ask for money to be admitted in a Secondary or Tertiary Hospital in exchange for their loyalty in the next elections. The vicious cycle of political patronage continues to persist.

Reforming the Primary Health Care system is important. This requires political will and coordination with other government agencies, particularly the Department of Interior and Local Government (DILG), imposing strict sanctions on these LGU's who without valid excuse continue to forsake their people's health needs by failing to provide the appropriate infrastructures and hire health workers.

The Aquino Administration must make it a policy: Health Is A Basic Human Right. In other words, any Filipino can demand from its government the right to health care. It is not a marketable commodity. It is a Basic Right. And each LGU must ensure that such right is guaranteed by the presence of strong health care systems.

For those with already existing infrastructures and workforce, what they need is now a strong system. It can be likened to the analogy of the LGU upgrading to the latest version its Operating System for its newly bought Personal Computer. Health Care systems, devoid of partisanship, must be strengthened as well.

There must be, for example, a strong referral system in place, between the barangay health center and the Municipal Health Office; between the Municipal Health Office and the Core-referral Hospital of the Interlocal Health Zone. There must also be a system on strict implementation of health programs by appointing local program coordinators and making them accountable. There must be a strong system on objective evaluation based on agreeable standards with consideration of the local situations.

At present, the Department of Health is encouraging Rural Health Units to upgrade into facilities that can provide higher level of care; such as converting an RHU to a birthing facility. As part of its reform, this strategy must not only be encouraged by DOH but must be demanded of from each LGU. It must be strictly required by the National Government that the LGU must invest in the restructuring of their RHU's into birthing facilities. If an LGU is not capable financially, the National Government shall subsidize through trust funds or grants the construction of these facilities. The LGU must also be required to complement the facility with the hiring of qualified health workers. If the LGU is still unable to attract health workers to work within its locality, the National Government must deploy on a contractual basis health workers, especially doctors, nurses and midwives, to work for the LGU until the LGU can either hire its own health workers or reach the capacity to hire and absorbed the deployed health worker. So far, the DOH has been deploying doctors (e.g. Doctors to the Barrios), midwives and with the help of DOLE even nurses (NARS). However, not enough municipalities were covered.

In order to enforce such reforms, the LGU, through its LCE as the health manager of its community, must be made accountable for any lack of or insufficient health care services as manifested by its poor health outcomes once validated by the Regional Office. A law must be passed (if there is none yet) criminalizing the failure to supply for the health care needs of its people; particularly, failures in 1) provision of logistics support for the implementation of the expanded program of immunization; 2) provision of logistics and workforce support for the successful implementation of the TB DOTS; 3) provision of logistics and workforce for the strict implementation of environmental health, to include solid waste management; 4) upgrading RHU to birthing facility complete with basic medical supplies and equipments and competent skilled birth attendants; 5) provision of logistics support for the eradication of malnutrition, to include mechanisms that would sustain surveillance of malnutrition among identified children; 6) provision of logistics and workforce support that would implement preventive health care, especially on non-communicable diseases, such as counselling on smoking cessation, blood sugar watch and managing complications of other non-infectious diseases; 7) provision of free or cheap drugs; 8) provision of logistics and well-trained workforce for emergency and disaster-preparedness, including the laying-out of preparedness plans that are effective enough to respond to the emergency needs of the people when a disaster strikes.

Provision of logistics imply that these medical supplies and equipments were properly purchased through transparent mechanisms and that they are inspected and considered of high quality. Provision of workforce imply that these hired workers, whether on a temporary or permanent basis, are compensated to the full, according to the law, especially in accordance with the Magna Carta for Public Health Workers.

Should the LGU fail to provide such basic health care services, my proposal is for the National Government to put up a Health Unit in that particular LGU that would provide such lacking health care. In other words, it will be an RHU under the National Government. However, the National Government shall only "manage" it for a brief particular period of time (let's say 2 years). Within that period, the LGU has enough time to prime up its financial capacity to become self-reliant in the future. Enhancing local revenues is one measure. After such period of time, the National Government must turn over the management of both facilities and workforce to the local government under a probationary status, with the expectation that the LGU must sustain, if not exceed, the expected health outcomes. Should the LGU fail again to sustain the RHU due to poor fiscal management (e.g. corruption, etc), then the National Government can re-take the facility and personnel and even file appropriate charges against the LGU after a thorough investigation. Of course, the National Government is the last option here. The Interlocal Health Zone can also do this or even the Provincial Government. If both of these systems fail, then it must be the responsibility of the National Government to step in and fill in the gap.

2) Universal Health Care Coverage - It must be the goal of the Philippine government that every Filipino must have health insurance. Rich or poor, every citizen must be covered. Of course, reforms in the health insurance system must also be put into place. The Philippine Health Insurance Company (PHIC or PHILHEALTH)must increase its benefits to the point of even providing 100% coverage to their clients.

In order to ensure health care coverage, it must also be ensured that a registry of all citizens must be in place. Every Filipino born in the country must be registered and that it must be the responsibility of the parents (whether legally married or not) to register their child's birth (including the birth attendant). It is the right of every child to be registered because through registration, the child attains his or her official citizenship and it is a basic right of the child to have a citizenship. My proposal is for the government to put up a national electronic registry so that every citizen can be tracked down only for the sole purpose of ensuring that every citizen has health insurance. For those who can afford to pay for their premiums, they can choose their health insurance provider. For the employed sector, the employer must insure its employees and has the right to choose his/her health insurance provider. For those who cannot afford, the government must ensure them through government subsidies. The identifying of government-sponsored clients must not be left to the local government units however. Based on experience, local chief executives choose constituents to enroll in Philhealth not on the basis of income but on the basis of their political loyalty. Leaving this to the LCE can place the LCE in a compromising situation.

Let us ensure everybody and by efficiently collecting our taxes, the Philippine government can fund such a "Draconian" move. Of course, any citizen who gets admitted in a public hospital gets to avail of reimbursements from their public-run health insurance. Therefore, it is also the prime responsibility of the Philippine Government to reform and upgrade its public hospitals.

Health Care insurances, including Philhealth, must also make sure that it can cover 100% the costs for: health care provider, hospital stay, routine laboratories and selected drugs (particularly first-line antibiotics).

From the farmer to the fisherman, from the student to the businessman, every Filipino must have health insurance. This must be the policy of the Aquino administration: It is everyone's right and duty to have health insurance.

3) Access to cheaper quality drugs - With the intricate grip of the pharmaceuticals in our politicians and even among medical practitioners, it is sometimes impossible to lower the cost of essential drugs. The government in the past has implemented various programs that would ensure accessibility to cheaper drugs (e.g. Botika ng Barangay), however, the problem with access to cheaper quality drugs is two-fold. Firstly, drugs that are supposed to be cheap are manufactured expensively that these pharmaceuticals (who are of course profit-driven) are forced to sell them at a relatively costly price in order to break even at least. Secondly, even if the drugs are already sold at a lower cost, there are still a lot of people who cannot even afford to buy the cheapest drugs due to poverty. In order therefore to address the issue of inaccessibility, the government must address these two issues.

The first issue was already addressed to some extent by passing the Cheaper Medicines Act. However, there are still quite a few more drugs that are sold expensively and for those drugs whose prices have been reduced, the reduction is still not low enough to make it affordable to the poor. The latter issue can be addressed through poverty reduction, increasing the purchase power of the citizenry.

Another problem with drugs is not only the access but the distribution. In the local setting, Local Chief Executives would buy medicines for their RHU but in most cases, instead of placing them in the RHU's pharmacy, LCEs would hoard them instead in their own private homes or offices and hand them out to constituents in exchange for political loyalty.

I am not sure if there is a law already but if there is none yet, my proposal is to criminalize illegal distribution or dispensing of drugs by non-competent people. By competent, I refer to professionals who are licensed to dispense drugs such as pharmacists and such drugs can only be accessed in a health facility or more appropriately in a pharmacy. For those in medical missions, it must be required that a pharmacist must be present as well during the collection of and dispensation of these medicines. This is to ensure distribution of quality drugs and that political patronage is once again minimized if not eliminated. In some countries, doctors are not even allowed to own or start a pharmacy unless the doctor has a Masters degree in Pharmacy.

4) Modernization of Government-Owned Hospitals - It is in the hospital that most of the health service delivery is taking place. Therefore, our government hospitals must be capable enough to deliver quality service and must be the standard of health care rather than the private hospitals. Modernization of these government-owned hospitals requires funding and it is here where President Aquino can exert his political will. One rich source of funds is the PDAF or pork barrel funds of the legislators. If President Aquino can direct at least 20% of the PDAF of each legislator into the modernization fund of the hospitals located in their respective districts (for Senators, those national or regional hospitals), it is possible that we can upgrade our lagging public hospitals.

It is the right of every health care worker to work in an environment conducive for working. The hospital is one such environment. In order to complement the skills of our health care workers and medical professionals, it is the duty of the government to ensure that they are working efficiently through ample logistics support.

If I were President Aquino, I will not approve the release of pork barrel funds unless 20% of them are invested on the funding of renovations and constructions and purchases of supplies for government-owned hospitals.

Things that must be modernized in our public hospitals include: 1) increasing the number of wards to avoid congestion of patients; 2) upgrading of laboratories, enhancing capacity to perform diagnostics, including upgrading of imaging laboratories such as X-rays and Ultrasounds and even CT Scans; 3) upgrading of Operating Rooms and Delivery Rooms, equipping them with state-of-the-art equipments at par with the modest private hospitals; 4) computerization of patient records, establishing databases that can be accessed within the hospital and even between institutions facilitating easy and fast referrals and retrieval of records; 5) institutionalizing research, providing grants for promising studies conducted by medical professionals working within or affiliated with the hospital.

5) Reforms in Medical Education - the groundwork for producing quality workforce lies in the medical education system. The kind of doctors we produce is dependent on how we have taught them while they were in medical school. In coordination with the Commission on Higher Education, the Government must now make it a policy that medical education must be 1) first and foremost accessible; 2) world-class quality and 3) balanced in its perspective (clinicals versus public health).

Medical Education must be accessible. At present, the government is sponsoring scholars through the PinoyMD program. This must be institutionalized in order to ensure its sustainability. National Government must ensure sustainability of funds by enacting laws that would make sure of such. Again, political will is required and if I were President Aquino, I would once again use 20% of the PDAF of the legislators to fund scholars who will be taking up medical courses. Of course, each scholar is required to serve for at least 2 years in a public health setting as payback for the government's sponsorship. It will also be the DOH's duty to provide job opportunities for the government scholars once they have taken up their licensing exams.

Medical Education must be world-class quality. I am not sure if at present there is a body or commission that supervises all medical schools in the country. If there is none, then the government must establish a Commission that would evaluate the quality of every medical school in the country based on various criteria, which may include the school's performance in the licensing exams. Medical schools that are constantly not producing enough board passers in proportion to the number of their graduates should be either improved through recommendations by the Commission or closed down.

Medical education must be balanced in its perspective. The medical curriculum must therefore be updated to provide the medical students the clearer choice between proceeding to specialization and private practice and a career in public health and policy. Most medical curriculum tend to focus heavily on training medical students to become clinicians. We have in fact many specialists in our country but we have so little rural health physicians. There is therefore maldistribution of doctors in the country, with specialists working more in the urban areas than in the rural areas where their services are needed the most. Perhaps because public health is considered less appealing than private practice or hospital-based practice. The medical curriculum must integrate public health as part of its curriculum and practicum.

There are certainly many more problems that hound the Health Care system and obviously these will not be solved in the span of the Aquino administration. But President Aquino and his new health secretary can start the groundwork, laying the foundation for a better health care system; a health care system that is responsive to the needs of the Filipino people.

Due to time constraints, I feel that those 5 issues that I mentioned can be addressed partially, if not completely, within the span of the Aquino administration.

I just wish that the Department of Health should now really focus on these issues, be firmer in its hold and should not basically leave it to the LGU simply because the health care system is devolved. The National Government can still influence the Local Government Unit and can step in if necessary for the sake of the people. While the national government should respect the autonomy of the LGU, it must intercede if the LGU, hiding under the mantle of its granted autonomy, is slacking in the implementation of its health reforms.

The key to health reforms, like any other reforms, is political will. Of course, the recognition of health as a priority is the first step. I just wish that the Aquino administration considers health as a top priority and not just a "distant" priority. We have been lagging behind other countries when it comes to health care. We simply cannot afford to be so still in the next 6 years.

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