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July 24, 2011

SONA: Must Highlight Health


I have heard a lot of SONA's in the past and yet, as far as I can remember, I have yet to hear a President talk about his or her comprehensive strategy towards the uplifting of our health situation as a nation. To put it bluntly, I have not encountered any Filipino president who has his or her heart set on prioritizing health. I am bitching about it not only because I am a doctor but because it is a personal conviction that the success of a country lies on how optimal its state of health as a nation.

The Philippines is literally a sick nation. While there have been some improvements done regarding maternal deaths and infant deaths for example, a lot can still be done. I can't help but have this feeling that there is something that is keeping us from moving forward as a nation when it comes to Health care. As far as I see it, there are basically 3 problem areas that are keeping us from improving our health care system.

Problem No. 1: Human resources. The Philippines is the No. 1 country in the world when it came to exporting nurses to the U.S., No. 2 when it comes to exporting doctors. Every year, there is at least 1,000 medical students who are passing the medical licensure exams adding at least 1,000 new doctors to our medical pool. And yet, despite these seemingly abundant number of medical providers, there is this appearance of want and scarcity when it comes to medical providers. Currently, the doctor to population ratio in the Philippines is 1 for every 26,000. At ground zero however, this does not usually manifest. There are towns with a population of more than 30,000 that are doctorless and there are towns with a population of 50,000 to 80,000 but with one doctor serving the entire municipality. These towns are usually GIDA's or geographically isolated and disadvantaged areas.

Why the lack of medical providers therefore? What is actually creating the appearance of scarcity especially in our rural areas is the inequitable distribution of doctors in the country. More doctors, whether specialists or General practitioners, prefer working in highly urbanized areas. Why is this so? Firstly, I think most doctors find no attraction to working in rural areas due to lack of pay and access. Most doctors as well are not attracted to working with government due to its highly partisan and political infiltration when it comes to medical care. The Department of Health has this program called the Doctors to the Barrios where volunteers (or at least, they used to be volunteers, now there are previous scholars of the government through the Pinoy MD scholarship program) are deployed to 4th or 5th class municipalities to work as their Municipal health officer or rural health physician for the next 2 years. After the end of contract however, the average retention rate of a DTTB, that is, the number of DTTB's who decided to continue working for government in their assigned areas or at least in other departments in the DOH (regional, provincial offices) is only less than 50% percent. Out of 20 DTTBs who would end their contract, only 2 or 3 would remain. The rest would either pursue specialty training or take the USMLE, the medical licensure exam for U.S. physicians. Among the many complaints are the endemic problem with local officials meddling in their politics with health care. There are cases such as reluctance of the Local Government unit to give to their MHO their rightful share of their Philhealth Capitation Fund for example. There are cases of failure to give to their MHO/RHP their rightful benefits and allowances as mandated by the Magna Carta for Public health workers. This inability to provide is not due to lack of resources but rather a choice of prioritizing other areas or personalities over and above their local doctor or nurse or midwife. In fact, I know of some towns who, despite the availability of a plantilla position for MHO and the availability of interested and qualified applicants for the said position, they choose not to hire despite being a mandated and obligatory position for a municipality/city.

Just like any ordinary human being, doctors too need to feed their families. Doctors too need to make a living. However, society as a whole, especially our politicians, see doctors as either figures of competition or a profession that is purely altruistic. It is not unusual therefore to see doctors either settling in the cities where pay is good and beyond the reach of politics, or due to an increasing number of doctors converging in cities and therefore narrowing the market field for patients, leave the country to find work abroad. For those doctors who stay in government, it is not unusual to see them swallowed up by the system.

The doctor, the nurse, the midwife, must be protected from the greasy hold of politics and politicians. The way to do so is either to enact a law that would bring back the responsibility of hiring, screening and deploying of doctors to municipal and rural health offices and other public medical facilities to the Department of Health (thus detaching the hold of these Local Chief executives over the doctor) or re-educate our politicians when it comes to proper management of their local health system, which brings me to the next problem...

Problem No. 2: Incompetent Health System Managers. The devolution of the health care system has been intended to make the local government units realize that health is their responsibility and ultimately their priority. However, what the devolution proponents failed to see, I think, is whether or not our local chief executives are ready to manage a local health system. Many of these mayors and governors are non-health care professionals. Some of them have not even finished High school. For towns and provinces whose political landscape manifests the unbreakable political dynasties of local clans, some of these mayors are not even sure of what they are doing when it comes to running a town/city.

Many mayors think that running a local health system is only synonymous to the conduct of hundreds of medical missions around their town. Thus, for these mayors, doing a lot of medical mission is already running a local health system. Many mayors think that purchasing a lot of medicines alone makes them a competent health systems manager. Thus, these mayors would purchase boxes and boxes of medicines, hoard them either in their own residences, or in the mayor's office or distribute them among their "favorite" barangays and provide them to their constituents who would profess loyalty to them come election time. I know of towns whose mayors would not give the purchased medicines to the local health office and instead keep them in their offices or houses and would only instruct the doctor or nurse to tell the patients, should they want medicines, to go to them instead. Or use these purchased medicines for their medical missions.

Many mayors would think that purchasing an ambulance or service vehicle for example is already running a local health system. Then, when the ambulance is in town, they would either stay in the Mayor's Office or the Mayor's residence and should a patient is required to be transported, they would either need the permission of the Mayor or Vice Mayor or First Lady or whoever is "politically influential" in the community. If you are a loyal constituent, then the ambulance will be made available for you. If you are tagged as a sympathizer of the previous administration or political opponent, you may not be able to use the ambulance despite the recommendation of the doctor who made the examination.

It is important therefore that firstly, the people must elect competent leaders who can definitely manage their local health system correctly. Secondly, elected leaders must make an honest assessment of their strengths and weaknesses and therefore ensure that they must allow the experts to advice them and recommend to them the proper initiatives or better still permit themselves to learn and improve on their weaknesses (e.g. health care systems). The former requires a genuine reform in our election system. The latter requires a genuine reform in our education system. By reforming the way we elect our leaders, we can minimize the mistake of choosing leaders whose main priority is the perpetuation of the family name despite and in spite of everything and instead, increase the chances of choosing leaders based on competency. By reforming our educational system, we will be molding future leaders who are not only competent but are quick to identify their weaknesses, show openness to learning, and manifest passion for service.

The National government itself must go down to the level of the local governments to further understand the local health situation. I always have this impression that policy-makers in the national level make policies without even considering to consult the local health situations from local health workers themselves. Thus, the national government would always have a "helicopter" perspective instead of the grassroot perspective. An example would be the perceived problem on "overpopulation". The Helicopter perspective is that there is food shortage and poverty thus the population has to be controlled and contraception therefore must be a first priority. What they failed to see at the grassroots level is that there is more than just poverty going on but more importantly impoverishment and therefore there is this sense of powerlessness among the people thus survival is seen as the first priority. Impoverishment is the act of making someone poor. When I attended a global health course at the University of Tampere in Finland in June of 2010, one of the professors talking about Human reproduction discussed what many would deem as a simplistic approach to managing human reproduction (e.g. somatic, fertility-oriented and control-oriented) and what should be the right approach, which is the holistic approach (e.g. multidisciplinary, health-oriented and consumer-oriented). He even questioned the idea of dealing with population-control as a means of solving the other problems of a country. He even asked, "Is Fertility a Disease?"


In the short term however, the President must declare in his SONA that he is ready to castigate local chief executives through his DILG who fail to make health as their priority. Friend or foe, the President, being the leading Chief executive of all chief executives in the land must make the health indicators of every town and city and province his measuring gauge. Indicators such as the percent alloted from the local budget for health expenditures, the presence of a municipal-hired doctor or nurse in plantilla position, the number of available rural health clinics and birthing facilities, the number of accredited local pharmacies selling low-priced generic drugs, the declining maternal mortality ratios, the declining infant mortality rates, the presence of a functioning local health board and other relevant monitoring bodies such as the maternal death review board or the Women's Health team and the number of true and genuine indigent families enrolled in Philhealth.

I would even go further as to summoning these mayors to answer to their substandard health care indicators and have both the DILG and DOH investigate if there is indeed some form of negligence on the part of the Local Chief executives. There has to be zero-tolerance on substandard performance. If the President can form a Truth Commission, then let him also form a Big Brother Commission whose job is to ensure that these local government units and other agencies for that matter are doing their job well. I don't think this would violate the autonomy of the local government units. The Big Brother Commission will ensure that the President has an eye on the mayors and governors who in themselves are little kings and queens of their own kingdoms. The report of the Big Brother Commission would be two-fold: to seek out any negligence on the part of these LCE's for failure to improve their health indicators and to study ways the National government can assist local government units, especially those who are genuinely working to improve their health situation. This entails a lot of political will from the President backed with a lot of financial investment from the Philippine Congress, which now brings me to my third problem...

Problem No. 3: Lack of Health Investment. The national budget is like a long grocery list where the National government would detail how much they would spend for every priority of the administration. The more money for such a department entails its high urgency and priority. The Health Budget is unfortunately not receiving the right amount of prioritization. With only less than 4% of the national budget, health is put on the sideline rather than on the spotlight. I have yet to encounter a Chief executive who has alloted a lot to the development of his or her health care system. This seemingly lack of attention to health by the national government is echoed in a lot of local government units, whose budgets also do not prioritize health.


While our government would boast of its economic upturns, it is no surprise to hear from the common folks how they do not feel the fruits of these economic successes. The money is simply not trickling down.

Investments are not just for infrastructure but also for the purchase of supplies and the development of our existing human resources. We need not look far to seek the proofs of thus statement. Public hospitals lacking medical supplies, towns without even a standing rural health clinic and seemingly out-of-dated management and approaches to common medical cases are just the common scenarios in our countryside.

I think it is high time to prioritize health. Instead of harping on the ghosts of Administration Past, let the President focus himself on the road to the future. This time, let health be the star of the SONA. Let it be the central theme that anchors all other government priorities. Thus, instead of mentioning the building of farm-to-market roads, let them be homes-to-hospital roads. Instead of mentioning the improvement of agriculture for our food security, let him mention also the improvement of agriculture for our Nutritional security and thus the prevention of malnutrition and diseases associated to such. Let him read the La Londe report citing that health is not just the objective of life, but the resource of every day life. Without a healthy nation, there will be no farmers to till the farms, no soldiers to defend us, no teachers to teach us, no students to fill our classrooms, no workers to build our roads and bridges and no tourists to visit our beaches.

I await the day when the SONA that will be delivered will be a SONA for Health.











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