THE DEVOLUTION OF THE DOH
VISION-MISSION OF DOH • Vision – To be the leader of health for all in the Philippines • Mission - Guarantee equitable, sustainable and quality health for all Filipinos, especially the poor, and to lead the quest for excellence in health.
HISTORY OF THE DOH • In 1947, under Executive Order No. 94, series of 1947, the Bureau of Public Welfare to the Office of the President and the Department was renamed Department of Health (DOH)
HISTORY OF THE DOH • In 1987, the re-organization under Executive Order No. 119, which placed under the Secretary of Health five offices headed by an undersecretary and an assistant secretary
– These offices are: • Chief of Staff, Public Health Services, Hospital and Facilities Services, Standard and Regulations, and Management Service
HISTORY OF THE DOH • In 1992, the full implementation of Republic Act No. 7160 or Local Government Code. The DOH changed its role from one of implementation to one of governance. • In 1999, the functions and operations of the DOH was directed to become consistent with the provisions of Administrative Code 1987 and RA 7160 through Executive Order 102
LOCAL GOVERNMENT CODE OF 1991 (LGC) • DEVOLUTION refers to the act by which the national government confers power and authority upon the various LGUs to perform specific functions and responsibilities.
LOCAL GOVERNMENT CODE OF 1991 (LGC) • The main feature of the LGC is the relinquishing of responsibilities of the national government in favor of local government units in the provision of public goods and social services. • To efficiently deliver the devolved tasks, the LGUs were given increased powers to mobilize their own resources.
LOCAL GOVERNMENT CODE OF 1991 (LGC) • AIM: To improve the health status of the Filipino people through greater and more effective coverage of national and local public health programs, increase access to health services especially for the poor, and reduce financial burden on individual families.
OFFICES IN THE DOH • The DOH is composed of: – about 17 central offices – 16 Centers for Health Development located in various regions – 70 hospitals and 4 attached agencies.
The central office is composed of the Office of the Secretary and five major function clusters • Office of the Secretary – Health Emergency Management Staff; Internal Audit Staff, the Media Relations Group and the Public Assistance Group including 3 major Zonal Offices of the DOH located in Luzon, Visayas and Mindanao. – These offices are mandated to coordinate and monitor the implementation the Health Sector Reform Agenda, the National Health Objectives and the Local Government Code with the various Centers for Health Development
• Sectoral Management Support Cluster – composed of Health Human Resource Development Bureau and the Health Policy Development and Planning Bureau
• Internal Management Support Cluster – composed of the Administrative Service, Information Management Service, Finance Service and the Procurement and Logistics Service
• Health Regulation Cluster – composed of the Bureau of Health Facilities and Services, Bureau of Food and Drugs and Bureau of Health Devices and Technology
• External Affairs Cluster – composed of the Bureau of Quarantine and International Health Surveillance, Bureau of International Health Cooperation and Bureau of Local Development
• Health Program Development Cluster – composed of the National Center for Disease Prevention and Control, National Epidemiology Center, National Center for Health Promotion and National Center for Health Facilities Development
THE CENTER FOR HEALTH DEVELOPMENT • Responsible for field operations of the Department in its administrative region • Providing catchment area with efficient and effective medical services • It is tasked to implement laws, regulation, policies and programs. • It is also tasked to coordinate with regional offices of the other Departments, offices and agencies as well as with the local governments.
DOH HOSPITALS • Provides hospital-based care • Provides specialized or general services • Some conduct research on clinical priorities and training hospitals for medical specialization.
ATTACHED AGENCIES • The Philippine Health Insurance Corporation – is implementing the national health insurance law – administers the medicare program for both public and private sectors.
ATTACHED AGENCIES • The Dangerous Drugs Board – coordinates and manages the dangerous drugs control program
ATTACHED AGENCIES • Philippine Institute of Traditional and Alternative Health Care
• The Philippine National AIDS Council
DISTRIBUTION OF TASKS BETWEEN LGUs
DOH Structure (Pre-devolution) Office of the Secretary of Health Executive Committee for National Field Operations
Regional Hosp. Medical Centers Sanitaria
15 Regional Field Offices Provincial Health Offices
Provincial Hospitals
District Health Offices City Health Offices
District Medicare & Municipal Hospitals
Municipal Health Offices BHSs
Health Structure (1993, Post-devolution) Office of the Secretary of Health Executive Committee for National Field Operations 15 Regional Field Offices
Regional Hosp. Medical Centers Sanitaria
Provincial Health Offices
Provincial Hospitals
A City Health Offices
B
District Medicare & Municipal Hospitals
District Health Offices
C
Municipal Health Offices BHSs
A Devolved to Prov’l Gov’t B Devolved to City Gov’t C Devolved to Municipal Gov’t
ROLES AND FUNCTION and POWERS OF DOH (E.O. #102) • ROLES: – lead agency in articulating national objectives for health to guide the development of local health systems, programs and services – direct service provider for specific programs that affect larger segments of the population – lead agency in health emergency response services, including referral and networking systems for trauma, injuries and catastrophic events
ROLES AND FUNCTION and POWERS OF DOH (E.O. #102) – technical authority in disease control and prevention – lead agency in ensuring equity, access and quality of health care services through policy formulation, standards development and regulations
ROLES AND FUNCTION and POWERS OF DOH (E.O. #102) – technical oversight agency in charge of monitoring and evaluating the implementation of health programs, projects, research, training and services – administrator of selected health facilities at sub national levels that act as referral centers for local health systems
ROLES AND FUNCTION and POWERS OF DOH (E.O. #102) – innovator of new strategies for responding to emerging health needs – advocate for health promotion and healthy life styles for the general population
ROLES AND FUNCTION and POWERS OF DOH (E.O. #102) - capacity-builder of local government units, the private sector, non-government organizations, people's organizations, national government agencies, in implementing health programs and services through technical collaborations, logistical support, provision of grant and allocations and other partnership mechanisms
ROLES AND FUNCTION and POWERS OF DOH (E.O. #102) - lead agency in health and medical research - facilitator of the development of health industrial complex in partnership with the private sector to ensure selfsufficiency in the production of biologicals, vaccines and drugs and medicines - lead agency in health emergency preparedness and response
ROLES AND FUNCTION and POWERS OF DOH (E.O. #102) • protector of standards of excellence in the training and education of health care providers at all levels of the health care system • implementor of the National Health Insurance Law; providing administrative and technical leadership in health care financing
POWERS AND FUNCTIONS OF DOH • Formulate national policies and standards for health • Prevent and control leading causes of health and disability • Develop disease surveillance and health information systems • Maintain national health facilities and hospitals with modern and advanced capabilities to support local services
POWERS AND FUNCTIONS OF DOH • Promote health and well-being through public information • To provide the public with timely and relevant information on health risks and hazards • The resource allocation shift, specifying the effects of the streamlined set-up on the agency budgetary allocation and indicating where possible savings have been generated
POWERS AND FUNCTIONS OF DOH • Develop and implement strategies to achieve appropriate expenditure patterns in health as recommended by international agencies • Development of sub-national centers and facilities for health promotion, disease control and prevention, standards regulations and technical assistance • Promote and maintain international linkages for technical collaboration
POWERS AND FUNCTIONS OF DOH • Create the environment for development of a health industrial complex • Assume leadership in health in times of emergencies, calamities and disasters; system fails • Ensure quality of training and health human resource development at all levels or the health care system
POWERS AND FUNCTIONS OF DOH • Oversee financing or the health sector and ensure equity and accessibility to health services • Articulate the national health research agenda and ensure the provision of sufficient resources and logistics to attain excellence in evidenced-based interventions for health
Impacts of Devolution
Introduction • 7100 islands • Political local government units – local chief executive • 18 administrative regions • Approximate population: 78 million – 52% urbanized
• “High functional literacy rates” • Life expectancy at birth – 68 years • Poverty – 37.5%
Introduction • Health profile – “generally typical of a middle developing country” • Persistent high fertility rates • Declining mortality rates – CVD & cancer – TB – 5th leading cause • High infant & maternal mortality • “Double burden”
Aims • Provide background to the introduction of devolution to the health system in the Philippines • Describe the impact of devolution on the health system, services, & selected health status in 2 selected provinces in the Philippines –
Surigao del Norte & South Cotabato
Methods •
Decentralization – delegation of powers from central towards provincial or district departments of health Rapid appraisals of health management systems
• – – –
Objectives: Baseline data for project monitoring & evaluation Analysis of the health situation for the provincial health office
Methods •
Methods used for appraisal: – –
Field observation Interviews –
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Group discussions –
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Health managers & staff, local chief executive, community members
Review of health information data & socioeconomic profile Survey questionnaires –
•
Health managers & staff, local chief executive, community members
Circulated to all district hospitals & rural health units
Facility response rate - >90%
Methods •
Data analysis through: Field Health Information System According to health management system themes:
• – – – – –
Health financing Human resource development Health referral systems Health planning Community participation
Results • Aims of decentralization & devolution: improve the efficiency & effectiveness of healthservice provision through reallocation of decisionmaking & resources to peripheral areas
Results • Negative effects: – Under- prepared middle level management – Increased local political influence & control over technical management – Decline in quality of infrastructure & service delivery
• Sharp decline in the accessibility & availability of rural health services
Human Resources Impacts • No strategic plan for the introduction of devolution • No prior development of health staff or local government executives & officials for their new roles • Insufficiently prepared to cope with the wide sweeping changes of devolution
Human Resources Impacts • LGAMS (Local Government Assistance & Monitoring Services) – Represent DOH in legislative bodies & inter- agency concerns related to devolution – To assist & support DOH representatives at the peripheral level – Limited resources & adequately prepared staff
Human Resources Impacts 1st year post devolution resulted into: – – – – – –
Decreased hospital occupancy & health center utilization rates Untimely or decreased procurement of drugs, medicines, and supplies Decreased maintenance & operating expenses for health facilities Loss of managerial & fiscal control of hospitals Resignation of key personnel Low staff morale
Human Resources Impacts • Perceived loss of regulatory control by the DOH • Perceived political recruitment & retention of health staff at the LGU level • Loss of national bureaucracy – Rapidly filled by local government political power
Health Administration Impacts • Difficulty in managing referral systems • Operations of the referral systems are hindered by the limits of jurisdiction – retrains the cooperative health activities of the devolution
Financing and Utilization of Health Services Impacts
Financing and Utilization of Health Services Impacts • Since the advent of devolution, the under financing of public health services had resulted in their slow decay. • Decay measured in terms of: under staffing low utilization rates un-maintained infrastructure unrepaired or unreplaced equipment
Financing and Utilization of Health Services Impacts • Provincial health expenditure statistics indicate very high expenditure on personnel, but contrastingly very low expenditure on resources to deliver services and virtually no funding for capital investment.
Financing and Utilization of Health Services Impacts • Lack of investment in public infrastructure and operational cost -> under utilization of services and the high out of pocket expenses by those who access the services
Table 1: Indicators of Provincial expenditure on health, Surigao del Norte and South Cotabato, the Philippines, 1998† http://rrh.deakin.edu.au/publishedarticles/article220_1.gif
Health Referral System Impacts • Due to understaffing, lack of operating expenses and decaying infrastructure -> distinction between levels of service was being lost • Primary and secondary hospitals -> sited next to rural health units but were performing same basic outpatient health center function
Health Referral System Impacts • Under financing and under resourcing -> primary and secondary hospitals incapable of providing referral services to the health centers • Access to essential surgical and obstetric services in the primary and secondary hospital was reduced
Health Referral System Impacts • National health system -> lines of authority and reporting are clear from central to peripheral level. • Devolved system -> relationships of power and authority between health managers at different levels are more complex (primary accountability is to political authority)
Responding to the effects of reform 1998 by making devolution work • “disintegration” of systems - most obvious feature of early implementation of devolution in the Philippines • Two options remained: reintegration of systems through re-nationalization reintegration of systems through “making devolution work”
Responding to the effects of reform 1998 by making devolution work • Third Philippines National Health assembly -> a concept for for an inter LGU health system based on Inter Local Health Zone was proposed to foster greater collaboration and coordination for health between LGUs
Responding to the effects of reform 1998 by making devolution work • In early 1999, League of governors, with DOH and DILG entered into health covenant to achieve a unified integrated health care delivery system based on Inter LGU approach.
Responding to the effects of reform 1998 by making devolution work • To encourage and facilitate inter-LGU cooperation and innovative strategies and approaches for basic health service delivery, President Estrada issued Presidential Executive Order 205 in January 2000 mandating establishment of ILHZ and Integrated (inter-LGU) Health Planning.
Responding to the effects of reform 1998 by making devolution work • In mid-2000, the then Hon. Secretary of Health, Alberto Romualdez launched the Health Sector Reform Agenda (HSRA) to guide the DOH in its support of LGUs in their efforts to 'make devolution work'. The HSRA outlines reforms in three key areas: Health services delivery reforms for local health systems, government hospitals and public health programs. Health regulatory reform to fill gaps post-devolution and since the advent of the ILHS. Health financing reforms for the National Health Insurance Program and creation of mechanisms for complementation with community health insurance schemes.
Discussion and conclusions • A primary aim of decentralization is to increase the resource base for primary care, by shifting as many resources as possible from central to peripheral locations.
Discussion and conclusions • A second aim is expand the ‘decision making space’ of middle and lower level managers, in order to increase the responsiveness of sub national authorities to local health needs and situations.
Discussion and Conclusions • A third aim of decentralization is to enhance the efficiency and effectiveness of health services management through prompt and appropriate middle level management decision-making.
Issues in the process of devolution Underspending in the health sector: • Health sector accounts for almost half of the devolved fxns to LGUs. • Nat’l healthcare spending continued to increase in nominal terms for the past years • Decline in percentage share of total gov’t spending on health
Issues in the process of devolution • Share of local gov’t in healthcare spending continued to increase in nominal terms after the devolution, in 1993. • Local gov’t expenditures increased in nominal terms from 7% of total gov’t expenditures in the 1985-1991 period, to 14.7% in the 1992-1997 period • LGU’s health expenditure has fallen short of the cost of devolved health fxns (CDHF).
• Due to devolution, the share of local gov’ts in health expenditures has increased, but the LGUs are spending less than what the nat’l gov’t used to spend for local health services before devolution. • Reduction in spending in health was actually accompanied by a marked decline in the quality of health services----proving that there was indeed underspending in the health sector.
Unfunded devolution: • Ironically, after the devolution, the national agencies continued to receive increasing budget allocations.
• These budgets do not even reflect devolutions as a priority. • Central office of the DOH accounts for almost 37% of the budget for administration and support. The regional offices share the rest which are the coordinating arms of the national agencies to the LGUs in the implementation of their task. • In health sector- regional offices is limited to managing the regional hospitals and assisting the nat’l agency in the implentation of public health programs.
• Regional agencies are expected to provide technical assistance to LGUs • They are not able to provide the LGUs with enough technical support to allow these LGUs to deliver effectively on devolved services due to inadequate finding and utilization of funds.
Mixed feedback on quality • DOH has achieved a certain degree of devolution with respect to functions • Quality of healthcare delivery after devolving the major task to LGUs should also be examined
Mixed feedback on quality • Poor availability of drugs in comparison with the period prior to devolution - experts expressed concern over the deterioration of technical quality, while most of the people expressed more views - technical performance – no significant change in the volume of in-patients treated or outpatient consultations
Mixed feedback on quality - quality of care deteriorated in terms of supplies equipment, and infrastructure because of decreased funds for maintenance and other operating expenses (MOOE) and almost non-existent funds for capital outlay (USAID n.d.)
In the management of devolved hospitals and availability of facilities, the ff were observed: • Devolved hospitals have deteriorated, since it cost more in 1998 to deliver the same volume of services delivered in 1992 • Philippine government hospitals, especially those at the provincial and district levels, have become poorly equipped and undernamed • Regional and national hospitals, owing to the unmet health demands at the local level, are congested
In the management of devolved hospitals and availability of facilities, the ff were observed: • Networking and patient referral systems between national and local, and between public and private, hospitals are inadequate • Gov’t hospitals still rely heavily on direct subsidies from national and local gov’ts • There is inadequate and uncoordinated implementation of public health programs in hospitals
In the management of devolved hospitals and availability of facilities, the ff were observed:
• Only 1/3 of the total number of hospitals and about ½ of hospital beds are public • Out of the country’s 41,000 barangays, only ¼ have barangay health stations. These gov’t facilities have regained notoriety as sorely lacking in equipment, medicines, and staff A number of researches support the observation that there has been deterioration of health services after devolution
Demoralization among rank and file • Significant deterioration of employment conditions of developed personnel, causing demoralization • Health sectors - salaries of devolved workers decrease relative to central gov’t employees (by 1/5 to 1/3 on avg), and civil servant vertical career mobility was interrupted by the fragmentation of the public health system
Demoralization among rank and file • Strong objections from health care workers brought about the passing of Magna Carta of health workers, which resulted in further disarray • Affected or devolved personnel have little or no chance of availing themselves of any training or scholarships, both local and foreign coz national employees are prioritized.
Re-nationalization of some hospitals • DOH continues to retain 48 hospitals, 35 of which are classified as tertiary. The renationalization of these hospitals resulted in the DOH putting 52% of its budget into the maintenance of these hospitals • Explains the continuous increase in the budget of DOH, despite the devolution of almost 70% of its personnel
Lack of coordination • Free riding and negative externalities • Quality of health of individuals in a municipality influences the health of adjacent municipalities • The delineation of responsibilities and functional relationships between nat’l gov’t agencies, including the DA, LGUs and other stakeholders, remain unclear and the linkages among research, training and extension remain weak.
What Went Wrong? •
Dependency on the IRA – – – – –
Failure to maintain developed hospitals Decline in quality of healthcare services Inability to sustain technical personnel Inability to shoulder the required costs Lack of funds by the LGUs
What Went Wrong? – IRA is not enough to cover the cost of devolution – Purpose of IRA is not to fully cover the cost but to augment the budget – Recommendation: IRA should be formatted to factor in a mechanism that will encourage LGUs to source their own funds – Dependency on IRA is not compatible with fiscal autonomy
What Went Wrong? 1. Lack of Technical Resources –
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LGUs cannot maintain their technical personnel due to insufficient financial resources LGUs should administer their localities and act as economic managers Lack of appreciation of developed tasks
What Went Wrong? 1. Plain Politics –
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Re-nationalization of some hospitals is a result of lack of budget of LGUs to maintain these medical centers Due to fiscal incapacity and result of politics The provision of social services depends not on what is needed but on what activities will get greater mileage for the political career of government officials
What Went Wrong? – Most appointments for position are based not on merit and credibility, but on personal relationship of individuals to lead local leaders – As a result, individuals without enough competence and skills are made to manage the delivery of social services
Congressional initiatives to address the problem of devolution • A number of initiatives seek to address the problem in healthcare delivery • Bills that aim to provide incentives and additional benefits to barangay heath care workers and rural health doctors • Bills that suggest the formulation of a National Health Code and a comprehensive national health facilities program
Congressional initiatives to address the problem of devolution • A bill that tries to address lack of operational budget • 2 possible reasons in attempting to re-nationalize hospitals: – LGUs lack the capability to maintain the hospitals – Politics
Conclusion • The obligation of LGUs to their constituencies has become a tool for politics • The effectivity and efficiency of decentralized governance is compromised • Decentralizing the provision of basic services will help people identify the kind and amount of services they want to receive
Conclusion • The problems with the IRA formula have to be addressed • Period of transition and adjustment for the LGUs, the national government, and the constituents • Premature to prescribe re-nationalization as the solution to improve the current state of social services delivery
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