Philippine Health Delivery

PHILIPPINE HEALTH DELIVERY CARE SYSTEM and HEALTH SECTOR REFORM AGENDA Isabelita M. Samaniego MD

Session Objectives ◆ ◆ ◆ ◆ ◆

1. To describe the Philippine Health situation. 2. To describe the role of the DOH in the health care delivery system. 3. To describe the effect of devolution . 4. To describe the impact of the programs on maternal & child health. 5. To describe the Health situation in the City of Manila

The Philippines

7,100 islands 1,700 LGUs 1 unitary/national government

General Health Status of the Filipinos ◆ Life

Expectancy: 68.6 yrs ◆ Female: 71.28 ; Male: 66.03 ◆ Highest: Central Luzon Southern Tagalog ◆ Lowest: ARMM & Eastern Visaya ◆ Impact: ❖ ❖

Higher proportion of elderly in general population Need to increase health & other socioeconomic inputs in some regions

Crude Birth Rate ❖ 28.9/1000

population (1946) ❖ 30.5 (1950) ❖ 24.8% (1972 lowest) ❖ 30.7 (1973 - 1979) ❖ Sex ratio: 109:100 (male)

Crude Death Rate ❖ 1946

to present - steady decline ❖ 1959 lowest decline - 7.3/1000 ❖ 1960 to 1990 - slow but steady decline ❖ Death Rates: (highest) infancy & C:\WINDOWS\hinhem.scr early childhood, decline by age 10 and sharp rise by age 40 ❖ Male death rate: 5.6/1000 ❖ Female death rate - 3.9/1000

Total Fertility Rate ❖ Average

number of births that a woman would have at the end of her reproductive life

❖ Important

in assessing impact of family planning and reproductive behavior

❖ TFR

highest in Asia ❖ 1995-97: 3.7 children/woman ❖ varies with education and location ❖ Urban: 3 children/woman ❖ Rural: 4.7 children/woman ❖ without education & with Elementary education: 5/woman ❖ High school: 3.64/woman ❖ College: 2.9/woman

IMR = # of deaths below 1 yr xF # of live births

Infant Mortality Rate ❖ Philippines

high compared to Thailand, Singapore, Brunei, Japan ❖ Rapid decline from 1970 to 1990 (62 & 36.8) ❖ Varies with socioeconomic & demographic factors ◆ Rural - 40.2 ; Urban - 340.9 ◆ MetroManila - lowest; ◆ Eastern Visayas - highest

◆ High ❖ low

IMR

educational status ❖ no antenatal and post natal care ❖ <20 y/o & >40 y/o ❖ male , small or very small infants ❖ birth order of 7 and above ❖ previous birth interval <2 years ❖ Respiratory and Pneumonia (most common cause)

◆ Impact

of High IMR

❖ improvement

of maternal and child health care ❖ uplifting socioeconomic conditions

MMR =deaths among women directly due to = pregnancy &puerperium Total live births

◆ Maternal ❖ Death

Mortality Rate

of a woman during pregnancy, at childbirth or in the period after child birth ❖ An indicator of nation’s health ❖ 1970 - 190/100,00 births ❖ 1995 - 2nd to Indonesia 179/100,000 ❖ Lifetime risk of dying from maternal cause is 1:100

◆ Causes

of Maternal Deaths

❖ postpartum

bleeding ❖ hypertension ❖ sepsis ❖ obstructed labor ❖ complications from abortion

TEN LEADING CAUSES OF MORBIDITY     No. & Rate/100,000 Population       PHILIPPINES, 2002 CAUSE

MALE

FEMALE

Rate**

Rate**

BOTH SEXES Number

Rate*

1. Pneumonias

931.1

881.7

734,581

924.0

2. Diarrheas

881.1

842.7

726,310

913.6

3. Bronchitis/Bronchiolitis

748.1

798.8

629,968

792.4

4. Influenza

565.9

622.7

484,388

609.3

5. Hypertension

339.8

427.3

304,690

383.2

6. TB Respiratory

161.0

113.6

114,221

143.7

7. Diseases of the Heart

58.2

67.0

52,237

65.7

8. Malaria

53.5

42.6

39,994

50.3

9. Chickenpox

33.8

35.6

28,600

36.0

10. Measles

30.5

29.0

24,639

31.0

                Source:

2002 FHSIS Annual Report                  ** rate/100,000 of sex-specific population

TEN LEADING CAUSES OF MORTALITY BY SEX Number, Rate/100,000 Population & Percentage Philippines, 2002 Cause 1. Heart Diseases 2. Vascular System Diseases

Male 39,502

Female 30,636

Both Sexes Number 70,138

C:\WINDOWS\hinhem.scr

Rate

Percent*

88.2

17.7

27,536

21,983

49,519

62.3

12.5

3. Malignant Neoplasm

20,440

18,381

38,821

48.8

9.8

4. Pneumonia

16,729

17,489

34,218

43.0

8.6

5. Accidents

27,448

6,169

33,617

42.3

8.5

           Source:

2002 Philippine Health Statistics            * percent share from total deaths, all causes, Philippines

TEN LEADING CAUSES OF MORTALITY BY SEX Number, Rate/100,000 Population & Percentage Philippines, 2002 Both Sexes Cause

Male

Female

Number

Rate

Percent*

6. Tuberculosis, all forms

19,293

9,214

28,507

35.9

7.2

7. COPD and allied conditions

13,007

6,313

19,320

24.3

4.9

8. Certain conditions originating in the perinatal period

8,520

5,689

14,209

17.9

3.6

9. Diabetes Mellitus

6,524

7,398

13,922

17.5

3.5

10. Nephritis, nephritic syndrome and nephrosis

5,358

3,834

9,192

11.6

2.3

Source: 2002 Philippine Health Statistics            * percent share from total deaths, all causes, Philippines          

DISEASE PATTERNS • Environmental and

Occupational Issues Battle Of The Bugs

Main Causes of Maternal Mortality ◆

◆ ◆ ◆ ◆

1. neonatal delivery & other complications related to pregnancy occurring in the course of labor delivery & puerperium. 2. Hypertension complicating pregnancy , child birth & puerperium 3. Post partum hemorrhage 4. Pregnancy with abortive outcome 5. Hemorrhage related to pregnancy

DISEASE PATTERNS ◆ ◆ ◆ ◆ ◆ ◆

Smallpox Poliomyelitis Malaria TB Pneumonia Influenza

◆ ◆ ◆

◆ ◆

Ebola AIDS Variant Creuzfeldsjacob SARS Bird Flu

Ten Leading Cause of Infant Mortality ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆ ◆

1. Respiratory conditions of the fetus & the newborn 2. Pneumonia 3. Congenital anomalies 4. Diarrheal diseases 5. Birth injury & difficult labor 6. Septicemia 7. Meningitis 8. Avitaminosis & other nutritional disorders 9. Other diseases of the respiratory system 10 Measles

Health Care Delivery System ◆ Significant

Milestones in public health care delivery system (25 years) ❖ Adoption

of Primary Health Care in

1979 ❖ Integration of public health and hospital services in 1983 (EO 851)

❖ Reorganization

(EO 119)

of DOH in 1987

❖ Devolution

of health services in 1992 to LGUs (Local Government Code of 1991 (RA 7160)

❖ Streamlining

of DOH’s organization and functions (EO 102)

Department of Health (DOH) ◆ Lead

agency ◆ Specialty and regional hospitals, and medical center ◆ Regional field office in regions ◆ Provincial health teams involved in controlling malaria and schistosomiasis ◆ Devolution of health services to LGUs

❖ Provincial

and district hospitals -Provincial government ❖ Municipal health units and barangay health units - Municipal government ❖ Private Sectors have important roles in the provision of health services ◆ Clinics

and hospitals

◆ HMO ◆ Manufacture

of drugs, medicines &

vaccine ◆ Medical supplies & equipment ◆ R & D ; HRD ; health related services

 

Vision

 

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.

Overview of the General Health Status of Filipinos points to several Principles to Improved Health 1

. Universal access to basic health services must be ensured

2

. The health and nutrition of vulnerable groups must be prioritized.

3

. The epidemiologic shift from

infectious to degenerative must be managed. 4.

The performance of the health sector must be enhanced.

GOALS 1. Improve the general health status of the population: ◆ Reduce

infant mortality rate ◆ Reduce child mortality rate ◆ Reduce total fertility rate ◆ Increase life expectancy and quality of life years

GOALS 2

.Reduce morbidity, mortality, disability and complications from the following diseases and disorders: ❖ Diarrheas

and other food and water borne diseases like typhoid, cholera and hepatitis A ❖ Pneumonia and acute respiratory infections ❖ Tuberculosis

❖ Dengue ❖ Intestinal

parasitism ❖ Sexually transmitted diseases, HIV/AIDS, and other reproductive tract infections ❖ Hepatitis B ❖ Dental caries and other periodontal diseases ❖ Rheumatic heart disease and rheumatic fever ❖ Coronary heart disease, hypertension and dyslipidemia

❖ Stroke ❖ Cancer ❖ Diabetes

mellitus ❖ Asthma and chronic obstructive pulmonary diseases ❖ Nephritis and other kidney diseases ❖ Mental disorders ❖ Protein-energy malnutrition ❖ Iron deficiency anemia ❖ Obesity ❖ Accidents, trauma, and injuries

◆

Eliminate the following diseases as public health problems. 3.

❖ Schistosomiasis,

malaria, filariasis, Rabies, Leprosy ❖ Vaccine preventable diseases: measles, tetanus, diphtheria and pertussis ❖ Vitamin A deficiency and iron deficiency diseases

◆ 4.

Eradicate poliomyelitis

◆ 5.

Promote Healthy life style

❖ Promote

healthy diet and nutrition ❖ Promote physical activity and fitness ❖ Promote personal hygiene ❖ Promote mental health &less stressful life ❖ Prevent smoking & substance abuse ❖ Prevent violent & risk-taking behavior

◆ 6.

Promote the Health and Nutrition of families & special population ❖ Neonatal

& infant health ❖ Children’s health ❖ Adolescent and youth health ❖ Adult’s health ❖ Women’s health ❖ Health of older people ❖ Health of indigenous people ❖ Health of overseas Filipino workers ❖ Health of the disabled persons ❖ Health of the rural and urban poor

Strategies ◆ Increasing

investments for Primary Health Care ◆ Development of National Standards and objectives for health ◆ Assurance of the Quality of Health Care ◆ Support to the Local Health System Development ◆ Support for frontline Health Workers

Department of Health Profile  (Thrust for 2004) ◆ The Department of Health (DOH) is the 

principal health agency in the Philippines

◆ Responsible for ensuring access to basic 

public health services to all Filipinos through  the provision of quality health care and regulation of providers of health goods and services.

◆ DOH Role ❖ stakeholder in the health sector,  and  ❖ a policy and regulatory body for health

◆ As a Major Player ❖ technical resource ❖ a catalyzer for health policy ❖ a political sponsor; and  ❖ advocate for health issues in behalf of the 

health sector.

DOH Offices ◆ 17 central offices ◆  16 Centers for Health Development 

located in various regions

◆ 70 hospitals;  and  ◆ 4 attached agencies.

Central Office ◆ Office of the Secretary and five major 

function clusters ◆Staff support services

–Health Emergency Management Staff – Internal Audit Staff,  – Media Relations Group  – Public Assistance Group  –Major Zonal Offices (Luzon, Visayas  and Mindanao.) 

Zonal Office ◆ Undersecretary (head)  supported by an 

Assistant Secretary.

◆ Mandated to coordinate and monitor 

the implementation of the  ff:

–Health Sector Reform Agenda –National Health Objectives  – Local Government Code with the various  Centers for Health Development

◆Sectoral Management Support 

Cluster

–Health Human Resource Development  Bureau  –Health Policy Development and Planning  Bureau.  ◆Internal Management Support 

Cluster

–Administrative Service – Information Management Service –Finance Service –Procurement and Logistics

◆Health Regulation Cluster  – Bureau of Health Facilities and Services – Bureau of Food and Drugs  – Bureau of Health Devices and Technology.  ◆External Affairs Cluster  –Bureau of Quarantine and International  Health Surveillance – Bureau of International Health Cooperation  – Bureau of Local Development

Health Program  Development Cluster ◆ National Center for Disease Prevention 

and Control ◆  National Epidemiology Center ◆ National Center for Health Promotion  ◆  National Center for Health Facilities  Development. 

Center for Health Development ◆ Responsibilities ❖ field operations of the Department in its 

administrative region  ❖ providing catchment area with efficient and  effective medical services.  ◆ Tasks ❖ implement laws, regulation, policies and 

programs. ❖ coordinate with regional offices of the other  Departments, offices and agencies as well as with  the local governments.

Attached Agencies ◆ The Philippine Health Insurance Corporation  ❖

 implement the national health insurance law, 

administers the medicare program for both  public and private sectors.  ◆ The Dangerous Drugs Board 

❖ coordinates and manages the dangerous drugs 

control program. 

◆ Philippine Institute of Traditional Medicine ◆ Alternative Health Care and the Philippine 

National AIDS Council.

◆Health Regulation Cluster 

– Bureau of Health Facilities and Services – Bureau of Food and Drugs  – Bureau of Health Devices and Technology. ◆ External Affairs Cluster 

–Bureau of Quarantine and International  Health Surveillance – Bureau of International Health  Cooperation  – Bureau of Local Development

Health System Characteristics (Mainstream) ◆

Observations on Philippine Health Care System - 1992, Solon ❖ ❖ ❖ ❖

Underinvestment in Health Unequal access to health services Inefficiencies in health services utilization Regressive tax structure Health Investments

Health System Characteristics . . . ◆

DOH efforts to achieve technical excellence and equity ❖

❖ ❖

capability to deliver health services that are technically excellent at the tertiary level strong service orientation at all levels of health service delivery a functional structure of health services at all levels of government up to the barangay level WHO-DOH Study, 1995

Health System Characteristics . . . ◆ ◆

high public acceptance of the DOH DOH commitment to devolution

Devolved Personnel, Budget and Facilities Department of Health 1992

PERSONNEL

BUDGET

78,080

P 10.227 B

FACILITIES

HOSPITAL        - 639 RHU/MHC/BHS - 12,580

DEVOLVED

46,080

RETAINED

32,000

DEVOLVED

P 4.215

RETAINED

P 6.012 B

DEVOLVED HOSPITAL - 595 RHU/MHC/BHS 12,580

RETAINED  HOSPITALS &  SANITARIA 50

Comparative Cost of Devolved  Health Functions by LGU Type (in Billion Pesos) Total Cost of Devolved Health Fuinctions - P 4.1 B Percentage to Total Cost of Devolved Functions - 65.42% Provinces 59% P 2.441 B Municipalities 38% Cities 3% P 0.109 B

P 1.583 B

DOH Devolved Cost Compared to  Other Agencies (in Billion Pesos)

Other Agencies (DA, DSWD, DENR, etc.) 34%

P 2.1 B

DOH 66% P 4.1 B

DOH Structure (Pre-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

District  Health  Offices City Health  Offices

District  Medicare &  Municipal  Hospitals

Municipal  Health  Offices BHSs

Health Structure (1993, Postdevolution) Office of the Secretary of Health Executive Committee for  National Field Operations 15 Regional  Field Offices

Regional Hosp. Medical Centers Sanitaria

A B C

Devolved to Prov’l Gov’t Devolved to City Gov’t Devolved to Municipal Gov’t

Provincial Health  Offices

Provincial  Hospitals

A City Health  Offices

B

District  Medicare &  Municipal  Hospitals

District  Health  Offices

C

Municipal  Health  Offices BHSs

Comparing Governance to Health Structure EXECUTIVE BRANCH NATIONAL  LEVEL

OFFICE OF THE PRESIDENT NATIONAL  GOV’T  AGENCIES

NATIONAL  GOV’T  AGENCIES

NATIONAL  GOV’T  AGENCIES

PUBLIC HEALTH SYSTEM

NATIONAL  GOV’T  AGENCIES

OFFICE  FOR  PUBLIC  HEALTH  SERVICES

HEALTH SECRETARY OFFICE FOR  OFFICE FOR  HOSPI- TALS  STAN-  &  DARDS AND  FACILITIES  REGULASERVICES TIONS

OFFICE  FOR  MANAGEMENT  SERVICES

REGIONAL LEVEL

REGIONAL HEALTH  OFFICE

PROVINCIAL  GOV’T LEVEL

PROVINCIAL  HEALTH  OFFICE

CITY GOV’T  LEVEL

CITY HEALTH  OFFICE DISTRICT OFFICE

MUNICIPAL GOV’T  LEVEL BARANGAY OR  VILLAGE LEVEL

RURAL HEALTH  UNIT BARANGAY  HEALTH STATION

OFFICE OF  THE CHIEF  OF STAFF

The Administration of Decentralization in Health ◆

Phasing of devolution process ❖

◆ ◆

◆

Changeover and Transition period to take 5 years

DOH and LGUs assumed a relationship based on a “partnership” Assignment of representatives to LGUs supervised by a central assistance and monitoring service. Defining new roles and functions under devolution; preparation of a strategy paper

Changeover to Stabilization Changeover Phase • Formal transfer of personnel, assets and liabilities from the NGA to LGUs

Transition Phase • Assisting LGUs • Assuring health services are not disrupted • Building the Capability of LGUs to manage health services • DOH restructuring

Stabilization Phase • Fully autonomous LGUs that manage local health services • DOH fully exercising its new functions

DOH Mechanisms for Partnership ◆ Comprehensive

Health Care

Agreements ◆ Health Development Fund ◆ Regional Field Offices as Technical Resource and Health Human Resource Development Centers ◆ Quick Health Response System

A Comprehensive Health Care Agreements (CHCAs) .

◆

◆

◆

Articulates the roles and responsibilities in the implementation of priority health programs Province or city shall be designated as program coordinator LGUs to provide counterpart funding

CHCA ... ◆

◆ ◆

◆

Provinces will be responsible for insuring compliance by their municipalities with these agreements Failure in compliance will result in partial or full suspension of the agreement Negotiations will be initiated with the exchange of an indicative CHCA package with the LGUs local area-based health plan DOH and LGU shall reconcile plans at the beginning of the fiscal year

B. Health Development Fund (HDF) ◆

an anti-poverty investment package for health to assist LGUs, NGOs, POs and the basic sector

◆

fund intended to support communitybased health programs

HDF .... ◆ ◆ ◆

◆

to be treated as trust fund by LGUs covered by a MOA; LHB resolution is a prerequisite Provincial Health Board to integrate all HDF-related projects DOH to prepare guidelines for utilization

C. DOH Regional Field Offices as Technical Resource and Health Human Resource Development Centers ◆

RFOs serve as technical resource management centers directing the flow and utilization of DOHprovided assistance to LGUs

Role of RFOs ◆ ◆ ◆ ◆ ◆

assess area-based plans of LGUs negotiate, conclude and monitor CHCAs with LGUs recommend HDF allocations mobilize technical and administrative assistance generate monitoring reports

Technical Resource and Health Human Dev’t ◆

◆

◆

Training programs for local health personnel shall be comprehensive LGUs to provide schedules of trainings to LGUs Cost-efficiency in training will be a consideration

D. Quick Health Response System ◆

◆ ◆

to be based at RFOs and CO and consists of a preventive element (Disaster Management Units) and a ready health team (STOP Death) DOH reps to LHBs shall provide the link to QHRS; make initial assessment DOH to declare an epidemic or public health emergency in consultation with LGUs

Quick Health Response ... ◆ ◆

◆

DOH to provide assistance even without a formal request from LGU DOH may provide continuing assistance though joint management by the higher LGU or DOH Continuing consultation during the duration of the joint management

New Roles and Functions ◆ ◆ ◆ ◆ ◆ ◆ ◆

Health Policy Development Guidelines, standard setting, and development of manuals of operation Licensing and Regulation Promulgation of national standards, goals, priorities and indicators Development of special health programs and projects Advocacy for health legislation National health campaigns

Reorganized Structure OFICE OF T HE SECRE TARY

Attached Agencies

Public Relations Unit

Health Emergency Mgt. Staff

Health Human Resource Bureau

Admi Service

Info. Mgt. Service

Health  Regulations

External Affairs

Specialty Hospitals

Internal Audit Health Policy Dev’t and Planning Bureau

Finance Service

Procurement and  Logistics Service

Health Operations

Centers for Health Dev’t Regional Hospitals, Medical Centers and  Sanitaria

ORGANIZATIONAL STRUCTURES IN THE LOCAL GOVERNMENT UNITS ◆

◆

◆

◆

Executive Health Agenda as determined by the Local Chief Executives and the Local Health Office Legislative Health Agenda as determined by the Committee on Health of the Local Sanggunian NGO/Private Sector/Communit y Health agenda as determined by the Private Sectors, NGO Representative DOH Policies, Programs, Priorities through DOH Representative

Local Development Council Sanggunian Personnel Division Budget Division Administrative Division

LHB

Planning Division

Other Offices with Health Related Concerns - Office of the Treasurer - Local Finance Council - Population Office - DSWD - DENR OUTPUTS: - DECS - Local Health Plan - Program Priorities, Resource Allocation - Support Systems and Resources to Health Plan - CHCA

Lessons from five years of decentralization ◆

◆ ◆

◆

Pay attention to geography, because political administration by local governments is governed by constituencies. Decentralization is a process. Decentralizing hospitals results to greater complexities in adapting to local government protocols Equity in resource distribution; commensurate to burden of responsibilities transferred

LGU Resources for Health 80 70 60

Billions of Pesos IRA Requirement Total Earmarked for Health

50 40 30 20 10 0

1992

1993

1994 Year

1995

1996

1997

Amount Required for Local Health Services versus Total Earmarked for Health Billions of Pesos

Year

Lessons ... ◆ Strategies for ensuring equity for health workers and local government units should be in place. ❖

allocation of resources and assistance based on LGUs relative financial capabilities to fund devolved functions

DOH uses the DFB Ratio (Devolution Financing Burden Ratio) as a basis for allocating resources and assistance to LGUs • Health Development Fund • Comprehensive Health Care Agreement • Financial Augmentation for Health Workers’ Benefits

Relative Financial Capability of LGUs to Fund Devolved Functions DFB  Category

Provinces

A B C

43 23    4

258 973 222

     *70

 * 1453

TOTAL

Municipalities

Cities

Total

0 1 64

301 997 290

      65     1588

* excluding ARMM Provinces, Municipalities and Cities

DFB Categories A B C

Interpretation LGU needing the most assistance form the National Government LGU can partially cover CODEF from its IRA resources LGU is financially capable of financing all obligations

Lessons ... ◆

◆

◆

Decentralization requires that pronouncements are made authoritatively and consistently. During the transition process, local and national health agencies must reach agreement on complementation of health services and technical assistance. an agency, before it is decentralized, has to have a vision and assign units and managers to accomplish it

What lies ahead ◆ Continuation ❖ ❖

of some major problems

inadequate financial base for devolved functions collateral actions working as a counter-stream to decentralization

◆ Changes

in administration may result to changes in policies as well recentralization? But, devolution can still work. Decentralization

Recentralization

ROLE OF PHYSICIAN PATIENT FAMILY COMMUNITY PROFESSION HIMSELF

RESPONSIBILITIES

FOCUS OF CARE ◆

◆ ◆

The Patient in Context of the Family The Family Unit The Community as it affects The Family

◆

Skilled Clinician

◆

Coordinator of Care

◆

Resource to a Defined Population

CHALLENGES IN HEALTH CARE ◆ ◆ ◆

Broader Perspectives in Health: Global and Local Challenges People Empowerment in Health & Community Participation Environment

MOBILIZING FOR HEALTH ◆ ◆ ◆

Empower Individuals, Families and Communities Promotes Wellness and Health Maintenance Sensitized citizenry, aware beneficiary and Community eager to participate

Student Activity ◆ ◆

Describe the 6 goals of the DOH to solve the health problems of the nation. Describe 4 strategies to attain the goals .

C:\WINDOWS\hinhem.scr FC:\WINDOWS\hinhem.scrunC:\WINDOWS\hinhem.scr FC:\WINDOWS\hinhem.scr

C:\WINDOWS\hinhem.scr FC:\WINDOWS\hinhem.scr