Health Care Delivery System

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THE HEALTH CARE DELIVERY SYSTEM

THE DEPARTMENT OF HEALTH Vision The leader, staunch, advocate and model in promoting Health for All in the Philippines Mission Guarantee equitable, sustainable and quality health for all Filipinos, especially the poor, and shall lead the quest for excellence in health by seeking all ways to establish performance standards for healthy human resources, health facilities and institutions, health products and health services that will produce the best health systems for the country. Department of Health Profile The recent change in political leadership provides the Philippines with the chance to revitalize the health care system. This is in line with the administration‘s thrust to prioritize delivery of services to the masses and improve the quality of life of all Filipinos, especially the poor. The differences in health status among various groups and regions in the country have widened through the years. These disparities indicate deficient economic and social policies, showing the need to reprioritize interventions to promote equity, fairness and immediate action. Unnecessary and unfair gaps in the health care delivery system that deprive the poor of access to basic services must be reduced. The system must work efficiently to reach the highest possible health standards that can be shared by all Filipinos, given the limited resources available for health. Although socioeconomic differences significantly influence health status, the equitable distribution of quality health services is an important measure of fairness in the country. Revitalizing the health care system must be seen within the broader context of several forces affecting the delivery of basic health services in the past two decades. Among these factors are the devolution of health services to local governments, passage of national legislation for universal coverage for health through social insurance, the epidemiologic shift and current double burden of disease brought about by the rise in degenerative diseases and the reemergence of previously controlled infectious diseases, demographic trends pointing to longer life span, greater number of adolescents and youth, rapid urbanization, industrialization, environmental degradation and climate change. Under these realities, the health sector must work to attain a common vision of health for all Filipinos. Its mission is to ensure accessibility and quality of health care to improve the quality of life of all Filipinos, especially the poor.

The DOH Offices The DOH is composed of about 17 central offices, 16 Centers for Health Development located in various regions, 70 hospitals and 4 attached agencies. Central Office The central office is composed of the Office of the Secretary and the following: Office of the Secretary The following comprise the staff support services to the Secretary of Health: Legal Service and Internal Audit Service, the Media Relations Group and the Public Assistance Group including 3 major Zonal Offices of the DOH located in Luzon, Visayas and Mindanao. These Zonal Offices are headed by an Undersecretary and supported by an Assistant Secretary. 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. Policy and Standards Development for Service Delivery Cluster It is composed of National Center for Disease Prevention and Control (NCDPC), National Epidemiology Center (NEC), National Center for Health Facilities and Services (NCHFD), National Center for Health Promotion (NCHP), Philippine National Aids Council (PNAC), and Health Emergency Service (HEMS). Sectoral Management and Coordinating Team Cluster It is composed of the Bureau of International Health Cooperation (BIHC), Health Human Resource Development Bureau (HHRDB), Health Policy Development Planning Bureau (HPDPB), Bureau of Local Health Development (BLHD), and Information Management Service. Policy Standards Development for Health Regulation Cluster It is composed of the Food and Drug Administration (FDA), Bureau of Health Facilities and Services (BHFS), Bureau of Health Devices and Technology (BHDT). Bureau of Quarantine and International Surveillance (BQIS), and Procurement Service. Special Concerns and Projects It includes Philippine Institute for Traditional and Alternative Healthcare (PITAHC) Internal Management Support It is composed of Administrative Service (AS) and Finance Service (FS). Center for Health Development

Responsible for field operations of the Department in its administrative region and for 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; specialised or general services, some conduct research on clinical priorities and training hospitals for medical specialisation.

Milestones of DOH 23 June 1898 Creation of the Department of Public Works, Education & Hygiene (now the Department of Public Works & Highways, Department of Education Culture & Sports, and Department of Health, respectively) through the Proclamation of President Emilio Aguinaldo. 29 September 1898 Establishment of the Board of Health for the City of Manila under General Orders No. 15. 1899 - 1905 Abolition of the Board of Health and appointment of Dr. Guy L. Edie as the first Commissioner of Public Health.   Act. No. 157 of the Philippine Commission - creation of the Board of Health for the Philippine Islands; it also acted as the Board of Health for the city of Manila Acts Nos. 307, 308 and 309-establishment of the Provincial and Municipal Boards of Health, completing the health organization in accordance with the territorial division of the Islands. Act. No. 1407- (also the "Reorganization Act‖) abolition of the Board of Health and its functions and activities were taken over by the Bureau of Health.



1906 Passage of Act No. 1487 of the Philippine Commission repealing Act No. 307 wherein the provincial Board of Health gave way to the Office of the District Health Officer 1912

Passage of Act. No. 2156, so- called "Fajardo Act", which authorized the consolidation of municipalities into sanitary division and established what is now known as the "Health Fund" 1915 Changing of the name of the Bureau of Health to the Philippine Health Service, which was later on changed to its former name. 1932 Passage of Act No. 4007, also "the Reorganization Act of 1932", which created the Office of the Commissioner of Health and Public Welfare, the Philippine General Hospital, and the five examining boards (medical, pharmaceutical, dental, optical and nursing). 01 January 1941 Creation of the Department of Health and Public Welfare as provided for in Executive Order No. 317, series of 1941. The Department was under the Secretary of Health and Public Welfare and also included the Bureau of Quarantine; the health department of chartered cities; the provincial, city and municipal hospitals; dispensaries and clinics, the public markets and slaughter houses; the health resorts; and all charitable and relief agencies. However, the Philippine General Hospital was detached from the Department and transferred to the Office of the President of the Philippines. 1947 Reorganization of government offices under Executive Order No. 94, series of 1947 with the transfer of the Bureau of Public Welfare to the Office of the President and the Department was renamed Department of Health (DOH). Under this set-up were the following: Office of the Secretary , composed of the Division of Administration, Accounting, Drug Inspection, Nursing Service ( newly- created ), Laboratories (included the Alabang Vaccine & Serum Laboratories which was previously under the Institute of Hygiene, University of the Philippines; the Malaria Control Section, Tuberculosis Control Section, and the Social Hygiene), and the Board of Examiners ( Medical, Dental, Nursing, Pharmaceutical and Optical) Bureau of Health (enforced preventive measures for the promotion, protection, and preservation of health of the people and the maintenance of the sanitary conditions therein). Bureau of Quarantine

Bureau of Hospitals (an offspring of the Bureau of Health which was established to attend to the curative phase). All City Health Departments 1950 Under Executive Order No. 392, s. 1950, the Department of Health gained additional functions brought about by the transfer of the Institute of Nutrition, together with the Division of Biological Research and the Division of Food Technology from the Institute of Science, and the Public Schools Medical and Dental Services from the Office of the President of the Philippines and the Bureau of Public School respectively to the DOH. Within the Department of Health, certain changes were also effected thru the transfer of the Division of Health Education and Information from the Bureau of Health to the Department proper, in exchange for which the drug Inspection Division was transferred to the former office from the latter; the conversion of the Section of Tuberculosis into a Division of Tuberculosis, directly under the Office of the Secretary, and the conversion of the Division of Laboratories into an Office of Public Health Research Laboratory. 1958 The creation of eight regional health offices and two Undersecretaries of Health: the Undersecretary of health and the Medical Services and the Undersecretary of Special Services. 1971 The creation of the Food and Drug Administration, Bureau of Disease Intelligence Center, Malaria Eradication Service, Bureau of Dental Health Service, the National Comprehensive Maternal and Child Health / Family Planning Program, National Nutrition Program, and the National Schistosomiasis Control Commission, among others. 1972 Through Letter of Implementation No. 8, pursuant to Presidential Decree No.1, September 24, 1972, the DOH was renamed Ministry of Health. The National Cancer Center and Radiation Health Service were created. The Ministry was divided into 12 regions covering several provinces and cities under a regional health director. Attached offices were the Philippine Medical Care Commission, the Dangerous Drugs Board, National Nutrition Council, Population Commission, National Schistosomiasis Control Council and the Tondo General Hospital. 1982

Under Executive Order No. 851, the Health Education and Manpower Development Service was created, and the Bureau of Food and Drugs assumed the functions of the Food and Drug Administration. 1986 The Ministry of Health became Department of Health again. 1987 Another 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 the Chief of Staff, Public Health Services, Hospital and Facilities Services, Standard and Regulations, and Management Service. The National Capital Region, Cordillera Administrative Region, and Autonomous Region of Muslim Mindanao were added to the 12 regional health offices. A National Health Facilities was created composed of seven special research centers and hospitals and eight medical centers. New buildings were erected and old ones were renovated within the San Lazaro Compound. The expanded program on Immunization and the National Drug Policy (the implementation of the Generics Law) were given importance. 1992 Full implementation of Republic Act No. 7160 or Local Government Code. The DOH changed its role from one of implementation to one of governance. Significant change: branching out of the Office of the Public Health Services to form the Office for Special Concerns. Two big offices merged to become the Office of Hospital Facilities, Standards and Regulation. Special projects were highlighted like the NID. National Micronutrient Campaign, Disaster Management, Urban Health and Nutrition Project, Traditional Medicine, Doctors to the Barrios Program, "Let‘s DOH It"! became a national battlecry. 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. The Health Sector Reform Agenda of the Philippines, 1999-2004 was launched. The reforms are: provide fiscal autonomy to government hospitals; secure funding for priority health programs; promote the development of local health systems and ensure its effective performance; strengthen the capacities of health regulatory agencies and expand coverage of the National Health Insurance Programs. National Objectives for Health 1999-2004 was launched. This states the Philippines objectives for the eradication and control of infectious diseases commonly affecting our people, major chronic illnesses and injuries that compromise lives of the productive sector. It encourages promotion of healthy lifestyle and health-seeking behaviors to prevent or control certain debilitating illness and life-threatening diseases Creation of the National Health Planning

Committee (NHPC) and the establishment of Inter-local Health Zones (ILHZs) throughout the country through E.O. 205. This promotes, encourages and ensures the full and integration of delivery and development of health care services throughout the country. It provides for the participation, involvement and collaboration of all local government units with major stakeholders namely Department of Health and Department of Interior and Local Government.

2000 The year 2000 marked the institutionalization of the Health Sector Reform Agenda (HSRA). The HSRA was endorsed for approval and support by the National Government Agencies, national and local stakeholders in health, and partners in the international community. The HSRA has become the major framework for policies and investments for the health sector. 2001 In July 13, 2001, Administrative Order 37 which contained the guidelines on the operationalization of the HSRA implementation plan was signed by Sec. Manuel Dayrit. It is also during this year that the 13 convergence sites or the advance implementation areas have been established. 2003 The One-Script Systems Improvement Program was established (AO 50. S. 2003) to orchestrate unity, synchronicity and focused targeting of priority public health programs that would provide the biggest impact to attaining equity, efficiency, access and quality health care in the country. A major breakthrough was achieved in providing fiscal autonomy to 68 DOH retained hospitals with the approval of a special provision of FY 2003 GAA which authorized 100% retention and the use of hospital income for upgrading of health facilities and services. 2005 FOURmula ONE for Health (F1) was launched as the health sectors blue print for the implementation of reforms to bring about better health outcomes, more responsive health system and more equitable healthcare financing. Province-wide Investment Plans for Health were developed in 16 provinces as the basis of F1 implementation in these sites. 2006 The Presidential Anti-Graft Commission recognized and awarded the DOH as the number one government agency in fighting corruption. DOH also topped in the Pulse

Asia 3rd Quarter Survey as the number one government agency in terms of overall performance.

FOURMULA ONE What is FOURmula ONE for Health? Defining the Road Map for Reforms FOURmula ONE for Health is the implementation framework for health sector reforms in the Philippines for the medium term covering 2005-2010. It is designed to implement critical health interventions as a single package, backed by effective management infrastructure and financing arrangements. This document provides the road map towards achieving the strategic health sector reform goals and objectives of FOURmula ONE for Health from the national down to the local levels. FOURmula ONE for Health engages the entire health sector, including the public and private sectors, national agencies and local government units, external development agencies, and civil society to get involved in the implementation of health reforms. It is an invitation to join the collective race against fragmentation of the health system of the country, against the inequity of healthcare and the impoverishing effects of ill-health. With a robust and united health sector, we can win the race towards better health and a brighter future for generations to come.

Fourmula One for Health Goals and Objectives Over-all Goals: The implementation of FOURmula ONE for Health is directed towards achieving the following end goals, in consonance with the health system goals identified by the World Health Organization, the Millennium Development Goals, and the Medium Term Philippine Development Plan:    Better health outcomes; More responsive health system; and More equitable healthcare financing.

General Objective: FOURmula ONE for Health is aimed at achieving critical reforms with speed, precision and effective coordination directed at improving the quality, efficiency, effectiveness and equity of the Philippine health system in a manner that is felt and appreciated by Filipinos, especially the poor. Specific Objectives: FOURmula One for Health will strive, within the medium term, to:  Secure more, better and sustained financing for health;  Assure the quality and affordability of health goods and services;  Ensure access to and availability of essential and basic health packages; and  Improve performance of the health system

Goal: Health Sector Reform Agenda (HSRA) Health Sector reform is the overriding goal of the DOH. Support mechanisms will be through sound organizational development, strong policies, systems and procedures, capable human resources and adequate financial resources. Rationale for Health Sector Reform Although there has been a significant improvement in the health status of Filipinos for the last 50 years, the following conditions are still seen among the population:  Slowing down in the reduction in the Infant Mortality Rate (IMR) and the Maternal Mortality Rate (MMR)  Persistence of large variations in health status across population groups and geographic areas.  High burden from infectious diseases.  Rising burden from chronic and degenerative diseases.  Unattended emerging health risks from environmental and work related factors.  Burden of disease is heaviest on the poor. The reasons why the above conditions are still seen among the population can be explained by the following factors:



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Inappropriate health delivery system as shown by an inefficient and poorly targeted hospital system, ineffective mechanism for providing public health programs on top of health human resources maldistribution. Inadequate regulatory mechanisms for health services, high cost of drugs and presence of low quality of drugs in the market. Poor health care financing and inefficient sourcing or generation of funds for healthcare.

The following are the implications of the above information:  There is poor coverage of public health and primary care services.  There is inequitable access (physical and financial) to personal health care services.  There is low quality and high cost of both public and personal health care. In order to address the problem in the way the Philippine health care system delivers and pays for health services, interrelated reforms in five areas have been identified as critical in transforming the health system into one that ensures the delivery of cost effective services, universal access to essential services and adequate and efficient financing. Areas that needed to be reformed are on health financing, health regulation, local health systems, public health programs and hospital systems.

Framework for Implementation HSRA: FOURmula ONE for Health This is adopted as the implementation framework for health sector reforms under the current administration. It intends to implement critical interventions as a single package backed by effective management infrastructure and financing arrangements following a sectoral approach.

Roadmap for all Stakeholders in Health: National Objectives for Health 2005 to 2010 The NOH 2005-2010 provides the road map for stakeholders in health and health – related sectors to intensify and harmonize their efforts to attain its time – honored vision of health for all Filipinos and continue its avowed mission to ensure accessibility and quality of life of all Filipinos, especially the poor.

The NOH sets the targets and the critical indicators, current strategies based on field experiences, and laying down new avenues for improved interventions. It provides concrete handle that would guide policy makers, program managers, local government executives, development partners, civil society and the communities in making crucial decisions for health. Building on the initiatives under Health sector Reform Agenda and as set forth in the NOH 1999-2004, an implementation is defined through FOURmula ONE for Health which strategically focuses on interventions that create the most impact and generates buy-in from all partners. FOURmula ONE for Health is an overarching philosophy to achieve the end goals of better health outcomes, a responsive health systems and equitable health care financing. It is directed towards ensuring accessible, affordable quality health care especially for the more disadvantaged and vulnerable sectors of the population.

Objectives of the Health Sector a) Improve the general health status of the population b) Reduce the morbidity and mortality from certain diseases as public health problems c) Eliminate certain diseases as public health problems d) Promote healthy lifestyle and environmental health e) Protect vulnerable groups with special and nutritional needs. f) Strengthen national and local health systems to ensure better health service delivery g) Pursue public health and hospital reforms h) Reduce the costs and ensure the quality of essential drugs i) Institute health regulatory reforms to ensure quality and safety of health goods and services j) Strengthen health governance and management support systems k) Institute safety nets for the vulnerable and marginalized groups l) Expand the coverage of social health insurance m) Mobilize more resources for health n) Improve efficiency in the allocation, production and utilization of resources for health

PRIMARY HEALTH CARE History of Primary Health Care in the Philippines (Adopted from IBON Foundation, Inc.) Primary health care as an approach in health programs has a long history in the Philippines. In the early 1970‘s, Community Based Health Program (CBHP) emerged after several groups began to question the government‘s existing health care approaches and started exploring new ways of answering the health needs of the people. In the urban areas, allied health students worked with concerned health professionals to serve the poor in Manila. A group of Catholic sisters from different congregations decided to work with health professionals and formed a mobile health team to serve the most depressed rural areas. The health team trained paramedics at the grassroots level. Soon, the sisters of the Rural Missionaries of the Philippines along with their health and community volunteers initiated programs in Luzon (Isabela), Visayas (Leyte) and Mindanao (Lanao del Norte), launching their pilot CBHPs in 1975. The CBHPs attempted to bring health education and services to the barrios that had long been neglected by clinic and hospital-oriented, city and town center based government health care system. Exposure to the realities in the barrios quickly deepened their views of a structural approach to the solution of the health problems of the people. The relationship of poverty to malnutrition and disease became painful explicit. Later, the experiences of CBHPs were adopted by other religious organizations like the National Council of Churches in the Philippines (NCCP), establishing their nationwide network. Those involved in CBHPs found out that the political, economic and cultural structures were related to the prevailing health situation then. This rule awakening catalyzed an understanding that health problems would need to be solved through people‘s organizations. Such organizations would be utilize in addressing the people‘s needs and problems as well as venues for discussions, planning, answering the needs and drawing up solutions. Thus, community organizing was seen as a key factor in CBHPs and in uplifting the situation of the people.

During the Time of Marcos Unfortunately, the development of CBHPs happened during the time of Martial Law. Advocates of CBHPs were tagged as subversives by local authorities. Several programs faltered and dropped their organizing efforts while others held on to organizing and/or coordinating with people‘s organizations, unmindful of the risks

involved. But when the Philippines became a signatory to the Alma Ata Conference in 1978, the government committees itself to the objectives and principles of primary health care. Suddenly, CBHPs became acceptable and respectable. The government then initiated research and development in Primary health care. However, it was only in 1981 when the nationwide implementation of PHC started. The government organized Primary Health Care Committees at all levels. ―Botika sa Barangay‖ and Barangay health programs bearing the slogan ‗Health for All‖ was seen all over the country. A lot of health programs were launched to promote the principles of Primary health care. Later the existence of acute malnutrition among children was discovered in negros. Which proved that much-needed health care among the people was not as effective as the government‘s slogan and mottos sounded.

During the Time of Aquino The ―Health for All‖ slogan slowly vanished and Primary health care as a core strategy was never adopted due to the Marcosian label alluded to it. Consequently, the Department of Health gave little attention. Its status of the implementation was linked not monitored religiously. The latest available data with complete information way back 1988 which indicated a decline in the total number of barangays initiated to primary health care with only 96.6% (39,629) against 98.3% (38, 629). It was only in 1991, barely a year before the end of President Aquino‘s term that a program using Primary health care was created. In a post-Research/Action Workshop on Partnership for Community Health Development (PCHd) in June 1991, then Health Undersecretary Mario Taguiwalo expresses the need to refocus Primary health care, as it was associated with a dictatorial regime.

During the Time of Ramos Secretary Juan Flavier continued Partnership for Community Health Development (PCHD) with a Php 149 million financial package from the World Bank. The health program saw the revival of catchy slogans that used to be a practice during the Marcos dictatorship. And with the implementation of the Local Government Code of 1991, the status of the Primary Health Care was aggravated even more. This spelled major revamp in the management of Primary Health Care. It transferred the responsibility of supervising the implementation of Primary Health Care from the national government to local government units (LGUs). The government sees this process called devolution as a way to bring government closer to people since the powers and responsibilities in the management of basic services were transferred into the hands of

the LGUs. Thus DOH formally declared ―Health in the Hands of the people‖ as the core strategy in the programs thrust of the government at all levels.

Primary Health Care (PHC) The Alma Ata Conference defines Primary Health Care as essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally, accessible to individuals and families in the community by means of acceptable to them, through their full participation and at a cost that community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part of both the country‘s health system, of which it is the central function and the main focus and of the overall social and economic development of the community. Goal: Health for all Filipinos and Health in the Hands of the People by the year 2020.

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Health begins at home, in schools and in the workplace because it is there where people live and work that health is made or broken. It also means that people will use better approaches than they do now for preventing diseases and alleviating unavoidable disease and disability and have better ways of growing up, growing old and dying gracefully. It also means that here will be even distribution among the population of whatever resources for health are available. It means that essential health services will be accessible to all individuals and families in an acceptable and affordable way.

Mission: To strengthen the health care system by increasing opportunities and supporting the conditions wherein people will manage their own health care.

Concept: Characterized by partnership and empowerment of the people that shall permeate as the core strategy in the effective provision of essential health services that

are community based, accessible, acceptable and sustainable at a cost which the community and the government can afford. It is a strategy, which focuses responsibility for health on the individual, his family and the community. It includes the full participation and active involvement of the community towards the development of self-reliant people, capable of achieving an acceptable level of health and well being. It also recognizes the interrelationship between health and the overall political, socio-cultural and economic development of society. Legal Basis Letter of Instruction [LOI] 949 signed on October 19, 1979 by then President Ferdinand E. Marcos – one year after the First International Conference of Primary Health Care was held in Alma Ata, USSR on September 6-12, 1978, sponsored by the World Health Organization and UNICEF.

Primary Health Care Concepts 1. Cooperation of the Community PHC represents a supplementary health system that is extended from the system rendered by the state at the community level with cooperation of the community.

2. Capability of people to determine and analyze their own problems cooperates in finding ways or solution to their problems and acceptance of their problems. PHC will come into being only when the community organizes and accepts their problems. Cooperates in finding ways to tackle such problem, the function of the government is to provide support that will enable the community to analyze and determine its own problems. PHC will equip the community with capability to solve its own problem through community participation and cooperates in organizing activities to solve problems faced by the community. 3. Voluntary Community Involvement

Community involvement is the heart and soul of PHC activities. The community support may be in terms of labor, money or cooperation on voluntary basis. The community must recognize its own problem.

4. Basic Minimum Needs of the Society should be spelled out. To provide opportunity for the underprivileged majority, to develop an acceptable level, a set of Basic Minimum Needs or MBN of the society should be spelled out as a common social goal for all. Food, clothing, shelter, environment, health education and means of livelihood must be provided.

5. Villagers work to ensure better living of the community Government officials do not work in place of the villagers, villagers do not work for Officials, villager‘s work to ensure better living of the community. 6. PHC to Achieve Better Quality of Life Good Health is related to living conditions and life style. PHC activities must be integrated with other development activities aiming better quality of life which encompasses satisfaction with various life circumstances such as health, income, standard of leaving, work conditions, marriage, family and friends, neighborhood system of government, public safety, and education. These are actual indicators for well being which can help in shaping the quality of life of the client. 7. Self-Reliance The Community must make take it as its role and responsibility to develop the basic needs. Individual Community and Society must subscribe to the principles of selfreliance which means the community can now manage it‘s own system and therefore can function independently. Empowerment is closely related to this in a sense that people can now stand alone; they can provide themselves with the basic need requirements for survival. 8. PHC activities must be in harmony with existing institutions and daily life of the community. Services should be delivered where the people are. Existing norms of the community need not to changed or altered just to fit in PHC activities to avoid resistance on the part of the people. PHC activities should consider the culture or practices of the people for it to be effective during the implementation phase. It should go in harmony with the life style of the people.

9. PHC as an appropriate strategy. PHC work should be feasible in its application for problem solving appropriate to social conditions and problems being encountered. Its pattern of work need not be identical in all villages.

10. PHC as a public health service PHC must be related to public health services in such aspects as technological support, referral of patients for medical treatment, provision of continuing education, provision of health information. 11. PHC Elements E – Education for Health Involves Human Development and it is people oriented. It is a dynamic process of giving information and as the first step to improve knowledge, attitude of people for them to voluntarily adopt these teachings as an entry point to human development. As health educators, we are not here to change the behavior of the individual but rather to motivate him through information campaign for him to voluntarily adapt to these changes as he interacts with the environment. L – Locally Endemic Disease Control Focuses on the prevention of the occurrence of endemic diseases because it is continuously present in the community.

E – Expanded Program on Immunization Exist to control the occurrence of preventable illness especially of children. Immunization on Poliomyelitis, measles, tetanus, diphtheria and other deadly bur preventable disease are given for free by the government and an ongoing program of the Department of Health. M – Maternal and Child Health

The mother and the child are the most delicate member of the community. Therefore, the maternal and infant mortality and morbidity rates are among the indicators of health of a particular community. So, the protection of the mother and child to illness and other risks would ensure a good health for the community. E – Essential Drugs This focuses on the information campaign on the proper utilization and acquisition of drugs. In response to this campaign, is the Generic Act of the Philippines. N – Nutrition Food is one of the basic needs of the individual, appropriate kind and preparation of it can contribute to a healthy state. There are a lot of resources available in our setting but because of lack of knowledge as well as faulty preparation, it leads to malnutrition, which is one of the major health problems we have in our country.

T – Treatment of Communicable Diseases Tuberculosis, malaria, schistosomiasis and other communicable diseases associated with poverty continue to be a serious problem with economic implications. 75,000 Filipino babies die of preventable causes every year and that most of these preventable diseases are communicable in nature. The government then has to focus on the prevention, control and treatment of these diseases.

S – Safe water and Sanitation Access to potable water within 250 meters or 10 minute walk and sanitary toilet is a must for every family. The government then has to see to it that policies, rules, regulation related to this must be implemented and followed strictly. Because this is also one of the basic needs of human beings for survival, clean environment is necessary to promote good health.

RATIONALE OF PRIMARY HEALTH CARE Through the years the government extended efforts to channel resources toward the expansion of conventional and structured health services. However, there are several areas that are not served. Some even die without passing through the hands of a health care provider. Communicable diseases are still dominating the cause of illness and deaths among all ages. Parallel to the situation is the rapid population growth rate, poor environmental sanitation, and lack of basic health knowledge.

Thousands of Allied Health Professionals were registered yearly but prefer to practice in the secondary or tertiary health care facilities and only few goes back to their own communities and work with primary health care facilities. The cost of medical services now a day is very high plus the emerging trends of Independent Practice and Health maintenance Organization. Budgetary allocations for Health care Institution are not enough to sustain the health of the population. Partnership between government and non-government sectors is not satisfactorily. Some still remain independent and isolated. Even within the health care system wherein a health care provider themselves competes with one another for professional dignity and few of them demonstrates collaborative actions.

Four Pillars of Primary Health Care 1. Equitable distribution Health services must be shared equally by all people irrespective of their ability to pay and and all (rich or poor, urban or rural) must have access to health services. 2. Community participation There must be a continuing effort to secure meaningful involvement of the community in the planning, implementation and maintenance of health services, beside maximum reliance on local resources such as manpower, money and materials. 3. Inter-sectoral Coordination Primary health care involves in addition to the health sector, all related sectors and aspects of national and community development.

4. Appropriate Technology Is technology that is scientifically sound, adaptable to local needs, acceptable to those who apply it and for those for whom it is used and can be maintained by the people themselves in keeping with the principle of self-reliance with the resources the community and country can afford.

PRIMARY HEALTH CARE PRINCIPLES AND STATEGIES 1. Accessibility, Availability, Affordability and Acceptability of Health Services Strategies: Health services delivered where the people are Use of indigenous/resident volunteer health worker as a health care provider with a ratio of one community health worker per 10-20 households Use of traditional (herbal medicine) with essential drugs. 2. Provision of quality, basic and essential health services Strategies: Training design and curriculum based on community needs and priorities. Attitudes, knowledge and skills developed are on promotive, preventive, curative and rehabilitative health care. Regular monitoring and periodic evaluation of community health workers performance by the community and health staff. 3. Community Participation Strategies: Awareness, building and consciousness raising on health and health-related

issues. Planning, implementation, monitoring and evaluation done through small group meetings (10-20 households cluster) Selection of community health workers by the community. Formation of health committees. Establishment of a community health organization at the parish or municipal level. Mass health campaigns and mobilization to combat health problems. 4. Self-reliance Strategies Community generates support (cash, labor) for health programs. Use of local resources (human, financial, material) Training of community in leadership and management skills. Incorporation of income generating projects, cooperatives and small scale industries. 5. Recognition of interrelationship of health and development Strategies:

Convergence of health, food, nutrition, water, sanitation and population services. Integration of PHC into national, regional, provincial, municipal and barangay development plans. Coordination of activities with economic planning, education, agriculture, industry, housing, public works, communication and social services. Establishment of an effective health referral system. 6. Social Mobilization Strategies Establishment of an effective health referral system. Multi-sectoral and interdisciplinary linkage. Information, education, communication support using multi-media. Collaboration between government and non-governmental organizations.

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Decentralization Strategies Reallocation of budgetary resources. Reorientation of health professional and PHC. Advocacy for political and support from the national leadership down to the barangay level.

APPLICATION TO COMMUNITY DEVELOPMENT The previous concepts discussed related to primary health care will be useless if we ourselves cannot implement this at out level. There is no such thing as a minimum requirement for the application of Primary Health Care concepts, principles towards community development. Attaining health for all Filipinos will only require expanding participation in health and health related programs whether as service provider or beneficiary. Empowering the people to make decisions on their own health should be one of our goals. Although the department of health acts as the lead agency in the implementation of primary health care programs, we as members of the allied health profession should define our own limits and learn to accept collaborative actions. We have to understand that there are people around us that can help us implement these health programs. It only takes a single step to reach out for these people and involve them in all our health care activities.

The definition, concepts, principles of primary health care should not remain dormant. It is simply stated and anybody who is really committed to community works can easily adopt and utilize this approach. Let us not repeat the previous movements but rather move towards the attainment of our national goal which is bringing health into the hands of the people. We have twenty years more to fulfill this dream and the future of our health care system is in our hands. At our level it takes a lot of courage to apply the above principles, commitment to the profession is also essential and above all is acceptance of the job tasked ahead of us.

CONCLUSION: An important concern in addressing health issues in the community is the need for enhanced capability for greater participation and involvement of the people in health efforts including policy making and influencing decisions. Often, the people most affected by the problem feel helpless simply because they do not believe they have the power to change their situation. In other words, community health nursing interventions must focus on providing health-related interventions to improve the health status of the population and enhancing capability of the community to manage its own health. The community health nurse also plays a significant role in enhancing active participation among its members in terms of planning, organizing, implementing and evaluating health programs. These significant roles would properly motivate the community to respond to their health needs that would contribute to the enhancement of the people‘s condition regarding health. It could also raise the level of consciousness and awareness of the community to the existing situation that prevail in the society that contribute to the detriment of the health status of the people. Health care practitioners, public health nurses in general must have a vision that is not only limited in seeing what good things this life has to offer but it must also extend to what is currently experienced by the whole community as well as what are the concerns of the family, particularly about health.

The Philippine Health Care Delivery System

HEALTH CARE SYSTEM an organized plan of health services. HEALTH CARE DELIVERY rendering health care services to the people. HEALTH CARE DELIVERY SYSTEM the network of health facilities and personnel which carries out the task of rendering health care to the people. PHILIPPINE HEALTH CARE SYSTEM is a complex set of organizations interacting to provide an array of health service. COMPONENTS OF THE HEALTH DELIVERY SYSTEM The Department of Health Mandate: The Department of Health shall be responsible for the following: formulation and development of national health policies, guidelines, standards and manual of operations for health services and programs; issuance of rules and regulations, licenses and accreditations; promulgation of national health standards, goals, priorities and indicators; development of special health programs and projects and advocacy for legislation on health policies and programs. The primary function of the Department of Health is the promotion, protection, preservation or restoration of the health of the people through the provision and delivery of health services and through the regulation and encouragement of providers of health goods and services (E.O. No. 119, Sec. 3).

Vision: Health as a right. Health for All Filipinos by the year 2000 and Health in the Hands of the People by the year 2020. Mission: The mission of the DOH, in partnership with the people to ensure equity, quality and access to health care: by making services available by arousing community awareness by mobilizing resources by promoting the means to better health

LEVELS OF HEALTH CARE FACILITIES 1. PRIMARY LEVEL OF HEALTH CARE FACILITIES are the rural health units, their sub-centers, chest clinics, malaria eradication units, and schistosomiasis control units operated by the DOH; puericulture centers operated by League of Puericulture Centers; tuberculosis clinics and hospitals of the Philippine Tuberculosis Society; private clinics, clinics operated by the Philippine Medical Association; clinics operated by large industrial firms for their employees; community hospitals and health centers operated by the Philippine Medicare Care Commission and other health facilities operated by voluntary religious and civic groups. 2. SECONDARY LEVEL OF HEALTH CARE FACILITIES are the smaller, non-departmentalized hospitals including emergency and regional hospitals. Services offered to patients with symptomatic stages of disease, which require moderately specialized knowledge and technical resources for adequate treatment. 3. TERTIARY LEVEL OF HEALTH CARE FACILITIES are the highly technological and sophisticated services offered by medical centers and large hospitals. These are the specialized national hospitals. Services rendered at this level are for clients afflicted with diseases which seriously threaten their health and which require highly technical and specialized knowledge, facilities and personnel to treat effectively.

FACTORS ON THE VARIOUS CATEGORIES OF HEALTH WORKERS AMONG COUNTRIES AND COMMUNITIES 1. available health manpower resources 2. local health needs and problems 3. political and financial feasibility

THREE LEVELS OF PRIMARY HEALTH CARE WORKERS A. VILLAGE OR GRASSROOT HEALTH WORKERS first contacts of the community and initial links of health care. Provide simple curative and preventive health care measures promoting healthy environment.

Participate in activities geared towards the improvement of the socio-economic level of the community like food production program. Community health worker, volunteers or traditional birth attendants. B. INTERMEDIATE LEVEL HEALTH WORKERS represent the first source of professional health care attends to health problems beyond the competence of village workers provide support to front-line health workers in terms of supervision, training, supplies, and services. Medical practitioners, nurses and midwives. C. FIRST LINE HOSPITAL PERSONNEL provide back-up health services for cases that require hospitalization establish close contact with intermediate level health workers or village health workers. Physicians with specialty, nurses, dentist, pharmacists, other health professionals.

TWO-WAY REFERRAL SYSTEM A two-way referral system need to be established between each level of health facility e.g. barangay health workers refer cases to the rural health team, who in turn refer more serious cases to either the district hospital, then to the provincial, regional or the whole health care system. Public P Barangay Health O Health Worker Nurse 2nd 3rd P HF HF U EA EA L Barangay RHU AC AC A Health Midwife Physician LI LI T Stations TL TL I HI HI O T T N RHS Sanitary Y Y Midwife Inspector

MULTISECTORAL APPROACH TO HEALTH (NLGNI, 8th edition, 1995) The level of health of a community is largely the result of a combination of factors. Other health-related Systems (government/ private

Ways of The People (Cultural) Environment (Social, Economic, physical, Etc.

Community Health

Health Care System

Health, therefore, cannot work in isolation. Neither can one sector or discipline claim monopoly to the solution of community health problems. Health has now become a multisectoral concern. For instance, it is unrealistic to expect a malnourished child to substantially gain in weight unless the family‘s poverty is alleviated…… In other words, improvement of social and economic conditions need to be attended to first or tackled hand in hand with health problems. 1. Intersectoral Linkages - Primary Health Care forms an integral part of the health system and the over-all social and economic development of the community. As such, it is necessary to unify health efforts within the health organization itself and with other sectors concerned. It implies the integration of health plans with the plan for the total community development. - Sectors most closely related to health include those concerned with: a. Agricultural b. Education c. Public works d. Local governments e. Social Welfare f. Population Control

g.

Private Sectors

The agricultural sector can contribute much to the social and economic upliftment of the people……. Demonstration to mothers of better techniques and procedures for food preparation and preservation can preserve the nutritive value of local foods. Through joint efforts, agricultural technology that produces side effects unsafe to health (for instance, insecticide poisoning) can be minimized or prevented. The school has long been recognized as an effective venue for transmission of basic knowledge to the community. Every pupil or student can be tapped for primary health care activities such as sanitation and food production activities….. Construction of safe water supply facilities and better roads can be jointly undertaken by the community with public works. Community organization (e.g. establishing a barangay network for health) can be worked through the local government or community structure. Likewise, better housing through social welfare agencies, promotion of responsible parenthood through family planning services and increased employment through the private sectors can be joint undertakings for health……We have to recognize that oftentimes health actions undertaken outside the health sector can have health effects much greater than those possible within it. 2. Intrasectoral Linkages - In the health sector, the acceptance of primary health care necessitates the restructuring of the health system to broaden health coverage and make health service available to all. There is now a widely accepted pyramidal organization that provides levels of services starting with primary health and progressing to specialty care. Primary health care is the hub of the health system.

LEVELS OF HEALTH CARE AND REFERRAL SYSTEM The Philippine Health Care Delivery System has a primary, secondary and tertiary level. Some health problems or concerns are within the capability of the Barangay Health Station (BHS) such as blood pressure monitoring and vaccinations. Health problems that are beyond the capability of the BHS units and beyond the competence of the workers are referred to an immediate health facility, usually a Rural Health Unit (RHU). The RHU team generally consists of the physician, dentist, public health nurse, midwife, sanitarian and other health workers. The District Community Hospitals attends to the cases needing hospitalization. Higher echelons of health services at the provincial, regional

and national levels, provides secondary or tertiary care to complete the health care given at district and peripheral levels. The higher the level, the more qualified the health personnel and the more sophisticated the health equipment. Under this structure, health care is provided by the suitable health facility on the basis of health need. There is better utilization of scarce health resources. References: Public Health Nursing in the Philippines, Department of Health

Related Articles: (1) Health system

Ministry of Health's mission, vision and objectives The Department of Health's vision is to be "The leader of health for all in the Philippines". Its mission is to "guarantee equitable, sustainable and quality health for all Filipinos, especially the poor, and to lead the quest for excellence in health". The goals of the health department align with the WHO health systems framework. Better health for the entire population is the primary goal. This means making the health status of the people as good as possible over the entire life cycle. The second goal is related to how the health system performs in meeting people‘s expectations and

satisfaction with the services it provides. Equitable health care financing is the third goal because health and illness involves large and unexpected costs that may result in poverty for many people. The strategic thrusts to achieve the three primary health goals mentioned above are anchored in the current programme of health reforms, labelled ‗Fourmula One for Health‘. It is designed to undertake critical reforms with speed, precision and effective coordination, with the end goal of improving the efficiency, effectiveness and equity of the Philippine health system. Vital reforms are organized into four major implementation components: health financing; health regulation; health service delivery; and good governance in health. Implementation will focus on four general objectives: (1) health financing, the general objective of which is to secure increased, better and sustained investments in health to provide equity and improve health outcomes, especially for the poor; (2) health regulation, which aims to assure access to quality and affordable health products, devices, facilities and services, especially those commonly used by the poor; (3) health service delivery, where health interventions are aimed at improving the accessibility and availability of social and essential health care for all, particularly the poor; and (4) good governance in health, aimed at improving health systems performance at the national and local levels. Organization of health services and delivery systems With the devolution of health services to LGUs under the Local Government Code of 1991, fragmentation of services became evident. Service provision is regarded as ‗dual‘, consisting of both the public and private sector. The public sector has three largely independent segments or sets of providers: (1) national government providers, which include, among others, hospitals run by national government agencies (e.g., hospitals of the Department of Health and the Department of National Defense), central and regional offices of the Department of Health; (2) provincial government providers, which include provincial hospitals, provincial blood banks and the Provincial Health Office; and (3) local (municipal or city) government providers, including rural health units or RHUs, city health centres and barangay health stations or BHSs. Each BHSs is staffed by a midwife, and each RHU by a doctor, a nurse and midwives. The Department of Health's role now focuses on regulation, technical guidelines/orientation, planning, evaluation, and inspection, while the provincial government is responsible for provincial and municipal hospitals, health centres and health posts, although funding flows do not exactly match responsibility. The municipal government-level role is not well defined and capacity is reportedly weak. With the decentralization of service delivery, local chief executives became core players in the health sector. The number of actors involved multiplied and hence the

need for coordination and policy monitoring. On health financing, for instance, the Department of Health and the Central Government are no longer in control of resource allocation. The need for better coordination and a better working relationship with the local government units and other stakeholders is well recognized. Private providers are predominantly located in highly urbanized areas. The private sector consists of a wide range of privately operated facilities, such as pharmacies, physicians in solo or group practices, small hospitals and maternity centres, diagnostic centres, employer-based outpatient facilities, secondary and tertiary hospitals, traditional birth attendants and indigenous healers. Ongoing reforms in health service delivery are aimed at improving the accessibility and availability of basic and essential health care for all, particularly the poor. Public primary health facilities are perceived as being low quality, hence they are frequently bypassed. Clients are dissatisfied due to long waiting times; perceived inferior medicines and supplies; poor diagnosis, resulting in repeated visits; and the perceived lack of medical and people skills of the personnel available, especially in rural areas. The result is that secondary and tertiary facilities are inundated with patients needing primary health care. Since public primary facilities are more accessible to households and are mostly visited by the poor, improving the quality of those services particularly demanded by the poor would improve their health. Furthermore, referral mechanisms among different health facilities across local government units need to be strengthened. Pharmaceutical challenges remain due to asymmetric information, income distribution and the inadequacy of the regulatory system. This stems from various factors such as massive campaigns and lucrative incentives from multinational drug firms, prolonged patent rights cases and a lack of appropriate public understanding regarding generics. Health policy, planning and regulatory framework The Government's policy to achieve improvements in health includes a perspective on the integral value of health for any nation, the coordination of resources from all sectors, the right to access quality care, and the presence of socioeconomic fundamentals. While the Government provides the leadership and stewardship to ensure that all efforts in the health sector lead to a common goal, greater support to local health systems development and emphasis on strong management and administrative support systems at all levels of governance is critical. Better coordination between national policies and external development partner priorities would also play a major role in fostering the harmonization of resources for health.

The Department of Health remains inadequate in regulating the quality of health services in the country. This is attributed to the immense gaps in health regulations caused by the lack of specific legal mandates, inadequate expertise, an inadequate number of health regulation officers, a lack of expertise and infrastructure in specialized services and laboratory facilities, and weak health regulatory systems and processes. Health care financing The financial burden on individual families remains high. The latest (2005) national health accounts show that the most common source of funds for health in the country today is still out-of-pocket payments (around 49%). Paying for health care is an issue because of its poverty impacts. Under the current health care financing arrangements, low-income families are pushed into poverty due to payments for health care. Almost 80% of total health expenditure is spent on personal health care services. In contrast, only 11% is used for public health care services. About 10% is used for the administrative spending needed to run the entire health system. These are signs that the Philippines is not spending enough or effectively for health. Health care financing resources are spent largely on hospital-based curative services and not enough on preventive and promotive health services, and subsidies for health services are poorly targeted. The large hospitals in Metropolitan Manila and other urban areas get the biggest share of spending, while non-hospital health services face difficulties in getting adequate funding. Meanwhile, the national health insurance programme has seen only a relatively slow and cautious increase in its share of total health expenditure. Possible reasons for this include its low benefit package and the fact that coverage of the informal economy has not increased. The limited financial protection of the national health insurance programme, PhilHealth, is closely related to its benefit coverage and provider payment system. As physicians provide more services and raise prices under the current fee-forservice system, medical care expenses increase rapidly. However, PhilHealth pays only up to the rather low benefit ceiling and patients pay the rest of the expenses. At the same time, physicians‘ have the freedom to bill without fee regulation. Discussions are now ongoing to explore the feasibility of extending benefit coverage by raising the benefit ceiling. Public health facilities are funded through a mix of public subsidies, such as Philhealth reimbursements, user fees and, to a limited extent, private health insurers. At the primary care level, public subsidies and Philhealth capitation allocations are funding services for both insured and non-insured members and for both public health and personal care. At the hospital level, the mix of funding is not well understood by regulators. Moreover, several schemes may be working at the same time, depending of local priorities and

management styles. Drugs are mainly purchased out-of-pocket from private for-profit retailers. The Government has recently introduced thousands of non-profit community outlets, but their impact on access and the costs supported by patients remains to be seen. In response to these issues, the Government is finalizing its health care financing strategy to improve health care financing polices that would realistically enhance access, equity and effectiveness in resource mobilization and allocation, as well as the use of health services. Human resources for health In 2004, there was one physician for every 880 people, one nurse for every 235, one dentist for every 1800, and one pharmacist for every 1664. However, these ratios have most likely changed, especially with the exodus of nurses in the past five years. The country is purportedly the leading exporter of nurses to the world and the second major exporter of physicians. Prevailing challenges include unmanaged immigration of Filipino health workers; a weak and inadequate human resources for health (HRH) information system; and an existing distribution imbalance, among others. Responses to HRH issues in the past have often been stopgap measures. In addition, the interventions of the agencies concerned have not always been well coordinated. In order to address such complex and multi-faceted issues, a comprehensive approach is needed. A master plan for human resources for health has been developed and implementation of activities is underway. A high-level coordinating body and multisectoral working group was established in 2006 to mobilize political commitment, donor/partner support and the funding needed to accomplish the priority activities of the master plan. Called the Human Resources for Health (HRH) Network, this group was able to successfully convene a policy forum to advocate their policy agenda, which aims to resolve issues related to production, entry and retention of health professionals, as well as their exit and re-entry. Strategic thrusts for 2005-2010 include development of HRH policies and strategies to address out-migration; sustaining incentive mechanisms for HRH distribution and complementation in underserved areas; and making education, training and skills development more appropriate to local needs. The strategies that are being undertaken include, among others, the institutionalization of the health human resource management and development system; improvement of the technical competence and relevant skills of health professionals through education and training; provision of targeted and performance-linked compensation benefits; strengthening of the coordination mechanism between the education sector, regulatory agencies and HRH users; and installation of and HRH information system.

Partnerships The attainment of national health goals has significantly progressed given the welldefined, commonly-shared vision and framework for health (now called ‗FOURmula ONE‘). Department of Health experience has shown that better harmonization of efforts among the various stakeholders at all levels is critical. Currently, assistance for the health sector comes mainly in the form of grants, loans and technical assistance. A sectorwide development approach for health (SDAH) between government and partners is being initiated to maximize investments, minimize duplication of initiatives and generate the necessary resources for the health sector. The Department of Health is also working closely with international organizations and global initiatives to strengthen implementation of priority health programmes. Challenges to health system strengthening The publicly funded health system has been undergoing a major reform programme since 1999. At the broadest level, this has included a review of the Department of Health‘s primary functions, roles and responsibilities and the suitability of the existing organizational structure to support these at both the strategic and service-delivery level. Introducing and pilot-testing the different concepts and strategies of heath sector reform in selected provinces has showcased some gains in health systems development. However, one of the gaps then was the absence of a comprehensive operational framework to implement the reform strategies. Thus, the FOURmula ONE framework was launched in August 2005 to set the direction and implementation arrangements for strengthening the way health care is delivered, governed, regulated and financed. FOURmula ONE is now on its third year of implementation and both the Department of Health and the LGUs are being challenged with operational issues, such as procurement. In addition, the health care delivery system has yet to address some major issues and challenges including, among others: the absence of data disaggregated at provincial/municipal level (for baseline and monitoring); the absence of a workable means of identification of the poor for targeted health interventions; the minimal involvement of the private sector in the delivery of public health programmes; the still excessive reliance on the use of high-end hospital services rather than primary care; the slow improvement in maternal mortality reduction; and population growth. Issues such as geographic inequity, where people who live in rural and isolated communities receive less and lower quality health services, and socioeconomic inequity, where the poor do not receive health services due to inaccessibility and/or unaffordability, continue to abound in the country.

More specific issues like out-migration of skilled health workers, low salaries/wages and lack of incentives and poor work environments, including shortages of basic medical equipment and supplies, continue to contribute to the worsening shortage of workers in rural areas, where health needs are greatest. Hospitals, both public and private, all over the country lament the loss of senior experienced nurses and doctors. The University of the Philippines-Philippine General Hospital (UP-PGH), the largest hospital in the country, loses 300 to 500 nurses of their 2000 nurse workforce every year. Midwives, the front liners in providing health services, are also seeking jobs as caregivers in other countries in need. There is a lack of reliable, disaggregated and integrated health and health-related data, evidence and information, and inability to use health information to ensure knowledge-based policies and programmes remains a major challenge. There is also low investment in health research and development systems, as well as in information management systems. In the area of health care financing, the following challenges remain: high out-of pocket spending; inadequate government spending on health; low spending for costeffective public health interventions; low social health insurance benefit spending; and identification of the ‗true‘ poor for social health insurance (sponsored programme). The high cost of drugs and medicines also remains a major challenge, as prices range from two times to as much as 30 times higher than in other neighbouring Asian countries. To date, the ‗Cheaper Medicines‘ Bill, which aims to effectively reduce the cost of medicines in the country, is yet to be signed by the President of the Philippines. The devolution of health services created new challenges for the Government in overseeing that local actions are in accordance with national policies and goals. Good governance in health at the local levels, particularly in improving transparency and accountability in finance and procurement, and logistics management remains a big challenge. With FOURmula ONE, systems of accountability and transparency are being established to minimize unscrupulous behaviour, thereby ensuring efficient use of available resources for health. Source: http://www.wpro.who.int/countries/2008/phl/national_health_priorities.htm (2) Health care beyond reach of poor, say critics By Kirsten Bernabe Philippine Daily Inquirer First Posted 05:35:00 04/13/2010 (11th of a series)

For any Filipino family, especially among the poor, an illness striking any of its members is viewed as a catastrophe. Six of 10 Filipinos who succumb to sickness die without ever seeing a doctor, according to the University of the Philippines‘ National Health Institute. Health care is one of the most important items that should be on the agenda of whoever gets elected president in the May election, according to a group of former senior government officials who have drawn up a list of urgent concerns for the next administration to address in its first year. Unlike in the United States, where health care occupied center stage in the past presidential election and continues to be a major program of the Obama administration, very little attention is focused on the current debates on this major problem that impacts heavily on improving education and easing poverty in this country. Ailing parents can‘t support their families. Sickly and malnourished children can‘t attend schools, setting back their education, the main vehicle for social mobility especially among the poor who have no access to wealth or capital. Even among those with a regular income, like Jeremy Macalalag, 39, surviving a major ailment is nothing short of a miracle. Macalalag was diagnosed with severe kidney problem requiring dialysis, an expensive treatment that cost P3,500 a session. He had to undergo this process or would die unless he had a P1.2 million transplant operation, doctors said. ―I didn‘t know from which pocket and from what kind of hand I would get the money to save my husband‘s life,‖ says Macalalag‘s wife, Joanne, 38, an ultrasound technician in a hospital who earned P30,000 a month on which her family of four depended to survive. With her social network, however, she secured help from humanitarian organizations, such as the Lifeline Foundation and the Philippine Charity Sweepstakes Office, to defray the cost of the transplant. Not many in this nation of 90 million are that fortunate, especially among the more than 27 million who survive on a dollar a day, the poverty threshold defined by the World Bank. Infant mortality rates The poorest Filipinos have an infant mortality rate of 42 per 1,000 births, compared with 19 per 1,000 births among the rich, according to a concept paper presented at a UP forum on universal health care last year. ―The same can be observed in maternal mortality rates. The lowest income groups are also 1.4 times more likely to be positive for tuberculosis based on X-ray exam compared to the highest income groups,‖ it says. Urban areas, such as the National Capital Region, have the highest number of health facilities, while the poorer regions such as the Autonomous Region in Muslim Mindanao have predominantly private facilities—far from the reach of the poor.

―Despite 76 percent coverage of PhilHealth insurance, 49 percent of health spending is still out-of-pocket. Due to increasing cost of services and the lack of appropriate social protection, illness now tends to be viewed as a catastrophic event, especially for the poorest Filipino families,‖ the paper says. Universal health care Dr. Ramon Paterno of the UP National Health Institute says the country needs a universal health care system where ―every Filipino has access to needed health care, with minimal or no co-payment.‖ He stresses that this isn‘t about charity. ―It is prepaid by taxes and social premiums.‖ Paterno laments that health care financing has almost always been troublesome. ―Government‘s budget for health care only amounts to less than 3 percent of the country‘s GDP (gross domestic product). This is 2 percent lower than the standard health care allocation, 5 percent, recommended by the World Health Organization,‖ Paterno says. ―As a nation, we spend P200 billion for health care but 60 percent of this are out-of-thepocket expenditures.‖ Philippine Health Insurance Corp. (PhilHealth) is a state agency attached to the Department of Health, which strives to deliver universal health care to its clients. The agency ―ensures sustainable, affordable and progressive social health insurance, which endeavors to influence the delivery of accessible quality health care for all Filipinos.‖ Public hospitals Workers pay P100 to P750 a month for PhilHealth, but 50 percent of the monthly premium is covered by their employers. Critics say that PhilHealth is one of the better-run state corporations, accumulating assets of up to P70 billion. But they say that little of PhilHealth‘s assets are being used to finance the improvement of provincial hospitals so that they can be accredited into the system and thereby ease the shortage of medical services in the rural areas. Little tertiary health care—services provided for major ailments by such hospitals as Makati Medical Center and Medical City—is available in the provinces. Valid concern Health Secretary Esperanza Cabral acknowledges this is a valid concern. ―We need to improve our activities as far as accrediting hospitals and clinics so that patients with PhilHealth cards can access them and they can be reimbursed for the services they provide so that they can have money that they can pour into other health services,‖ Cabral says.

―The support value is only about 30 percent. At the moment, we actually say that is the only amount that we can afford. I have to take a serious look as to whether that is true and whether, if that‘s the only thing we can afford, we are putting it in the right places.‖ Paterno shows documentaries of the rural poor who are unable to avail themselves of medical services. ―There‘s nothing I can do,‖ says an ailing woman profiled in the documentary. ―I am just waiting to die if no one lends help,‖ she says, tears welling in her wrinkled eyes. Health on P1.10 a day? How does the average Filipino cope? ―I do everything. I sell perfumes and I work during my days off. We also collect bottles, newspapers, boxes and the like, and sell them,‖ Joanne Macalalag says. ―We are in a hand-to-mouth condition. My kids are used to eating corned beef almost always. We cannot afford other extra expenses.‖ Based on the allocation of government‘s budget, a tax-paying Filipino spends only P1.10 a day for health care compared to P21.75 spent on debt-servicing, authorities say. Apparently, P1.10 a day isn‘t giving the Jeremy Macalalags in this country too much hope. While every Filipino is entitled to health care in the Constitution, it is regarded more as a privilege, as poverty incidence widens. ―Health care in the Philippines is costly as it is mostly given for profit. Most Filipinos are poor and health care becomes least in their priorities next to food, shelter and education,‖ says Dr. Geneve Rivera, secretary general of Health Alliance for Democracy. She says the profit-driven nature of health care is characterized by privatization of services, including those dispensed by government facilities, as well as the western orientation of health education designed for the needs of other countries. Ill-equipped gov‘t hospitals ―Government hospitals are ill-equipped that a PhilHealth member will have minimal use of the membership,‖ Rivera says. For example, she says, few public hospitals have an ultrasound facility. Which means, you have to go to a private hospital to avail yourself of this service and pay for it. ―PhilHealth also has various limitations in its coverage,‖ Rivera says. ―But the whole concept of it does not answer the bigger problems. In these times when most Filipinos can barely afford to buy food, how can one pay for the contributions?‖ she says. ―Government policies on health care provision have made the health care services more and more inaccessible to the people especially the underprivileged. The continued privatization of government hospitals, the low priority in allocating budget for

health, and the continuing program of sending our health professionals abroad are all contributing to the worsening of the health care delivery in the country,‖ she says. And unfortunately, health professionals who choose to stay in the country and do community work are being targeted as enemies of the government and are being harassed, like the 43 health workers allegedly illegally arrested and detained in Camp Capinpin. The case has reached the Commission on Human Rights. Rivera says that the government should promote community health work and ensure that volunteers are safe from harassment. ―The government should work on making health and other social services equitable, those who have less should receive more,‖ says Rivera, one of the few doctors who immerse themselves in depressed communities and serve the poor. Alternative medicine Because of the high cost of health care, many Filipinos resort to alternative medicine. Norberto Cervales, a 32-year-old jobless father, usually brings his 16-month-old daughter to a mangtatawas, a sort of an exorcist, whenever she gets sick. Tawas is a ritual to find out supernatural causes of physical illnesses. The practitioner chants a prayer. A candle is lit and as the melted wax drops in a basin of water, an image is formed, said to be the creature responsible for the ailment. The sick then sleeps on the wax image and, voila, the ailment disappears. Cervales says he had tried to raise P300 for a doctor‘s consultation fee, but decided he couldn‘t afford it, much less the prescribed medicine. ―We are asked to return again and again,‖ he says. ―We don‘t have the money for it.‖ Lita Panganiban, 64, a mangtatawas, says that her patients are growing. ―Even in the middle of the night, they come to my house,‖ she says.

Faith healing Panganiban says she learned the ritual from her mother back in her Masbate hometown. ―If you‘re smart, you can easily learn the prayer,‖ she says. Panganiban‘s services are also very much affordable. She accepts any donation the patient hands over. ―I am not totally against health care alternatives, but it depends on the method,‖ says Dr. Imelda Ferrer. ―As long as it is sanitary and does not let patients take drugs prior to doctor‘s prescription.‖ Ferrer also says it can get dangerous. ―The illness can get worse,‖ she says. ―With spiritual healing, I must say that it is important for a patient‘s recovery.‖ It‘s all about faith, when all else fails. Source: http://newsinfo.inquirer.net/inquirerheadlines/nation/view/20100413263926/Health-care-beyond-reach-of-poor-say-critics

(3) Press Release May 27, 2009 RURAL AREAS SUFFER MOST FROM POOR HEALTH CARE SYSTEM, SAYS ANGARA Seeks to bridge urban-rural gap through Telehealth system Senator Edgardo J. Angara today promoted a national Telehealth system in the country saying that this means access to quality health care for every Filipino, which could hopefully bridge the gap between health care in the urban and rural areas. "Two perennial problems haunt and hurt the health-care system in the Philippines: its shortage of doctors, and the concentration of health professionals in urban areas. For a country that exports doctors and nurses, the Philippines suffers from a low 1:15,000 doctor-to-population ratio, more than double the ideal 1:6,000 and a far cry from the US ratio of 1:150," said Angara who chairs the Senate Committee on Finance and authored pioneering laws such as the PhilHealth Act and the Senior Citizens' Act. He added, "Worse, majority of these doctors reside in urban areas. For instance, the disparity between the number of doctors in the National Capital Region (NCR) and in provinces, such as the Cordillera Administrative Region (CAR) and the Autonomous Region in Muslim Mindanao (ARMM), is ghastly alarming." According to a paper the Philippines presented to the Association of Southeast Asian Nations in 2005, there were 658 doctors in government hospitals in the NCR in 2002, in contrast to the 85 doctors in CAR and 69 in ARMM. Also, data from Social Watch Philippines show that in 2004, there were 197 private and public hospitals in the NCR, again a stark contrast against the 54 hospitals in CAR and 17 in ARMM. Angara told that access to health-care significantly affects the quality of life in a region's population. For instance, while the child-mortality rate in the NCR is eight per 1,000 children below five, the figure in CAR is more than double, with 20 deaths for every 1,000 children. The child-mortality rate in ARMM is worse, more than four times the NCR statistics at 33 deaths for every thousand children. Twenty-four babies die for every thousand infants born in the urban areas, while the infant-mortality rate in rural areas is higher by 50 percent: 36 babies die for every thousand live births. "There is an urgent need to increase expert health-care services in the countryside. Fortunately, advances in technology provide a means to overcome personnel and regional constraints through out-of-the-box solutions, such as the National Telehealth System," Angara added. The National Telehealth System, a project first piloted by University of the Philippines Manila in 1998, imparts clinical information and education to distant areas using information and communications technologies (ICT). Through computers and the

Internet, supplementary expert care can be delivered to far-flung provinces where health-care specialists are scarce. Angara added that in 2009 P100 million was allotted to expand the reach and scope of the National Telehealth System. Through ICT, the National Telehealth System will allow remote consultation with experts in the Philippine General Hospital regarding trauma and poison cases, and in determining and responding to epidemics. An electronic health-record system for poison and trauma patients shall also be developed to provide relevant information and health education to the public, and facilitate continuous learning for health professionals. "Our Constitution has recognized the right to health of every Filipino long before US President Obama said it was the right of every American during his campaign. "This means access to quality health care for every Filipino, regardless of whether he lives in the streets of Manila or at the foothills of Sierra Madre. The National Telehealth System, we hope, could bridge the gap between health care in the urban and rural areas, and make quality health care more accessible to the rural folk", said Angara. Source: http://www.senate.gov.ph/press_release/2009/0527_angara1.asp (4) Source: http://www.crsprogramquality.org/storage/pubs/health/Healthinnovations-microscopy2.pdf

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