HEALTH Writer Simon Peter Gregorio Editors Chay Florentino-Hofileña Giselle Baretto-Lapitan Project Management Amihan Perez Ateneo Center for Social Policy and Public Affairs (ACSPPA) Technical and Editorial Team Rene “Bong’Garrucho, LGSP Mags Maglana, LGSP Fe Salcedo, LGSP Myn Garcia, LGSP Florencia Dorotan Art Direction, Cover Design & Layout Jet Hermida Photography Ryan Anson
HEALTH FACING UP TO THE HEALTH CHALLENGE
Facing Up To The Health Challenge Service Delivery with Impact: Resource Books for Local Government Copyright @2003 Philippines-Canada Local Government Support Program (LGSP) All rights reserved The Philippines-Canada Local Government Support Program encourages the use, translation, adaptation and copying of this material for non-commercial use, with appropriate credit given to LGSP. Although reasonable care has been taken in the preparation of this book, the publisher and/or contributor and/or editor can not accept any liability for any consequence arising from the use thereof or from any information contained herein. ISBN 971-8597-06-9 Printed and bound in Manila, Philippines Published by: Philippines-Canada Local Government Support Program (LGSP) Unit 1507 Jollibee Plaza Emerald Ave., 1600 Pasig City, Philippines Tel. Nos. (632) 637-3511 to 13 www.lgsp.org.ph Ateneo Center for Social Policy and Public Affairs (ACSPPA) ACSPPA, Fr. Arrupe Road, Social Development Complex Ateneo de Manila University, Loyola Heights, 1108 Quezon City This project was undertaken with the financial support of the Government of Canada provided through the Canadian International Development Agency (CIDA).
A JOINT PROJECT OF
Department of the Interior and Local Government (DILG)
National Economic and Development Authority (NEDA)
IMPLEMENTED BY
Agriteam Canada www.agriteam.ca
Federation of Canadian Municipalities (FCM) www.fcm.ca
Canadian International Development Agency
CONTENTS FOREWORD ACKNOWLEDGEMENTS PREFACE ACRONYMS EXECUTIVE SUMMARY INTRODUCTION
1 2
CHAPTER 1: OVERVIEW OF THE HEALTH SECTOR Health Status of Filipinos Financing: Sources and Uses Health Human Resources and their Distribution Health Facilities Health Sector Reform Agenda CHAPTER 2: LGU MANDATES ON HEALTH SERVICE DELIVERY The Local Government Code Laws and Policies Governing Local Health Service Delivery CHAPTER 3: IMPLEMENTATION & POLICY ISSUES AND RECOMMENDATIONS Institutional Development Health Care Financing Delivering Quality Health Services CHAPTER 4: GOOD PRACTICES IN HEALTH SERVICE DELIVERY Planning Health Service Delivery Financing Health Service Delivery Delivering Quality Health Services CHAPTER 5: REFERENCES AND TOOLS References Resources for Health Service Delivery Resources for Inter-Local Health Zones
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
FOREWORD
T
he Department of the Interior and Local Government is pleased to acknowledge the latest publication of the Philippines Canada Local Government Support Program (LGSP), Service Delivery with Impact: Resource Books for Local Government; a series of books on eight (8) service delivery areas, which include Shelter, Water and Sanitation, Health, Agriculture, Local Economic Development, Solid Waste Management, Watershed and Coastal Resource Management. One of the biggest challenges in promoting responsive and efficient local governance is to be able to meaningfully deliver quality public services to communities as mandated in the Local Government Code. Faced with continued high incidence of poverty, it is imperative to strengthen the role of LGUs in service delivery as they explore new approaches for improving their performance. Strategies and mechanisms for effective service delivery must take into consideration issues of poverty reduction, people’s participation, the promotion of gender equality, environmental sustainability and economic and social equity for more long- term results. There is also a need to acquire knowledge, create new structures, and undertake innovative programs that are more responsive to the needs of the communities and develop linkages and partnerships within and between communities as part of an integrated approach to providing relevant and sustainable services to their constituencies. Service Delivery with Impact: Resource Books for Local Government offer local government units and their partners easy-to-use, comprehensive resource material with which to take up this challenge. By providing LGUs with practical technologies, tested models and replicable exemplary practices, Service Delivery with Impact encourages LGUs to be innovative, proactive and creative in addressing the real problems and issues in providing and enhancing services, taking into account increased community participation and strategic private sector/civil society organizational partnerships. We hope that in using these resource books, LGUs will be better equipped with new ideas, tools and inspiration to make a
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
I
FOREWORD
difference by expanding their knowledge and selection of replicable choices in delivering basic services with increased impact. The DILG, therefore, congratulates the Philippines-Canada Local Government Support Program (LGSP) for this milestone in its continuing efforts to promote efficient, responsive, transparent and accountable governance.
HON. JOSE D. LINA, JR. Secretary Department of the Interior and Local Government
II
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
ACKNOWLEDGEMENTS
T
his publication is the result of the collaboration of institutions and individuals committed to supporting the improvement of the delivery of health services by local governments to their constituents The Philippines- Canada Local Government Support Program led by Alix Yule, Marion Maceda Villanueva and Rene "Bong" Garrucho for providing the necessary direction and support Florencia Dorotan and her team at LIKAS Incorporated, particularly Dr. Suzanne Halum and Lorenzo G. Ubalde for undertaking the research and roundtable discussion and preparing the technical report which was the main reference for this resource book; and for assisting in the review of the manuscript Participants to the Roundtable Discussion on Exemplary Practices in LGU Health Service Delivery held on August 6, 2002 in Davao City. Their expertise and the animated exchange of opinions helped shape the technical report on which this publication is based: Mayor Fernando C. Corvera San Jose Buenavista; Mayor Valente Yap of Bindoy; Mayor Dicken Otero of Sta. Josefa; Melanie V. Tolentino of Kalibo; Dr. Jarvis Punsalan of Capiz; Dr. Fidencio Aurelia of Bayawan District Hospital; Ma. Laurisse Gabor of Butuan City; Tomas Cruiz of Cantilan; Florencio Q. Liray of Quezon, Bukidnon; Dr. Ma. Corazon S. Ariosa of Zamboanga del Sur; Ray Roquero of the LMP; and Jose Corenales of NEDA XI/SEDS Earl Enrico Alcala of WHSMP; Dr. Jose Rodriguez of PMTAT-Management Sciences for Health; Dr. Eddie Dorotan of Management Sciences for Health; Mel Villacin of Quedan-KAISAHAN; Florante Villas of XAES; Dam Vertido of Mindanao Land Foundation; Rory Villaluna of PCWS-ITNF; Ratan Budhathoki of PCWS-ITNF/NEWAH; Aida Lananjo of Pipuli Foundation, Marites Qui単onez of CERD, Inc. and Ma. Sheila Labos of KALIWAT Theater Collective; S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
III
ACKNOWLEDGEMENTS
LGSP Managers Evelyn Jiz, Teresita Gajo, Abe de la Calzada, and Victor Ozarraga; Program Officer Abduljim Hassan Fe Salcedo for providing feedback that helped ensure that the resource book offers information that is practical and applicable to LGU needs and requirements Simon Peter Gregorio for effectively rendering the technical report into a user-friendly material Chay Florentino-Hofile単a and Giselle Baretto Lapitan for their excellent editorial work Amihan Perez and the Ateneo Center for Social Policy and Public Affairs for their efficient coordination and management of the project Mags Z. Maglana for providing overall content supervision and coordinated with the technical writers Myn Garcia for providing technical and creative direction and overall supervision of the design, layout and production Sef Carandang, Russell Fari単as, Gigi Barazon and the rest of the LGSP administrative staff for providing support
IV
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
PREFACE
S
ervice Delivery with Impact: Resource Books for Local Government are the product of a series of roundtable discussions, critical review of tested models and technologies, and case analyses of replicable exemplary practices in the Philippines conducted by the Philippines-Canada Local Government Support Program (LGSP) in eight (8) service sectors that local government units (LGUs) are mandated to deliver. These include Shelter, Water and Sanitation, Health, Agriculture, Local Economic Development, Solid Waste Management, Watershed and Coastal Resource Management. The devolution of powers as mandated in the Local Government Code has been a core pillar of decentralization in the Philippines. Yet despite opportunities for LGUs to make a meaningful difference in the lives of the people by maximizing these devolved powers, issues related to poverty persist and improvements in effective and efficient service delivery remain a challenge. With LGSP’s work in support of over 200 LGUs for the past several years came the recognition of the need to enhance capacities in service delivery, specifically to clarify the understanding and optimize the role of local government units in providing improved services. This gap presented the motivation for LGSP to develop these resource books for LGUs. Not a “how to manual,� Service Delivery with Impact features strategies and a myriad of proven approaches designed to offer innovative ways for local governments to increase their capacities to better deliver quality services to their constituencies. Each resource book focuses on highlighting the important areas of skills and knowledge that contribute to improved services. Service Delivery with Impact provides practical insights on how LGUs can apply guiding principles, tested and appropriate technology, and lessons learned from exemplary cases to their organization and in partnership with their communities.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
V
PREFACE
This series of resource books hopes to serve as a helpful and comprehensive reference to inspire and enable LGUs to significantly contribute to improving the quality of life of their constituency through responsive and efficient governance. Philippines-Canada Local Government Support Program (LGSP)
VI
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
ACRONYMS AO BFAD BHPDP BIHC BLHD BTL CBMIS CHCA CHD CHO CHW CIDA CSO DOH DSWD DTI EHS EO EPI FAMUS FP GSO HAMIS HEALTHDEV
Administrative Order Bureau of Food and Drugs Bureau of Health Policy Development and Planning Bureau of International Health Cooperation Bureau of Local Health Development Bilateral Tubal Ligation Community-Based Monitoring and Information System Comprehensive Health Care Agreement Center for Health Development (formerly Regional Field Office or Regional Health Office) City Health Office; City Health Officer Community Health Worker Canadian International Development Assistance Civil Society Organization Department of Health Department of Social Welfare and Development Department of Trade and Industry Environmental Health Service Executive Order Expanded Program on Immunization Family Health By and For Poor Settlers Family Planning General Services Office Health Management Information System Health Alternatives for Total Human Development Institute
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
VII
ACRONYMS HSRA IEC ILHZ IRA IRR LCE LGSP LGU LIKAS LPP MCH MGP MHO MOA MOOE MSH NGO NHIP OTC PCHD PDI PHC PHIC PHO PITC
VIII
Health Sector Reform Agenda Information, Education and Communication Inter-Local Health Zone Internal Revenue Allocation Implementing Rules and Regulations Local Chief Executive Local Government Support Program Local Government Unit Lingap Para Sa Kalusugan ng Sambayanan, Incorporated LGU Performance Program Maternal and Child Health Matching Grant Program Municipal Health Office; Municipal Health Officer Memorandum of Agreement Maintenance and Other Operating Expenses Management Sciences for Health Non-Government Organization National Health Insurance Program Over The Counter Partnership for Community Health Development Parallel Drug Importation Primary Health Care Philippine Health Insurance Corporation (also PhilHealth) Provincial Health Office; Provincial Health Officer Philippine International Trading Corporation
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
ACRONYMS PITAHC PMCC PNDF PNP PO RHU VSS WHSMP WHSMP-PC
Philippine Institute for Traditional and Alternative Health Care Philippine Medical Care Commission Philippine National Drug Formulary Philippine National Police People’s Organization Rural Health Unit Voluntary Surgical Sterilization Women’s Health and Safe Motherhood Project Women’s Health and Safe Motherhood Project – Partnership Component
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
IX
EXECUTIVE SUMMARY THE HEALTH SECTOR
H
ealth service delivery has always been an important concern of the government, assuming even greater significance after the devolution of health services to Local Government Units (LGUs) in 1992. More than ten years after devolution, LGUs continue to grapple with the challenges of devolution while at the same time confronting new issues and problems emerging from the changing times. The renewed emphasis on poverty reduction and sustainable economic and social development has brought to the fore the need for a healthy citizenry. While significant gains have been achieved in the last half-century in reducing maternal and infant mortality, the country still lags behind its neighbors in these key indicators. Preventable communicable diseases like diarrhea, pneumonia, and bronchitis continue to afflict millions of Filipinos. Tuberculosis and hypertension are becoming more and more prevalent among the population. Lifestyle diseases like diseases of the heart and the vascular system and malignant neoplasms are rising as causes of death. Access to health care remains very limited. People are constrained in improving their health-seeking behavior by the location of health facilities, low levels of education, limited income, and high prices of medicines and hospital care. Overall public spending in health remains below international standards. In the absence of universal health insurance coverage, health expenditures continue to be financed largely from the pockets of patients and their families. Spending is still heavily in favor of hospital or curative care to the neglect of preventive and promotive health services. Human resources of the health sector are poorly distributed across regions, with many doctors and nurses found in urban centers like Metro Manila.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
XI
EXECUTIVE SUMMARY
LEGAL FRAMEWORK The Local Government Code of 1991 devolved the delivery of basic services and the operation and maintenance of local health facilities from the Department of Health (DOH) to provinces, cities, and municipalities. This means that each local government unit is now responsible for the performance of functions that were previously vested in the national government, specifically the Department of Health (DOH). These functions comprise the following: (1) general control and supervision over devolved personnel and facilities, (2) the operation and maintenance of local health facilities like provincial hospitals and health centers, (3) service delivery such as the implementation of promotive, preventive, curative, and rehabilitative health programs and services, and (4) regulatory functions such as the formulation and enforcement of local ordinances related to health, nutrition, sanitation, and other healthrelated concerns. In a devolved set-up, the DOH exercises oversight and regulatory functions, provides technical assistance, formulates standards and guidelines, and manages the operation of retained hospitals, regional medical centers, regional training and/or teaching hospitals, specialized health facilities, and national government hospitals. Besides the Local Government Code, there is a whole compendium of laws and policies governing various aspects of health service delivery by LGUs. These laws are categorized in this resource book under six headings: Local Health System Development, Public Health Reform, Hospital Reform, Drug Management System, Health Care Financing/Social Health Insurance, and Specific Concerns In 1999, the DOH crafted a Health Sector Reform Agenda (HSRA) to address the abovementioned situation. The HSRA describes the major strategies, organizational and policy changes, and public investments needed to improve the delivery, regulation and financing of health care. The HSRA guides
XII
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
EXECUTIVE SUMMARY
the health sector and more importantly, the LGUs, in improving their capacity and capability to implement health delivery services in five (5) areas: Local Health Systems Development: Promote the development of local health systems and ensure its effective performance. Public Health Reforms: Secure funding for priority public health programs. Hospital Reforms: Provide fiscal autonomy to government hospitals. Health Regulation Reforms: Strengthen the capacity of health regulatory agencies. Health Care Financing: Expand the coverage of the National Health Insurance Program (NHIP).
WHAT THE LGUs CAN DO The Philippines faces these tremendous challenges in the health sector: making devolution work; ensuring community participation in the delivery of health services; recruiting, retaining, and building the capability of health personnel; and financing and implementing health service programs. The country can surmount these challenges only through the enactment and implementation of comprehensive reforms. LGUs, standing at the frontline of the health delivery system, play a critical role in realizing the goals of the HSRA and improving health services in general. Some of the issues confronting LGUs and the corresponding reforms include establishing and strengthening inter-local health systems and their subsystems, implementing the Barangay Health Workers’Incentives Act, increasing the Internal Revenue Allotment (IRA) for health to a fixed percentage and the budget for health to five (5) percent of the local and national budgets, increasing enrollment in the Philippine Health Insurance Corporation’s (PHIC) Social Health Insurance Program, and advocating
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
XIII
EXECUTIVE SUMMARY
and encouraging national government and devolved hospitals to become fiscally autonomous through the charging of user fees, income retention schemes, and other revenue enhancing methods.
WHAT SOME LGUs HAVE DONE In the effort to deliver health care services, LGUs need various kinds of assistance. The need for financial resources remains an obvious and perennial concern. Equally important is the need for information on good practices that LGUs can study, emulate, and adapt to their situation. This resource book provides nineteen (19) cases of LGUs from across the country that responded effectively to problems in health service delivery. The cases show how LGUs have dealt with the challenges of planning, financing, and delivering health services and the innovative practices that have developed along the way. Among such practices are mobilizing popular support; generating participation in health care projects; and instilling a culture of quality service among health workers.
XIV
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
INTRODUCTION
A
modest objective of this resource book is to provide a handy reference for local governments from all over the country—from the local chief executive to the rank and file employees of the local bureaucracy. This reference will help in making decisions, preparing budgets, and implementing projects related to health service delivery. This book also contains basic information on health service delivery that will be useful to the rank and file employees of the Department of Health, non-government organizations, and agencies that provide assistance to LGUs. On a grander scale, this resource book seeks to make local governments—and anyone who cares deeply about health— begin thinking systematically about the problems of the sector. More importantly, the book aims to prod concerned agencies and individuals to act on these problems, or advocate reforms with the proper authorities. The resource book dares local governments to make good on the often-heard motto, “A healthy citizenry is the catalyst for economic and social development.” It further challenges local governments to achieve this goal by:
Entering into partnerships to promote effective local health systems Prioritizing public health programs Improving the efficiency and effectiveness of hospital services and facilities Ensuring the safety, quality, and accessibility of health products and services Extending health protection to the poor through social health insurance
This book casts a wide net over many health sector areas, from the planning to actual delivery of services, from policies to implementation tools. Some readers may feel that certain topics have not been discussed with a level of detail that does justice to the subject. This is a valid expectation for a monograph, but not for a resource book. A resource book’s primary audience are practitioners who need S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
1
INTRODUCTION
to know the issues quickly and concisely, be informed of their options and available resources, and see how things turned out for those who faced similar situations. Details that may be of specific interest to health researchers and academics are therefore not included. The resource book also focuses on the public health sector, specifically those areas where local governments play an important role. Except for a few recommendations affecting them, this resource book does not deal with the private health sector. Even with the public health sector, the book does not attempt to be exhaustive or extensive. It focuses only on areas most relevant to LGUs and on issues where LGU efforts can have the most impact. This resource book is divided into five (5) chapters:
Overview of the Health Sector Mandates of the Local Government Units Implementation & Policy Issues and Recommendations Case Studies on Good Practices in Health Service Delivery Tools and References
The first chapter provides a general picture about the health situation in the country, touching on topics such as mortality rates, financing, health facilities, human resources, and the Health Sector Reform Agenda. The second chapter highlights the role of LGUs in delivering health services under a devolved set-up. It compares the mandates of LGUs under the Local Government Code with the following roles of the DOH: (1) personnel management and human resource management, (2) facilities management, (3) planning and decision-making, (4) procurement of drugs and other health products, and (5) financing
2
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
INTRODUCTION
and implementing health projects. This chapter also enumerates the various laws and policies (Constitutional provisions, Republic Acts, Department Orders, etc.) that govern health service delivery by LGUs. The third chapter discusses issues regarding service delivery and advances several recommendations. These issues were raised during the Round Table Discussion on Health Service Delivery on August 2002 in Davao City, sponsored by the Philippine-Canada Local Government Support Program (LGSP). This section also identifies reforms that the LGUs can undertake on their own, through their various Leagues (Municipalities, Cities, and Provinces), and with the executive and legislative branches of the national government. The fourth chapter presents 19 case studies on these various issues and are classified according to the functions undertaken by LGUs: Planning Health Service Delivery, Financing Health Service Delivery, and Delivering Quality Health Services. The two (2) cases on Planning Service Delivery emphasize the need for adequate information on the health needs of the population and the sicknesses ailing them. These cases also show how this information can be gathered, collated, stored, analyzed, and used for deciding on the appropriate intervention; how these interventions can be monitored; and, finally how this data can be used for impact evaluation. The section on Financing Health Service Delivery has ten (10) cases. Each of them illustrate one or several strategies that LGUs have used to address the constant lack of funding: socialized user fees, matching grant schemes, setting up trust funds for hospitals, pooling hospital drug procurement, bulk and parallel procurement and distribution of drugs, joint ventures, fund raising among overseas Filipino workers and overseas Filipino communities, tracking and allocating costs among different hospital units. S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
3
INTRODUCTION
The third (and last) section on Delivering Quality Health Services presents seven (7) cases. These cases demonstrate the importance of popular support and participation, a responsive project design, and a culture of quality in effective health service delivery. The fifth chapter contains tools and references that readers may consult and find useful to deepen their understanding of the issues presented here. Some of topics discussed in the five chapters may already be familiar to LGU readers, and they may feel justified to skip or skim over those portions. Nevertheless, it is recommended that this resource book be read in full, perhaps not in one sitting but in several, choosing portions that are relevant and important for the challenge of the day. For direction-setting and programming purposes, local chief executives and elected officials may find most useful these sections on the LGUs’mandates, laws and policies governing health service delivery, and the issues and policy recommendations. On the other hand, the case studies section illustrates how policies work out in actual practice and what their implementers undergo. Local health workers may spend some time looking at the case studies for approaches and practices they can adopt in their own programs and projects. The question and answer portion that immediately follows is meant to clarify the adopted approaches, their advantages and disadvantages, their applicability in other situations, the resources used by this particular approach, and the resulting benefits. The case studies chosen for this book were designed to meet specific challenges at a particular time and context. They may or may not be applicable to those who are situated differently. They are presented here to inform, inspire and trigger the thinking process. 4
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
INTRODUCTION
This resource book is also for civil society partners, people’s organizations, and non-government organizations engaged in policy advocacy and health service delivery, especially in collaboration with LGUs and agencies providing various kinds of assistance (e.g., capability building to LGUs) The resource book can help to better understand local government partners—where they are coming from and what constrains them from delivering the kind of services that people need. Compared to the scope and burden of the challenges facing the sector, the successes cited in this resource book might appear modest. Hopefully these small accomplishments will encourage people to start projects, however small and humble they may be. It is hoped that local government leaders will be motivated to see the big picture and the possibilities in health service delivery yet to be realized. LGU leaders are thus prodded to “Start Small, Think Big, Scale Up Fast.”
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
5
1 OVERVIEW OF THE HEALTH SECTOR
8
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
OVERVIEW OF THE HEALTH SECTOR
1
CHAPTER
T
his chapter provides a bird’s eye view of the Philippine health sector. The performance of the sector has been mixed, to say the least. While gains have been made over the last 50 years in maternal and child mortality rate, the country continues to lag behind its neighbors in these key indicators. Preventable communicable diseases like diarrhea, pneumonia, and bronchitis remain as the leading causes of illness. A disturbing trend is the re-emergence and increasing prevalence of tuberculosis in the general population. Lifestyle diseases like diseases of the heart and the vascular system and malignant neoplasms are the leading causes of death. Access to health care and health-seeking behavior remain poor, constrained as they are by the location of health facilities, the low levels of education and the limited income of many Filipinos, and the high prices of medicines and hospital care. Overall public spending in health remains below international standards. In the absence of universal health insurance coverage, health expenditures continue to be financed largely from the pockets of patients and their families. Spending is still heavily biased in favor of hospital or curative care to the detriment of preventive and promotive health services. Health human resources are poorly distributed across regions. Most of the doctors are in the National Capital Region and in urban metropolitan centers. Four out of 10 doctors in the whole country are in Metro Manila. Ten years after devolution, the number of DOH-retained hospitals is increasing, as provincial and district hospitals are reclassified as regional and national centers. As a result, the DOH is spending more on a relatively small number of hospitals than it was doing before devolution. On the other hand, provincial and district hospitals perform poorly due to the financial constraints of the LGUs, among other factors.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
9
1 HEALTH
To address these problems, the DOH crafted a Health Sector Reform Agenda (HSRA) in 1999. The HSRA describes the major strategies, organizational and policy changes, and public investments needed to improve the way health care is delivered, regulated, and financed. The HSRA guides the health sector, especially the LGUs, in improving their capability to implement health delivery services in five (5) areas, to wit: Local Health Systems Development: Promote the development of local health systems and ensure its effective performance. Public Health Reforms: Secure funding for priority public health programs. Hospital Reforms: Provide fiscal autonomy to government hospitals. Health Regulation Reforms: Strengthen the capacity of health regulatory agencies. Health Care Financing: Expand the coverage of the National Health Insurance Program (NHIP)
❙ HEALTH STATUS OF FILIPINOS ◗ MATERNAL AND INFANT MORTALITY (DEATH) RATES Over the last 50 years, the health of Filipinos has improved significantly. From 1990 to 1995, infant mortality declined from 56.7 per 1,000 live births to 48.9 per 1,000 live births in 1995. Child mortality went down from 79.4 per 1,000 children (under five years of age) in 1990 to 66.8 in 1995. Maternal mortality rate also went down from 209 per 100,000 live births in 1990 to 180 in 1995. The overall improvement in child and maternal mortality has not been uniform across all the regions and provinces of the country. Large differences separate the five lowest mortality provinces from the top five high mortality provinces, as shown by Table 1.
10
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
OVERVIEW OF THE HEALTH SECTOR 1
Table 1. High and Low Infant Mortality and Maternal Mortality Provinces, 1995 HIGH MORTALITY PROVINCES IN 1995 Province
LOW MORTALITY PROVINCES IN 1995
Rate
Province
Rate
64.6 65.8 66.4 67.1 69.1
Bulacan Cavite Pampanga Laguna Rizal
34.8 35.8 36.7 37.2 38.2
267.0 296.4 299.1 311.6 333.7
Cavite Batangas Rizal Davao Del Sur Pangasinan
116.0 139.1 140.1 148.6 147.0
Infant Mortality Ifugao Eastern Samar Northern Samar Samar Lanao Del Sur
Maternal Mortality Sultan Kudarat Maguindanao Tawi-Tawi Aurora Sulu Source: NSCB (1995)
â—— LEADING CAUSES OF ILLNESS AND DEATH Most of the leading causes of illness or morbidity are communicable diseases, but noncommunicable diseases like hypertension and other diseases of the heart are fast rising as the leading cause. The leading causes of illness are: 1. Diarrhea 2. Pneumonia 3. Bronchitis S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
11
1 HEALTH
4. Influenza 5. Tuberculosis, respiratory 6. Hypertension 7. Malaria 8. Chicken pox 9. Diseases of the heart 10. Measles The leading causes of death or mortality are mostly non-communicable diseases. Yet fast rising causes of deaths are diabetes mellitus and accidents and injuries. The 10 leading causes of death/mortality are: 1. Diseases of the heart 2. Diseases of the vascular system 3. Pneumonias 4. Malignant neoplasms or different kinds of cancers 5. Tuberculosis, all forms 6. Accidents 7. Chronic obstructive pulmonary diseases and allied conditions 8. Other disease of the respiratory system 9. Diabetes mellitus 10. Diarrheal diseases
◗ ACCESS TO HEALTH SERVICES AND HEALTH-SEEKING BEHAVIORS Physical barriers, such as the location of health centers and hospitals, hamper many Filipinos’access to health services. Education and location are important factors that determine whether mothers bring their sick children to a health facility or a health provider, for instance. Another example is the higher prevalence of acute respiratory infection in the rural areas than in urban areas, and among
12
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
OVERVIEW OF THE HEALTH SECTOR 1
Table 2. Health-Seeking Patterns by Income Group, 1993 (In Percent) Response to Health Complaint
Poorest Quartile
Quartile 2
Quartile 3
25
36
37
48
Consulted other health professional
5
3
1
1
Consulted traditional healer
6
2
2
1
64
59
60
50
100
100
100
100
Consulted doctor
Self-care Total number of respondents
Richest Quartile
Source: DOH-PIDS Household Survey (1993)
children of less educated mothers. In contrast, the percentage of children taken to a health facility or provider is higher in urban areas and among children of more educated mothers. Income is another factor that determines whether the services of a health provider or a health facility will be used. The poorest members of the population resort to self-care more than the richest quartile. More often, they go to other health professionals and traditional healers and consult the doctor less frequently than the richer quartiles.
â—— CAPACITY TO FINANCE HEALTH CARE Many Filipinos cannot afford medical care because of limited incomes and high costs. The prices charged to charity patients in a private hospital far exceed those charged to an insured patient in a public hospital. Neither does health insurance help bring down prices. Both private and public hospitals charge insured patients more than they do uninsured patients, as Table 3 shows. Many who cannot avoid hospital-based care bring the sick to public hospitals where facilities, equipment, and services cannot compare with private hospitals. S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
13
1 HEALTH
â?™ FINANCING: SOURCES AND USES In 1998, the Philippines had a total budget of P540.783 billion. Of this amount, only an estimated three centavos for every peso budgeted went to health. Table 3. Predicted Bills and Costs for a Standard Package of Services (In Pesos) Predicted Price Charged to
Private Hospital
Public Hospital
Difference
Charity patient
4,590
838
3,752
Uninsured patient
6,663
1,539
5,124
Insured patient
8,359
2,777
5,582
Compared to the country’s Gross National Product (GNP), combined public and private sector spending on health was only P88.4 or about 3.5 percent of GNP. This figure was below the minimum standard for health spending of five (5) percent of GNP prescribed by the World Health Organization (WHO) for developing countries.
Breaking down the 1997 health spending, 72 centavos for every peso spent went to personal health care services like the purchase of medicines, consultation fees, and diagnostic tests. Only 13 centavos for every peso spent went to public health services. The rest (15 centavos) went to the cost of running the health system, like salaries of doctors, nurses, hospital administrators, etc.
Source: Solon, et al.
By source, about 46 centavos for every peso spent came from the pockets of individuals. Government contributed only 39 centavos for every peso spent—21 centavos from the national government and 18 centavos from the local government. The National Health Insurance Program (NHIP) contributed only 7 centavos for every peso spent. Private health insurance and community-based health financing schemes shared the remaining 8 centavos. Most of the spending heavily favored curative, rather than preventive and promotive health services. The large government hospitals in Metro Manila got the biggest share while an insufficient budget was given to primary care facilities at the local level.
14
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
OVERVIEW OF THE HEALTH SECTOR 1
❙ HEALTH HUMAN RESOURCES AND THEIR DISTRIBUTION From 1990 to 1995, the World Health Organization (WHO) estimated that there were 82,494 doctors, 259,629 nurses, and 102,878 midwives. Majority of these, however, worked in the private sector and engaged in private practice. In 1997, the LGUs employed 3,123 doctors, 1,782 dentists, 4,882 nurses, and 15,647 midwives. The Department of Health employed 4,232 doctors, 179 dentists, 4,837 nurses, and 241 midwives. Comparing government health workers to the population, the ratios were:
1 doctor per 9,727 people 1 dentist per 36,481 people 1 nurse per 7,361 people 1 midwife per 4,503 people
However, the distribution of health workers tells another story. Most of the doctors are based in the National Capital Region and in urban metropolitan centers. Four out of 10 doctors in the whole country are in Metro Manila.
Ratio of government health workers to the population 1 doctor per 9,727 people 1 dentist per 36,481 people 1 nurse per 7,361 people 1 midwife per 4,503 people
❙ HEALTH FACILITIES More than ten years after the devolution of health services and facilities from the DOH to LGUs, 48 hospitals still remain under the DOH as retained hospitals. The number of DOH-retained hospitals
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
15
1 HEALTH
has been slowly increasing because of the reclassification of some provincial and district hospitals into regional or national centers. Concerns have been raised about the lack of resources and the need to expand capacity to accommodate patients who now bypass poorly equipped provincial and district hospitals and instead proceed to regional and national centers. As a result, the share of the DOH budget spent on retained hospitals has substantially increased. In fact, the DOH now spends more on a much smaller number of hospitals than the period before devolution. The reclassification of hospitals into regional or national centers and their retention by the DOH is an inefficient strategy to address the problems of health service devolution. Thus regional hospitals spend more in dealing with cases that can best be handled by provincial and district facilities. Thus far, the provincial and district hospitals have poorly performed under devolution. This stems from the LGUs’ unwillingness and inability to spend for these hospitals at levels prior to their devolution. Reduced spending affects mostly the maintenance and other operating expenses (MOOE) of hospitals. This situation leads to a lack of supplies, drugs, and allowances for repair and maintenance of medical equipment. In the end, service delivery and the poor patients of these hospitals suffer.
â?™ HEALTH SECTOR REFORM AGENDA To address problems of the health sector, the DOH drafted a Health Sector Reform Agenda (HSRA) in 1999 to describe the major strategies, organizational and policy changes, and required public investments to improve the way health care is delivered, regulated, and financed. The HSRA guides the health sector and more importantly, the LGUs, in improving their capacity and capability to implement health delivery services in five areas:
16
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
OVERVIEW OF THE HEALTH SECTOR 1
Local Health Systems Development: Promote the development of local health systems and ensure its effective performance. Public Health Reforms: Secure funding for priority public health programs. Hospital Reforms: Provide fiscal autonomy to government hospitals. Health Regulation Reforms: Strengthen the capacity of health regulatory agencies. Health Care Financing: Expand the coverage of the National Health Insurance Program (NHIP). 1. Promote the development of local health systems and ensure its effective performance. Local health systems development seeks to institutionalize local health systems within the context of local autonomy and to develop mechanisms for inter-LGU cooperation. It also aims to (a) upgrade health care management and service capabilities of local health facilities; (b) promote inter-LGU linkages and cost-sharing schemes including local health care financing systems for better use of local health resources; (c) foster the participation of the private sector, non-government organizations (NGOs), and communities in local health systems development; and (d) ensure the quality of health service delivery at the local level.
Five Areas for Improvement in Health Service Delivery 1. Local Health Systems Development 2. Public Health Reforms 3. Hospital Reforms 4. Health Regulation Reforms 5. Health Care Financing
2. Secure funding for priority public health programs. Public health reforms seek to significantly reduce the burden from infectious and degenerative diseases through the adoption of multi-year budgets, and by increasing investments to address emerging health concerns and to advance health promotion and prevention programs. In order to ensure the effective use of such investments, the management capacity and infrastructure of public health programs must be improved. Capability building is also necessary for these programs to provide technical leadership over local health systems. S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
17
1 HEALTH
3. Provide fiscal autonomy to government hospitals. The reform of hospital systems aims to convert government hospitals into financially independent entities and to develop the Philippine hospital system with the private sector. More specifically, hospital reform attempts to upgrade provincial and district hospitals to strengthen the delivery of promotive and preventive health services, and the primary, secondary, and in selected provincial hospitals, even tertiary curative services. Parallel to the expansion of health insurance coverage, hospital reform seeks to convert regional and national hospitals into fiscally autonomous facilities, and eventually, into financially viable government corporations. Financial autonomy can be achieved if government hospitals are allowed to collect socialized user fees to reduce the dependence on direct subsidies from the government. Hospitals’ critical capacities like diagnostic equipment, laboratory facilities, and medical staff capability must be upgraded to effectively exercise fiscal autonomy. Such investment must recognize the complimentary capacity provided by public-private networks. Moreover, such capacities allow government hospitals to supplement priority public health programs. Appropriate institutional arrangements must be introduced, such as allowing government hospitals autonomy in view of converting them into government corporations without compromising their social responsibilities. Thus the goal is to make government hospitals become more competitive and responsive to health needs. 4. Strengthen the capacity of health regulatory agencies. Reforms in this area seek to ensure the quality, accessibility, and safety of health care products, facilities and services through stronger health regulatory agencies. Weaknesses in regulatory mandates and enforcement mechanisms must be effectively addressed. Appropriate legislation must be enacted to fill regulatory gaps. Public investments must be made to upgrade facilities and human resource capabilities in standards development, technology assessment, and enforcement.
18
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
OVERVIEW OF THE HEALTH SECTOR 1
5. Expand the coverage of the National Health Insurance Program (NHIP). Health care financing reforms focus on making the National Health Insurance Program (NHIP) a major payor of health services by expanding the National Health Insurance Program toward universal coverage. A priority is extending protection to the poor. To achieve this, health insurance benefits must be improved to make the program more attractive. Improved benefits and services will be used to aggressively enrol members. Adequate funding must be secured for premium subsidies that are needed to enrol indigents. Effective mechanisms must be developed to cover and provide service to individually paying members. As membership expands and benefit spending increases, appropriate mechanisms to ensure quality and cost effective services must be developed and introduced. Capacities and new administrative structures must be developed to allow the Philippine Health Insurance Corporation (PHIC) to effectively service more members and manage increased benefit spending.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
19
2 LGU MANDATES ON HEALTH SERVICE DELIVERY
22
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
LGU MANDATES ON HEALTH SERVICE DELIVERY
2
CHAPTER
T
his chapter discusses the mandates of the LGU in relation to the delivery of health services and the operation and maintenance of local health facilities. By virtue of the Local Government Code of 1991, each local government unit is responsible for the performance of functions that were previously vested in the Department of Health (DOH). These functions are: (a) general control and supervision over devolved personnel and facilities, (b) the operation and maintenance of local health facilities like provincial hospitals and health centers, (c) service delivery such as the implementation of promotive, preventive, curative, and rehabilitative health programs and services, and (d) regulatory functions such as the formulation and enforcement of local ordinances related to health, nutrition, sanitation, and other health-related concerns. In a devolved setup, the DOH, on the other hand, exercises oversight and regulatory functions; provides technical assistance; formulates standards and guidelines; and, manages the operation of retained hospitals, regional medical centers, regional training and/or teaching hospitals, specialized health facilities, and national government hospitals. Besides the Local Government Code, there is a whole gamut of laws and policies that govern various aspects of health service delivery by LGUs. These laws are categorized here under six (6) headings: 1. 2. 3. 4. 5. 6.
Local Health System Development Public Health Reform Hospital Reform Drug Management System Health Care Financing/Social Health Insurance Specific Concerns
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
23
2 HEALTH
❙ THE LOCAL GOVERNMENT CODE Challenges to LGUs 1. Enter into partnership to promote effective local health systems 2. Prioritize public health programs 3. Improve efficiency and effectiveness of hospital services and facilities 4. Ensure safety, quality and accessibility of health products and services 5. Extend health protection to the poor
24
The Local Government Code of 1991 devolved the delivery of basic services and the operation and maintenance of local health facilities from the DOH to provinces, cities, and municipalities. This means that each local government unit is now responsible for the performance of functions that were previously vested in the national government, specifically the DOH. These are: Formulation and enforcement of local ordinances related to health, nutrition, sanitation, and other health-related concerns Implementation of health programs in accordance with national policies, standards and regulations Provision of promotive, preventive, curative and rehabilitative health programs and services Operation and maintenance of local health facilities (e.g., district and provincial hospitals under the provincial government, rural health units, health centers and barangay health stations under the municipal or city government) Capability building of health personnel Establishment of a functional local health information system Monitoring and evaluation of the implementation of various health services Establishment of partnership with all sectors including inter-local government unit collaboration in health promotion Provision of funds for health at local levels Table 4 summarizes the functions of the LGUs vis-à-vis the DOH under a devolved set-up.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
LGU MANDATES ON HEALTH SERVICE DELIVERY 2
Table 4. Health Functions Devolved to LGUs, and Functions, Services, Facilities, Programs, Personnel and Assets Retained by the DOH Local Government Units
Department of Health
General control and supervision Service delivery functions Regulatory functions (e.g., sanitation)
Remaining powers and functions Oversight (general supervision, monitoring and evaluation functions) Formulation of standards and guidelines Technical and other forms of assistance
Examples
Examples: Components of national programs that are funded from foreign sources. Nationally funded programs that are in the process of being pilot-tested or are in the process of being developed. Health services and disease control programs that are covered by international agreements such as illnesses that require their carriers to be quarantined and disease eradication programs. Regulatory, licensing and accreditation functions in accordance with existing laws such as the Food, Drugs, and Cosmetic law, the Traditional and Alternative Medicine law, and hospital licensing. Regional hospitals, medical centers, and specialized health facilities.
Working with the health officers and other members of the local health board to ensure that health services planned and implemented respond to the health needs of the community. Working with the local Sanggunian, the local chief executive ensures that health plans integrated in the local development plans are given financial support. Ensuring equity, quality and access to health services for all people in the community.
Figure 1 describes the facilities devolved to LGUs and their links to the DOH national and regional offices. As the figure shows, the DOH retains control over regional medical centers, regional training and/or teaching hospitals, specialized health facilities like the Philippine Heart Center, leprosaria, and sanitaria, national government hospitals, and other retained hospitals. Independent and highly urbanized cities control the city hospitals and city health offices. In turn, the city health S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
25
2 HEALTH
PROVINCE
INTER-LOCAL COOPERATION OR PARTNERSHIP Hospitals of Component Cities
Diagnostic Facilities e.g., TB Clinic, STD Clinic, etc.
Provincial Hospital
District and Municipal Hospitals
INTER-LOCAL COOPERATION OR PARTNERSHIP
CITY
City Health Office
INTER-LOCAL COOPERATION OR PARTNERSHIP
Provincial Health Office
MUNICIPALITY
Municipal Health Office
City Hospital (independent) and highly urbanized)
Lying-in Clinics
Rural Health Units
Health Centers
Barangay Health Stations DOH - CENTER FOR HEALTH DEVELOPMENT (Formerly DOH-Regional Health Office or DOH- Regional Field Office)
DOH Attached Agencies - (BFAD - PhilHealth - PITAHC)
DOH CENTRAL OFFICE
Figure 1. Health Facilities Devolved to Local Government Units and Retained by the Department of Health
26
- Regional Medical Centers - Regional Training and/or Teaching Hospitals - Specialized Health Facilities (e.g., Phil. Heart Center, leprosaria, sanitaria) - National Government Hospitals - Retained Hospitals
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
LGU MANDATES ON HEALTH SERVICE DELIVERY 2
office supervises the health centers, the lying-in clinics, and diagnostic facilities. The municipal health office manages the rural health units and the barangay health stations. At the provincial level, the provincial health office controls the provincial hospital, the hospitals of component cities, and the district and municipal hospitals. The province, cities, and municipalities have inter-local cooperation or partnership. The DOH’s Center for Health Development provides support to the inter-local cooperation.
❙ LAWS AND POLICIES GOVERNING LOCAL HEALTH SERVICE DELIVERY The following are laws and policies governing local health service delivery. They are grouped according to the priority areas of the Health Sector Reform Agenda:
◗ LOCAL HEALTH SYSTEM DEVELOPMENT The table below provides the relevant constitutional provisions, policy mandates, as well as legal documents supporting the institutionalization of partnership and cooperation among local government units, specifically in the organization of a local health system. The basic role of LGUs in local health system development lies in building mechanisms and partnerships for the effective delivery of quality preventive, promotive, and curative health services. These partnerships are done at different levels: 1. Intra-LGU, e.g., strong local health boards, partnership with civil society organizations and the private sector 2. Inter-LGU, e.g., inter-local health zones, health district approach, cooperative LGU schemes 3. Supra-LGU, e.g., partnerships between the LGU and the national government
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
27
2 HEALTH
LGU MANDATES UNDER THE LOCAL HEALTH SYSTEM Laws / Policies
28
Specific Provision
Remarks
Section 2, Article X of the 1987 Constitution
“The territorial and political subdivisions shall enjoy local autonomy.”
Provides the basis for the creation of public quasi-municipal corporations for the administration of some State or public, but not self-governing functions. Local or specific legislations are usually provided to support such administrative bodies.
Section 11, Article X of the 1987 Constitution
“The Congress may, by law, create special metropolitan political subdivisions…. The jurisdiction of the metropolitan authority…shall be limited to basic services requiring coordination.”
Basis for the creation of a special metropolitan political subdivision, an inter-local government cooperative arrangement for coordinating the delivery of basic services.
Section 13, Article X of the 1987 Constitution
“Local governments may group themselves, consolidate or coordinate their efforts, services and resources for purposes commonly beneficial to them.”
A most direct mandate in the creation of an inter-local health system by clustering municipalities into interlocal health zones.
Section 14, Article X of the 1987 Constitution
“The President shall provide for regional development councils or other similar bodies composed of local government officials, regional heads of departments and other government offices and representatives of nongovernment organizations.”
Basis for the creation of regional development councils or inter-local development councils for administrative decentralization to strengthen autonomy and accelerate development.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
LGU MANDATES ON HEALTH SERVICE DELIVERY 2
Laws / Policies
Specific Provision
Remarks
Section 17 of the 1991 Local Government Code
“Local government units shall endeavor to be self-reliant and shall continue exercising the powers and discharging the duties and functions currently vested upon them…. and the functions and responsibilities of national agencies and offices devolved to them.…”
A mandate to local government units at various levels to be self-reliant and exercise their functions and duties including those formerly dispensed by the national government agencies prior to the devolution. This covers, among others, programs and projects necessary for the effective and efficient delivery of health services.
Section 33 of the 1991 Local Government Code
“Local government units may, through appropriate ordinances, group themselves, consolidate, or coordinate their efforts, services and resources for purposes commonly beneficial to them.”
A constitutional provision to enter into inter-local government cooperative arrangements for the mutual benefits of cooperating LGUs.
Section 34 to 35 of the 1991 Local Government Code
“Local government units shall promote the establishment and operation of people’s and nongovernmental organizations…. (they) may enter into joint ventures and such other cooperative arrangements…in the delivery of certain basic services, capability building and livelihood projects….”
Basis for mutually beneficial partnership between the local government and civil society organizations. It makes enormous sense to foster partnership as a strategy of complementation and supplementation when addressing the various health concerns of a community.
Section 102 of the 1991 Local Government Code
“There shall be established a local health board in every province, city or municipality.”
Basis for the creation and composition of the local health boards. The provision recognizes the significance of the contribution of civil society, the private sector, and the DOH toward the crafting of better health policies for LGUs.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
29
2 HEALTH
Laws / Policies
30
Specific Provision
Remarks
Section 106 to 115 of the 1991 Local Government Code
“Each local government unit shall have a comprehensive multisectoral development plan to be initiated by its development council and approved by its sanggunian…. the development council at the provincial, city, municipal, or barangay level, shall assist the corresponding sanggunian in setting the direction of economic and social development, and coordinating development efforts….”
Bases for the creation of intra-local development councils for multisectoral development including public investment programs to promote health.
1999 Health Covenant
A covenant by the League of Provinces signed in March 1999 together with the Secretaries of the Department of Health and the Department of the Interior and Local Government.
Made during a convention entitled “Governors’Workshop on Health: Partnership for Devolution.” This articulates the commitment for the implementation of the district health system.
Executive Order (EO) No. 205
An order providing for the creation of a national health planning committee and the establishment of inter-local health zones throughout the country.
Basis for the creation of a national health planning committee and the establishment of inter-local health zones. The EO is in support of devolution and the decentralization of health services.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
LGU MANDATES ON HEALTH SERVICE DELIVERY 2
◗ PUBLIC HEALTH REFORM This section presents the policies and laws governing the necessary reforms in the area of public health. The laws and policies mandate investments in public health programs, improvements in physical infrastructure and management structure at all levels of the health system, and capability building. The basic role of LGUs in this area comprise the following: (a) to prioritize public health programs; (b) reward, boost the morale, and raise the quality of health personnel under their wing; (c) to encourage more people to become barangay health workers; and (d) recruit more nurses and doctors.
LGU MANDATES UNDER PUBLIC HEALTH REFORM Laws / Policies
Specific Provision
Remarks
Republic Act 7305
Magna Carta of Public Health Workers of 1992.
Provides the mandate for the recruitment and selection, tenure, duties and obligations, rights and privileges, benefits, incentives, development and capacity building of public health workers.
Republic Act 7883
“The Primary Health Care Approach is recognized as the major strategy towards health empowerment, emphasizing the need to provide accessible and acceptable health services through participatory strategies…” (Section 2 of RA 7883)
The Barangay Health Workers’ (BHWs) Benefits and Incentives Act of 1995 is a law that grants benefits and incentives to accredited BHWs. It aims to set up a system for them to gain access to a package of resources and opportunities that would lead to their personal and professional development.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
31
2 HEALTH
Laws / Policies
32
Specific Provision
Remarks
Administrative Order No. 11, s. 1993
Establishing primary health care as the core strategy in program thrusts of government at all levels and creating the various structures to oversee its implementation.
DOH, 31 March 1993
Administrative Order No. 31e, s. 1994
Guidelines for the payment of laundry and subsistence allowance of public health workers under RA 7305.
DOH, 29 June 1994
Administrative Order No. 2, s. 1996
Validation and update of Barangay Health Workers master list.
DOH, 15 January 1996
Administrative Order No. 22b, s. 1997
Operational guidelines in the implementation of the Doctor to the Barrios Program.
DOH, 2 October 1997
Administrative Order No. 15a, s. 1998
Guidelines in the implementation of Barangay Health Workers’ Scholarship under the Integrated Community Health Services Project.
DOH, 17 April 1998
Administrative Order No. 81, s. 2000
DOH guidelines for Board of Investments registration of health care projects.
DOH, 12 July 2000
Administrative Order No. 22, s. 2001
Amendment to the revised implementing rules and regulations of the Magna Carta of Public Health Workers.
DOH, 4 June 2001
Administrative Order No. 181a, s. 2001
Revised operational guidelines for the implementation of the Doctor To The Barrios Program.
DOH, 8 February 2001
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
LGU MANDATES ON HEALTH SERVICE DELIVERY 2
◗ HOSPITAL REFORM The specific policies listed below are relevant to the improvement of hospital systems in the country. The basic role of LGUs in hospital reform is to improve the facilities and services of devolved hospitals, and integrate the services of these hospitals with the LGUs’primary health care programs.
LGU MANDATES UNDER HOSPITAL REFORM Laws / Policies
Specific Provision
Remarks
Administrative Order No. 32h, s. 1994
Amendment of AO 68a, s. 1989 regarding the Registration, Licensure and Operation of Hospitals in the Philippines.
DOH, 7 July 1994
Administrative Order No. 34, s. 1994
Rules and regulations on the supervision of Health Maintenance Organizations.
DOH, 29 July 1994
Administrative Order No. 21, s. 1996
Revised guidelines for the procurement of equipment for hospitals.
DOH, 4 June 1996
Administrative Order No. 27a, s. 1997
Guidelines for the bed subsidy program for private hospitals.
DOH, 11 November 1997
Republic Act 8344
An act penalizing the refusal of hospitals and medical clinics to administer appropriate initial medical treatment and support in emergency and serious cases.
An amendment to Batas Pambansa Bilang 702
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
33
2 HEALTH
Laws / Policies
Specific Provision
Remarks
Administrative Order No. 5b, s. 1998
Implementing rules and regulations of RA 8344.
DOH, 18 February 1998
Administrative Order No. 67a, s. 2001
Implementing guidelines for the provision of assistance in the upgrading of devolved local health hospitals and RHUs based on Sentrong Sigla Standards, PHIC Accreditation and DOH Licensing Standards.
DOH, 14 December 2001
â—— DRUG MANAGEMENT SYSTEM The laws and policies listed below govern the procurement of drugs, other drug products, health supplies, and equipment of LGUs. They also provide guidelines on making medicines more accessible and affordable. The basic role of LGUs in the drug management system is the procurement, marketing, distribution, and sale of safe, cheap but good-quality drugs needed by the majority of citizens.
34
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
LGU MANDATES ON HEALTH SERVICE DELIVERY 2
LGU MANDATES UNDER THE DRUG MANAGEMENT SYSTEM Laws / Policies
Specific Provision
Remarks
Administrative Order No. 10, s. 1995
Authority of DIRFO directors to purchase drugs, medical, and dental supplies for vertical public health programs implemented by their units and as assistance to LGUs and NGOs as partners in national health development.
DOH, 26 May 1995
Administrative Order No. 23, s. 1997
Addendum to the implementing guidelines on the purchase of drugs and medicines by LGUs.
DOH, 10 October 1997
Administrative Order No. 27, s. 1998
Guidelines and procedures on the accreditation of government suppliers for pharmaceutical products.
DOH, 22 December 1998
Administrative Order No. 13c, s. 1999
Procurement guidelines for drugs and medicines.
DOH, 29 April 1999
Administrative Order No. 22, s. 1999
Amendment to AO 2a, s. 1999 regarding the accreditation of suppliers.
DOH, 30 June 1999
Administrative Order No. 47, s. 1999
Guidelines for the implementation/operations of the expansion of the Gamot sa Presyong DOH (Medicine at DOH Prices).
DOH, 3 November 1999
Administrative Order No. 23a, s. 2000
Creation of Joint DOH-DTI AO 23a, s. 2000 regarding the creation of a Joint DOH-DTI Task Force on Pharmaceutical Concerns.
DOH, 7 April 2000
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
35
2 HEALTH
Laws / Policies
36
Specific Provision
Remarks
Administrative Order No. 23c, s. 2000
Policies and guidelines on over-thecounter drugs and drug products.
DOH, 9 March 2000
Administrative Order No. 32-1, s. 2000
Amendment of Joint DOH-DTI Task Force on Pharmaceutical Concerns.
DOH, 2 March 2000
Administrative Order No. 50-1, s. 2000
Procurement benchmarks.
DOH, 10 May 2000
Administrative Order No. 82, s. 2000
Policies and guidelines governing the sale by drug outlets of generic alternatives at discounted prices.
DOH, 13 July 2000
Administrative Order No. 85, s. 2000
Registration requirements for a government agency importing a pharmaceutical product with a registered counterpart brand in the Philippines.
DOH, 14 July 2000
Administrative Order No. 119, s. 2000
Additional guidelines on the promotion of OTC drugs to the public.
DOH, 25 September 2000
Administrative Order No. 130, s. 2000
Rules and regulations on genericprescribing by government physicians.
Administrative Order No. 1, s. 2001
Granting of provisional accreditation to pharmaceuticals suppliers.
DOH, 10 October 2000 DOH, 26 February 2001
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
LGU MANDATES ON HEALTH SERVICE DELIVERY 2
Laws / Policies
Specific Provision
Remarks
Administrative Order No. 69, s. 2001
Guidelines and procedures in the use of funds for drug importation and distribution for the Pharma 50 Project implementation/operations of the expansion of the Gamot sa Presyong DOH.
DOH, 20 December 2001
Administrative Order No. 70, s. 2001
Licensing of Botika ng Barangay in various LGUs.
DOH, 3 January 2002
Administrative Order No. 177, s. 2001
Amendment to AO 117, s. 2000 relative to the guidelines on the accreditation of suppliers of medical equipment, parts, accessories, and medical equipment repair shops.
DOH, 24 January 2001
Administrative Order No. 122, s. 2002
Policy guidelines and procedures in implementation of the P60,000,000 financial assistance from the PCSO for the purchase of drugs and medicines by the DTI through the Philippine International Trade Corporation to be sold in government hospitals.
DOH, 29 May 2002
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
37
2 HEALTH
â—— HEALTH FINANCING/SOCIAL HEALTH INSURANCE The mandates below provide policy support for the financial sustainability of the health service delivery system. This support is particularly relevant to the viability of inter-local health zones. The basic role of LGUs in health financing and social health insurance is to extend health protection to as many of their constituents as possible, especially the poor who can ill-afford to get sick.
LGU MANDATES UNDER HEALTH FINANCING Laws / Policies
38
Specific Provision
Remarks
Republic Act 7875
An act instituting a National Health Insurance Program for all Filipinos and establishing the Philippine Health Insurance Corporation for the purpose.
Also known as the National Health Insurance Law. This mandates the PHIC or PhilHealth to provide universal coverage of social health insurance to all, especially the poor.
Republic Act 8291
An act expanding and increasing the coverage and benefits of the GSIS, instituting performance therein, and for other purposes.
PD 1140 as amended
Administrative Order No. 101a, s. 2000
Management of the indigency fund at the DOH specialty hospitals.
DOH, 14 August 2000
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
LGU MANDATES ON HEALTH SERVICE DELIVERY 2
â—— SPECIFIC HEALTH CONCERNS The LGUs also have specific mandates related to their participation in national health programs like the Sentrong Sigla, the Anti-Polio Drive, and the Philippine Quality Award.
LGU MANDATES UNDER SPECIFIC HEALTH CONCERNS Laws / Policies
Specific Provision
Remarks
Republic Act 9013
An act establishing the Philippine Quality Award.
RA 9013 encourages organizations in the private and public sectors to attain excellence in the production and/or delivery of their goods and services.
Administrative Order No. 1a, s. 1996
Guidelines on routine immunization of infants during Knock Out Polio Days.
DOH, 15 January 1996
Administrative Order No. 12, s. 1999
Guidelines to operationalize the voluntary redeployment of CO personnel.
DOH, 26 March 1999
Administrative Order No. 22, s. 1999
Policies and guidelines in the conduct of local and foreign medical and surgical missions.
DOH, 30 January 2001
Administrative Order No. 24, s. 1999
Voluntary redeployment of CO personnel to RHO/retained hospitals.
DOH, 6 July 1999
Administrative Order No. 34a, s. 2000
Adolescent and youth health policy.
DOH, 10 April 2000
Administrative Order No. 43a, s. 2000
Reproductive health policy.
DOH, 24 April 2000
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
39
2 HEALTH
Laws / Policies
40
Specific Provision
Remarks
Administrative Order No. 144, s. 2000
Guidelines on the handling and treatment of children involved in armed conflict.
DOH, 30 October 2000
Administrative Order No. 7, s. 2001
Implementing guidelines for the provision of grants and technical assistance in support of the implementation of the Sentrong Sigla Movement 2002 (Center of Health Movement 2002).
DOH, 15 March 2001
Administrative Order No. 30, s. 2001
Guidelines for the implementation of the LGU Performance Program for 2001-2002.
DOH, 26 June 2001
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
3 IMPLEMENTATION & POLICY ISSUES AND RECOMMENDATIONS
42
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
3
CHAPTER
IMPLEMENTATION & POLICY ISSUES AND RECOMMENDATIONS
T
he Philippines faces tremendous challenges in the health sector: making devolution work; ensuring community participation in the delivery of health services; recruiting, retaining, and building the capability of health personnel; and financing and implementing health service programs. The country can surmount these challenges only through the enactment and implementation of comprehensive reforms. Local government units (LGUs) have a major role to play in pursuing and undertaking these reforms. In carrying out their role, LGUs have encountered implementation and policy issues, to which recommendations have been identified. The issues are grouped into functions normally carried out by a health service organization or LGU. The categories are: Institutional Development Devolution and Community Participation Human Resource Development Support Functions: Health Research, Education, and Information Health Care Financing Public spending for health Making quality health services accessible and affordable for all Delivering Quality Health Services Delivery of Public Health Programs and Services Management of Health Facilities Procurement of Medicines and Other Health Products by the Government and Citizens The reforms are classified into two. First, reforms that can be undertaken by the LGU and secondly Reforms that LGUs can advocate to the national executive and legislative bodies. The Leagues (municipalities, cities, and provinces) are LGU mechanisms through which policy advocacy and development are pursued at the national level. S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
43
3 HEALTH
❙ INSTITUTIONAL DEVELOPMENT ◗ DEVOLUTION AND COMMUNITY PARTICIPATION The years immediately following devolution saw the fragmentation of the health system. Planning was done inconsistently and individually by LGUs without regard for the larger picture. Priorities changed depending on the local chief executive. One positive result of devolution, however, was the opportunities it presented for the participation of people’s and non-government organizations in local special bodies like the Local Health Board and the Local Development Councils. These opportunities have injected energy and creativity into the local health sector. To continue the gains made by devolution and to remedy its ill effects, the following reforms are recommended: ON DEVOLUTION AND COMMUNITY PARTICIPATION Issues and Concerns
Recommendations
Cooperation and integration of LGUs and other stakeholders Operationalization of local health boards Determining priority health programs and activities Integration of health services management with long-term development plan of LGUs Partnerships and alternative strategies for health services delivery
Can be undertaken by the LGUs: Empowering the local health board— policies, implementation of health programs, budget, and BHW membership approval Institutionalizing NGO-PO-GO cooperation at all levels (barangay, municipal, provincial and national levels)* Establishing and strengthening inter-local health systems and their subsystems (integrated health planning, referral system, health information system, drug management, human resource development, and financial management)* Ensuring continuity of relevant health programs regardless of who the secretary of health or the local chief executive is* Can be advocated by the LGUs: Redefining the functional relationship between regional offices and LGUs especially as provider of technical assistance and setting standards Developing and strengthening health programs and policies in the DILG *Can be undertaken by the LGU in collaboration with the national government
44
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
IMPLEMENTATION & POLICY ISSUES AND RECOMMENDATIONS 3
◗ HUMAN RESOURCE DEVELOPMENT The Philippine public health system suffers from the inadequate number and competence of health workers. Poor salaries and the lack of opportunities for continuing development make the public sector unattractive as a lasting career option. More rewarding opportunities abroad and in the private sector have reduced the ranks of doctors and nurses working in the public sector. Inconsistencies in the compensation and rewards systems at the local level have led many resident doctors in district hospitals to leave their posts and seek employment as municipal doctors because the latter position paid more. The distribution of health professionals, like doctors and nurses, remains lopsided in favor of Metro Manila and the country's urban metropolitan centers-to the neglect of rural municipalities and villages. To address these problems, the following reforms are recommended: ON HEALTH HUMAN RESOURCES Issues and Concerns
Recommendations
Inadequate number and competence of health workers Recruitment, selection, performance evaluation and merit promotion plan Career path, continuing education and development Tenure, compensation, benefits, incentives, and rewards system
Can be undertaken by the LGUs: Implement RA 7883 Barangay Health Workers incentives and continuing education, non-monetary benefits Develop career path for health officials and employees at the local level Implement the benefits under the Magna Carta for Health Workers* Promote Code of Ethics for the health workers* Increase the number and availability of midwives, nurses and doctors* Encourage public recognition of outstanding health workers* Develop a system to compensate capable and competent health workers with integrity* Can be advocated by the LGUs: Develop a system to encourage doctors, midwives, and nurses to work outside Metro Manila and other urban metropolitan centers * Can be undertaken by the LGU in collaboration with the national government
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
45
3 HEALTH
◗ SUPPORT FUNCTIONS: HEALTH RESEARCH, EDUCATION AND INFORMATION The timeliness, quality, and efficiency of health services delivery depend on the quality of the supporting services or functions. To improve the quality of support services and functions, the following reforms are recommended: ON HEALTH RESEARCH, EDUCATION, AND INFORMATION Issues and Concerns No common agenda and coordination regarding health research Western-oriented, curativeoriented health education Lack of qualified medical personnel in poor and rural communities Lack of awareness among people about patients’ rights
Recommendations Can be undertaken by the LGUs: Can be undertaken by the LGUs: Encourage or even require medical and paramedical students/graduates to render rural or urban poor service* Institutionalize information/public information units up to the barangay level to improve health intelligence/statistics* Develop the Patient’s Rights Code* Raise consciousness of people’s/patient’s/consumer’s rights in relation to malpractice* Can be advocated by the LGUs: Strengthen inter-agency cooperation on various aspects of health research (Health Intelligence Service, PCHRD, Department of Science and Technology) Develop common research agenda that would be implemented extensively Change curricula of all health workers to include traditional and alternative/complementary medicine, gender sensitivity, preventive health care, primary health care, and cultural sensitivity Continue stepladder health education program
*Can be undertaken by the LGU in collaboration with the national government
46
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
IMPLEMENTATION & POLICY ISSUES AND RECOMMENDATIONS 3
❙ HEALTH CARE FINANCING ◗ PUBLIC SPENDING FOR HEALTH The World Health Organization (WHO) recommends that governments spend a minimum of five (5) percent of GNP for health. However, the Philippines has yet to reach that standard. Moreover, public expenditure is erratic and is often at the mercy of changing priorities, budget cutbacks, reserve requirements, and budget deficits. To address the problems of sufficiency and security in funding, the following reforms/steps are recommended:
ON PUBLIC SPENDING FOR HEALTH Issues and Concerns
Inadequate funding Inefficient sourcing Ineffective allocation Sustainable local budgetary provisions
Recommendations Can be undertaken by the LGUs: Increase the Internal Revenue Allotment (IRA) for health to a fixed percentage Increase budget for health to five (5) percent of national and local budget* Provide fiscal government autonomy to hospitals to reduce their dependence on direct subsidies from government. The resources freed up could be channeled to priority health programs.* Set up trust funds for health programs and health facilities like hospitals* Adopt multi-year budgets* Can be advocated by the LGUs: Augment the health budget of poor municipalities Establish and develop the National Health Finance Program to define sources of funds for various public health programs Review the indemnity insurance in relation to the quality and cost of services in hospitals *Can be undertaken by the LGU in collaboration with the national government
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
47
3 HEALTH
◗ MAKING QUALITY HEALTH SERVICES ACCESSIBLE AND AFFORDABLE TO THE POOR People cover the cost of medicines, consultation, diagnostic tests, and hospitalization largely from their savings. Many of the poor forego seeking medical attention because of the high cost of health care. While there are many Health Maintenance Organizations (HMOs), the cost of enrollment or membership is beyond the reach of many. Strict admission standards also disqualify many who have chronic illnesses like diabetes, hypertension, etc. Some of these HMOs have so poorly managed their finances and operations that they fail to deliver the promised package of benefits to their members. Moreover, health insurance benefits are biased toward hospital-based care when most Filipinos require outpatient care. To ease the financial burden of the poor and provide them to quality health services, the following reforms are recommended:
ON MAKING QUALITY HEALTH SERVICES ACCESSIBLE AND AFFORDABLE TO THE POOR Issues and Concerns
Recommendations
Access to and financing of quality health care, especially by the poor and the marginalized
Can be undertaken by the LGUs: Increase enrollment into the PHIC’s social health insurance program Institute means test for indigents* Develop and strengthen community-based health financing schemes and seek ways to link them up to the national health insurance program* Can be advocated by the LGUs: Address gaps, put safeguards, and review the National Health Insurance Act Regulate Health Maintenance Organizations (HMOs) * Can be undertaken by the LGU in collaboration with the national government
48
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
IMPLEMENTATION & POLICY ISSUES AND RECOMMENDATIONS 3
❙ DELIVERING QUALITY HEALTH SERVICES ◗ DELIVERY OF PUBLIC HEALTH PROGRAMS AND SERVICES To make public health programs and services more responsive to the needs of citizens and to improve quality, the following reforms are recommended:
ON PUBLIC HEALTH SERVICES Issues and Concerns Effective health services delivery by LGUs Prioritization of relevant health programs Sustainability of communitybased health programs Health-seeking behavior of communities
Recommendations Can be undertaken by the LGUs: Prioritize public health and preventive services* Establish a National Preventive Health Program* Set up the National Public Health Standards for major public health programs Institutionalize community-based health programs* Integrate public health and hospital services in health facilities* Integrate traditional/indigenous and alternative/complementary health care into the mainstream of health care delivery system while taking into account rich cultural nuances* Develop a policy and program to consolidate all emergency medical services in the country with regard to disaster preparedness to establish the necessary protocol in giving adequate, timely, appropriate medical care to emergency cases, and giving adequate hospital care (Pinoy 911)* Develop and strengthen policies on anti-smoking with sanctions for smoking practices in public places* Develop and strengthen other legislation and policies on lifestylerelated diseases and environmental health*
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
49
3 HEALTH
Issues and Concerns
Recommendations Can be advocated by the LGUs: Develop the National Policy on Mental Health (Mental Health Code) Develop the National Nutrition Code to include fortification of other basic food commodities and address other types of micronutrient malnutrition Develop the National Commission on Occupational Health, Safety and Compensation to address the needs of health workers in a rapidly industrializing society Establish a health environment and protection agency that addresses health and environment hazards/risks Advocate the Civil Protection Act, to rationalize and demilitarize disaster mitigation efforts and transfer them to the health and civilian sectors· Develop a national land use plan to show the cities/urban areas, agricultural lands, forest lands, sources of water and the site of various industries
*Can be undertaken by the LGU in collaboration with the national government
50
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
IMPLEMENTATION & POLICY ISSUES AND RECOMMENDATIONS 3
◗ MANAGEMENT OF HEALTH FACILITIES Physical facilities, equipment, and services of devolved hospitals deteriorated after the Local Government Code was passed in 1991. The morale of health workers dropped as budgets decreased. There are several reasons for diminished funding of devolved hospitals: Insufficiency of the IRA given to provinces to meet the cost of the devolved hospitals. The number and size of devolved hospitals exceeded the needs of the localities. Before devolution, construction of hospitals proceeded without any sound basis regarding size, coverage, and number. Legislation to construct provincial and district facilities did not meet local resistance since the facilities were to be funded with national sources. Bureaucratic Procedures. After devolution, local executives had to confront bureaucratic procedures to get funds for salaries and MOOE items. It was noted that a devolved set-up required at least 17 signatures (compared to two to three signatures before devolution) needed for purchases to be made, and involved a delay of at least two months before medicines and other supplies were delivered. Delays in the repair and maintenance of hospital facilities and equipment further aggravate the lack of funding and slow disbursement of funds for hospital operations. During the years prior to devolution, no capital outlays were budgeted for the renovation or repair of facilities of devolved hospitals. To restore the morale of hospital personnel, rehabilitate facilities, and purchase new equipment for hospitals, the following reforms are recommended:
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
51
3 HEALTH
ON HEALTH FACILITIES Issues and Concerns Adequacy and resources of health facilities Management of LGU health facilities
Recommendations Can be undertaken by the LGUs: Expansion of the fund allotment system for the hospitals. This would assure hospitals of funding without experiencing undue delays.· Upgrade of regional, provincial, district and municipal hospitals* Increase of the number of hospitals at local levels Advocacy and encouragement of hospital income retention and other revenue enhancing methods* Can be advocated by the LGUs: Conversion of all leprosaria to general hospitals, health training centers, or turn them over to LGUs Legislation covering national health facilities development Comprehensive national health facilities enhancement program to rationalize hospital development, infrastructure, and equipment support throughout the country Involvement of health NGOs in hearings on privatization of specialty hospitals Review of monitoring systems that check on compliance with standards of hospital accreditation *Can be undertaken by the LGU in collaboration with the national government
52
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
IMPLEMENTATION & POLICY ISSUES AND RECOMMENDATIONS 3
◗ PROCUREMENT OF MEDICINES AND OTHER HEALTH PRODUCTS BY GOVERNMENT AND CITIZENS The purchase of medicines, supplies, and other health products constitute the bulk of the procurement of government hospitals. Most of the citizens' out-of-pocket expenses for health go to medicines, especially maintenance medicines. A comparative study of involved ASEAN nations shows that prices of medicine in the Philippines are significantly higher compared to its neighbors. To bring down the cost of medicines, the following reforms are recommended:
ON DRUGS AND OTHER HEALTH PRODUCTS Issues and Concerns Access to reasonably-priced but safe and effective drugs Safety and efficacy of other health products
Recommendations Can be undertaken by the LGUs: Procurement of drugs in bulk* Encouragement of local production of drugs and other health products* Strict implementation of the Generics Law, with amendments to include stiffer penalties* Rationalization of drug procurement in government hospitals by adopting scientific tools like ABC and VEN analyses** Can be advocated by the LGUs: Continuation and expansion of parallel drug importation Creation of the Philippine Pharmaceutical Institute to address research problems, especially in the pharmaceutical field, and to take care of medicine importation Streamlining the bureaucracy to facilitate the procurement of health products and make the process more transparent Implementation of PhilHealth’s policy of limiting its drug reimbursements
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
53
3 HEALTH
Issues and Concerns
Recommendations Regulation of the price of drugs, organic foods, food supplements, and herbal medicines Development and implementation of national guidelines on Botika sa Barangay Creation of a Bureau of Health Technology to expand the mandate of DOH over products and processes to include foreign health equipment and technology that will increase with globalization of trade Advocacy to urge the President to exercise presidential powers as mandated in Section 4 on the Tariffs and Customs law to reduce protective measures and duties on essential drugs Updating the Philippine National Drug Formulary
*Can be undertaken by the LGU in collaboration with the national government **For an explanation of what ABC and VEN analyses were, please refer to Chapter 4, specifically the case study on Pangasinan Province's Pooling Hospital Drug Procurement.
54
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
4 GOOD PRACTICES IN HEALTH SERVICE DELIVERY
GOOD PRACTICES in health service delivery
CHAPTER
4
The 19 cases presented in this chapter illustrate effective responses of LGUs to specific issues and problems in delivering health services. The 19 cases are clustered into three general headings: Planning Health Service Delivery Financing Health Service Delivery Delivering Quality Health Services
The two cases under the Planning section show how two cities responded to the problem of inadequate information that was hampering effective planning, response, and assessment. The city of Malaybalay in Bukidnon was the prototype for the Community Based Monitoring and Information System that identified the needs of vulnerable groups in the community. The system has since been adopted by many other LGUs. The City of Bago in Negros Occidental pioneered the installation of a Community Disease Surveillance System (CDSS), the elements of which became the basis for a training program that has been rolled out to other LGUs. Financing Service Delivery is a perennial challenge for many LGUs. The ten (10) cases show different ways by which LGUs confronted the problem of insufficient funding. One way is by raising funds. Funds can be raised from various sources. Bucking opposition, the Municipality of Malalag in Davao del Sur charged socialized fees from the users of its health services. Sagay City in Negros Occidental and the Municipality of Bindoy in Negros Oriental both availed of the matching grant scheme to provide health insurance coverage to their indigents. In setting up a Community Clinic and related facilities, the Municipality of Sebaste in Antique entered into joint ventures with private practitioners and companies and mobilized the funds of overseas Filipino workers and Filipino communities abroad.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
57
4 HEALTH
A second way of ensuring the viability of health service delivery is by increasing efficiency. There are many ways of doing this. Provincial and city hospitals in Negros Oriental, Misamis Occidental, Bulacan, and Pasay and Roxas Cities are using computers to better track and allocate costs among different units. The Province of Capiz availed of the Parallel Drug Importation Scheme to purchase affordable but quality drugs. The Province of Pangasinan pooled the procurement of its hospitals, resulting in savings and greater availability of drugs and medical supplies. A third way of ensuring continuous funding for health facilities and services is by introducing sound financial management policies and mechanisms. Quezon Province established a trust fund for its provincial hospital, a portion of which came from the hospital’s own earnings. With this scheme, hospital administrators could no longer blame the budget office for lack of funds. It also served as an incentive for these same administrators to use resources more efficiently and to increase revenues from operations, knowing full well that the surplus and savings would be ploughed back to the hospital. The Province of Negros Occidental instituted a performance-based sub-granting scheme for its municipalities to prod them to improve the delivery of health services. In neighboring Negros Oriental, Bayawan City, and the Municipalities of Basay and Sta. Catalina, they organized themselves into an interlocal health zone to implement a district-approach matching grant program. The third section contains seven cases on delivering services. Often, many well-intentioned programs and projects fail because they are unable to gain the support of the community. The Municipality of Sampaloc in Quezon Province illustrates how people’s organizations (POs) can be mobilized to recruit members for a social health insurance scheme. The case of Surigao City shows the benefits of mobilizing and organizing women to address the poor health-seeking behavior of the community and to promote primary health care programs. In Irosin, Sorsogon, the municipal government organized and utilized the expertise of traditional healers to serve as frontline health workers.
58
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
Another reason for the failure of projects lies in the mismatch between the design and needs of the target group. Talisay City in Cebu Province managed the problem of finances and poor healthseeking behavior of the community by giving personalized call slips to delinquent clients. The personalized call slips made the people feel that they were important to the local government. Another critical element in project design is the incentives for proper behavior. San Jose del Monte in Bulacan rewarded mothers who availed of the municipality’s feeding and immunization services and whose babies showed signs of improvement after a prescribed period. The last two cases emphasize the importance of not only doing things right, but also delivering services with the highest quality. The Pangasinan Provincial Hospital in San Carlos City introduced the Japanese 5S quality system to address poor hospital management and to instill a culture of service excellence within the organization. A culture of excellence and quality can only be achieved if employees are experiencing high morale. The Municipal Mayor of San Luis in Aurora Province knew this and sought to motivate health workers by ensuring that their salaries were paid on time and that they had the requisite resources. The mayor also tapped volunteers to assist in the municipality’s health projects.
❙ PLANNING health SERVICE DELIVERY Excellent service delivery begins with a sound plan. A sound plan fits the service-its features and delivery system-to the needs of citizens, and stretches the capacity of the service organization. A sound plan is realistically idealistic; it reaches up to achieve a vision or goal while remaining grounded in the realities of both the service organization and the citizen-clients. A sound service plan is backed up by relevant, timely, accurate and reliable information, and systems to collect that information, analyze, store, and periodically update them. Two cities, Malaybalay in Bukidnon and Bago City in Negros Occidental, established such systems.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
59
4 HEALTH
Planning HEALTH Service Delivery USING A COMMUNITY-BASED MONITORING AND INFORMATION SYSTEM (CBMIS) TO REDUCE UNMET NEEDS: MALAYBALAY CITY, BUKIDNON
Contact Information: City Health Officer Malaybalay City Health Office Bukidnon Tel. No.: (088) 8132750, (088) 221-2242
Project Description The City of Malaybalay established and maintained a CBMIS to identify and prioritize women who have unmet needs for family planning and, along with their children, are in need of health services.
What is CBMIS? CBMIS is a system of gathering information and giving feedback, operated and maintained by the community itself. CBMIS aims to provide decision-makers and service providers relevant, timely, accurate, and reliable information on the nutritional and health status of a specific barangay or purok, especially the unmet needs of its more vulnerable members like children, women, and elderly so that the appropriate programs and projects can be planned and designed. How was CBMIS set up? Mobilization of households and data collection team In Malaybalay, the City Health Office mobilized approximately 500 households to collect household data. The data collection team was composed of barangay health workers (BHWs), barangay nutrition scholars, barangay kagawads on health, and other community volunteers. Conduct of a household survey The team conducted a survey and completed family profiles for permanent residents or those who had lived in the barangay for at least six months.
60
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
PLANNING HEALTH SERVICE DELIVERY Malaybalay City
Establishment of a color-coded master list for target clients. The target clients were children between zero to four (0-4) years old in need of vaccinations included in the Expanded Program on Immunization (EPI) and Vitamin A supplementation, and pregnant and nonpregnant women of reproductive age in need of tetanus toxoid vaccinations and family planning services. At the end of the survey, the midwife checked the individual family profiles under her jurisdiction. With the BHWs, they established a color-coded master list of individuals for each barangay. This facilitated the tracking of unmet needs and the updating of family profiles. How was the CBMIS sustained or updated? The color-coded master list made it easier for the BHWs to pinpoint the people or families who had unmet needs and identify what these unmet needs were. The BHWs prioritized these families. The BHWs’ visit served as an occasion to update the master list, which was done every month. To sustain the CBMIS, Malaybalay invested in: The capability building of BHWs The production of an information and education kit A handbook written in Cebuano covering topics such as maternal and childcare, breastfeeding, nutrition, family planning, infectious diseases and the management of diarrhea What are the benefits of having a CBMIS? Focusing services on priority clients The monthly updating of the family profiles allowed the City Health Office to focus its services on priority clients. Improvement in acceptance of family planning, immunization rates for women and children The CBMIS led to improvements in family planning, the vaccination of children less than 12 years old against six diseases, tetanus toxoid immunization for women, and the provision of vitamin A supplements for children between 12 to 59 months old. Source: Department of Health. List of Sentrong Sigla Awardees
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
61
4 HEALTH
Planning HEALTH Service Delivery MONITORING THE OUTBREAK OF DISEASES: BAGO CITY, NEGROS OCCIDENTAL Project Description Contact Information: City Health Officer Bago City Health Office Negros Occidental Tel. No.: (034) 461-0196, (034) 461-0118
In 2000, the City of Bago established a community-based surveillance system (CDSS) that was intended to: Provide early warning about disease outbreaks Formulate and carry out appropriate and timely interventions Determine trends of diseases under surveillance Describe the demographic characteristics of identified cases Assess the effectiveness of health interventions using the CBMIS that Bago City has implemented as a complementary data-gathering system Generate information that can be used to lobby for more support for health How is a CDSS installed? The Bago City Health Office received technical assistance from the Management Sciences for Health (MSH), a consulting firm for USAID-funded health projects in the Philippines. The system entails the following: Study tour Staff of the health office went on a study tour at the Epidemiology and Disease Surveillance Unit of Parañaque City, the only LGU in the country with a computerized CDSS, to observe and learn about its system.
62
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
PLANNING HEALTH SERVICE DELIVERY Bago City
Training course The Bago City Health Office then held a five-day training course on the CDSS for its health staff. The course included training in the use of epidemiological information for database management and an analysis. Adoption of existing worksheets To speed up the installation of the CDSS, the group agreed to adopt the worksheets developed by Para単aque City. What are the important considerations in setting up the system? Involvement of epidemiologists During the planning stage, it is important to involve national and regional epidemiologists (specialists who track diseases in the population) to ensure support for implementation. Complementation among local health surveillance systems and support for the national level surveillance system Complementation means the use of common information systems, common reporting formats and disease naming, and consensus on a common set of diseases that the whole Philippine surveillance system will track over and above those that would be specifically monitored by a local surveillance system. Local level surveillance systems must complement each other and provide support for a national level surveillance system. What are the diseases that the CDSS monitored? The CDSS of Bago City was designed to monitor 13 diseases, among them, animal bites, dengue hemorrhagic fever, diarrheal disease, measles, typhoid fever, cholera, and viral hepatitis.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
63
4 HEALTH
Bago City PLANNING HEALTH SERVICE DELIVERY
Who are involved in the Community-Based Disease Surveillance System? The important actors in the CDSS are: the barangay health workers (BHWs) the surveillance officers City Health Office staff of nurses, doctors, and midwives How does it work? The CDSS follows a six-step process: 1. The midwife or the BHW identifies the cases. 2. The midwife completes the individual treatment record (ITR) and CDSS worksheet. 3. The midwife submits the CDSS worksheet to the surveillance officer at the end of the week. 4. The surveillance officers enter the clinical data gathered, using the EPI information. 5. The surveillance officers prepare reports for dissemination. 6. The City Health Office takes appropriate actions based on recommendations. What are the benefits from a CDSS? Faster response to outbreaks In Bago City, the installation of the CDSS enabled local health managers to respond to outbreaks immediately. Aid to assessing the adequacy of preventive measures CDSS complemented the operations of the CBMIS. The system helped local health workers assess the adequacy of preventive measures such as immunization and micronutrient supplementation.
64
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
PLANNING HEALTH SERVICE DELIVERY Bago City
Better information for decision-makers The CDSS informed local politicians about the city’s health problems, encouraging them to provide support to health programs and services. Provides a basis for LGU training course On a wider scale, Bago City’s experience became the basis for a training course to prepare other LGUs for setting up a basic disease surveillance system and conducting outbreak investigations. Several LGUs in Negros Island and Iloilo Province have availed of this training course. Source: Department of Health. Sentrong Sigla, 1999
❙ FINANCING HEALTH SERVICE DELIVERY The quality of services and the timeliness and cost-efficiency of their delivery depend upon a sound financial base and the steady flow of funds. There are three strategies that can achieve financial stability: Raising Funds Increasing Efficiency Sound Financial Management Policies and Mechanisms
◗ RAISING FUNDS Funds can be raised from internal and external sources. One way is by charging fees from the users of health services and facilities.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
65
4 HEALTH
FINANCING HEALTH SERVICE DELIVERY CHARGING USER FEES FOR BASIC HEALTH SERVICES: MUNICIPALITY OF MALALAG, DAVAO DEL SUR
Project Description: Contact Information: Municipal Health Officer Municipality of Malalag Malalag, Davao del Sur Telefax: 109-082-1987114 or 109-082-1987116
In 1993, the municipal government of Malalag passed the Malalag Revenue Code that, among others, charged fees for basic health services using a socialized scheme. Like many changes, the Code met resistance from the people, which the opposition party exploited. Some of the municipal councilors who voted for the Code lost their seats in the next election. In time and through consultations, information and education campaigns, the people came around to paying the fees, and more importantly, developed a sense of responsibility that were numbed by dole-outs for many years. What is a socialized payment scheme? A socialized payment scheme charges fees for services on the basis of the customer’s capacity to pay. The wealthier members of the community pay more than the poorer members. What are its advantages and disadvantages? The scheme makes it possible for the poor to access basic services without unduly burdening them. The difficulty lies in determining whether the person is really poor. People tend to understate their income to pay less.
66
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
FINANCING HEALTH SERVICE DELIVERY Malalag, Davao del Sur
Under what circumstances is a socialized payment scheme most likely to work? A socialized payment scheme works best in a small setting like Malalag, where everyone knows almost everybody, and where information about a person’s economic status is easy to gather or verify. For a socialized payment scheme to work, there must be significant differences in the income or economic situation of users. Otherwise, a flat rate might be best. In areas where there are many providers of the same service, it is important to know how much “competitors” are charging. Making richer clients pay more than what competitors charge may push richer clients to shift to rival health providers, making it less likely for the socialized scheme to work. How does charging socialized user fees affect the behavior of clients and of health personnel? Now that the people of Malalag are paying to maintain their health, they have become more conscious of the quality of services. This motivates the staff of the rural health units and the municipal health office to perform better. If raising revenues from users are difficult despite a socialized payment scheme, the LGUs can try raising the money from external sources like: National government funds consisting of grants and subsidies lodged in national programs like AntiTB and “Garantisadong Pambata” Official Development Assistance (ODA) in the form of grants and loans Private donations both within and outside the LGU—in cash or health commodities or services from individuals, philanthropic organizations, corporate foundations, nongovernment organizations, i.e., “Kapwa Ko, Mahal Ko” Loans provided by government and private financing institutions Bond issuances Joint ventures with the private sector Social health insurance schemes implemented by the Philippine Health Insurance Corporation and by cooperatives, self-help groups, people’s organizations and locally- based associations Source: Galing Pook, 1996.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
67
4 HEALTH
FINANCING HEALTH SERVICE DELIVERY PROVIDING SOCIAL HEALTH INSURANCE COVERAGE THROUGH A MATCHING GRANT SCHEME: SAGAY CITY, NEGROS OCCIDENTAL
Contact Information City Health Officer City Health Office of Sagay, Negros Occidental Tel No.: 034-4880114 Fax No.: 034-4880187
Project Description Sagay City in the Province of Negros Occidental was one of the first LGUs to enroll in the Matching Grant Program of the Department of Health (DOH). Under this program, an LGU set aside a portion of its health budget for social health insurance, which was matched by PhilHealth giving a proportionate amount. The program had two phases:
Phase 1 consisted largely of hospital benefits. Phase 2 included a capitation fund that provided for out-patient or out-patient care. How can an LGU provide social health insurance through a matching grant program? Social health insurance aims to provide coverage to poor, non-formally employed members of the community by having an LGU and the National Government share the cost of the premium through the Philippine Health Insurance Corporation. An LGU or a group of LGUs enters into a Memorandum of Agreement with PhilHealth to enroll a number of indigent or poor residents. The LGU pays a set portion of the premium, while PhilHealth covers the rest. The enrollees receive an ID that identifies them as a member and entitles them and their qualified family members to a package of benefits.
68
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
FINANCING HEALTH SERVICE DELIVERY Sagay City, Negros Occidental
LGU partnerships are the best set-up because they maximize leverage. Leverage occurs when partners make small individual contributions and are able to access and use a pool of funds larger than the amount they could access individually. For an annual contribution or premium of P118.80 per enrollee, a member is entitled to a package of benefits 10 to 20 times larger than that amount. What are the benefits of being a PhilHealth member? PhilHealth extends to its members the following benefit package: “Unified” Regular In-Patient and Out-Patient Program room and board services of health care professionals diagnostic, laboratory, and other medical examination services prescription drugs and biologicals in-patient education packages out-patient services, e.g., chemotherapy, radiotherapy, hemodialysis, cataract extraction, minor surgical procedures performed in an operating room complex Special Programs (through LGU-managed Rural Health Units) out-patient diagnostic package other programs as may be determined by PhilHealth board Who benefited from the social health insurance of Sagay? Phase 1 of the Social Health Insurance for Indigents of Sagay served monthly an average of 50 clients who stayed in the hospital for an average of three days. Sagay’s main health center also served 90 PhilHealth members. The center gave first priority to these clients.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
69
4 HEALTH
Sagay City, Negros Occidental FINANCING HEALTH SERVICE DELIVERY
What is a capitation fund and how does it work? A capitation fund is a means of guaranteeing the LGUs a return for their premium. PhilHealth paid the LGUs for the services rendered by RHUs and devolved hospitals to PhilHealth members. A capitation fund released money to the LGU on a regular basis. To avail of the fund, Sagay had to obtain accreditation for its main health center. Use of the fund was governed by guidelines, among them, limiting spending for administrative purposes to only 20 percent of the released amount. What were the benefits under Phase 2 of the capitation fund? Under the capitation fund, the members in Sagay enjoyed free chest X-rays. The City Health Office provided the X-ray films to the district hospital for the use of the referred PhilHealth clients. What are some of the issues/challenges in social health insurance? Identifying the Poor Programs targeted for the poor like Social Health Insurance often face problems in separating the poor and non-poor and making sure that only the poor get the benefits. Preventing “political enrollees” is another problem. One way to prevent this from happening is to institute means testing. Means testing involves the development and administration of an instrument (usually a questionnaire) to determine a person’s poverty and hence, his eligibility to join the program. An example of a means test is the Community-Based Information System-Minimum Basic Needs survey done by local social welfare offices.
70
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
FINANCING HEALTH SERVICE DELIVERY Sagay City, Negros Occidental
Access Another issue faced by a social health insurance program is access. While the program can enroll many, membership is useless if necessary facilities like hospitals and pharmacies are either: absent in the locality; costly to access; or, in the case of hospitals, are not accredited by PhilHealth. The lack of access and the means to gain access are one of the main reasons why utilization levels among the poor, especially those in the rural areas, remain low. Limitations in the Benefit Package Limitations in the benefit package also discouraged many LGUs to enroll. The package consisted largely of hospital-provided benefits. Most people had illnesses that did not require hospitalization. This is one reason why PhilHealth devised the capitation fund. How would this affect LGU-initiated social health insurance schemes and other LGU programs? Existing LGU-initiated social health insurance schemes can complement the Matching Grant Scheme by increasing the benefits provided by PhilHealth, or by addressing gaps or needs not addressed by the partnership (for example, maintenance medicine for chronic illnesses). Social health insurance can free resources that otherwise would have been used for programs such as Aid to Individuals in Crisis Situations and charity patients. In the neighboring province of Negros Oriental, the municipality of Bindoy also started its own Social Health Insurance and PhilHealth Capitation Fund. Source: Management Sciences for Health and Johns Hopkins University. Tulong-Sulong sa Kalusugan (Health Sector Reform Agenda) Kit. Manila: Management Sciences for Health and Johns Hopkins University, 2002.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
71
4 HEALTH
FINANCING HEALTH SERVICE DELIVERY MEDICARE PARA SA MASA: MUNICIPALITY OF BINDOY, NEGROS ORIENTAL
Project Description Contact information: Office of the Mayor Bindoy, Negros Oriental Tel. No.: (0912) 890-3616
Bindoy is the first LGU in Region 7 to have its Rural Health Unit accredited in the Out-Patient Consultation Benefit Package. A PhilHealth representative introduced the Out-Patient Consultation Benefit Package (OPCBP) in August 2001. The municipality signed a Memorandum of Agreement (MOA) with PhilHealth in October 2001. Bindoy’s Sangguniang Bayan passed a resolution in January 2002 committing P100,000.00 as PhilHealth premium subsidy. The PhilHealth Capitation Fund was created. The Association of Barangay Captains (ABC) of Bindoy also passed a resolution committing one percent of their Internal Revenue Allotment (IRA) as counterpart funding. Distribution of identification cards (IDs) followed the CBIS-MBN (Community-Based Information System and Minimum Basic Needs) survey in January. In February 2002, IDs were distributed to 784 initial enrollees. In April, another batch consisting of 898 people were enrolled. In May 2002, Bindoy received P107,000 as Capitation Fund for the first 784 enrollees. In June 2002, another 2,076 people from 394 households were enrolled. All told, Bindoy’s “Medicare para sa Masa” had a total fund of P563,700.00 , in 2002 from the Barangay Internal Revenue Allotment, the municipal counterpart, the provincial
72
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
FINANCING HEALTH SERVICE DELIVERY Bindoy, Negros Oriental
counterpart, and the BINATA-Inter-Local Health Zone LGU counterpart. This amount was expected to enroll about 4,744 households at a premium contribution of P118.80 per household. Funds are available for health insurance and for the delivery of certain services. But money for health infrastructure is not as easy to obtain. Infrastructure projects require a bigger budget that would have to be raised from a variety of sources. They also require a variety of financing schemes. Source: Tulong-Sulong sa Kalusugan, 2001.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
73
4 HEALTH
FINANCING HEALTH SERVICE DELIVERY MOBILIZING OVERSEAS FILIPINOS’ SAVINGS AND USING JOINT VENTURES TO BUILD A COMMUNITY CLINIC: MUNICIPALITY OF SEBASTE, ANTIQUE
Project Description Contact Information Officer-in-Charge Sebaste Lying-In Clinic Sebaste, Antique
Like many municipalities in the country, Sebaste had a Rural Health Center manned by a government physician, a public health nurse, six midwives, and a sanitary inspector. The Center operated on a standard office schedule, opening at 8:00 a.m. and closing shop at 5:00 p.m. Beyond these hours, residents had no place to bring their sick. Moreover, the lone government physician was not always present, being away at various times on official travel to the Provincial Health Office in San Jose or to the Regional Health Office in Iloilo City. Also, the Health Center could not accommodate patients who required prolonged hospitalization and surgery. Even simple laboratory tests could not be done in the Health Center. To address this problem, Mayor Juanita de la Cruz worked to set up a community clinic in the municipality. She allotted funds for the community clinic from the Development Fund of the IRA. Knowing these efforts were inadequate, the Sebaste Municipal government sought the help of residents who had migrated to Germany and Austria. Throughout the whole province, Sebaste was known as the dollar capital of Antique because of the significant number of its populace (mostly nurses) working abroad. Mayor de la Cruz herself went to Europe to drum up support for the project.
74
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
FINANCING HEALTH SERVICE DELIVERY Sebaste, Antique
Her visit and proddings led to the formation of the Eugene Daberto Memorial Foundation (EDABEM) in Austria and the Capiznon, Ilonggo, Aklanon, Antiquenhon Association (CIAA) in Austria. These two associations raised funds among themselves and from other funding agencies in Europe that enabled the municipality to purchase medicines, supplies, and medical equipment, including an ambulance. To deal with the problem of funding the establishment of an in-house pharmacy, laboratory, and dental facilities, the municipal government entered into a joint venture with Gerden, a private business firm supplying pharmaceutical products and services. For the dental clinic, it entered into a partnership with a local dentist. What were the terms of the joint ventures? The private pharmaceutical supply firm set up a pharmacy and laboratory and brought in its own employees to operate the facilities. The Sebaste municipal government received 10 percent of the income and exercised regulatory functions over Gerden’s pricing. The municipal government also entered into a joint venture agreement with a local dentist. The dentist himself provided the equipment and services, while the LGU provided the building for a clinic and children’s ward, funded through the Countryside Development Fund (CDF) of the local congressman. What were the services available in the community clinic? The Sebaste community clinic had the following facilities: Pharmacy Laboratory Dental Clinic Ambulance Five beds (initially)
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
75
4 HEALTH
Sebaste, Antique FINANCING HEALTH SERVICE DELIVERY
It had two physicians, four nurses, three nursing attendants, two utility workers, one security guard, and four volunteers. It was open 24 hours a day and provided the following services: Primary health care Early detection and intervention Dental care Laboratory In-House pharmacy Minor surgery Longer stay-in hours What were the benefits of setting up a community clinic? Savings in Time and Money Before the clinic was established, the nearest government hospital was four kilometers away in the town of Pandan. But Sebaste residents preferred to bring their sick to a secondary hospital 20 kilometers away because it had better facilities and better trained personnel. Transportation to and from Sebaste was limited and expensive. Whenever there were emergencies, residents had to spend from P500.00 to P1,000.00 for transportation alone. Accessible Source of Reasonably-Priced Medicines Since the clinic also had a pharmacy, the residents of Sebaste had an accessible source of medicines at regulated and reasonable prices. Source: Galing Pook, 1998.
76
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
◗ INCREASING EFFICIENCY Increasing efficiency is the second strategy for achieving a sound financial position. The cost drivers of a particular service should first be identified. Cost drivers are the 20 percent of cost items that eat up 80 percent of the total cost. This is easier said than done, for often, many health units, especially hospitals, have no system for monitoring and allocating expenditures among their different service units. Expenses are primarily recorded according to the budgetary line items prescribed by the Department of Budget and Management (DBM) and in conformity with the government’s accounting manual. There is no monitoring of expenses per hospital unit, much less relating these expenses to the quality and quantity of the services delivered. Expenses are allowed as long as they are done within approved or accepted guidelines; their necessity is not questioned. But all of these are changing. Among government policy makers, health practitioners, public hospital staff, and the general public, there is a growing awareness and acceptance of the need to monitor public expenditures.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
77
4 HEALTH
FINANCING HEALTH SERVICE DELIVERY MONITORING AND ALLOCATING COSTS IN GOVERNMENT HOSPITALS: PROVINCIAL HOSPITALS OF MISAMIS OCCIDENTAL AND NEGROS ORIENTAL; PASAY CITY GENERAL HOSPITAL, ROXAS MEMORIAL HOSPITAL, AND BULACAN PROVINCIAL HOSPITAL
Project Description: Contact Information Provincial Health Officer Oroqueta, Misamis Occidental Telefax: 088-5311529 Provincial Health Officer Dumaguete City, Negros Oriental Tel # 0352550950/2252615 City Health Officer Pasay City Hall FB Harrison, Pasay City Telefax: 02-8318201
HOSPICAL or the Hospital Cost Allocation tool was developed by the Management Sciences for Health (MSH) during a project with the Kenyan Health Ministry. HOSPICAL is a spreadsheet-based software that is relatively simple and easy to use. It had been pre-tested in three local hospitals, and is in various phases of being rolled out in the provincial hospitals of Misamis Occidental and Negros Oriental, and in the Pasay City General Hospital, Roxas Memorial Provincial Hospital, and Bulacan Provincial Hospital. What are the resources and preparations needed for installing and operating a HOSPICAL system?
The experiences of the five pilot hospitals showed that the successful installation of the system required the following: Enough time given to hospital staff to participate in data collection Records of actual budget expenditures being within easy reach of those participating in the costing exercise Enough computer units Training to build the confidence of hospital staff who do not have enough experience with spreadsheet operations and who prefer manual encoding
Provincial Health Officer Bulacan Provincial Hospital Mojan, Malolos, Bulacan Telefax # 044-7910630
78
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
FINANCING HEALTH SERVICE DELIVERY
Monitoring and Allocating Costs in Government Hospitals
How does one choose a monitoring and evaluation systems software? Nowadays, monitoring and evaluation systems come in software packages. One can opt to purchase offthe-shelf software or commission the development of customized software. The choice would depend on the following considerations: Budget The needs of the hospital vis-à-vis the features of off-the-shelf software available in the market The need to interface with other critical players in the information environment The ease and cost of upgrading The possibility of sharing costs with other hospitals and LGU units What steps were followed in instituting and rolling out HOSPICAL? The first step was pre-testing. HOSPICAL was pre-tested in at least three hospitals. A team then reviewed the software and the manual, discussing approaches and potential problems in adopting the tool in LGU hospitals. Based on their feedback, HOSPICAL was adopted in LGU hospitals. Rolling out the cost allocation tool followed four phases: 1. Formation of a costing core group in each of the hospitals, a general orientation on the HOSPICAL cost allocation tool, and orientation on building the HOSPICAL database 2. Actual data collection and encoding 3. Analysis of results and presentation to hospital officials and core group 3. Training selected hospital staff in managing the HOSPICAL tool Who were involved in instituting the tool? An important step in instituting the tool was the formation of a costing core group whose task was to
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
79
4 HEALTH
Monitoring and Allocating Costs in Government Hospitals FINANCING HEALTH SERVICE DELIVERY
supervise the costing exercise. The members of this core group were either knowledgeable about the financial operations of the hospital or were familiar with the activities of the hospital’s major divisions/units. The following could be members of the costing core group: Administrative Officer Chief of Clinics or Hospital Chief Pharmacist Supply Officer (CSR) Bookkeeper Maintenance/engineer/building administrator Personnel Officer Chief Nurse Billing and Collections Clerk Records Officer Medical Social Worker (optional) What were the common problems or issues encountered in the costing exercise? Padded procurement costs of drugs and medicines which made it difficult to estimate the real cost Difficulty in estimating the actual level of effort needed by the different service divisions of the hospital due to the detailing of hospital personnel in the provincial capitol, and inconsistency between the job description of some hospital personnel and the actual tasks they were performing. HOSPICAL data requirements were not consistent with the data recording and reporting system in most of the hospitals Too much political interference hindered the appropriate classification of patients
80
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
FINANCING HEALTH SERVICE DELIVERY
Monitoring and Allocating Costs in Government Hospitals
What are the benefits of doing a good cost allocation exercise? Accurate Estimation of Cost The hospital can easily determine how much it actually takes to deliver a particular service. How much does a caesarian delivery cost? How much is the room and board? How much is the anesthesiologist’s fee? This will make financial planning easier. It will also allow the hospital to estimate how much it needs to charge patients to recover cost and generate a surplus. Identification of Revenue and Cost Centers Revenue centers and cost centers can be determined. From there, transforming cost centers into revenue centers can be planned, or if that is not possible, reducing their cost or allocating them accordingly across the whole organization. Performance Measurement The cost information can be related to the quality and quantity of the services delivered to come up with a comprehensive picture of the performance of a unit or whole organization. Benchmarking with Similar Hospitals and the Industry’s Standard With this information, the hospital can compare itself with its competitors or with the so-called industry standard to find out how it stands. From there, it can develop the appropriate strategies and plans to strengthen and improve performance. Once the cost drivers are identified, the second step is to find ways of reducing them. Drugs are a common expense of patients, whether inside or outside the hospital. They also eat up a large portion of the Maintenance and Operating Expenses (MOOE) of government hospitals. A patient’s health insurance coverage or a provincial trust fund will not go a long way unless the prices of drugs are brought down to more affordable levels. Two provinces—Capiz and Pangasinan—succeeded in this effort. The former tapped alternative and cheaper sources; the latter re-engineered its procurement process. Source: Management Sciences for Health (MSH) for the Department of Health
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
81
4 HEALTH
FINANCING HEALTH SERVICE DELIVERY MAKING HIGH-QUALITY DRUGS AFFORDABLE THROUGH PARALLEL DRUG IMPORTATION: PROVINCE OF CAPIZ
Project Description Contact Information Provincial Health Officer Provincial Health Office Roxas City, Capiz Tel. No.: (036) 621-0320
The province of Capiz in the island of Panay, Western Visayas is a pilot area for PhilHealth’s Health Passport Program that aims to achieve universal health coverage. The program’s success, however, was threatened by the lack of high quality affordable medicines in pharmacies that were located in the vicinity. In 2000, the provincial government purchased medicines under the Parallel Drug Importation (PDI) scheme implemented by the Philippine International Trading Corporation (PITC) of the Department of Trade and Industry (DTI). What is parallel drug importation? Parallel drug importation is a program undertaken by the government aimed at lowering the prices of drugs in the country. Under the program, the government—through the Philippine International Trading Corporation (PITC)—imports drugs from cheaper sources (e.g., manufacturers in India) and distributes them to pharmacies in government hospitals. What and how much resources were used by Capiz for PDI? Capiz’s parallel drug importation had an initial budget of P1 million—P500,000 from the Operationalization of the Inter-local Health Zones (ILHZ) and P500,000 in counterpart funding from the 20 percent Development Fund of the province.
82
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
FINANCING HEALTH SERVICE DELIVERY Province of Capiz
What kinds of drugs are best purchased through PDI? The best drugs that could be imported through PDI are expensive and maintenance drugs for chronic illnesses like hypertension, asthma, and diabetes, as well as expensive drugs to treat tuberculosis. Because these are maintenance medicines, the demand for them is steady, and government pharmacies are sure to have regular customers. Making them accessible and affordable improves the patients’ compliance with the treatment regimen, which is crucial in curing TB and managing chronic illnesses. The first and second deliveries of PDI drugs to Capiz consisted of four drugs: Nifedipine (Adalat) for hypertension Gibenclamide (Daonil) for diabetes Cotrimoxazole (Bactrim) for infections Salbutamol (Ventolin) for asthma What systems/mechanisms or resources are required for PDI to work? Affordable drugs are useless unless they are also credible and accessible. Critical to the success of PDI is a good marketing system. Effective Marketing The job of a marketing strategy is to prove that although drugs are cheap and its brands are not well known, these are as effective as expensive and branded drugs. A marketing program has to prove and communicate this fact to doctors whose cooperation is crucial since the law declares that drugs could not be sold without prescription. Thus doctors are the point of contact between the product and the buyer. In Capiz, the first delivery sold out in just a month. News traveled fast through the radio, by word of mouth, and a few key idealistic doctors who told their fellow doctors about the effectiveness of the medicines.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
83
4 HEALTH
Province of Capiz FINANCING HEALTH SERVICE DELIVERY
A Good Distribution Network After proving the drugs’ effectiveness, the next task is to make them accessible to people. The Capiz provincial government distributed the drugs to government hospital pharmacies located at the center of the province’s five Inter-Local Health Zones. Equitable Purchase Policies Meanwhile, policies were crafted to ensure that as many people as possible benefited from the drugs. The provincial government set the maximum quantity that could be bought at one month’s supply for maintenance medicines and a week’s full course for antibiotics. What are the benefits of PDI? Based on the Capiz experience, the following were the benefits of PDI: Improved Patient Compliance with Treatment Guidelines With lower prices, patients could afford to buy the drugs, thereby improving their compliance with treatment. Greater Variety of Drugs With poor people being able to pay for affordable drugs, the trust fund for medicines did not run out and even grew, allowing the provincial government to import four more kinds of drugs. Enhanced Reputation of Government Hospitals With PDI, government hospitals acquired a good reputation. People patronized the pharmacies as a source of affordable and good quality medicines.
84
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
FINANCING HEALTH SERVICE DELIVERY Province of Capiz
Reduced Prices of Drugs Procured by Other Means Finally, the provincial government used the success of the program as leverage in its negotiations with a multinational pharmaceutical firm. It succeeded in getting the firm to lower its selling price for a drug from P390.00 to P150.00 per vial, resulting in a discount of more than 50 percent. How could the program be sustained and expanded? The provincial government imposed a mark-up of 30 percent of the acquisition cost. The provincial accountant created a separate book for recording the sales of medicines. The sales were deposited in a trust fund from which subsequent purchases were charged. For wider distribution, the provincial government thought of tapping private pharmacies and encouraged municipalities to make PDI an economic enterprise.
Source: Tulong-Sulong sa Kalusugan, 2001.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
85
4 HEALTH
FINANCING HEALTH SERVICE DELIVERY POOLING HOSPITAL DRUG PROCUREMENT: PROVINCE OF PANGASINAN
Project Description Contact Information Provincial Population Officer Provincial Population Office Lingayen, Pangasinan Te. No.: (075) 542-6349, (075) 542-3981
In 1998, Pangasinan Governor Victor Agbayani embarked on a program to improve the quality of hospital operations including drug procurement. The program covered all 14 hospitals managed by the province. With the help of Management Sciences for Health (MSH), the governor ordered the pooling of the drug procurement of all 14 hospitals.
What are required for pooling drug procurement? Preparatory Meetings Setting up the system started with a series of meetings with hospital chiefs, General Services Office (GSO) staff, hospital staff, and suppliers. MSH conducted interviews with key LGU officials and personnel concerning the LGU’s standard operating procedures in procurement. Training The hospital staff was trained in the use of VEN analysis and ABC analysis to help them prepare the annual procurement plan. Familiarity with and Use of Critical Information The staff had to be familiar with the leading causes of illnesses and deaths in the locality, the treatment protocols, and the Philippine National Drug Formulary (PNDF). These served as the bases for the preparation of the annual procurement plan.
86
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
FINANCING HEALTH SERVICE DELIVERY Province of Pangasinan
An Active Hospital Therapeutic Committee Procurement regulations required that the hospital’s annual procurement plan should be reviewed by a Hospital Therapeutic Committee before it is finalized. Pooling forced the hospitals to revive their Hospital Therapeutic Committees. What is a procurement plan? An annual procurement plan contains the items that the organization will purchase for the year—including price, specifications, and quantity. What is the Philippine National Drug Formulary? The Philippine National Drug Formulary (PNDF) is a list of drugs that are most essential for common local diseases and conditions. It also describes the appropriate use of these essential drugs. The use of the PNDF as a basis for the government’s drug procurement was made mandatory by Executive Order No. 49 issued in 1993 by then President Fidel Ramos. What is VEN analysis? VEN stands for Vital, Essential, and Non-Essential. Drugs can be classified according to these categories depending on different sets of criteria. One set of criteria is the locality’s profile of causes of death and illnesses. Drugs that are vital are those needed to address the Top 10 leading causes of illness in the locality. Another set of criteria is found in the Philippine National Drug Formulary (PNDF). The drugs are considered Vital, Essential, and Non-Essential based on the frequency of occurrence of the illness, the number of persons affected, the severity of the conditions, and the action of the drug.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
87
4 HEALTH
Province of Pangasinan FINANCING HEALTH SERVICE DELIVERY
What is ABC analysis? A-B-C analysis is one way of organizing purchases and inventory according to degrees of importance, usually measured in pesos used or bought. Belonging to the A category are items that are very important. Those in Category B are items that are moderately important; and those in Category C are least important. Items under Category A generally account for about 15 to 20 percent of the number of items that are purchased or kept in inventory but they constitute 60 to 70 percent of the total cost of purchases. At the opposite end, Category C items may account for about 60 percent of the number of items purchased, but only about 10 percent of the total purchase cost. How do ABC and VEN analyses help in rationalizing drug procurement and reducing drug expenditures? Relating ABC to VEN analysis, a hospital’s procurement plan is rational if all items in Categories A and B are drugs listed as vital and essential. Non-essential drugs should never be in Category A. Money is saved if the hospital concentrates on purchasing the right kind of drugs (vital and essential) and buys them at the most reasonable prices. What are the benefits of pooling the procurement of drugs? € Sizeable savings are made due to the ability to purchase in bulk, the avoidance of expensive and frequent emergency purchases, and improved and more competitive bidding procedures € Better quality products are more available because of the quality inspection measures instituted at the hospital. If the products delivered are unacceptable, the end-user completes a Product Problem Report submitted to the Hospital Therapeutic Committee. The Hospital Therapeutic Committee sends drug preparations suspected of being of poor quality to the Bureau of Food and Drug for analysis.
88
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
FINANCING HEALTH SERVICE DELIVERY Province of Pangasinan
Procurement is processed faster because of lesser paperwork involved in both hospitals and the provincial General Services Office that handles procurement. Stocks are available in hospitals every quarter; purchase requests are prepared by the hospital every quarter. The inventory system is better controlled because of the introduction of a common inventory control system in all 14 hospitals. Hospital Therapeutic Committees are revitalized. Source: Sentrong Sigla, 1998
◗ SOUND FINANCIAL MANAGEMENT POLICIES AND MECHANISMS Before 1992, hospitals were permitted by the Department of Health to set up their own trust funds. With devolution, most LGUs prohibited hospitals from maintaining these trust funds. Instead, hospitals were required to give all receipts or incomes derived from the operation and provision of services to the Provincial Treasury, where these funds became part of the general fund. This system led to a general deterioration in the quality of services, shortages in medicine and supplies, and overall financial distress for the hospitals. These were caused by: The removal of any incentive for the hospitals to earn more from their operations, since there was no certainty that the funds would be returned to them Changing priorities in allocation every year Delays in procurement, as purchase requests had to pass through the budget officer The provincial government of Quezon realized the ill effects of this practice early on and included hospitals in its provincial Trust Fund account.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
89
4 HEALTH
FINANCING HEALTH SERVICE DELIVERY ENSURING FINANCIAL STABILITY OF HOSPITALS THROUGH PROVINCIAL TRUST FUNDS: PROVINCE OF QUEZON
Project Description: Contact Information Provincial Health Officer Integrated Provincial Health Office QMH Compound, Quezon Ave. Lucena City Tel # 042-7102440 Fax # 042-7103444
In 1993, Quezon province received a considerable increase in its IRA. The increase was intended to cover the costs of devolution like salaries and benefits of devolved personnel. Departing from the usual practice of many LGUs, the provincial government included hospitals in the provincial Trust Fund account.
The inclusion allowed them to remit to the fund income from medical and operating room supplies, X-ray, laboratory, ambulance, and other kinds of fees. Income from hospital services such as accommodation and subsistence allowance, and physicians’ and anesthesiologists’fees were remitted to the provincial government as part of the general fund. What is the General Fund? The general fund is used to account for monies and resources that may be received by and disbursed from the local treasury. The general fund is available for the payment of expenditures, obligations or purposes that are not specifically declared by law as accruing and chargeable to, or payable from any other fund. (RA 7160, section 308)
90
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
FINANCING HEALTH SERVICE DELIVERY Province of Quezon
What is a Trust Fund? A trust fund consists of private and public monies that have officially come into the possession of the local government or a local government official as a trustee, agent, or administrator. A trust fund can only be used for the specific purpose for which it was created. What are the advantages of a Trust Fund? Earmarked for Specific Purposes Funds held in trust are earmarked or set aside for specific purposes. Earmarking assures funding for items that hospitals need on a continuous and regular basis like medicines and supplies like cotton, syringes, etc. It also protects these items from changing priorities in allocation. Faster Processing Time Processing time is also faster, since purchase requests for items to be charged to the trust fund need not pass through the LGU’s budget office. The reduction in processing time is crucial during emergencies. How does a Trust Fund work? In the 14 hospitals, trust funds were used for medicines, hospital supplies, emergency materials, and equipment. The Provincial Health Officer and the Chief of Hospitals made a request to the Sanggunian Chair for Health, who, as a member of the Local Health Board, then sponsored a resolution for the request. The Sanggunian approved the request. What is required to make a Trust Fund work? The success of the trust fund in Quezon was made possible by a hospital cashiering system that
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
91
4 HEALTH
Province of Quezon FINANCING HEALTH SERVICE DELIVERY
accounted, classified, and segregated the hospital receipts and remitted the fees and charges to the appropriate fund. The module was part of the HAMIS Information System for Hospitals piloted in Quezon Memorial Hospital, and later expanded to all hospitals within the province. What were the benefits of a Trust Fund? Faster Access to Funds The trust fund allowed greater and faster access to funds, a large part of which the hospitals themselves generated. Purchase of New Equipment With greater access to funds, the Quezon Memorial Hospital succeeded in purchasing new equipment like an X-ray machine, an electrocardiogram unit, air conditioner, and an ionic enzyme analyzer. Who benefited from the Trust Fund? Hospital staff Hospital management, nurses, and doctors immediately felt the benefits in the form of better working conditions and better equipment for training and use. Staff morale rose with these improvements. Hospital patients, especially the poor In the end, the patients of the hospital, many of whom were poor, benefited from better equipment and availability of emergency supplies. Sound financial management involves the development of mechanisms to maximize the often-limited funds available to LGUs. Tying together financing with performance provides incentives to deliver quality services. Source: Gems and Jewels, 1996.
92
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
FINANCING HEALTH SERVICE DELIVERY MAXIMIZING THE USE OF FUNDS THROUGH SUB-GRANTING: PROVINCE OF NEGROS OCCIDENTAL
Project Description Negros Occidental was among the first group of grantees under the LGU Performance Program (LPP) of the DOH. The province was expected to achieve the project’s benchmarks for child immunization, tetanus toxoid immunization, vitamin A supplementation, and contraceptive prevalence rate by the year 2000. As an incentive, all grantees that achieved the benchmarks before 2000 received premiums. Negros Occidental was one of the LPP Top Performers.
Contact Information Provicial Health Officer Provincial Administration Center Capitol, Bacolod City, Negros Occidental Tel.# 034-4340671 Telefax # 034-4323362
To maximize the use of its premium grant, Negros Occidental decided to subgrant 70 percent of the amount to select municipalities and component cities, enabling them to expand and improve the delivery of their health services. How did sub-granting work? Soliciting Proposals During the initial phase, the province solicited proposals from municipalities and component cities that did not qualify under the Matching Grant Program (MGP) of the DOH. The selection of sub-grantees was based primarily on the quality of their proposal, which means that the activities should generate demand, expand the delivery of sustainable and high-quality health services, and demonstrate a measurable impact on service coverage within 12 months.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
93
4 HEALTH
Negros Occidental FINANCING HEALTH SERVICE DELIVERY
Providing Counterparts The LGUs should also commit counterpart funds equal to at least 25 percent of the maximum sub-grant of P100,000 per LGU. Ensuring Accountability To ensure accountability, each sub-grantee was required to designate a coordinator, open a separate trust fund account, and submit a quarterly progress and financial report. They were also required to establish a community-based monitoring and information system (CBMIS). What are the advantages of sub-granting compared to other modes of providing assistance? Greater Flexibility Compared to in-kind assistance, sub-granting gave the recipients more power to decide on and implement specific projects needed by their citizens. In-kind assistance normally did not distinguish between the different municipalities, and unlike cash, could not easily be shifted to urgent concerns. Stronger Partnerships and Ownership of the Projects Sub-granting also fostered partnerships between the province and the municipalities. The partnership and ownership of the projects would not have been as strong if the grant were managed from a central office. More Efficient Fund Allocation Asking for proposals and setting criteria for choosing the recipients allowed the province to direct the use of available resources on priority localities and activities. If the funds were divided equally among all municipalities, significant impact would not have been attained.
94
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
FINANCING HEALTH SERVICE DELIVERY Negros Occidental
Greater Commitment The requirement for counterpart funds ensured commitment from the recipients. It communicated the message that the funds were not a dole-out. Performance-Driven Setting performance standards and accountability measures ensured that the funds would be used properly and poured into activities that would have an immediate impact. A different way of implementing the Matching Grant Program (MGP) happened in the neighboring province of Negros Oriental. Instead of proceeding vertically from province to municipalities, the scheme adopted a district approach. Source: Sentrong Sigla, 1999.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
95
4 HEALTH
FINANCING HEALTH SERVICE DELIVERY A DISTRICT APPROACH TO IMPLEMENTING THE MATCHING GRANT PROGRAM: BAYAWAN CITY, BASAY AND STA. CATALINA, PROVINCE OF NEGROS ORIENTAL
Project Description Contact Information Chief of Hospital and District Health Officer Bayawan District Hospital Bayawan City, Negros Oriental Tel. No.: (035) 531-0169; (035) 531-0485
The Santa Bayabas (acronym for Bayawan City, Basay, and Sta. Catalina) is the only district or formal inter-LGU system currently participating in the Matching Grant Program (MGP). District Health Officer Dr. Fidencio Aurelia enrolled the district in the MGP. How does the district approach work in implementing the MGP?
The District Health Board serves as the overall policy and decision-making body for MGP Implementation. The District Health Officer is the overall MGP Coordinator while the Bayawan Treasurer’s Office manages the grant. The LGU counterpart comes from the district’s common fund. The LGUs contributed to this fund based on their financial capability while the provincial government contributed half a million pesos. The district has an MGP Plan that serves as a roadmap for the implementation of projects. This plan was formulated with the participation of the district office staff, the city/municipal health officers, the nurses and midwives, and representatives from the Provincial Health Office and Center for Health Development of Region 7. This plan was later presented to the governor and the mayors during a workshop. Source: Sentrong Sigla, 2000
96
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
❙ DELIVERING Quality Health SERVICES To ensure that the appropriate services are delivered when and where people want it, or offer quality and timely service, a service organization must consider the following: Participation of those who stand to benefit from the services and those who can influence its delivery Responsiveness of the delivery design and mechanisms Commitment and culture of the service provider
◗ MOBILIZING POPULAR SUPPORT AND GENERATING PARTICIPATION IN DELIVERING SERVICES The participation of affected groups enhances the chances of project success and makes the delivery of health services easier and cheaper. Ownership by the stakeholders (those affected and those who can affect project success) increases the probability that the project will continue even in the absence of the pioneering local official. The three cases below illustrate how organized groups, women, and traditional healers were mobilized to participate in the delivery of vital health services.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
97
4 HEALTH
DELIVERING QUALITY HEALTH SERVICES VIGOROUS RECRUITMENT IN PARTNERSHIP WITH PEOPLE’S ORGANIZATIONS: MUNICIPALITY OF SAMPALOC, PROVINCE OF QUEZON
Project Description Contact Information Municipal Health Officer Rural Health Office Sampaloc, Quezon Tel # (109) 042-1981605
In 1992, the Municipality of Sampaloc, Quezon started Medicare II, a program meant to provide health insurance coverage for most of its population who were not formally employed such as farmers and market vendors.
How did the Mayor mobilize people’s organizations to recruit people into the program? Active Recruitment To recruit more members, the program tapped people’s organizations and self-help groups like the Senior Citizens’ Group, the Quezon Women’s League, the purok leaders and the Farmers’ Association of Sampaloc to promote the program and to recruit more members. Community-based Payment Scheme The Farmers’ Association used its “turnuhan,” a rotating credit and savings scheme, to alternately pay for the premium of its members. Monitoring The purok leaders installed purok tally boards to monitor the recruitment campaign. In the Activities Center of the municipality, a listing of all enrolled citizens was posted in blue, while those not enrolled were posted in red.
98
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
DELIVERING QUALITY HEALTH SERVICES Sampaloc, Quezon
What were the benefits of the program? Better and Greater Benefits Sampaloc’s Medicare II Program covered patient and in-patient services. With more members, the Program provided greater and better benefits. Protection in Times of Illness With insurance coverage, members did not have to use up their savings, get into debt, or sell property to have a sick member of the family treated. More Savings for the LGU and the Hospital As a result, there were fewer people who availed of the “Bigay Kalinga”or the Aid to Individuals in Crisis Situations (AICS) program of the local Department of Social Welfare and Development (DSWD). The municipality had more savings as it subsidized less of the expenses of indigents hospitalized in the Sampaloc Medicare Hospital. The hospital also had less charity cases. With more savings, the Sampaloc Medicare Hospital could hire more people and purchase better equipment. Source: Gems and Jewels, 1996
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
99
4 HEALTH
DELIVERING QUALITY HEALTH SERVICES MOBILIZING WOMEN FOR PRIMARY HEALTH CARE: CITY OF SURIGAO, PROVINCE OF SURIGAO DEL NORTE
Project Description Contact Information Office of the Mayor Surigao City, Surigao del Norte Tel #: (086) 8260299; 8264131
Surigao City successfully mobilized women to address the community’s lack of awareness of health programs and to promote primary health care programs in the different barangays. The program commenced in January 1997, equipped with a budget of P1.2 million from the local government. The women initially started as a group of volunteer health workers supporting the implementation of the DOH programs. They eventually formalized their association into the Primary Health Care Federated Women’s Club. The club conducted purok level health education activities and participated in the implementation of DOH programs. The club also promoted income-generating projects. What is primary health care? Primary health care should be distinguished from primary care. Primary care covers services like health education, maternal and child health, family planning, nutrition, supply of essential drugs, treatment of common diseases, immunization, and control of locally endemic diseases like malaria and dengue. On the other hand, primary health care is a strategy—not a program or service—for improving the health and the related needs of an individual, family, and community so that they can enjoy life. Primary health care entails the management of all the elements involved in meeting those needs.
100
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
DELIVERING QUALITY HEALTH SERVICES
City of Surigao,Surigao del Norte
How important is the participation of women in primary health care? In general, women look after the daily needs of family members—from planning the family’s meals, budgeting the money, marketing, preparing food, to caring for sick children and relatives, bringing them to the doctor, and supervising their medication. With these tasks and responsibilities already providing family care, it is much easier to get women to volunteer for health-related activities. Involving women in community development activities leads to the following benefits for the community: Women’s self-esteem is enhanced Increased participation expands the pool of leaders within the community. Children and families consequently enjoy better health and nutrition. What are the effects of the project? Socio-Economic. Because of the project, the earning capacity of the members improved. Moreover, the problem of sanitation has been addressed by the intensified environmental sanitation campaign, especially through the construction of sanitary toilets at the purok level. People Empowerment. The project led to the formation of a voluntary women’s organization that provided the needed human resources for the implementation of health programs in the city. The partnership between the City Health Office and the women’s organization tapped indigenous capacities and strengthened community structures. Efficiency of Delivery. Service delivery became more efficient because of the use of indigenous capacities. Source: Galing Pook, 1995
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
101
4 HEALTH
DELIVERING QUALITY HEALTH SERVICES MOBILIZING TRADITIONAL HEALERS TO PROVIDE PRIMARY HEALTH CARE: MUNICIPALITY OF IROSIN, PROVINCE OF SORSOGON
Project Description Contact Information Executive Director LIKAS, Inc. LIKAS – RIDGE Complex Maharlika Highway, San Pedro, Irosin, Sorsogon Tel. No.: (109) 1984922 – 5553250; (0920) 408-8374
Irosin is famous for its pioneering efforts to promote traditional medicines, with its barangay herbal gardens and the accreditation of the arbularyos or traditional medicine men and women. The traditional medicine men and women serve at the frontlines, complementing the work of barangay health workers and providing on-the-spot treatment for certain illnesses. This freed up the barangay health centers to concentrate on other tasks.
Why mobilize traditional healers? Despite advances in public health services, many poor people still seek remedies for all kinds of illness from traditional healers. Traditional healers are accessible, well known, and trusted in the community. They can also be paid in kind for their services and do not charge as much as the doctors who reside in the poblacion or town center. The treatments they prescribe are inexpensive and they use resources available in the community. The former Irosin mayor, Eddie Dorotan, saw the potential of tapping these traditional healers to support the health objectives of the municipal government.
102
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
DELIVERING QUALITY HEALTH SERVICES
Irosin, Sorsogon
How were they mobilized? The traditional healers were oriented on the basics of primary health care at the municipal health office. During the orientation, the traditional healers also described their practices and remedies for the benefit of the health office staff. The municipal health office staff examined these practices and remedies in the light of basic hygiene and good health practices. After undergoing the orientation, the traditional healers were accredited. What duties were entrusted to traditional healers? The traditional healers became the frontline of the municipality’s barangay health system, working alongside barangay health workers. Traditional healers were allowed to continue prescribing remedies proven to be safe and effective. Certain practices were discontinued such as the way they treat snake and dog bites. Traditional healers usually sucked the blood from the wound of the bite victim, a method found to be unsafe because infection was highly probable and facilitated the spread of other diseases like hepatitis. What were the benefits of mobilizing traditional healers? Savings for the LGU Mobilizing traditional healers saved the LGU money that would have otherwise gone into the hiring, training, and honoraria of barangay health workers. Savings for the Poor The project saved the poor money that would have otherwise gone to doctors’ fees and synthetic drugs.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
103
4 HEALTH
Irosin, Sorsogon DELIVERING QUALITY HEALTH SERVICES
Promotion of Herbal Medicine The project promoted the use of inexpensive, easy to grow medicinal plants and herbs. It encouraged people to preserve and cultivate these plants. Enhancement of Western Medicine and Preservation of Indigenous Medical Knowledge Western medical knowledge was enriched while traditional or indigenous knowledge and practices were preserved and enhanced. Source: Gems and Jewels, 1996
â—— DESIGNING THE DELIVERY SYSTEM TO MATCH THE NEEDS AND SITUATION OF THE CLIENTS Many projects begin with good intentions and end in failure because of poor design that is not responsive to the needs and situation of clients. Some projects fail to take into account the culture of people, their patterns of living, capacities, location, interests and motivations. The two cases below are models for getting the incentives right and matching the delivery system with the needs of clients.
104
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
DELIVERING QUALITY HEALTH SERVICES PERSONALIZED FOLLOW-UP OF CLIENTS THROUGH CALL SLIPS: TALISAY CITY, PROVINCE OF CEBU
Project Description A Commission of Audit regulation states that incentives cannot be provided to government workers for traveling within a 50-kilometer radius in the fulfillment of their duties. This meant that health workers had to use their own funds when visiting their areas. As a result, health workers stayed in the health centers and waited for clients to come to them.
Contact Information City Health Officer Talisay, Cebu Tel.: (032) 2735599
To deliver services, the health centers carried out a monthly Panagtambayayong or outreach. In preparation for the Panagtambayayong, the barangay health workers distributed call slips to program delinquents advising them to come to the health center during the scheduled dates of the Panagtambayayong. How did the Panagtambayayong work? Panagtambayayong or outreach ran for three days, usually starting on Wednesday. An outreach team consisted of a doctor or nurse, two or three midwives, and the volunteer health worker of the barangay. Every member of the team received P250.00 per day as incentive. What are personalized call slips? Personalized call slips are sheets of paper distributed to those not diligently participating in their program, advising them to come to the health center and indicating what services
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
105
4 HEALTH
Talisay, Cebu DELIVERING QUALITY HEALTH SERVICES
they should access. Three types of call slips were given out: one for child immunization, another for tetanus toxoid immunization, and the third for Family Planning (FP). During the Panagtambayayong, the people presented these call slips to health center personnel. What makes personalized call slips effective? The personalized call slips added a personal touch to the delivery of routine services. It indicated to the recipients that they were important, and that health workers were concerned with their welfare. The personalized call slips aim not merely to satisfy but to please the clients as well. What systems/mechanisms were required to make personalized call slips effective? Personalized call slips work only if there is an operative community-based monitoring and information system (CBMIS), such as the one described earlier in the section on Planning Service Delivery (section A of this chapter). This system keeps track of people in the community who have incomplete immunization or who have not received micronutrient supplementation. Yet even if the services are already delivered at people’s doorstep, the problem sometimes lies with the beneficiaries—their mindset, attitudes, and health practices. What were the benefits of the personalized call slips? The personalized call slips led to: Improved coverage rates in immunization Increased demand for routine health services Stronger partnerships between health workers and barangay leaders Allocation of medical supplies based on priorities Source: Sentrong Sigla, 1999
106
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
DELIVERING QUALITY HEALTH SERVICES MOTHER–BABY WATCH: MUNICIPALITY OF SAN JOSE DEL MONTE, PROVINCE OF BULACAN
Project Description San Jose del Monte was a 1999 recipient of the LGU Performance ProgramMatching Grant Program (LPP). Through the Community-Based Monitoring and Information System (CBMIS), the municipal health office identified problems of poor health-seeking behavior and poor health practices among mothers. Specifically, these were in the areas of pre-natal and post-natal care, family planning, immunization, and growth monitoring for infants and pre-schoolers.
Contact Information City Health Officer City Health Center City of San Jose del Monte, Bulacan Telefax # 044-6912584
To address these problems, the “Mother-Baby Watch”(MBW) concept under the “Sustansya para sa Masa”(SPM) or “Nutrition for the People”banner of the government was implemented. How did the Mother-Baby Watch concept work? Enrollment. The Mother-Baby Watch concept started with enrollment of high-risk pregnant women who were screened and then monitored regularly throughout the course of their pregnancies. At birth, their babies were likewise enrolled, and each mother-and-child pair was followed up until the baby turned 24 months. Issuance of MBW Cards. These cards were issued to all enrollees to keep track of the services they used. Three types of incentive points were awarded depending on the type of service obtained: must-points, extra points, and star points.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
107
4 HEALTH
San Jose del Monte, Bulacan DELIVERING QUALITY HEALTH SERVICES
For Mothers: Must points for mothers: These were issued when they had regular pre-natal check-ups or received a tetanus toxoid shot. Extra points for mothers: If the mothers used iodized salt and attended a health/nutrition class. Star points for mothers: These were issued to fully immunized mothers, mothers who breastfed up to six months, and those whose babies were fully immunized at nine months of age. For Babies Must points for babies: These were issued when mothers plotted monthly weights on the growthmonitoring chart and when they introduced complementary food at the proper time. Extra points for babies: These were issued when the mother maintained the growth chart and its trend indicated an upward growth curve. Star points for babies: These were issued when the baby sustained an upward growth curve during a 12-month period. Redemption of Points. The Municipal Health Office estimated that a mother-child pair could earn a total of 25 points in a month. Each point was equal to one peso. Attending health personnel gave a coupon to the mother for every 25 points earned. The mothers redeemed the coupons at designated redemption centers, such as the main health center. How did the LGU sustain the funding for the program? The municipal health office mobilized and organized a group of SPM (Sustansya para sa Masa) benefactors. Each SPM benefactor could opt to support several mother-baby pairs. Among themselves, the SPM benefactors organized a movement to help health center personnel manage the program. Source: Sentrong Sigla, 1999.
108
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
â—— INSTILLING QUALITY CONSCIOUSNESS AMONG SERVICE PROVIDERS Because of devolution, the local public hospital system did not receive the attention and support it duly deserved. This led to a mismanaged public hospital system and the delivery of unresponsive and poor services. In the Health Sector Reform Agenda (HSRA), hospital reform was one of the key areas because public health facilities were vital elements of the health care delivery system. The hospital reform program under the HSRA hopes to re-establish linkages among both devolved and retained hospitals, and to strengthen the capabilities of these hospitals to work within a decentralized set-up and respond to the needs of the community. A critical component of the hospital reform program is building a culture of quality among hospital staff.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
109
4 HEALTH
DELIVERING QUALITY HEALTH SERVICES QUALITY IMPROVEMENT PROGRAM IN THE PROVINCIAL HOSPITAL: PROVINCE OF PANGASINAN
Project Description Contact Information Provincial Population Officer Provincial Population Office Lingayen, Pangasinan Tel. No.: (075) 542-6349, (075) 542-3981 Provincial Health Officer Provincial Health Office 2/F Calantiao Bldg., Lingayen, Pangasinan Telefax: (075) 542-3997 Email: pangpho2@yahoo.com
With the help of the DOH and the United States Agency for International Development (USAID), the Provincial Government of Pangasinan introduced the 5S Quality Improvement Program in the Pangasinan Provincial Hospital in San Carlos City. What is 5S? The 5S quality improvement program was originally conceived by the Japanese to improve work standards in the industrial sector. The 5S stands for: Seiri (Sort), Shiketsu (Systematize), Seiso (Sweep), Seiton (Standardize), and Shitsuke (Self Discipline).
Adopting the 5S program seeks to inculcate positive values in the hospital staff to make them more organized and more responsive to the needs of hospital clients. It also seeks to make them internalize the virtues of self-discipline, and initiate and implement improvements without having to be told to do so. How does it work? 5S is a method of providing fast, efficient, and appropriate services to an organization’s internal customers. Internal customers are persons and units within the organization that use
110
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
DELIVERING QUALITY HEALTH SERVICES
Province of Pangasinan
another unit’s outputs. The method satisfies internal customers by eliminating waste due to unnecessary movement, searching, work repetition, and workplace clutter. The first S, Seiri, means Sort Out. The organization or its units must decide which items are to be disposed. Disposing these items saves valuable space and reduces the time wasted on searching and unnecessary movement and travel. The second S, Shiketsu, means Systematize. The unit must arrange the necessary items in good order so that they can easily be retrieved when needed. The people in the organization must think where things should be placed or stored, consider how often things are used, decide on the proper place for things to be stored or kept, and label all cabinets/shelves and their contents. The third S, Seiso, means Sweep. The unit must clean its workplace to avoid dust and dirt anywhere. The unit is directed not to wait until things get dirty, set aside three minutes everyday to clean the workplace, be responsible for the surrounding areas, never throw anything around, and staff must do the cleaning themselves. The fourth S, Seiton, means Standardize. The unit must always maintain a high standard of housekeeping. The unit must continue implementing not only the first 3Ss, but instead create a maintenance system for housekeeping. The unit must make a schedule for regular cleaning and sorting. An inter-departmental 5S competition is also seen to help maintain this method or system. The fifth S, Shitsuke, means Self-Discipline. This also means spontaneously doing things, without having to be told or ordered.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
111
4 HEALTH
Province of Pangasianan DELIVERING QUALITY HEALTH SERVICES
What were the results of the 5S program? The 5S program was one of the major reasons behind the four-fold jump in the income of the Pangasinan Provincial Hospital—from P2.4 million in 1998 to P10.5 million in 2000. Hence, it is difficult for health workers to treat citizens as customers if their own organization fails to treat them in similar fashion. Health workers serve in the frontline; yet also make up the internal customers of the finance, procurement, and administration units of their service organizations.
Source: Management Sciences for Health (MSH) for the Department of Health.
112
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
GOOD PRACTICES IN HEALTH SERVICE DELIVERY 4
DELIVERING QUALITY HEALTH SERVICES BOOSTING MORALE AND TAPPING INTO THE SPIRIT OF VOLUNTEERISM: MUNICIPALITY OF SAN LUIS, AURORA
Project Description Contact Information Municipal Health Officer San Luis, Aurora
Immediately after devolution, Mayor Annabelle Tangson launched a campaign to improve the delivery of social services in her municipality. Along with the Municipal Health Officer, Dr. Maria Pura Valenzuela, the mayor: (a) rationalized the health budget; (b) minimized duplication of functions by having one nutrition program; (c) launched health education, sanitation, and environmental programs; (d) encouraged each barangay health center to have its own herbal garden and every family in the municipality to grow medicinal plants; and (e) started a social health insurance scheme. What were the Mayor’s strategies for improving the delivery of social services? Improving Discipline At the start of devolution, poor discipline among the health workers was a problem. Mayor Tangson sought to boost morale, and instill and improve discipline by making sure health workers’ salaries were paid on time and by speeding up the procurement of supplies. The health workers had no more reason to complain and were motivated to perform better. Rationalizing the Budget A certified public accountant, the mayor introduced order into the budget. She allotted 15 percent of the municipal budget for health.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
113
4 HEALTH
San Luis, Aurora DELIVERING QUALITY HEALTH SERVICES
Prioritizing Purchases and Promoting Preventive Medicine Due to limited funds, the Municipal Health Office became selective about the kind of medicines they bought. Instead of encouraging people to become dependent on dole-outs, the health workers emphasized preventive medicine. Encouraging Volunteerism The mayor actively promoted volunteerism in the different projects of the municipality. The Volunteers Club sustained the enthusiasm of the volunteers by holding parties and picnics. Networking Because of the limited equipment of its lying-in clinic, the municipality entered into partnerships with hospitals in many areas. Residents in coastal barangays were consulted about which municipalities they would find easier to go to for medical consultations. Who benefited from the strategies? These groups in the municipality benefited from the changes: Health Workers. The health workers received their salaries on time and they received their supplies faster. The Poor. Sanitation and nutrition projects benefited the poor who could not afford to get sick. Residents of Remote Areas. Those living in the remote areas of the municipality benefited from the partnerships created with other hospitals and municipalities.
Source: Gems and Jewels, 1996.
114
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
5 REFERENCES AND TOOLS
REFERENCES AND TOOLS
5
CHAPTER
â?™ REFERENCES â—— BOOKS, MANUALS AND MONOGRAPHS
Berman, Peter (Ed.). Health Sector Reform in Developing Countries: Making Health Development Sustainable. Boston: Harvard University Press, 1995. Bishops-Businessmen's Conference Livelihood Foundation, Inc. Directory of Foreign and Local Development Assistance Agencies. 3rd Edition. Makati City: Society of St. Paul Printing Press, 1998. Department of Health. Health Sector Reform Agenda, Philippines (1999-2004), Monograph Series No. 2, Manila, 1999 Department of Health. National Objectives for Health, Philippines (1999-2004), Manila, 1999. Department of Health-Environmental Health Service. Implementing Rules and Regulations of Chapters 2, 3 and 17 of the Code on Sanitation of the Philippines (P.D. 856). Manila: Department of Health-Environmental Health Service, 1995. Department of Health-Environmental Health Service. Implementing Rules and Regulations of Chapters 9, 14, 16 and 21 of the Code on Sanitation of the Philippines (P.D. 856). Manila: Department of Health-Environmental Health Service, 1997.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
117
5 HEALTH
Department of Health, Environmental Health Service. Implementing Rules and Regulations of Chapters 5, 8, 10 and 15 of the Code on Sanitation of the Philippines (P.D. 856). Manila: Department of Health-Environmental Health Service, 1998. Department of Health, Environmental Health Service. Implementing Rules and Regulations of Chapter 7 "Industrial Hygiene" of the Code on Sanitation of the Philippines (P.D. 856) Amending Administrative Order No. 111 s. 1991. Manila: Department of Health-Environmental Health Service, 1999. Department of Health-Environmental Health Service, et. al.. Environmental Health Risk Perception Survey, Philippines. Manila: Department of Health-Environmental Health Service, College of Public Health University of the Philippines-Manila, International Development Research Centre (IDRC), Canada, 1998. Department of Health Environmental Health Service, et. al. Environmental Health Risk Perception Survey, Philippines: Executive Summary. Manila: Department of Health Environmental Health Service, College of Public Health University of the Philippines-Manila, International Development Research Centre (IDRC), Canada, 1998. Department of Health-Environmental Health Service. Philippines: Environmental Health Assessment Volumes 1,2 and 3. Manila: Department of Health-Environmental Health Service, 1996. Department of Health-Environmental Health Service. Philippines: Environmental Health and the Environment. Manila Department of Health-Environmental Health Service, 1996. Department of Health Environmental Health Service, et. al. Philippines - Health and Environment: The Vital Link. Manila: Department of Health Environmental Health Service, College of Public Health University of the Philippines-Manila, International Development Research Centre (IDRC), Canada, 1998.
118
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
REFERENCES AND TOOLS 5
Department of Health - Environmental Health Service et.al. Philippines - Health and Environment: The Vital Link (Executive Summary). Manila: Department of Health Environmental Health Service, College of Public Health University of the Philippines - Manila, International Development Research Centre (IDRC), Canada, 1998. Department of Health Environmental Health Service, et. al. Health and Environment Intersectoral Consultations: A Component of the Health and Environment Policy Impact Project. Manila: Department of Health Environmental Health Service, College of Public Health University of the Philippines - Manila, International Development Research Centre (IDRC), Canada, 1998. Department of Health, Environmental Health Service. Philippine National Framework and Guidelines for Environmental Health Impact Assessment. Manila: Department of Health-Environmental Health Service, 1997. Department of Health - Local Government Assistance and Monitoring Service (LGAMS). Health Services and Local Autonomy. Manila: Department of Health - Local Government Assistance and Monitoring Service (LGAMS). Department of Health - Local Government Assistance and Monitoring Service (LGAMS). Responding to Questions on Devolution of Health Services (Guidebook for Governors, Mayors and Members of the Local Health Board). Part 1: Health and Development. Manila: Department of Health Local Government Assistance and Monitoring Service (LGAMS), 1993 (First Edition). Department of Health - Local Government Assistance and Monitoring Service (LGAMS). Responding to Questions on Devolution of Health Services (Guidebook for Governors, Mayors and Members of the Local Health Board). Part 1: Health Planning. Manila: Department of Health - Local Government Assistance and Monitoring Service (LGAMS), 1993 (First Edition).
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
119
5 HEALTH
Department of Health - Local Government Assistance and Monitoring Service (LGAMS). Responding to Questions on Devolution of Health Services (Guidebook for Governors, Mayors and Members of the Local Health Board). Part 1: Health Services Management. Manila: Department of Health Local Government Assistance and Monitoring Service (LGAMS), 1993 (First Edition). Department of Health - Local Government Assistance and Monitoring Service (LGAMS). Responding to Questions on Devolution of Health Services (Guidebook for Governors, Mayors and Members of the Local Health Board). Part 1: The Local Health Boards. Manila: Department of Health - Local Government Assistance and Monitoring Service (LGAMS), 1993 (First Edition). Department of Health - Local Government Assistance and Monitoring Service (LGAMS). Responding to Questions on Devolution of Health Services (Guidebook for Governors, Mayors and Members of the Local Health Board). Annexes to Guidebooks. Manila: Department of Health - Local Government Assistance and Monitoring Service (LGAMS). 1993 (First Edition). Department of Health and Management Sciences for Health - Health Sector Reform Technical Assistance Program (HSRTAP). A Handbook on Inter-Local Health Zones: District Health System in a Devolved Setting. Manila, 2002. Department of the Interior and Local Governments. Rules and Regulations Implementing the Local Government Code of 1991. 1992. Kaban Galing: The Philippine Case Bank on Innovation and Exemplary Practices in Local Governance. Ford Foundation, United Nations Development Program (UNDP), UNICEF, Galing Pook Foundation, Local Government Academy. 2001 Edition. Lansang, Mary Ann and Rebullida, Ma. Lourdes O., eds. Lifestyle-Related Diseases in the Philippines: Areas for Health Policy and Systems Research. HPSR Monograph No 2. Manila: Department of Health Essential National Health Research, 1998.
120
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
REFERENCES AND TOOLS 5
Lansang, Mary Ann and Rebullida, Ma. Lourdes O., eds. Nutrition in the Philippines: Areas for Policy and Systems Research. HPSR Monograph No 2. Manila: Department of Health Essential National Health Research, 1998. Lansang, Mary Ann and Rebullida, Ma. Lourdes O., eds. The Expanded Program of Immunization in the Philippines: Areas for Health Policy and Systems Research. HPSR Monograph No 2. Manila: Department of Health Essential National Health Research, 1998. Lansang, Mary Ann and Rebullida, Ma. Lourdes O., eds. The Health of Filipino Women: Areas for Health Policy and Systems Research. HPSR Monograph No 2. Manila: Department of Health Essential National Health Research, 1998. Lansang, Mary Ann and Rebullida, Ma. Lourdes O., eds. Sexually Transmitted Diseases and HIV/AIDS in the Philippines: Areas for Health Policy and Systems Research. HPSR Monograph No 2. Manila: Department of Health Essential National Health Research., 1998. Lansang, Mary Ann and Rebullida, Ma. Lourdes O., eds. Tuberculosis: Areas for Health Policy and Systems Research. HPSR Monograph No 2. Manila: Department of Health Essential National Health Research., 1998. Pons, Melahi and Schwefel, Detlef, eds. Health and Management Information Systems (HAMIS) Good Health Care Management: The Winners of the First HAMIS Contest. Manila: Department of Health and Deutsche Gesellschaft fur Technische Zusammenarbeit, 1993. Quimpo, Bernadette A., ed. Devolution Matters: A Documentation of Post-Devolution Experiences in the Delivery of Health Services. Manila: Department of Health- Local Government Assistance and Monitoring Service.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
121
5 HEALTH
Rebullida, Ma. Lourdes G., and Elma B. Torres. Training Needs Assessment of Sanitation Officers for Capability Building in Integrated Health and Environment in Local Government Units. Manila: Department of Health - Health Policy Development and Planning Bureau, Foundation for Integrative and Development Studies, University of the Philippines Center for Integrative and Development Studies, 2002. The Association of Foundations Philippines, Inc. Philippine NGOs: A Resource Book of Social Development NGOs. Quezon City: The Association of Foundations Philippines, Inc., 2001. Veneracion, Cynthia C. Community Health Development: Experiences from Rural Philippines. Quezon City: Institute of Philippine Culture, Ateneo de Manila University, 1994. Women's Health and Safe Motherhood Project - Partnership Component RPMU CARAGA. Community Development Field Guide. July 2001. Veneracion, Cynthia C. Implementing Projects and Activities for Community Health Development: Partnership in Community Health Development Experiences, 1991-1993. Quezon City: Institute of Philippine Culture, Ateneo de Manila University, 1994. Veneracion, Cynthia C. Initiatives and Strategies for Community Health Development. Quezon City: Institute of Philippine Culture, Ateneo de Manila University, 1993. Veneracion, Cynthia C. NGOs in Primary Health Care: The Philippine Experience 1978-1998. Quezon City: Institute of Philippine Culture, Ateneo de Manila University, 1999. Veneracion, Cynthia C. Partnership Building and Planning for Community Health Development: PCHD Experiences, 1990-1993. Quezon City: Institute of Philippine Culture, Ateneo de Manila University, 1993.
122
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
REFERENCES AND TOOLS 5
Veneracion, Cynthia C. PCHD Community Project Implementation 1991-1993. Quezon City,: Institute of Philippine Culture, Ateneo de Manila University, 1993.
â—— REPORTS AND OTHER UNPUBLISHED MATERIALS Department of Health. List of Sentrong Sigla Awardees. Department of Health - Matching Grant Program. MGP LGUs as of June 30, 2002. Department of Health. National Health Planning Committee Annual Meeting. December 19, 2001. Holiday Inn, Manila. Department of Health. Setting the Agenda for Reform, Annual Report 1999. Manila. Department of Health - Bureau of International Health Cooperation. Pipeline Projects as of June 20, 2002. Department of Health - Bureau of International Health Cooperation. Profile of Ongoing Foreign Assisted Projects in the Department of Health, for CY 2002. Department of Health - Health Policy Development and Planning Service. Governors Workshop for Health: Partnership for Devolution. March 9-10, 1999. Westin Philippines Plaza Hotel, Manila. HEALTHDEV Institute. Development of a Genuine People Initiated Legislative Agenda on Health. Quezon City: HEALTHDEV Institute, 1996. The National College of Public Administration and Governance, University of the Philippines, for the Department of Health - Community Health Service. Primary Health Care Resource Center Project: Profile of Institutions and PHC Practitioners - Region IX. 1998.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
123
5 HEALTH
The National College of Public Administration and Governance, University of the Philippines, for the Department of Health - Community Health Service. Primary Health Care Resource Center Project: Profile of Institutions and PHC Practitioners - Region X. 1998. The National College of Public Administration and Governance, University of the Philippines, for the Department of Health - Community Health Service. Primary Health Care Resource Center Project: Profile of Institutions and PHC Practitioners - Region XI. 1998. The National College of Public Administration and Governance, University of the Philippines, for the Department of Health - Community Health Service. Primary Health Care Resource Center Project: Abstract of PHC Researches, Regions IX - XII and ARMM. 1998. Social Development Research Center, De La Salle University, Manila for the Department of Health - Community Health Service. Research Abstracts: NCR, Regions VI, VII, VIII, XII. 1998. Social Development Research Center, De La Salle University, Manila. Exaltacion E. Lamberte, Alice Manlangit and Mark Miranda. Research Abstracts: A Report Submitted to Department of Health - Community Health Service. 1999. Women's Health and Safe Motherhood Project - Partnerships Component. Extension Mission Report, July 2001, Manila: Department of Health.
â—— GOVERNMENT DOCUMENTS La Vina, Antonio GM and Aguirre, Vyva Victoria M., eds. Health Laws and Administrative Issuances, Volume V, Department orders Part II. Quezon City: Department of Health - Health Policy Development Program, 1994.
124
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
REFERENCES AND TOOLS 5
Department of Health - Health Policy Development and Planning Service. Listing of Administrative Orders. Medical Laws: Republic Act Nos. 70, 349, 1056, 2382, and 4224. National Health Planning Committee (NHPC). LGU Health Planning Guidelines for CY 2002. A Joint Administrative Order by DOH and DILG. National Health Planning Committee (NHPC). LGU Health Planning Guidelines for CY 2003. Joint Administrative Order No. 1 s 2002.
â—— JOURNALS AND PERIODICALS "A District Approach to Implementing the Matching Grant Program." Updates from the Field: Best Practices, No. 1 Series of 2002. "A Health Insurance Program for Indigents." Updates from the Field: Technical Notes, No. 2 Series 2002. Alon, Alvic P. "An ICHSP Journey to the Last Frontier." Health Beat, Issue No. 21 (NovemberDecember 1999), 19-22. "AusAID grants P12.75M to Bukidnon health projects." Today, August 31, 2002, 4. "Basilan, Sulu hospitals receive support from RP-Canadian governments." Bulletin Today. August 8, 2002. "Bringing Sterilization Services to the Main Health Center." Updates from the Field: Best Practices, No. 2 Series of 2001.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
125
5 HEALTH
Challenges of Providing Health Services to the Urban Poor." Updates from the Field: Best Practices, No. 6 Series of 2001. "Collaboration Between Local Government Units and NGOs for Bilateral Tubal Ligation in North Cotabato." Updates from the Field: Best Practices, No. 5 Series of 2002. "Collaborating with Population Services PILIPINAS to Provide Bilateral Tubal Ligation." Updates from the Field: Best Practices, No. 4 Series of 2002. "EPI Plus." Updates from the Field: Best Practices, No. 1 Series of 2000. "Expanding the Delivery of Health Services Through a Community-Based Monitoring and Information System." Updates from the Field: Technical Notes, No. 1 Series 2001. "Importation of Parallel Drugs: Making High-Quality Drugs More Affordable." Updates from the Field: Technical Notes, No. 1 Series 2002. "Integrated Community Health Services Project. Guimaras Health Insurance Program: A Model in Health Care Financing." Health Beat, Issue No.35 (March-April 2002), 25-28. "Mother-Baby Watch." Updates from the Field: Best Practices, No. 2 Series of 2000. "Personalized Client Follow-Up through Call Slips." Updates from the Field: Best Practices, No. 1 Series of 2001. "Pooled Pharmaceutical Procurement in Pangasinan." Updates from the Field: Technical Notes, No. 2 Series 2001.
126
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
REFERENCES AND TOOLS 5
"Promoting No-Scalpel Vasectomy: The Bago City Experience." Updates from the Field: Best Practices, No. 2 Series of 2002. "Responding to the Health Needs of Aetas in Lupang Pangako." Updates from the Field: Best Practices, No. 3 Series of 2001. "The Importance of Local Leaders in Promoting Health." Updates from the Field: Best Practices, No. 5 Series of 2001. "Using the Community-Based Monitoring and Information System to Help Reduce Unmet Needs." Updates from the Field: Best Practices, No. 4 Series of 2001. "Mobilizing Resources for the Matching Grant Program." Updates from the Field: Best Practices, No. 3 Series of 2002. "Setting Up a Community-Based Disease Surveillance System." Updates from the Field: Technical Notes, No. 4 Series 2001. "Strengthening Provincial-Municipal Partnerships Through Subgranting." Updates from the Field: Technical Notes, No. 5 Series 2001. "The Matching Grant Program: A Strategy to Expand Local Health Service Delivery." Updates from the Field: Technical Notes, No. 6 Series 2001. "The 2000 Family Planning Survey: Variation in Use of Modern Contraceptives." Updates from the Field: Technical Notes, No. 3 Series 2001.
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
127
5 HEALTH
â—— BROCHURES AND FLYERS Department of Health. A Primer on Sentrong Sigla (Philippine Quality Assurance Program). Department of Health. Integrated Community Health Services Project: A DOH Response to the Challenges of Devolution. Manila: Department of Health. Department of Health - Matching Grant Program. Frequently Asked Questions. Manila: Department of Health - Matching Grant Program. Department of Health. German Support to the Philippine Health Sector (2001-2004). Manila: Department of Health. Management Sciences for Health and Johns Hopkins University. Tulong-Sulong sa Kalusugan (Health Sector Reform Agenda) Kit. Manila: Management Sciences for Health and Johns Hopkins University, 2002.
â&#x2014;&#x2014; WEBSITES <www.msh.org> (Date of visit: July 2002) <www.doh.gov.ph> (Date of visit: August 9 and 26, 2002.)
128
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
REFERENCES AND TOOLS 5
❙ RESOURCES FOR HEALTH SERVICE DELIVERY ◗ BILATERAL AND MULTILATERAL FOREIGN ASSISTED PROJECTS
ONGOING FOREIGN ASSISTED PROJECTS, DOH, CY 2002 Fund Source / Type and Duration
Area of Coverage
Contact
Title/Description
Dr. Ma. Virginia Ala Head, Unified Project Management Division, BIHC (02) 7438301 local 1304
Women’s Health and Safe Motherhood Project – focus on women of reproductive age, reduce female morbidity and maternal mortality, promote safe motherhood; 1) service delivery 2) institutional strengthening 3) community partnership 4) policy operations and research
WB – Loan ADB – Loan KFW – Grant EU – Grant AusAID – Grant 95 – 01 Extended to June 02
Nationwide
Ms. Cherrylyn Daus Chief Health Pro-gram Officer, BIHC (02) 7438301local 1306, 07
Early Childhood Development (10 yrs) – ensure survival and promote physical and mental development of young children in the worst vulnerable and disadvantaged segments of the population
ADB – Loan WB – Loan 98 – 04
6, 7, 12
Southern Phil Irrigation Sector Project (SPISP) – construct and develop small/ medium scale irrigation system, drainage facilities, intensive cultivation of rice and other crops; NIA, Schistosomiasis Control
ADB – Loan 99 – 05
7, 13, ARMM
Infectious Disease Surveillance and Control Project (IDSCP) – DOH and LGUs
USAID – Grant 99 – 02
CAR, 7, 12
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
129
5 HEALTH
ONGOING FOREIGN ASSISTED PROJECTS, DOH, CY 2002 Contact Dr. Criselda Abesamis National Center for Health Facilities (02) 7438301local 1400, 1401
130
Title/Description
Fund Source / Typeand Duration
Area of Coverage
Upgrading of Zamboanga City Medical Center and Zamboanga del Sur Provincial Hospital
Spanish gov’t – Loan 02
Zamboanga City, 9
Construction and Equipping of the Outpatient and Preventive Care Center of the Davao Medical Center Project
JICA – Grant 99 – 02
11
Ms. Cecilia Pangilinan (02) 7438301local 1333
Integrated Family Planning and Maternal Health Program – (7 yrs) reduce unmet need for FP and selected child health services 1) private sector/NGO 2) LGU performance program 3) National Services
USAID – Grant Aug 99 – Sep 02
Nationwide
Dr. Rosalinda Majarais (02) 7438301local 1305
Support to DOH Reproductive Health
UNFPA – Grant 00 – 04
2, 6, 12, ARMM
Dr. Claude Bodart (02) 7438301local 1340
German Support to the Health Sector - FP and HIV/AIDS Prevention ProjectSocial Marketing (DKT II) condoms and OCP· - Philippine – German Technical Cooperation Project on Health Care Equipment
KFW – Grant 99 – 03
Nationwide
GTZ – Grant 99 – 01
Nationwide
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
REFERENCES AND TOOLS 5
ONGOING FOREIGN ASSISTED PROJECTS, DOH, CY 2002 Contact
Title/Description
Fund Source / Type and Duration
Area of Coverage
Dr. Leo Reyntjens Dumaguete City (035) 2258680,422-9272
Belgian Integrated Agrarian Reform Support Program 2 – alleviate poverty, improve agricultural production, uplift well-being of lowincome communities (ARCs)
Belgian gov’t – Grant Sep 00 – Aug 03
7 – 46 ARCs 9 – 28 ARCs
Engr Bonifacio Magtibay 781-8843781-5890
Integrated Community Health Services Project
ADB – Loan 97 – Jun 02
Kalinga, Apayao, Guimaras, Palawan, So. Cotabato, Surigao del Norte
AusAID – Grant 97 – Sep 03 GOP Dr. Loreto Roquero Director Center for Family and Environmental Health (02) 7438301 local 1728, 2254, 2256
Family Health International/IMPACT
USAID – Grant Jun 98 – Sep 02
Dr. Ma. Virginia Ala Head, Unified Proj Mgt Div, BIHC (02) 7438301loc 1304
2nd Social Expenditure Project – Health Component (SEMP II) – accelerate HSRA implementation 1) improve access and quality of health care for the poor 2) introduce financing, regulatory and organizational changes – for purchase of drugs
WB – Loan 02
Engr. Rolly Mercado (02) 7438301loc 1307
Rural Water Supply and Sanitation Sector Project (RW3SP) – LGUs
ADB – Loan Nov 97 – Aug 01 Extended to 02
Metro Manila, Cebu City, Davao City, Angeles City
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
131
5 HEALTH
ONGOING FOREIGN ASSISTED PROJECTS, DOH, CY 2002 Contact
132
Title/Description
Fund Source / Type and Duration
Dr. Criselda Abesamis National Center for Health Facilities (02) 7438301local 1400, 1401
Hospital Development Project – medical/non-medical equipment of 4 medical centers/regional hospitals, 12 provincial hospitals, 7 district hospitals
Austria – Loan 01 – 03
Dr. Consorcia Lim Quizon Dir., National Epidemiology Center (02) 7438301local 1907
AIDS Surveillance and Education Project (ASEP)
USAID – Grant WHO – Grant 92 –00 Extended to 02
Dr. Claude Bodart (02) 7438301local 1340
German Support to the Health Sector · Social Health Insurance Networking Empowerment (SHINE) · Family Health by and for Poor Settlers (FAMUS) – LGUs through NGOs
GTZ – Grant 96 – Mar 03
Dr. Esperanza Espino RITM 809-7599
Implementation and Evaluation of a Self Sustaining Community-Based Malaria Control – community volunteer system health insurance scheme, health education and surveillance system
AusAID – Grant 95 –00 Extended to 03
Dr. Loreto Roquero Director, Center for Family and Environmental Health (02) 7438301local 1728, 2254, 2256
5th Country Program for Children – Maternal and Child Friendly Movement
UNICEF – Grant 99 – Dec 03
Family Planning/Maternal and Child Health Project Phase II
JICA – Grant
GTZ – Grant Feb 99 – Dec 01 Extension proposed
Area of Coverage
4, 6, 7, 8,9, 10, 13,NCR
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
REFERENCES AND TOOLS 5
PIPELINE PROJECTS UNDER HOSPITAL REFORM, DOH Title/Description
Contact
Fund Source / Type and Duration
Area of Coverage
Construction and Equipping of the Phil Blood Transfusion Center and 2 Regional Blood Centers (Cebu and Davao)
NVBSP
PHP 709M5 yrs (03-07)
JICA – Grant
Upgrading of Zamboanga City Medical Center and Zamboanga del Sur Provincial Hospital
CHD 9
PHP 463M
Spanish government
Development of Subspecialty Capabilities for Heart, Lung and Kidney Patients in the Philippines
CHD 1, 5, 6, 7, 9, 10
PHP 803M
JICA – Grant Netherlands – Loan
Construction of OPD Bldg and Upgrading of Med Equipment CARAGA Regional Hospital
CARAGA Regional Hosp (13)
PHP 326M
JICA – Grant
Upgrading of Medical Equip-ment and Facilities of Amai Pakpak Medical Center
Amai Pakpak Medical Center
PHP 110M
Austrian – Loan
Establishment of Women and Children Protection Unit in BGHMC, VSMMC and DMC
CHD – CAR CHD 7 CHD 11
PHP 2.6M PHP 2.49M PHP 1.76M
British government
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
133
5 HEALTH
PIPELINE PROJECTS UNDER PUBLIC HEALTH REFORM, DOH Contact
134
Title/Description
Fund Source / Type and Duration
Area of Coverage
Japan Aid to Phil Fight Against Infectious Diseases – upgrade national center and sub national centers, diagnostic, management and surveillance system, research, community-based prevention and control program for parasitic diseases
NCDPC
PHP 200M 03 – 07
JICA
Quality TB Control Program – network of TB laboratories (1 national, 2 regional), DOTS, operational researches
NCDPC
PHP 117M 03 – 07
JICA
Japan Special Aid for Children for follow-up measles campaign
NCDPC
US$ 3.17M Apr-Aug 03
JICA
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
REFERENCES AND TOOLS 5
PIPELINE PROJECTS UNDER LOCAL HEALTH SYSTEM, DOH Contact Hospital Equipment Assistance Project (HEAP) Dona Gregoria Memorial Hospital Quirino Provincial Hospital Masbate Provincial Hospital Biliran Provincial Hospital Alfredo Maranon Sr. Memorial Hospital Kalinga Provincial Hospital Abra Provincial Hospital Ifugao Provincial Hospital San Jose City General Hospital Rizal Provincial Hospital Laguna Provincial Hospita Iloilo Provincial Hospital Dr. Locsin Memorial Hospital Mariano J. Cuenco Provincial Hospital Leyte Provincial Hospital Aurora General Hospital Cotabato Provincial Hospital Quezon City General Hospital Samar Provincial Hospital Siquijor Provincial Hospital
Title/Description LGU â&#x20AC;&#x201C; DILG
Upgrading of Medical Equipment Regions 9, 10, 12, ARMM for Selected Government Hospitals (Mindanao Area Mindanao Area-Based Hospital Development Plan)
Fund Source / Type and Duration
Area of Coverage
PHP 797.67M (Spanish loan: P 76.28M, DILG: PHP 121.39M)
Spanish government â&#x20AC;&#x201C; Loan
No figure
Finland
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
135
5 HEALTH
PIPELINE PROJECTS UNDER LOCAL HEALTH SYSTEM, DOH Contact Upgrading of Essential Medical Equipment for Strategic Government Referral Hospitals in Southern Mindanao Region Davao Medical Center Davao Regional Hospital – Tagum Montevista District Hospital Davao Oriental Provincial Hospital Davao del Sur Provincial Hospital South Cotabato Provincial Hospital General Santos City Hospital Samal District Hospital Lupon District Hospital Gregorio Matas District Hospital in Davao del Sur Kiamba District Hospital in Saranggani Province
136
Title/Description CHD 11
Fund Source / Type and Duration PHP 881M
Area of Coverage JICA – G
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
REFERENCES AND TOOLS 5
PIPELINE PROJECTS - OFFICE OF THE REGIONAL GOVERNOR, ARMM Contact
Title/Description
Upgrading of Hospitals in the Provinces of Sulu and Basilan (UHPSB) â&#x20AC;&#x201C; Sulu Provincial Hospital, Luuk District Hospital, Pangutaran District Hospital, Parang District Hospital, Siasi District Hospital, and Lamitan District Hospital
Office of the Regional Governor of the Autonomous Region of Muslim Mindanao (ORG-ARMM) through the Department of Health of ARMM (DOH-ARMM)
Fund Source / Type and Duration Canadian International Development Agency (CIDA) and National Economic Development Authority (NEDA) through the Philippines-Canada Development Fund (PCDF)
OTHER PIPELINE PROJECT IN MINDANAO Creating Child-Friendly Families and Communities in Mindanao (Projects in health, children in need of special protection, education, communication, and gender and development)
Bukidnon, Agusan del Sur, Davao City, Sarangani, Sultan Kudarat, Sulu and Zamboanga del Sur
AusAID and UNICEF
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T
137
5 HEALTH
❙ RESOURCES FOR INTER-LOCAL HEALTH ZONES ◗ MAIN SOURCES OF FUNDS Regular budget of the LGUs for hospitals and RHUs - through Internal Revenue Allotment (IRA) 20% development funds of LGUs Augmentation and subsidies for Department of Health (DOH) and Centers for Health Development (CHD) Congressional funds Health insurance scheme through PhilHealth
◗ OTHER SOURCES OF FUNDS
Cost-sharing Revenue enhancement Utilization of income Community-base health insurance Bulk or pooled procurement system of drugs and supplies Grants Establishment of cooperatives Fund raising
Source: Department of Health and Management Sciences for Health - Health Sector Reform Technical Assistance Program (HSRTAP). A Handbook on Inter-Local Health Zones: District Health System in a Devolved Setting. Manila, 2002.
138
S E R V I C E D E L I V E R Y W I T H I M P A C T: R E S O U R C E B O O K s F O R L O C A L G O V E R N M E N T