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UP Public Lectures on the Macapagal-Arroyo Presidency and Administration (2001-2004)
Twelve Herculean labors and accomplishments of the Department of Health under the Arroyo administration
By Secretary Manuel Dayrit MD, MSc, Department of Health
Under the leadership of President Gloria Macapagal-Arroyo, the Department of Health and its partners in the health sector have done unprecedented accomplishments over the last three years (February 2001 to February 2004). In this presentation, I will liken these accomplishments to the 12 labors of Hercules, Greek mythology’s greatest hero.
This presentation will show that during its term, the Arroyo administration has protected the health of Filipinos from new and emerging infections, expanded the coverage of and access to basic public health services, widened health security through greater health insurance coverage of indigents, improved the availability of quality low-priced (including half-priced) medicines throughout the country and minimized corruption in its administrative and procurement processes.
The Department of Health has been perceived favourably for its accomplishments. Independent surveys (SWS and Pulse Asia) showed consistent rankings of 1st or 2nd in public approval ratings throughout the 3-year period. In 2003, the Makati Business Club (which normally only cites agencies involved in trade, finance, the economy and banking) named the DOH one of the top 5 government agencies in 2003 because of its handling of the SARS crisis.
The accomplishments of this 3-year term must be viewed within the continuum of efforts to improve the quality of life and health status of all Filipinos. Every administration faces a specific historical situation. How it responds in the face of challenges is the grist of historical judgements made by stakeholders and beneficiaries combined.
This administration will face those judgments with both a sense of pride and humility – pride because we know we worked very hard and accomplished much given the resources available, humility because we know that so much more needs to be done and because we know we cannot succeed all by ourselves.
Let us thus begin by putting things in perspective. In the area of health, it is often said that improvement of the health status of Filipinos has slowed compared to our Asian neighbors. While we had comparable life expectancies with Thailand and South Korea at 48 years in the 1950s, the life expectancy of these countries have risen higher than ours. For example, by the 1990s, life expectancy in these countries had risen to 70 years (Thailand) and 72 years (South Korea) while ours had risen to only 65 years.
Infant mortality rate in the Philippines has fallen from 57 per 1,000 live births in 1990 to 29 in 2001 but it has fallen at a slower rate compared to Malaysia (8 per 1000, 2001), South Korea (5 per 1000, 2001) Thailand (24 per 1000, 2001), and Japan (3 per 1000, 2001). (State of the World’s Children 2003, UNICEF).
Our Maternal Mortality Rate (MMR) on the other hand has barely improved compared to other Southeast Asian nations. From 190 per 100,000 live births in 1970, our MMR has barely improved to 170 per 100,000 in 1998. We have a long way to go to reach our goal of 52 per 100,000 by 2015. In contrast note the MMR of our neighbors in 1995-2001 are: Thailand (44 per 100,000), Malaysia (41 per 100,000), South Korea (20 per 100,000), Japan (8 per 100,000). (State of the World’s Children, UNICEF, 2001)
Our population growth has averaged 2.7% through the 1970s, dropped to 2.3% in the 1980s and has remained at that level to the present. Our Medium Term Philippine Development Plan has set a target of 1.9% growth rate. In contrast, our neighbors have settled on an average of 1% growth rate in the 1990s. (Herrin 2003, Population and Development in the Philippines).
As we keep these health and population indicators in the back of our minds, let us now look at the 12 Herculean labors which the Department of Health and its partners in the health sector faced. These labors were undertaken under the following conditions: a) very limited resources i.e. government budgets in the neigborhood of 10B every year with estimated shortfalls of 1B to 2B pesos yearly depending on what needed to be accomplished. For example, unfinished infrastructure projects were estimated at 600-800M but there was no capital outlay for these. These amounts do not include other renovations requested to improve the infrastructure of devolved provincial hospitals. b) a wide-ranging re-organization of the DOH bureaucracy which had caused discontent and demoralization among certain sectors of the organization (something to be expected); c) frequent disruptions in the political scene eg. May 1, 2001 siege of Malacanang by forces loyal to ex-President Erap Estrada; repeated coup attempts, kidnappings, crisis situations – disasters (natural and man-made); d) the unexpected emergence of global infectious disease problems which caused severe economic consequences.
1. Fighting SARS and other emerging infections; Control of epidemics (Killing the Lion of Nemeia)
Like the Nemeian Lion, a beast no weapon could wound, no vaccine or drug could protect against or treat SARS infection. Over 8,000 people were affected worldwide with 800 deaths. Worst hit were countries in the Asian region. But beyond the illness that SARS wrought was the mass hysteria that led to severe consequences to business and tourism in Asian countries. SARS caused about $59B in lost business revenue in Asia – China $18B; Hong Kong $12B; Singapore $8B; South Korea $6.1B; Taiwan $4.6B; Thailand $4.5B; Malaysia $3B; Indonesia $1.9B; Philippines $600M; Vietnam $400M. (TIME Magazine, Feburuary 9, 2004).
The Philippines defended against the SARS contagion through effective epidemiological surveillance, contact tracing, quarantine of suspects, and isolation of cases. It was a massive organizational effort facilitated immensely by Executive Order 201 that designated the Health Secretary as the Crisis Manager with authority to mobilize various agencies of government to fight the entry and spread of infection.
The DOH effectively mobilized a vast array of forces to fight the SARS contagion. These included: a) the network of epidemiological surveillance units in the regions, provinces, cities and municipalities b) special SARS hospitals (Research Institute for Tropical Medicine, San Lazaro Hospital, DOH Regional Hospitals, selected private hospitals c) Immigration, quarantine and administrative staff nationwide in airports and seaports d) health and local government personnel down to the barangay level e) local and international infectious disease experts.
President Arroyo allocated a billion pesos from the Philippine Charity Sweepstakes as standby budget for the containment of SARS. Of this, 100 million was actually released to set up hospital isolation rooms in all regions, to provide personal protective equipment for health personnel and for special training of health workers.
The strategy against SARS rested on 5 pillars: 1. minimizing the entry of imported cases through monitoring and screening passengers in seaports and airports; 2. averting local transmission of cases through contract tracing, quarantine of suspects and isolation of cases; 3. preventing SARS deaths by supportive treatment in hospital; 4. public information and health advisories to control fear and panic; 5. mitigating the non-health consequences of SARS ( a task shared with other agencies like the Department of Tourism and the private sector eg. Chambers of Commerce).
The crisis lasted 5 months, from March 15, 2003 when WHO issued the global alert to mid-July 2003 when the last SARS case was reported and contained in Taiwan. The Philippines had a tally of 14 SARS cases of which 2 died, the lowest count of 30 countries affected by the disease.
The Social Weather Station (SWS) survey gave DOH a 58+ net approval rating for its effort. The President’s ratings jumped 28 points from –14 to +14 as a result of the successful handling of SARS.
Emerging infections will continue to plague us in the future. Mad cow disease, anthrax, Influenza H3N2 Fujian strain and now the avian flu virus will be constant threats. To defend against Avian Flu (H5N1) which has caused the culling of 20 million chickens in neighboring countries, we have activated similar systems as that for SARS. The Department of Agriculture has already banned importation of poultry from countries affected by the H5N1 virus and a crisis management system is also in place.
Finally in this section, the DOH has constantly been called to help control outbreaks of familiar pathogens wherever they occur. The recent waterborne cholera outbreak in Tondo which affected thousands of people was successfully controlled in cooperation of Maynila Water Services and the Manila City Government under Mayor Lito Atienza. Pseudoepidemics have also been managed effectively eg. Anthrax scare and the influenza scare in Pasig schools in 2001.
2. Controlling the spread of diseases by widening coverage of public health services (Killing the 9-headed Hydra)
Many diseases loomed large during the 3-year period just past. It was like dealing with the 9-headed Hydra whose head grew back everytime it was cut off. These diseases included: the mutant polio virus (vaccine-derived polio virus), TB, measles, dengue, cholera, HIV/AIDS, iodine deficiency, Vitamin A deficiency, smoking, lifestyle diseases including obesity, heart disease and diabetes, fireworks injuries, medical emergencies and natural disasters.
The DOH has implemented many successful programs and mass campaigns:
a) Polio Patak (Door to Door) in February and March 2002 immunized 12 million children twice over. This campaign was designed to suppress the spread of the vaccine-derived polio virus which emerged when polio immunization rates dropped in the previous two years. b) The Follow-up Measles Immunization Campaign (Door to Door) in February 2004 was designed to reach 18 million children aged 9 months to less than 8 years old. Combined with routine immunization, this campaign was designed to eliminate measles epidemics among children and to prevent child deaths. c) Iwas Paputok yearly campaigns reduced the incidence of Christmas Season and New Year’s eve injuries by over 60% from 1,200 injuries in 2001 to 500 in 2003. d) Iodized salt market monitoring campaigns and collaboration with the Salt Industry raised the household use of iodized salt from 25% in 2001 to 60-80% by 2003. This achievement was lauded by Unicef which noted that iodized salt use had languished at the 25% level for close to 10 years despite the passage of a law that mandated its use. e) TB Control reached new heights with 100% DOTS coverage of the public sector and the strengthening of the PHILCAT as the umbrella organization for TB workers nationwide. The DOH solved procurement problems for drugs making their availability reliable in the health centers. Also Executive Order No.187 signed by President. Arroyo mandated the unification of treatment protocols for TB in the public and private sectors. Currently, the Philippines is close to achieving the Global Target of 70% case detection and 85% treatment success, a feat anticipated by WHO. To secure its drug supplies, the TB program has gotten additional support from the TB Global Drug Facility of WHO and will soon be using fixed dose combinations to make patient’s compliance better. This March, another TB campaign is set to boost DOTS coverage. f) Healthy Lifestyle campaigns have been conducted yearly and in February 2003, 100,000 people exercised at the Luneta to beat the Guiness Record for Mass Aerobics. Documents are under process to made the feat official. g) Yearly Dengue control campaigns have kept the Dengue infection from escalating as it did during the 1990s. Collaborative work is continuing with St. Luke’s Hospital to monitor the prevalence of Dengue serotypes. h) Food Fortification (Vitamin A, iron and iodine) is being pursued with the commercial sector as mandated by law. i) The low prevalence of HIV/AIDS was maintained and the DOH is working to improve access to anti-retroviral medicines for persons with HIV. j) A breakthrough in the anti-tobacco campaign was also achieved with the conclusion of the negotiation for the Framework Convention on Tobacco Control and the signing of the treaty in New York in October 2003. (I signed the treaty in behalf of the Republic of the Philippines.) At around this time of the approval of the global treaty, local legislation for tobacco control was passed. k) As mandated by law, DOH has started implementing its role in screening for users of shabu and marijuana and is preparing to take over the existing drug rehabilitation centers. The President has signed an Executive Order providing 350 million pesos to manage this transition. l) A Newborn Screening Program has been passed into law which mandated the newborns be screened for congenital diseases like hypothyroidism. The DOH will be working with the University of the Philippines National Institute of Health on this.The program hopes to save about 10,000 newborn infants from congenital diseases every year. m) Financing for preventive public health services through social insurance schemes has started. Maternity packages for safe motherhood, voluntary sterilization for men and out-patient benefit packages for PhilHealth card-bearing TB patients and indigents are milestones towards the goal of improving the benefit package of PhilHealth. n) Health emergency management teams have been trained in DOH hospitals and they have been first on the scene in case of disaster and emergencies. o) Other programs like Control of Rabies and Eradication of Lymphatic Filariasis have been continuing but accomplishments have yet to be documented.
3. Half-priced medicines and other low-priced drugs (Capturing the Erymanthian Boar)
High-priced medicines were like the Erymanthian Boar which had to be trapped and captured. Several strategies were employed to do this.
First, through the GMA 50 program (Gamot na Mabisa at Abot Kaya – 50% cheaper than commercial retail prices), the DOH expanded the implementation of parallel drug importation initiated by the previous administration. Initially operating in a few hospitals with limited number of medicines worth 5 million pesos, these imports were later increased to 42 essential drugs worth 100 million pesos which were available in all 72 DOH hospitals and a few LGU hospitals. Importation of medicines were done by the Philippine International Trading Corporation. Funding was provided by the Philippine Charity Sweepstakes Office. The DOH recommended the medicines to be procured and retailed these in its hospitals so that prices could be controlled. (Subsequently re-purchases were limited to the fast moving medicines like anti-asthmatics, anti-hypertensives, and anti-diabetic agents.)
Secondly, the DOH enlisted the support of local pharmaceutical companies and invited them to consign quality, low-priced generic products in government hospitals. To ensure that only high quality medicines will be made available to the public, all prospective suppliers were pre-screened and were required to have a Certificate of Good Manufacturing Practice from the BFAD. At present, 4 local drug companies namely the United Laboratories Inc., Ashford Pharmaceuticals Laboratories Inc., Blue Sky Trading Company Inc., and Integrated Pharmaceuticals Inc., have been allowed to consign products in DOH pharmacies.
A third initiative was the promotion of generic products by the DOH through television commercials.
The fourth initiative was the widening of the distribution system for over-the-counter medicines and herbal remedies through the NFA Rolling Stores and the Botika ng Barangay. To set up a Botika ng Barangay, the prospective barangay staff are trained in the management of the botika. When the staff and physical plant have been prepared (usually a room in a barangay hall with shelves for medicines), 25,000 pesos worth of medicines are given to the barangay to sell. The barangay turns over the inventory, earns some profit from the sale, and re-orders new stocks. People are happy that they have access to low cost medicines in their barangay. In all over 500 Botika ng barangay have been established nationwide. PCSO provides money for the purchase of medicines by PITC which are turned over to the barangay. DOH supervises the setting up and regulation of these botikas. This program continues to expand with a target of 1,500 BnBs by middle of 2004.
As a result of the government’s initiatives in the pharmaceutical sector, a number of things have occurred:
a). Two drug companies, United Laboratories and Glaxo Smith Klein have put in the market a line of products 30-50% less than their regular prices. Unilab’s line is marketed as Rite Med and this started in 2002. Glaxo Smith Klein announced that it was setting by at least 30% its prices for 15 of its saleable essential medicines beginning early 2004.
b). Generics companies have become more competitive and are now providing medicines to hospitals at a price even lower than competing parallel imports.
c). In the SWS survey of the last quarter of last year, 49% of respondents who bought medicines 2 weeks before the SWS interview claimed they were able to buy low-priced medicines. Forty two percent said that they thought prices of medicines are now cheaper.
4. Expanding health insurance for indigents (Overcoming the Cretan Bull which was half monster, half bull)
Providing public health insurance to the country’s poorest was like Hercules trying to overpower the Cretan Bull (half-monster, half-bull). Even in the face of a monstrous budget shortages, insurance for indigents was relentlessly pursued by PhilHealth (Philippine Health Insurance Corporation) in response to President Gloria Macapagal-Arroyo’s July 2001 SONA pledge. President Arroyo’s pledge of enrolling 500,000 urban poor beneficiaries by the end of June 2002 served as a catalyst for the massive enlisting of half a million families (equivalent to 2.5 million individual beneficiaries). At the end of last year, there had been an 8.1 million indigents enrolled. When added to 30+ million employed members and another 1.7 individually paying member, the total percentage of Filipinos enrolled in PhilHealth is 54% as of the end of 2003.
Not content with this achievement, PhilHealth is moving to enroll another 5 million family beneficiaries (25 million people) for the first semester of 2004 to boost the drive towards universal health insurance as mandated by President Arroyo. Financial support for this has been allotted: 3 billion pesos of which 1.5 billion will comes from national government and the 1.5 billion LGU counterpart to be provided by PCSO When this is accomplished, 87% of all Filipinos will have health insurance, an accomplishment no previous administration has come close to achieving.
To increase utilization and to aid in improving access to health care facilities, the Outpatient Consultation and Diagnostic Package was added to the regular inpatient benefits. In return for enrollment of members by LGUs, PhilHealth gives capitation payments to LGUs whose rural health units are accredited with PhilHealth. These funds can be used to pay for administrative costs, drugs, medical supplies and equipment necessary to deliver the required services.
Current premium collection from the sponsored and individually paying groups in 2003 is only 58% and 42% respectively. This needs to be improved since Fund Utilization of PHIC for claims is 86% at current 4% utilization.
5. Family Planning and Population Management; Natural Family Planning (Driving away the Stymphalian Birds)
Family planning is usually seen as a tool for regulating fertility (birth control). In the 1990s it assumed a more prominent role as a tool for ensuring the health of mothers and children (birth spacing).
Like driving away the enormous number of Stymphalian birds, previous administrations have tried to decrease population growth by promoting artificial birth control methods.
The policy of the Arroyo administration regarding this issue stands on 4 pillars: 1) respect for life (no abortion) 2) responsible parenthood 3) birth spacing 4) informed choice. At the outset of its term, the Arroyo administration veered towards the promotion of natural family planning by national government. Although this policy leaves it up to the local government to promote and provide services for artificial methods which they have been doing for many years, this policy has come under attack from various groups who claim the national policy to be anti-poor and anti-women.
Recent changes in policies of USAID which will be phasing out its contraceptive donations have triggered a paradigm shift in the Family Planning Program. USAID has come to the conclusion that providing free contraceptives to the Philippines for the last 30-35 years has not met with commensurate success (the use of modern artificial methods is at disappointing 30% despite the millions of dollars spent in contraceptive donations and promotions). By tapering off its donations, USAID hopes to stimulate greater commercial participation in contraceptive supply and to target its residual donations to the very poor (this strategy is called market segmentation). From the years 2000-2004, total USAID assistance to the Family Planning Program in the Philippines is in the neighborhood of 200-240 millions.
While contraceptive prevalence rate stands at 49% (30% accounted for by artificial methods), 18% of FP practitioners use traditional methods (rhythm and withdrawal), while barely 1% claim to use natural family planning methods. While the goal of the FP program is to increase CPR in general, it specifically aims to reduce the use of the unreliable traditional methods, to increase social acceptance of modern methods, both natural and artificial. A television ad campaign is currently ongoing with USAID funding.
Perhaps the biggest accomplishment of the Arroyo administration in this area is the mainstreaming of NFP and its recent partnership with Couples for Christ (CFC) in the promotion of NFP. For the first time ever, funds were allocated to NFP through a Congressional initiative of Speaker Jose de Venecia in the amount of 50 million pesos, 15million of which has been released to CFC.
At present, the FP program is undergoing strategic re-orientation: a) President Arroyo signed an Executive Order making the Population Commission an attached agency of the DOH transferring it from NEDA b) the DOH has created a distinct Natural Family Planning Program separate from the traditional FP program whose expertise is in the area of artificial methods. Each program will have its own set of staff and resources c) the DOH is working with different stakeholders to look for ways to revitalize the program. Surveys show that while fertility rates have fallen from an average of 6 children in the 1970s, the desired family size elicited in surveys is still 3.6 children.
From a population perspective, the growth rate of 2.3% is said to be too high. The Medium Term Philippine Development Plan sets a desirable target of 1.9%. The challenge is how to make people truly committed to the spacing of births, to decreasing family size, and to improving the quality of life of the family.
6. Improving the quality of hospital services (Bringing back the belt of Hippolyta)
Because of tight budgets, DOH hospitals have had to make do with very little resources in the face of increasing demands from an ever increasing number of patients. Extracting more resources for hospitals is tantamount to the Herculean task of acquiring the precious belt from the Amazon Queen Hippolyta.
There are currently 72 DOH retained hospitals using up about 69% of the annual budget. Resources going into the hospital are derived from the national budget as well as PhilHealth reimbursements. Unfortunately, in the past, revenues made by the hospital are remitted to the national treasury and only a small proportion are returned to the hospitals to support. Fortunately, budgetary reform ha progressively allowed hospital to retain their income: 30% in 2001, 60% in 2002, and 100% in 2003 and 2004.
Under budget constraints, remarkable strides have been made to improve the quality of hospital services. This has come about with better management of the hospital as well as the careful selection of qualified and honest hospital directors. A tour of DOH hospital facilities will reveal that many hospitals have really lifted the quality of their physical plant, equipment and services by managing its revenues or through some grants/loans. Let me cite some of them:
1. Basilan General Hospital (Budget 13.7M, 2003) -- Total renovation of the hospital with assistance from Balikatan and US Military (21M) 2. Las Pinas District Hospital ( Budget 43.5M, 2003) – Construction of an Annex for hospital services worth about 10M with the help of Sen. Manuel Villar and Rep. Cynthia Villar (10M) 3. Amang Rodriguez Medical Center in Marikina (Budget 83.1M, 2003) – Completion of Hospital Renovations worth 120M with a loan from the French Government 4. Davao Regional Hospital in Tagum City (Budget 96.3M, 2003) Completion of its OPD/ER Complex as well as of its Cancer Treatment Facility costing about 40M total 5. Rizal Medical Center in Pasig (Budget 147.8M, 2003) Renovation of its lobby and ongoing renovation of its emergency room. About 10M pesos 6. Quirino Memorial Medical Center in Quezon City (Budget 146M, 2003) Renovation of its façade and lobby, construction of a new OPD/ER complex and acquisition of new equipment, about 40M pesos. 7. National Children’s Hospital in Quezon City (Budget 115.5M, 2003) Construction of new building for inpatients at a cost of 40M 8. Research Institute for Tropical Medicine in Alabang (Budget 104.5M, 2003) Construction of new isolation facilities for SARS patients, about 15M 9. Jose B. Lingad Regional Hospital in Pampanga (Budget 103.6M, 2003) Planned renovation of its old hospital structure to cost 80M. 10. Western Visayas Medical Center in Iloilo (Budget 148.8M, 2003) – Renovation of its administrative offices after it was damaged by fire, and construction of a new OPD complex, about 20M 11. Zamoboanga City Medical Center (Budget 121.8M, 2003) Construction of a new building for its CAT scan, completion of its facility for cobalt treatment and completion of the Spanish loan for hospital equipment 160M. A new construction for rehabilitation of disabled persons and provision of prosthetic limbs is being built with a donation of 5M from the Tzu Chi Foundation. 12. Baguio General Hospital and Medical Center in Baguio City (187M, 2003) Repair of its operation facilities damaged by landslide and construction of a building for in-patients with the assistance of Sen. Juan Flavier (About 65M total) 13. Davao Medical Center (Budget 191M, 2003) Construction of a brand new OPD/ER facility with a JICA grant of 700M. 14. Jose Reyes Memorial Medical Center in Manila (Budget 284M, 2003) Construction of new dormitory facilities about 10M 15. San Lazaro Hopital in Manila (Budget 268M, 2003) and all Regional Hospitals Construction of SARS isolation facilities worth at least 1.5M each.
Finally, most DOH hospitals have also invested in improving their pharmacies and their operations for retailing of medicines in order to provide half-priced medicines to the public. This has been a major change since in the past the hospital pharmacy only catered to in-patients. Now the hospital pharmacy is a major center for revenue generation.
7. Cleaning up against Corruption (Cleaning the Augean stables)
Many corrupt practices in government happen during the procurement process. These anomalies could occur at various stages of the procurement process: from the definition of the specifications for the material to be procured, the actual bidding process, the final awarding of bids to suppliers, the delivery and inspection of the goods, and the payment of the supplier. Solving the problem of corruption was like cleaning the Augean Stable.
In October of 2001, President Arroyo signed Executive Order No. 40 consolidating procurement rules and procedures for all national government agencies, government-owned or controlled corporations and government financial institutions, and requiring the use of the government electronic procurement system.
This E.O. institutionalized the Bids and Awards Committee from a mere Ad Hoc group. E.O. 40 was superseded by RA 9184 which rationalized procurement process and put in place institutional safeguards and reforms.
Every year, the DOH central office procures approximately P300 million of essential drugs and vaccines. Through reforms in the procurement process, the department was able to save between 20 to 25% in its allocation for these medicines. There are also medicines being procured through international entities like UNICEF and WHO. The involvement of non-government organizations as observers in the bidding process has also minimized corruption in the Department. A system to monitor prices of medicines has also been established to provide information on market trends as well as to provide information/guidance to the bidding process.
Lifestyle checks have also been conducted for officials of the DOH and so far no one has been found to have unexplained wealth.
In a SWS survey from 2002-2003, the DOH was cited by the Department of Budget and Management for its efforts in fighting corruption.
8. Managing the Bureaucracy for Efficiency and Effectiveness and achievement of the Millenium Development Goals (Rounding up the Mares of Diomedes)
The devolution of health services and the subsequent streamlining and reorganizations of the bureaucracy from 1992 to 2000, have had mixed results in achieving their intent of a lean and mean bureaucracy. When the Arroyo administration took over in 2001, it inherited a fourth incompleted reorganization which had left many in the DOH confused and angry. A court case had been filed by disgruntled DOH employees known as MEWAP to reverse the reorganization began in 2000. Efforts to stabilize the DOH and to focus its energy in productive pursuits was like rounding up the Mares of Diomedes.
To stabilize the organization, the reorganization was suspended and the legitimate grievances of staff were addressed. Although MEWAP employees still refuse to be re-assigned pending final resolution of their cases, the DOH has prevented any escalation of the issue and has since moved on to productive pursuits.
In order to improve efficiency of operation, an administrative order calling for the implementation of One Script Program was issued. This program was designed to focus the efforts of the bureaucracy on fewer priority programs and to ensure better coaching of implementers and monitoring of operations.
The DOH worked to define and specify more outcome-oriented performance indicators for which it can be held accountable. The results of these efforts are detailed in the accomplishments already discussed in the previous sections.
The One Script Program resonated with the WHO’s report on Investing on Health and Economic Development which called on all stakeholders to participate in achieving priority programs for public health. These included among others: program for low-priced medicines, health insurance for indigents, TB, malaria, HIV/AIDS, rabies control, EPI, micronutrient supplementation and food fortification, safe motherhood and family planning, and healthy lifestyles
Since the DOH is not spared from budget cuts, a social expenditure management loan from the World Bank was made so that logistics of priority programs of TB, EPI, and rabies vaccine would be protected from the government’s budget deficit reduction program.
Looking ahead, national commitments must be matched with corresponding infusion of domestic funds of about P2 billion annually and donor investments of about the same amount, focused on priority programs, if the Millenium Development Goals (see Annex) are to be attained.
9. Developing Human Resources and dealing with the migration of health workers ( Bringing back the golden apples of Hesperides)
Our trained health personnel might be compared to the golden apples of Hesperides which we need to put in the service of the nation even as they seek greener opportunities elsewhere. Three items are presented here.
First, The Department of Health has built on the Doctors to the Barrio program (DTTB) by launching a project with the Ateneo School of Government and Pfizer called the Leader for Health Project (LHP).. Now on its second year of implementation, the LHP seeks to develop the leadership potential and technical skills of committed physicians by deploying them in communities where working with local chief executives, local leaders, and NGOs, they can create new development initiatives in close collaboration with their partners.
The concept goes beyond the initial vision of the DTTB of fielding a doctor to a doctorless area to provide medical services. (Since the program began 10 years ago, the DOH has been able to deploy 410 doctors to poor municipalities. Oftentimes however, the doctor whose salary is fully supported by national government has become viewed as a hand-out from national government and a reason for local government to no longer invest local resources for health. Thus, when the physician leaves, the local health system is back to its original state since no local capacity was built up.
After LHP training, initially conceived to be 2 years but now being re-designed for 4 years, th physician gets a Masters of Health Care from Ateneo University (MBA for Health).
Second, the DOH strives to place qualified and honest people in key pots of directors and hospital chiefs. The placement of unqualified political appointees has been stopped. Charges have been filed against erring officials and people have actually been removed from office if found guilty. (I will not cite any specific examples here for obvious reasons.). The effective and efficient management of hospitals and DOH units is testimony to the work of these fine people.
Third, the exodus of nurses and the shift of physicians into the nursing profession in order to find jobs abroad is a cause for concern. Records from the labor department show that at least 2,000 of our medical workers leave the country every month to become foreign workers. While there is no law preventing our people from migrating abroad, their leaving caused shortage of experienced and skilled health staff particularly in our tertiary hospitals. The trend is expected to continue considering that the United States and European countries are expected to increase their demand for foreign health workers over the next 10 years.
To manage this exodus and re-entry of health workers, the DOH is working with UPNIH, DOLE, DFA, CHED, and the nursing schools and the nursing associations to find strategic short and long-term solutions to this phenomenon. Also the Department of Health is working with the Dutch government so that the deployment to Holland and future re-entry of returning health workers can be managed cogently
10. Managing the devolved health system and focusing services to the poor (Herding the cattle of Geryon)
Part of Health Sector Reform, managing the devolved system and targetting services to the poor for equity considerations has been like herding the three-headed Cattle of Geryon into converging directions. Let me provide three areas for discussion.
First, through establishing Inter-Local Health Zones (known in the past as the District Health System), the DOH has brokered the convergence and integration of preventive and curative services among various municipal governments and the provincial governments. This is a strategic approach to repair the fragmentation of health services as a result of the devolution. This strategy has proven to work in 31 pilot provincial areas and it includes components like: health insurance for indigents, procurement of medicines, support for the district hospital, and provision of basic public health services.
Second, through the Sentrong Sigla program, DOH has developed a quality assurance program for health centers. DOH re-created Sentrong Sigla from an input indicator- oriented quality assurance program (eg. availability of certain types of equipment as a basis for measuring quality of service) to a systems-oriented (input-process-output-outcome) quality assurance paradigm. From 1998 to 2003 there were 1,390 Sentrong Sigla certified regional health units, municipality and city health centers out of their total number of 2,405. Today, Sentrong Sigla certification means that a certain health facility has passed rigorous standards set by the DOH.
Third, under the leadership of President Arroyo, the KALAHI program was established to provide direct medical services to blighted communities. Close to three thousand patients were provided medical and surgical services through this mechanism. Also, the recent initiative to provide potable water in waterless barangays is being scaled up in urban areas starting with MetroManila.
11. Foreign Assistance and International Health (Bringing Cerberus, the 3-headed dog up from Hades)
By rationalizing its system for managing foreign-assisted projects, the DOH slew a confusing multi-headed system of project management which caused much inefficiency and failure in the management of projects. It was like raising the 3-headed Cerberus from Hades. Now there is a Unified Project Management Office which works even if severely overworked, and an Undersecretary who has oversight for foreign-assisted projects.
1. We have been able to acquire critical foreign grants for the implementation of critical disease control programs: For example, US$7.8M worth of measles vaccine for the Ligtas Tigdas Measles Elimination campaign for 2004.
2. Lessons learned form the management of past projects have been used to improve the management of on going projects including the Spanish loan, the Austrian loan, loans form the World Bank and Asian Development Bank.
3. We have gotten grants from the Global Fund for AIDS, TB, and Malaria to supplement our domestic resources.
4. We have gotten access to the Global Drug Facility for TB for new fixed-dose combinations of TB medications.
Finally, our participation in the Executive Board of the World Health Organization as well as in the World Health Assembly has earned us recognition from our international colleagues.
12. Revitalizing Health Research (Capturing the Cerynitian Hind or stag with the golden horns)
Several facilities of the DOH is involved in research. The Research Institue of Tropical Medicine has been doing research for H. influenza vaccine with Finnish scientists. Called the ARIVAC project, the research has shown promise.
The DOH is trying to capture the golden-horned stag of research by partnering with DOST and UP-NIH and other stakeholders (called the Philippine National Research System of PNRS) to constantly fine-tune research priorities and make maximum use of meager research funds.
At present, DOH provides some grant money to academics and professional groups of needed research activities. The survey on cardiovascular diseases undertaken by the FNRI in collaboration with the Philippine Heart Association is a case in point.
Expansion of clinical trials to document the therapeutic efficacy of coconut oil and monolaurin for infectious diseases like HIV/AIDS, drug-resistant TB, and leprosy is being planned.
Conclusion
Perhaps the biggest single legacy of the Arroyo administration in the area of Health and Population is Good Governance in the face of tight budgets, emerging infections, and attempts at political de-stabilization. In the face of all this, the Arroyo administration actually continued and expanded the scope and quality of health services, widened health insurance, made medicines more affordable, and minimized corruption.
As we scan the future, and ponder the targets of the Millenium Development Goals (See Annex), the following imperatives need to be addressed:
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