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
(Editors Note: below this article are the responses to it.)
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.
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:
- We need to increase investments in health at all levels of the health system. While this administration did well under severe budgetary constraints, additional resources managed well provide the promise of greater gains in health status and outcomes. An additional 1-2 billion pesos a year to improve health infrastructure, provide benefits to health workers (particularly the Magna Carta benefits which have been legislated) and fund operations will be ideal.
- We must continue to invest to build the capacities of our health human resources. The nation’s public health and hospital system must be managed by people totally committed to the welfare of our people, properly trained and equipped, closely in-touch with each other, and well supervised. We must invest in building leaders in the various areas of the health system.
- We must come to terms amongst ourselves in the most controversial areas governing family planning and population growth. The policy articulated by the Arroyo administration has given rise to working relationships with groups that would not normally support government’s family planning policies. And yet the policy does not prevent action by local governments and the private sector in widening the scope of family planning services which people may desire within the boundaries of the law. In the final analysis, programs for poverty reduction, better education of men and women, job opportunities must all act in synergy to improve the quality of family life and the progress of society.
Response of the Non-Government Organization Sector to the Public Lecture of DOH Sec.Manuel M.Dayrit on Health and Population
by Eleanor A. Jara, M.D.
February 27, 2004
College of Nursing Auditorium
University of the Philippines – Manila
Greek mythologies are often replete with tragedies. Tragedies that would never have occurred if not for the whims and caprices of the gods and goddesses of Mt. Olympus. Tragedies that shouldn’t have come to pass, if only they cared enough to leave their lofty palace and mingled with ordinary mortals.
As a community-based health program practitioner, I am well aware that the people’s health is far from improving. Aside from the prevailing socio-economic and political conditions in the country, the lack of genuine pro-people government health policies spell doom for the people. Secretary Manuel Dayrit’s speech proved that if there’s one thing the Department of Health is good at, it is in producing technical papers that could impress technocrats and professionals alike. However, whether the contents of his speech actually do good to the people remain debatable.
While Sec. Dayrit harped on the government’s alleged major achievements while keeping mum on the government’s health policy frameworks, we in the NGO community based health programs (CBHPs) throughout the country could cite countless specific instances to prove our assertion that the people’s health continues to worsen. Secretary Dayrit mentioned that under President Gloria Macapagal-Arroyo’s administration, the Department of Health and the private sector have unified their TB treatment protocols. But what does it mean for the thousands of TB patients who haven’t received treatment yet? Or haven’t even been diagnosed? The World Health Organization’s 2002 report said that the Philippines has the 7th highest TB rate in the world and the 2nd highest number of new cases in the Western Pacific region. The high occurrence of TB in the country is due in part to the inaction of the government. A study conducted by international TB expert Dr. John Peabody found that only 45 percent of cases are diagnosed, while only 38 percent of cases get treated in our country.
TB is one of the top killer diseases in this country, yet the government’s actions against it remains inadequate, to say the least. It is no wonder then that other communicable diseases remain as rampant as ever. A few years ago, a measles epidemic struck Mangyan communities in Oriental Mindoro. In one tribe, out of 25 children, only one survived. When this happened, government doctors from the province were nowhere in sight. It was through the efforts of people’s organizations and other concerned doctors and individuals that medical relief missions were held in some of the affected areas. Less than two months ago, another 25 indigenous children died of measles in Mindanao.
Amidst the worsening health conditions of the people, health services remain beyond the reach of the majority of Filipinos. Instead of allotting a bigger budget for health, the health allotment even decreases. The government has even institutionalized the collection of fees for service, medicines, diagnostic tests and supplies in government hospitals. The Health Sector Reform Agenda, coupled with the devolution of health care, are virtual Pandora’s boxes that bring more deaths and hardships to an already sick population. The Department of Health itself admitted that eight out of ten Filipinos cannot afford the health care they need. At the Philippine Heart Center for example, a transplant costs P300,000. Charity patients needing transplants have to wait for six months to three years. Many die before their turn comes.
The government said that PhilHealth would help ordinary Filipinos cope with the continuing commercialization of health care. But who pays for the premiums? As it is, the people cannot even afford to buy their basic needs. Even if they could pay for the premiums, the coverage of the PhilHealth is not enough to offset the costs of health services. Sources from the DOH said that PhilHealth covers only 30 percent of the health care costs of an insured person. For every P1 contribution, only 22 centavos go for the actual health care expenses.
When the provision of health services was devolved to local government units, the national government reasoned out that it would make health policies more responsive to the people’s needs. Today, the opposite is happening. In Isabela, Governor Faustino Dy Jr closed down ten health centers, affecting more than 300,000 residents from 164 barangays and 18 towns. The closure quickly resulted in the death of a young mother who died of hemorrhage due to placental retention. Since the nearest hospital where the woman lived was closed down, she was brought to the Provincial Hospital 35 kilometers away from her home. How many more suffer the same fate?
These incidences are just some of the realities that our brothers and sisters are forced to bear. In this regard, the Philippine health situation is very much like a Greek tragedy. The comparison ends there, however. Unlike Greek tragedies, our tragedies are all too real. Greek tragedies teach us about human foibles and the vanities of the gods and goddesses. Our tragedies teach us about the follies of government politicians and technocrats. Comfortable in their lofty positions, government officials refuse to acknowledge and feel the gravity of the health situation, as how ordinary mortals feel and experience it. Coupled with the prevailing socio-economic and political mess we are in, the prognosis of the people’s health remains grim.
To say otherwise would be to perpetuate the myth that the people’s health situation is improving.
To insist otherwise would be to turn lies to truth.
Dr.Jara is the executive director of the Council for Health and Development, the national organization of community-based health programs (CBHP). Since its inception 30 years ago, thousands of community members have received health trainings to become community health workers.
THE FUNDAMENTALS IN HEALTH AND FUNDAMENTALISM IN POPULATION POLICY Reaction to DOH Secretary Manuel Dayrit’s Assessment on Health and Population
Professor Roland G. Simbulan
Vice Chancellor for Planning and Development
I have titled my response to Secretary Manuel Dayrit’s assessment of the Department of Health’s accomplishments under the Arroyo government as “The Fundamentals in Health and Fundamentalism in Population Policy”.
The Politization of Health Services
I am quite distressed that healthcare services, in reference to DOH programs with acronyms like GMA 50(Gamot na Mabisa at Abot Kaya) or PhilHealth’s GMA 500 have become part of the national patronage system to magnify the personal power of the incumbent president. It cheapens the dignity of our healthcare system and its workers when they are made to peddle political gimmicks like the National Food Authority’s GLORIA LABANDERA mobile foodstalls.
This “you-owe-me” message sends the signal that beneficiaries of DOH programs are feudal subjects dependent on the personal benevolence of the sovereign monarch, rather than as citizens with formal rights to health care and services. Let us remind ourselves that the resources the president gives away do not personally belong to her; the citizens do not receive the benefits that come their way as private favors but as entitlements under a system of law defining the relationship between public authorities and citizens. To proclaim public programs and projects as the personal achievement of any public official is to degenerate to a form of patrimonial governance that allows the personal exploitation of the means of administration. It is not good governance, for it politicizes even health care services that can become unsustainable if a new
administration comes into power. At worse, this political habit treats the fulfillment of our people’s basic needs as conditional on the personal benevolence of elected officials.
Prioritizing Health and Social Services
The trends in the national budget do not reflect the pronounced constitutional and national priorities for health and other basic social services, even in the context of limited financial resources. Despite budgetary deficits, I submit that the country’s limited finances should prioritize social services. This country should look at the Cuban model even alone for the priority it gives to its health care system, which is considered as one of the best among developing countries. Last month, I had the privilege of listening to the lecture in UP Diliman of the Cuban Foreign Minister Felipe Perez Roque who discussed Cuba’s social expenditures for 2004. Despite the continued economic, commercial and financial blockade and embargo by its superpower neighbor, the United States, Cuba earmarked 59% of its 2004 budget for education, public health, social security and welfare, culture and housing and community services, accounting for 37% of Cuba’s GDP. Cuba’s local pharmaceutical industry produces 67% of the medications required in its healthcare system.
It would be useful to reflect on the chronic budgetary discrepancy in the Philippines’ National Expenditures Program for the past three years. Together with debt service (both interest and principal amortization), the defense budget has one of the highest growth rates in the national government’s expenditure program. From 2003 to 2004, debt interest payment grew by 24% and principal debt amortization grew by 13.3% while defense grew by 6.4%. In contrast, appropriations for social services even decreased by 5% from the 2003 appropriations. Thus, while the government will be spending about P109,589,041 everyday for defense in 2004, it will be spending only P0.43 per person daily for health and P9.40 for each public elementary and high school student daily. What the government considers as priorities in both the budget and its development plan can only be too obvious.
The Big Picture: Globalization and the
Commodification of Health Services
The country’s ailing health care system has consistently been experiencing budgetary cuts. These budgetary cuts are not only the result of the lesser priority given to basic services compared to the increasing debt servicing and defense expenditures. It is also in line with the policy dictates of the IMF-World Bank to reorient the bureaucracy towards privatization and to implement austerity programs to ensure debt servicing. In the Philippine Memorandum of Intent for IMF Loan Structural Reforms, titled Memoranda of Economic and Financial Policies of the Philippine Government, March 11, 1998, it is stated in Sec. 27 that:
“We will endeavor to move forward the Government Re-engineering Program which was initiated in 1994…We expect the reduction in staffing will result from the merger or abolition of redundant agencies, the devolution of activities and programs of local government, and the further privatization of public services…”
Translated in real terms, the World Bank’s policies include cutbacks in government spending on health, thus leaving the responsibility of health care to the person who needs the service and privatization of medical and health care services by transferring government services, which in the past were subsidized, to big business.
Now we should watch out how the Health Sector Reform Agenda is being implemented in the context of the thrust and orientation as spelled out by our government’s commitment to the IMF-World Bank’s structural reforms.
On the issue of management and financial efficiency, while it is true that, according to Sec. Dayrit, “ In a SWS survey from 2002-2003, the DOH was named as the 3rd government office that is sincere in fighting corruption”, it still has a long way to go. According to the Philippine Center for Investigative Journalism(PCIJ) in their book INVESTIGATING CORRUPTION(2002):
“Results of surveys by Social Weather Stations appear to support the perception that the DPWH, Department of Education and the Department of Health, which get huge slices of the national government’s annual procurement pie, consistently appear on the list of government agencies perceived by citizens to be among the most corrupt.” It is disturbing to note that the private enterprises which SWS polled confirm that business firms set aside an average of 19% of the contracts they get from the government for bribes or kickbacks, according to the PCIJ.
Need to Develop Local Pharmaceutical Industries
The DOH must help develop a local pharmaceutical industry that will have the capability of producing pharmaceutical chemicals and intermediate active ingredients for local manufacture, thus reducing the country’s dependence on imported drugs and foreign companies which dominate and hold a 70% share in the local market. Full support must be given to local companies manufacturing generic products so that every Filipino can gain access to safe, effective and affordable drugs.
Global Marketization of Health Workers
The Department of Health does not seem to have any mechanism or master plan to manage the very serious brain drain of our health and medical practitioners to other countries. I was looking for this in the report, even as the DOH recognizes this problem which has intensified even more in recent years. In fact, we get the impression that the global marketization of Filipino health workers has become even a policy of the national government, with the proliferation of nursing schools, now numbering more than 140. Our entry into the General Agreement on Trade and Tariffs(GATT) which GMA sponsored when she was senator has now made not only our basic services market-driven, but the training and education of our health workers as well. All this at the expense of the national health care system.
The Devolution Issue
I beg to disagree with the idea that devolution is the culprit for the mess that the health care delivery system now finds itself in. This is not the issue here. The issue is the patronage system and the politization of our basic services whether on the national or local level.
The New Local Government Code was precisely legislated so that local authorities can play a key role in making sustainable development activities happen, since many of the problems facing the country have their roots in local activities. Local authorities have the advantage of being the arm of government closest to the people. They should therefore play a vital role in educating and mobilizing the public and local communities around sustainable health programs. My problem with devolution is that, in implementing the IMF’s wishes, devolution has only conformed to the cost-cutting measures and revenue-enhancing programs of the government. Revenue-enhancing programs wherein poor patients are made to pay for services such as blood pressure taking, room and linen use, hospital food and even immunization. The local government code now allows LGUs to involve private corporations in the maintenance and operation of local hospitals which were once run by the Department of Health. More and more, under this set-up, big business is being given the primary role in the production and provision of basic services like health. It diminishes the role of the national government from being the main provider of health care services to that of being a mere health regulator.
What we fundamentally need is an administration that is firmly committed to improve significantly the access of the population to basic social services through substantial increases in the national appropriation for these purposes and mobilization of support from the private sector, particularly local communities, NGOs and business groups.
The government must affirm that health is a basic human right, and that family planning, nutrition and sanitation are necessary conditions for good health. Government must see to it that the delivery of health services is community-based and flexible enough to respond to the different needs of particular communities. First priority should be given to primary health care, preventive measures against communicable diseases and malnutrition, and basic sanitation. The cooperation of local NGOs, civic societies and sectoral groups can be most easily enlisted in these tasks, resulting in savings of government funds and manpower. These community resources should also be involved in monitoring and evaluating program implementation in their communities.
“Fundamentalism” in our Population Policy
What is described as “natural family planning methods” or “responsible parenthood” is actually a safe but weak means of implementing a population program that refuses to antagonize the No. 1 opposition to family planning, the Roman Catholic Church. Studies have shown and proven that this has a very poor success rate in terms of birth control. The fear of the Church and the strong influence of the Church have stunted the country’s population policy which has remained in the realm of demography studies and research. This is why the Philippines still has one of the highest annual population growth rates in Asia. Ask the women’s groups and those involved in reproductive health advocacy and they will describe our population policy as toeing the Roman Catholic Church’s “fundamentalism” when it comes to reproductive health and family planning issues.
Adequate Health Services Remain Inaccessible to the Poor
Whatever claims government makes to the contrary, more families at the bottom of the social strata still consider health care a luxury instead of a basic necessity. The poor will more likely have far worse health outcomes in the coming days as a result of mass layoffs of industries and the spiraling costs of living. More notable is the fact that poverty-related diseases are still the main source of illness among Filipinos, despite the much-daunted economic growth in our newspapers. Indeed, the main indicator of development, which is health status, demonstrates how far the country is from real and genuine progress. All of which goes to show that administration claims to having markedly improved the health of Filipinos are nothing more than what Hercules, the Nemean lion, Cerberus, and the other characters mentioned truly are. They are a myth.
And while we do not doubt the dedication and patriotism of our health workers who have chosen to serve this country, we cannot ignore the shortcomings of government in addressing health care problems. The effort made by health workers have indeed been Herculean; in contrast, the Arroyo administration’s support for health care has been Lilliputian. And now, in election season, let us not be misled by the Medusas in our midst, lest they mesmerize us and turn us – and our hearts – into stone.
A reaction to the Secretary of Health’s speech on the so-called accomplishments of the DoH under the Arroyo administration
By Dr. Edgardo N. Clemente, General and Cancer Surgeon
Upon receiving the speech entitled “A Herculean labor and the triumph of a three-year regime: the Department of Health under the Arroyo administration”, I was really impressed by such a beautiful title. Imagine selecting parallels to Greek mythology and comparing the difficult tasks of the DoH to that of Hercules.
Certainly the speechwriter or speechwriters must come from a highly educated and select circle, the type that comprises products of the University of the Philippines. It is a great honor indeed to be able to present my reaction to the Health Secretary’s speech to this distinguished audience.
I tried long and hard to dig into my college education in U.P. Diliman to find certain lessons and answers that I can use to react, support or demolish the DoH official position paper on its alleged accomplishments. Since 2004 is presidential election year, the term of President Gloria Macapagal Arroyo may end or if elected to serve another six years, the current Health Secretary may be changed. In other words, the previously read paper could be the valedictory address of a DoH Secretary. Should the current DOH Secretary’s appointment extend beyond 2004, then this analysis would cover only the first semester or trimester of his stay in office.
Due to time limitations and lack of expertise on certain areas covered, I would limit myself to giving comments to only a few of the twelve points covered.
Comments on the Introduction – The fallacy of comparing apples and oranges
The DoH starts with the use of the words “achieved major targets, particularly in the health sector”, “its contribution to the quality of life of Filipinos”, and “it contributes directly to the capacity of the human resources in the country by improving the health status of Filipinos, protecting them from excessive costs in attaining desired health and providing client satisfaction.”
To prove its point the DoH speech enumerated the improvements in vital health indicators such as infant, under-five and maternal mortality rates. While it concedes that the gains were modest, the introduction ends with the words “During its 3-year term the GMA administration is proud to say that it was able to deliver vital services and improve the quality of health in the country”.
Excuse me, I beg your pardon. Speeches made for a U.P. audience should be well crafted since supposedly intelligent students see through errors in grammar, logic and reasoning. The speech cited vital health indicators and their improvements from 1990 to 1998 but the coverage of the speech should include only 2001, 2002 and 2003 since the Arroyo administration only took power in 2001. Remember EDSA II. Therefore the improvement cited should rightfully be credited to the latter part of the Aquino administration (990-1991) and the whole of the Ramos administration (1992-1998). Strictly speaking we should even include the Estrada administration since he was President in the second half of 1998.
Nowhere are the cited statistics anywhere near 2001 when President Arroyo assumed office. The speech should instead use the 2001, 2002, and 2003 statistics if the DoH wants us to believe that indeed there were health indicator improvement during the Macapagal administration. Such lapse in logic is unpardonable. This can only be due to a major booboo, intellectual dishonesty, a subtle attempt at credit grabbing or a genuine effort to mislead the public by citing statistics not relevant to the timeframe of the speech in question.
Since the conclusions cited in the introduction are already flawed, I am hoping that the body of the speech is a little bit more grounded in reality.
Point Number 1: The SARS Scare – Nice try but no cigar
The main argument of the DoH is that it was instrumental in containing the SARS outbreak in the Philippines. Citing all their efforts to contain the disease, the DoH now claims to the high heavens that, in their own words, their Herculean interventions topped the spread of SARS in its tracks.
Now forgotten is the fact that during the early days of the SARS outbreak, the DoH and the Department of Tourism actually invited foreign tourists to visit our shores because the Philippines was still SARS-free. This was a naïve call since tourists then in Mainland China and Hong Kong who would have cut short their visits there could have proceeded to the Philippines to complete their overseas vacation trips. Had some of them been exposed to SARS and were still in the incubation phase and not yet symptomatic, they could have been the carriers of the disease to our country. Such a misplaced call is unprecedented in the annals of the study of public hygiene and sanitation. While the error was understandable from the side of the Tourism Secretary due to lack of technical understanding and capacity, for the Health Secretary to blindly follow the then administration line could have resulted in a health disaster. A lower DoH official was correct in stating that over and above all factors considered, the Philippines was just lucky to have dodged the bullet, in spite of our gross mishandling of the situation.
The audience should also be informed that there were reported major breaks in the manner that isolation techniques were handled in the Regional Institute for Tropical Medicine. The barangay or barrio that was quarantined also reported major violations in which the resident under observation freely traveled to adjoining neighborhoods. The Philippines was lucky indeed. I just do not know how gross incompetence could be repackaged as a major achievement. Nazi Germany’s concept that a lie told a thousand times could be mistaken as the truth somehow has a ring of truth in it.
Since the DoH enumerated the SARS Scare as its number one achievement, I can only say that this a classic example of “claiming victories where there are none”. I just hope we have learned from the situation to the point that when another similar problem crops up we can react better next time.
Point Number Two: Public Health Reforms – Please define your assumptions
My attention was drawn to the Patak Polio campaign, which in 2002 was reported to have had a 98.8% to 102% success rate. Such figures are only found in Cuban presidential elections or Iraq when Saddam Hussein was still in power. U.P. students are trained to be critical in their analysis and a healthy dose of skepticism is part and parcel of an education in natural and biological sciences.
The 98.8% to 102% figure, if left unqualified could only mean that the whole Philippines was adequately immunized for polio probably within a certain age group among children. A country that has universal protection against polio is certainly one that has to be applauded and praised. My only problem is that I live in Quezon City with a significant squatter population and huge concentrations of urban poor. Since I do a lot of walking as an exercise I am able to engage dozens of poor families in small talk in the course of these trips. Few of them seem to remember any anti-polio medications for their children. Using the DoH lower value of 98.8% polio vaccination, is it possible that the DoH program missed many children in our city, thus becoming part of 1.2% of children not immunized nationally? How about children in remote areas where there are no roads, there are ongoing rebellions, and there are no health workers to speak of?
In effect, I am wondering as to what is the target population on which the polio immunization statistics were derived. Does the DoH mean the whole Philippines? Does the DoH mean certain targeted communities only, thus leaving significant numbers of our population unprotected from polio? Assuming the universal polio immunization scenario, then we have nothing to worry about. If the target population only refers to significant areas identified by the DoH, then there is still much work to be done. In the meantime, the DoH reaps awards and citations, when in fact if the second scenario is closer to the truth, we may have to adjust our inflated statistics downward or drastically qualify the existing ones.
Point Number 3: PhilHealth – Degenerating into a political campaign office
The Philippine Health Insurance Corporation Law of 1995 is an improvement over the old 1970 Medicare Law. The revision was made to further add teeth to the aim of universal coverage. Since the PHIC Law took effect in 1997, there has been a progressive increase in the membership as envisioned by the new law. To start with, about six million members of the Social Security System (private sector) and one million members of the Government Service Insurance System (public sector), representing about thirty-five million beneficiaries, formed the initial bulk of PhilHealth. This figure has progressively increased with the inclusion of individually paying members and subsidized indigent members. No special call or order was necessary for the PHIC to fulfill its mandate. The concerted effort of the DoH and PHIC to project a massive recruitment program is premised only on the ability to churn numbers for public relations consumption. During this presidential campaign, PHIC cards are given away to indigents in an attempt to entice them to vote for the incumbent president. This is very obvious with the GMA cards that stand for Greater Medicare Access, a play on the presidential initials. To emphasize my point of a political agenda, the picture of the sitting president is prominently displayed in the PHIC indigent cards. This campaign gimmickry and antics are cheap tricks to generate votes come May 10. The basic problem with this is that the PHIC should be insulated from politics so as to maintain its character as a professional organization. The blatant attempt to float the figures of 5 million family beneficiaries involving twenty-five million people are numbers that are picked out from thin air but may give potential voters some hope and therefore translate to votes for the administration. The administration shows signs of panic and desperation when they have to project progressively higher quantitative targets that they need not even have to fulfill should they be kicked out of office in May.
Point Number 4: Half-priced medicines – Buy them from your newspapers
In my columns from the Business World, I have always emphasized my support for government moves to lower the prices of medicines. The parallel importation program espoused and piloted by the Department of Trade was and still is a step in the right direction. While it is true that massive importations of life-saving drugs can depress the prices in the market, the DTI importations amounted to only to hundreds of millions of pesos while the annual Philippine gross sales is in the more than sixty billion pesos a year level. In other words, the DoH is able to monitor the reduction in prices only while the stocks are in the market. Once the newly imported stocks are consumed, the drug prices manage to get up again. So while it is true that the DoH and DTI were indeed able to show that the prices of medicines can come down, the volume of imports is so small compared to the total needs that the drop in medicine prices are transient and temporary. As the saying goes, “Buy them while the supplies last”. Unfortunately overall most drug prices have gone up within the last three years brought about by the depreciating peso since most medicines or their components for manufacture are imported.
The DoH has started to believe their own press release sin an effort to claim still further victories during their watch. The operational law here is nothing but the Law of Supply and Demand and since the DoH/DTI efforts are minimal, the small drops in prices that they are able to monitor are soon overwhelmed by the realities of increasing energy, labor, transportation and other costs on top of rising inflation and depreciating peso. Discerning consumers laugh at DoH statistics. Since most of the low priced medicines are only read in the newspapers but seldom seen in the real market place, the joke is for the buying public to purchase their medicines from the newspaper offices.
Point Number 5: Family Planning – A policy of abdication
The cute administration of President Arroyo came up with what it considers a Solomonic solution to the family planning problem, a truly contentious issue indeed. Called natural family planning, the program goes to the root causes of poverty and unemployment to solve the rise in population that has gone out of control. Any high school student who has taken up what during our time was called social studies knows that. The very lessons of Mathus are that the rise in population is geometric while the increase in available resources is arithmetical in progression. The very essence of the family planning program is to buy time by reducing the number of mouths to feed. In truth, the current DoH family planning program is a cop-out. The DoH does not have to do anything about controlling the population since resolving the poverty and unemployment issues would ultimately solve the population problem. As if poverty and unemployment can be solved without reducing the population rate increase. I believe the underlying reason for the DoH soft stance on population planning is to avoid a frontal clash with the powerful Catholic Church. In allowing the government’s family planning program to wither in the vine, the DoH showed weakness, indecisiveness and lack of firm leadership.
Point Number 6: Hospital Reforms – Killing them softly
The number one problem of most Philippine hospitals today is how to deal with the government bureaucracy specifically PhilHealth red tape. Hospitals and PHIC patients spend billions of pesos trying to comply with fluctuating rules and regulations when filing for PHIC reimbursements. Paper requirements in the form of birth certificates, payment records, hospital bills, employment status and the like keep an army of PHIC reimbursement hopefuls shunting from their places of work, hometowns, hospitals and PHIC offices in the never ending task of trying to comply or fulfill the fickle requirements needed to file a hospitalization reimbursement claim.
In closing I agree with the Health Secretary’s speech on the “Herculean labor” part of the title but I would certainly dispute the use of the word “triumph” in that same title. Using “mediocrity” or “making a mountain out of a molehill” would have been more appropriate. I read the speech over and over and really tried to look for the so-called accomplishments but I have yet to find them. Of course, I appreciate the reference to Hercules, it was really highly informative. So as not to leave the audience with a feeling of emptiness with regards to some literary masterpiece, I have brushed up on my Shakespeare to come up with an appropriate quote for the occasion. With your permission, I would like to entitle this piece, “Much Ado About Nothing”.
The date posted here is due to our website rebuild, it does not reflect the original date this article was posted. This article was originally posted in Yonip in Mar 11th 2004