Health Systems and the Philippine Health Care System

1. AN INTRODUCTION TO HEALTH
SYSTEMS
An Overview of the Philippine Health Care System
and Health Systems Thinking
Paolo Victor N. Medina, M.D.
Assistant Professor for Community Medicine
University of the Philippines College of Medicine
Former Municipal Health Officer
Municipality of Quezon, Alabat Island, Quezon

2. OBJECTIVES

3. Objectives
 To provide an introduction to Health Systems.
 To give an overview of the Philippine Health Care
System Using the WHO Health Systems Framework
 To illustrate the present and potential roles medical
students have in the Philippine Health Care System.

4. Putting things into Perspective…
CONTEXT

5. As medical students, are you part of
the Philippine Health Care System?

6. Of course you ARE! =)
From the Facebook page of JB Besa; photo by Ithran Kho (used with permission)

7. You are Here…
https://upcm89.files.wordpress.com/2011/04/img_0851.jpg
http://commons.wikimedia.org/wiki/File:Philippin_General_Hospital,_Manila,_Philippines.jpg

8. Training to Be…
http://imgkid.com/cartoon-doctor.shtml http://www.wpclipart.com/medical/personnel/surgeon.jpg

9. You are Here…

10. Where Will You Be?
“Sixty percentof
ourcountrymen
who succumbto
sicknessdie
without seeing a
doctor.”
-Pres.Noynoy Aquino

11. The WHO Health Systems Framework
Contextualizing Philippine Health Care within the WHO – HSF

12. Health System Basics (WHO, 2007)
 Health System (def.)
 Consists of all organizations,
people and actions whose
primary intent is to restore or
maintain health.
 Includes efforts to influence
determinants of health as well as
more direct health-improving
activities.
 It is MORE than the pyramid of
publicly owned facilities that
deliver personal services.
 Guiding values and
principles
 Values and goals enshrined
in the Alma Ata
declaration.
 WHO’s commitment to
gender and human rights.
 World Health Report of
2000
“Everybody’s Business, Strengthening Health Systems to Improve Outcomes, WHO’s Framework for Action”. WHO. 2007

13. Health System Basics (WHO, 2007)
 Health Systems Goals:
 Overall Outcomes (World Health
Report 2000):
 Improving health and health equity
through ways that are:
 Responsive
 Financially fair
 Best or most efficient use of
available resources
 Intermediate Goals:
 Greater access to and coverage
for effective health interventions
 Provider quality and safety are not
compromised
“Everybody’s Business, Strengthening Health Systems to Improve Outcomes, WHO’s Framework for Action”. WHO. 2007

14. WHO Building Blocks for Health
From the WHO WPRO Website: http://www.wpro.who.int/health_services/health_systems_framework/en/

15. Basic Concepts
Leadership and Governance

16. Leadership and Governance
 Ensuring the existence of
strategic policy frameworks
combined with:
 Effective oversight
 Coalition-building
 Provision of appropriate
regulations and incentives
 Attention to system design
 Accountability
 Active Local Health
Board

17. Leadership and Governance
 Health governance (stewardship)
context:
 Wide range of functions carried out
by governments to:
 Improve population health while
ensuring:
 Access to services
 Quality of services
 Patients’ rights
 Examples:
 Administrative details
 Logistics and Operations
 Planning and Policy Making
 Monitoring and Evaluation

18. Leadership and Governance
 Governance:
 Roles, responsibilities and
relationships (Interplay) of:
 Public sector
 Private sector
 AND Voluntary sectors
(including civil society)
In pursuit of national health
goals
 Ensure clarity AND
actualization of health
system vision-mission

19. Philippine Health Care System
Leadership and Governance

20. The Department of Health (DOH)
Mandate (E.O. No. 119, Sec. 3):
 The Department of Health (DOH) shall be
responsible for the following: formulation and
development of national health policies, guidelines,
standards and manual of operations for health
services and programs; issuances of rules and
regulations, licenses and accreditations; promulgation
of national health standards, goals, priorities and
indicators; development of special health programs
and projects and advocacy for legislation on health
policies and programs. The primary function of the
Department of Health is the promotion, protection,
preservation or restoration of the health of the
people through the provision and delivery of health
services and through the regulation and
encouragement of providers of health goods and
services.
 THE DOH IS THE LEAD AGENCY FOR PHILIPPINE
HEALTH CARE
http://www.mb.com.ph/doh-denies-18-ebola-cases-in-qc/

21. The Department of Health
 Vision
 Health for ALL Filipinos
 Mission
 To ensure accessibility
and quality of health
care to improve quality
of life of all Filipinos,
especially the poor
Reference: DOH/DAP module for DTTBs – on Economics and Governance of Health Systems, courtesy of Dr. Michael Caampued

22. Primary Goals of the Health Sector
The primary goals of the health sector:
 Better health outcomes
 Attaining the best average level of health
care for the entire population and attaining
the smallest feasible differences in health
status among individuals and groups
 More responsive health system
 Meeting the people’s expectations of how
they should be treated by health providers
and the degree by which people are
satisfied with the health system
 More equitable health care financing
 Distributing the risk that each individual
faces due to cost of health care according
to ability to pay rather than the risk of
illness Reference: DOH/DAP module for DTTBs – on Economics and Governance of Health Systems

23. Important Contextualizing Concepts
DEVOLUTION
 RA 7160 (Local Government
Code of 1991)
 The act by which the Philippine
Government “devolved” basic
services (health services,
agriculture extension, livelihood
development, forest
management, barangay roads
and social welfare) to Local
Government Units (barangay,
municipality/city, province)

24. Important Contextualizing Concepts
Implementation of
Devolution in 1992:
 Management and delivery
of health services
 From DOH to locally
elected provincial, city and
municipal governments
 4 Essential Health
System Functions
 Service provision
 Resource generation
 Financing
 Stewardship

25. Important Contextualizing Concepts
Devolution in ARMM:
 Retained centralized
character of its health
system
 DOH ARMM directly
runs its provincial and
municipal health
facilities (hospitals,
RHUs)
 Interlocal Health Zones (ILHZs)
 Inspired by WHO District Health System
 Pseudo legal entities
 (Ideally) An integrated health management
and delivery system based on defined
administrative and geographical area
 District Hospital + surrounding/covered
municipalities
 Usually composed of adjacent municipalities
with similar health needs
 Resource sharing
 Common health goals
 Mutual planning, policy formulation, health
operations implementation and monitoring and
evaluation

26. Basic Organization

27. Basic Concepts
Health/Health Care Financing

28. Health/Health Care Financing
 Good Health Financing:
 Two Main Characteristics:
 Raises adequate funds for
health to ensure that
people get to use needed
services
 People who use health
services are shielded from
financial catastrophe or
impoverishment associated
with having to pay for them

29. Health/Health Care Financing
 Health and Health Care are major political
and economic issues
 Health financing impacts the analysis of:
 Health policies
 Fund sources
 Effectiveness and efficiency of health services
for populations
 Health Financing Goals:
 Raising sufficient funds for health
 Ensure adequate spending on health
 Effective allocation of finite financial resources
to different types of public and personal health
services
 Pooling financial resources across population
groups and sharing financial risks
 Using funds for health efficiently and equitably

30. Philippine Health Care System
Health/Health Care Financing

31. Philippine Health Financing
 4.6% of GDP (World
Bank, 2012); Global
average is 10.2%
 Very high proportion of
out-of-pocket (OOP)
spending
 Presently:
 Fragmented
 Inequitable
 Main fund sources:
 Government
 Private (OOP, HMOs, life
insurance, etc.)
 Social Health Insurance
 Others (grants, aid, etc.)
 Filipino households continue to
bear the heaviest burden
(2012, PSA) – 57.6% OOP

32. Health Expenditure by Fund Source
20111/
2012
GOVERNMENT 20.2 18.5
National Government 12.5 11.4
Local Government 7.7 7.1
SOCIAL INSURANCE 9.4 11.1
National Health Insurance Program 9.4 11.1
Employees' Compensation2
0.0 0.0
PRIVATE SOURCES 69.5 69.6
Private Out-of-Pocket 57.7 57.6
Private Insurance 1.7 1.5
Health Maintenance Organizations 6.9 7.1
Private Establishments 2.2 2.5
Private Schools 0.9 0.9
REST OF THE WORLD 0.8 0.9
Grants 0.8 0.9
ALL SOURCES 100.0 100.0
SOURCE OF FUNDS
PERCENT SHARE
20111/
2012
GOVERNMENT 84,139 86,423 2.7
National Government 51,940 53,176 2.4
Local Government 32,199 33,247 3.3
SOCIAL INSURANCE 39,209 51,863 32.3
National Health Insurance Program 39,104 51,750 32.3
Employees' Compensation 104 112 8.0
PRIVATE SOURCES 289,655 325,526 12.4
Private Out-of-Pocket 240,485 269,419 12.0
Private Insurance 7,222 7,086 (1.9)
Health Maintenance Organizations 28,944 33,181 14.6
Private Establishments 9,297 11,603 24.8
Private Schools 3,707 4,236 14.3
REST OF THE WORLD 3,478 3,987 14.6
Grants 3,478 3,987 14.6
ALL SOURCES 416,480 467,798 12.3
Growth RateSOURCE OF FUNDS
AMOUNT
(in million pesos, at current prices)
Source: Philippine National Health Accounts. Philippine Statistical Authority;
National Statistical Coordination Board

33. Only those with money (i.e., the rich) can fully
pay for out of pocket payments and often
they have generous health insurance
The near-poor and the lower middle
classes can become impoverished to meet
out of pocket payments for health care.
The very poor don’t even
have pockets

34. Fragmented Health Financial System
Source: Lagrada, L. Principles of
Social Solidarity, Equity, Quality
Assurance and Cost
Containment: PHIC Enrollment,
Coverage and Expenditures.
April 14, 2010. Slide
Presentation. DOH-HPDPB.

35. The National Health Insurance Program
 RA 7875
 National Health
Insurance Act of 1995
 Established the Philippine
Health Insurance
Corporation (PHIC)
 More commonly known
as: PhilHealth
 PhilHealth
 Employed Sector Program
 Compulsory coverage: ALL government AND
private employees
 Individually Paying Program
 Voluntary coverage: self-employed and
“others”
 Sponsored Programs
 Covers “poorest of the poor” (Quintiles 1
and 2)
 Overseas Filipino Workers
 Lifetime Member Program
 60 y.o. and above who have completed 120
monthly contributions (before)
 Senior Citizens automatically covered (2015)

36. DOH Budget 2010 – 2014
 Personnel Services Increase (2010 – 2014)
because of Salary Standardization Law
Implementation
 Increase in MOE and CO can be attributed to two
(2) activities only under the DOH budget:
 PhilHealth Premiums for Indigents :
 FY 2011 – P3.5B;
 FY 2012 – P12.028B;
 FY 2013 – P12.628B;
 FY 2014 – P35.338B
 HFEP (Health Facility Enhancement Program)
 FY 2010 – P3.252B;
 FY 2011 – P7.144B;
 FY 2012 – P5.078B;
 FY 2013 – P13.558B;
 FY 2014 – P18.002B
 Increases in other MOOE activities are due to the 4%
inflationary increase
 Capital Outlay:
 Increase in CO also pertains to HFEP only

37. Of Sin and Taxes

38. Basic Concepts
Health Workforce (Human Resources for Health/HRH)

39. Human Resources for Health
 To achieve the best health
outcomes possible:
 Sufficient numbers
 Right mix of staff
 System-wide deployment and
distribution (equitable)
 Established job-related norms
 Enabling work environments
 Just compensation/payment
systems – right kind of
incentives

40. Human Resources for Health
 Population needs determine the
development and sustaining of health
workforce
 Education, training and continuing
competence
 Utilization, management and retention
 Strategic response to evolving and unmet
health service needs
 Governance, leadership and partnerships
for sustained HRH contributions to improved
population outcomes
 Regulation
 Deployment
 Compensation
 Continuing career enhancement and
development

41. Philippine Health Care System
Health Workforce (Human Resources for Health/HRH)

42. HRH in the Philippines
 22 categories of trained health workers
in the Philippines (MD, RN, RM, BHW,
RMT, Rad Tech, etc.)
 Some categories do not correspond to
international classifications – emerged
due to local/national demand
 No actual count of active health
workers; metrics mostly estimates (PRC,
professional societies, etc.)
 No actual data on distribution, numbers
 The need is felt and obvious but no
formal data available
 Cannot plan/intervene accordingly
 HOPE IS NOT A STRATEGY!

43. HRH in the Philippines
 Market Oriented
 Brain Drain phenomenon
 70% of those who stay are employed in
the private sector serving only 30% of the
population
 30% are in the public sector catering to the
majority
 Largest categories of HRH: midwives and
nurses
 Many newly licensed nurses are unable to
find employment
 When they do, they do not work as RNs
 There is underproduction in other
categories such as doctors, dentists, med
techs, etc.
“Sixty percentof
ourcountrymen
who succumbto
sicknessdie
without seeing a
doctor.”
-Pres. NoynoyAquino
Source: A. Romualdez UPCM Centennial Lecture, 2008

44. HRH in the Philippines
 Inequitably distributed
 Majority of HRH are hospital-based
 Most HRH are in the more lucrative private
sector
 NCR, Region 3 and Region 4A have a higher
proportion of government health workers
than anywhere else in the Philippines
 Effect of Devolution:
 Mostly negative
 Unresolved Issues on compensation,
benefits, continuing education, training,
etc.
 Hiring, firing, development, etc. – heavily
dependent on LCE, local authorities
 Lack of incentives to choose
service-oriented career
paths
 For MDs in particular:
 Government positions are not
attractive among newly-
licensed/trained MDs
 As of 2008 (DOLE):
 Specialists – 68%
 Generalists – 32%
 52% concentrated/clustered
in Metro Manila

45. Notable DOH HRH Programs
 DOH HRH Efforts:
 Doctors to the Barrios (DTTB)
 Nurses Deployment Program (NDP formerly RN-
HEALS)
 Rural Health Midwife Placement Program
(RHMPP)
 However:
 Seeming lack of long-term, sustainable, intelligent
and needs-based nationwide HRH program/plan
 DOH efforts are characterized by:
 “Hope as a strategy”
 “Heroic” and “Sacrificial” methods
 Contractualization
 Less than ideal incentivization
 Vulnerability to Patronage Politics

46. Basic Concepts
Access to Essential Medicines and Technologies

47. Access to Essential Medicines and Technologies
 Ensured equitable access to:
 Essential medical products
 Effective, Safe, Cheap Medicines
 Vaccines
 Affordable and readily available
Medical Technologies
 Governing Principles of:
 Quality
 Safety
 Efficacy
 Cost-effectiveness
 Scientifically sound

48. Access to Essential Medicines and
Technologies
 Essential medicines and
technologies save lives, reduce
suffering and improve health
 Available
 Affordable
 Assured quality (evidence-
based, GMPs, etc)
 Used properly by both provider
and patient
 Price can be afforded by
individuals and the system
 Equity in access is crucial

49. Philippine Health Care System
Access to Essential Medicines and Technologies

50. Essential Medicines
 Supply-driven distribution scheme (PHAP
2008, WHO 2011)
 Drugstores – 80.1%
 Hospitals – 9.7% (gov’t at 2.3%)
 Others – 10.2% (including government
agencies at 0.3%)
 Strong market orientation
 Generics Act/Law since 1988 but
compliance to it is still an issue
 Generally lax regulation with strong
pharmaceutical/nutritiutical company
lobbying influence (FDA lead agency)
 Major Constraints in Accessing
Essential Drugs (DOH 2008)
 Limited availability
 Irrational use
 High costs
 Effect of Devolution:
 LGUs left to budget for
medicines
 Result: great variability among
access to such, particularly
basic meds across the country’s
LGUs

51. Medical Technologies and Devices
 Distribution of Medical Devices
 General radiography (basic X-ray)
represents the most basic equipment
available across the country
 As of 2009, these devices totaled to
3860, 31% of which are found in
NCR
 Effect of Devolution:
 LGUs left to budget for medical
instruments, devices, equipment
 Result: great variability among access
to such across the country’s LGUs

52. Basic Concepts
Health Information and Research

53. Health Information and Research
 Reliable and timely Health
Information Measures:
 Health determinants
 Health systems performance
 Health status
 A good system is one where
Health Information is:
 Produced
 Analyzed
 Disseminated
 Used

54. Health Information and Research
 Health information is a national
asset and used by many:
 Policy-makers
 Planners
 Health care providers
 Development partners
 The general public
 Uses:
 Track health system performance
 Support better health policies
 Make effective health-related
decisions

55. Philippine Health Care System
Health Information and Research

56. Health Information in the Philippines
 Poor integration and weak
governance of national and local
health information systems
(Marcelo, 2005)
 Telecom infrastructure mostly
concentrated in urban centers
 Unclear considerations for the
role of IT in primary health care
in the Philippines
 Lack of IT governance structures
(standards, etc.)
 Existing DOH Information
Gathering Systems
 Allegedly computerized
but still highly reliant on
outdated paper and pen
systems in the frontlines
 eFHSIS, PIDSR, SPEED,
ClinicSys, PhilHealth
Dashboard

57. National Telehealth Service Program (NTSP)
 NTSP
 “Aims to improve communication
capabilities and provide better
access to up-to-date information,
consultations with clinical
specialists and other forms of
support for health professionals
in remote communities or those
providing health care to
marginalized and vulnerable
groups separated from the
mainstream of socio-economic
actvities”
 eMedicine
 Telereferrals
 RxBox – biomedical device
designed to provide improved
access to life-saving healthcare
services in GIDAs
 ECG
 Sphygmomanometer
 Pulse Oximeter
 Tocometer
 Fetal Doppler/Heart Monitor

58. National Telehealth Service Program (NTSP)
 eRecords
 Digital storage of
patient’s medical records
whether online or offline
 Computerized retrieval
of patient records as
needed
 CHITS, WAH, etc.
 eSurveillance
 Electronic monitoring of
health indicators and
performance
 Also for epidemiologic
use
 PIDSR, SPEED, eFHSIS,
etc.

59. Basic Concepts
Health Service Delivery

60. Health Service Delivery
 Good health services:
 Deliver effective, safe
and quality health
interventions to those
who need them; when
and where needed,
with minimum waste of
resources

61. Health Service Delivery
 All services dealing with
disease diagnosis and
treatment
 All services for the
promotion, maintenance
and restoration of
health
 Both personal and non-
personal services

62. Health Service Delivery
 Health services – most visible
functions of any health system
 Service provision: the way inputs
(money, staff, equipment, drugs, etc.)
are combined for the delivery of
health interventions
 Ensured availability of key resources
as well as good service management
and organization result in:
 Improved coverage
 Better quality of health services
 Ultimate aim:
 Equity in health outcomes

63. Health Service Delivery
 Key Elements:
 Organizing health services as
networks of primary care
backed up by hospitals and
specialized care
 Providing a package of health
benefits with clinical and public
health interventions
 Ensuring access and quality of
services
 Holding providers accountable
for access and quality and
ensuring consumer voice

64. Philippine Health Care System
Health Service Delivery

65. Forms of Health Service Delivery In the Philippines
 Public Sector
 Financed through taxes
 Budgeting system is done
at the local AND national
level
 Health care service is
ideally “free” at point of
care
 Greatly impacted by
devolution
 Public Health
 LGU (barangay, municipal/city,
province) – direct delivery of public
health services
 LCE-dependent
 Vulnerable to political patronage
 DOH – “technical assistance”
 Capacity building
 Advisory services for disease
prevention and control
 Provides selected free medicines (NTP,
Filaria, Malaria, etc.) and vaccines
(EPI)
 Ideally should be the primary health
authority

66. Forms of Health Service Delivery In the Philippines
 Private Sector
 Profit and non-profit
providers
 Usually market-driven
 Services are often not-free
 OOP schemes
 Insurance
 External funding/grants
 May not necessarily be
needs-based
 Often abused/misused

67. Health Facilities in the Philippines
 Classification of Health
Facilities
 Ownership
 Scope of services
 Functional capacity
 According to
Ownership:
 Government
 Private
Source: DOH AO 2012-0012: Rules and Regulations Governing the New
Classification of Hospitals and Other Health Facilities in the Philippines

68. Health Facilities in the Philippines
 According to Scope of
Services:
 General Facilities/Hospitals
 UP Philippine General
Hospital, Jose Reyes Memorial
Medical Center, etc.
 Specialty Centers/Hospitals
 Philippine Heart Center,
National Kidney and
Transplant Institute, etc.
Photo by David Montasco from http://www.panoramio.com/photo_explorer#view=photo&position=3562&with_photo_id=95985836&order=date_desc&user=4955072

69. Health Facilities in the Philippines
 Classification
According to
Functional Capacity

70. Health Facilities in the Philippines

71. QUESTIONS?

72. Which of the 6 building blocks of Health
Systems is the most important for you? Why?
Food for Thought…

73. Where Will You Be?

74. Gmail, Facebook: paolo.medina.md@gmail.com
Twitter: @lopaomd
Instagram: @lopaomd #buhaymho #buhaypublichealth #buhayhealthprofessionseducator
Maraming Salamat Po!!!

75. References
 Romualdez, A. et al (WHO, Asia Pacific Observatory on
Health System and Policies 2011). The Philippine Health
Systems Review.
 WHO 2007. “Everybody’s Business, Strengthening Health
Systems to Improve Outcomes, WHO’s Framework for
Action”.
 WHO WPRO Website (www.wpro.who.int)
 DOH/DAP Manual for DTTBS. Module On Economics and
Governance.