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MDGs in the Context of the

Philippine Health System


Emerito Jose A Faraon, MD
20 August 2014
Multi-Purpose Hall Annex II
UP College of Public Health

Extreme poverty can be eliminated


by 2025.
Carefully planned development
aid
Very poor countries are in the lowest
step

Clinical economics - diagnose countries, then 'cure' them


Strong supporter of the UN-driven MDGs; 1.1 B very
poor

POVERTY
More than 8 million people die each
year
Reason: ?
They are simply too poor to stay alive

POVERTY
There are 2 kinds
Absolute - no food, no water, no
sanitation, no clothing, no shelter, no
health care, no education.
Relative - economic inequality

Presentation Outline
1. What is Health?
2. What is Health and Development?
3. The Philippines and MDGs
4. 2012 Global Updates
5. Wrap-up and Summary

What is Health ?
Alma-Ata Declaration

Almost 35 years
ago
September
1978

What is Health?

What is Health and Development?

Inequality
- means the obvious gap between two comparisons

What is Health and Development?

What is Health and Development?

But wait, does everyone know what MDGs


are?
Why are there MDGs?

Introduction
Millennium Development Goals:

8 major goals

21 targets

60 indicators

25-year timeline

Base year: 1990

End year: 2015


Solita Collas-Monsod

Hey, it's already August 2014. Do you think


we can deliver all the MDG targets?
Maybe. We can always hope.

Philippines' Health and Development


Challenges
Fragmented

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
Governance

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
POVERTY: Good and Bad News

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Poverty in the Philippines: Let's Do Simple


Math
2011: P16,841.00 per year
P1,403.42 per month or P46.78 per day
More than 26.5% of 95M (2012) = More than 25,175,000 are poor
Filipinos

Philippines' Health and Development


Challenges
POVERTY: Elementary and Hungry!

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
POPULATION GROWTH

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
Food Security - having sufficient food all the time

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
Education: Good News

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
Education: Bad News

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
Gender: Good and Bad News

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
Disasters: Name it, we have it !

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
Choking Pollution

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
Poor Sanitation

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
Quality of Water Supply

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
Double Burden: NCDs & Infectious Diseases

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
Double Burden: NCDs & Infectious Diseases

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
HIV Cases: On the Rise

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
Maternal Mortality Figures Disappoints

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
Maternal Mortality Figures Disappoints

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
Limit Pregnancies and Increase Birth Intervals

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
Abortion is Illegal

Even when a woman's life or health is in


danger
Rape or
incest
Women, single or married go to great lengths
to have abortions
Out of nearly 3.5 million pregnancies per year,
15% are aborted.
Post-abortion care is lacking and a major
cause of maternal mortality
SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to
2016

Philippines' Health and Development


Challenges
Adolescents

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
Indigenous Kababayans

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

Philippines' Health and Development


Challenges
Other Vulnerable Groups

SOURCE: WHO Country Cooperation Strategy for the Philippines, 2012 to


2016

2012 MDG UPDATES

Extreme poverty is
falling in every region
SOURCE: 2012 UN MDG REPORT UPDATES

SOURCE: 2012 UN MDG REPORT UPDATES

2012 MDG UPDATES

Achieved parity in
primary education
between girls and boys

More children enrolled, and girls ---

SOURCE: 2012 UN MDG REPORT UPDATES

2012 MDG UPDATES

Child survival progress


is gaining momentum

SOURCE: 2012 UN MDG REPORT UPDATES

2012 MDG UPDATES

Access to HIV treatment


increased in all regions

SOURCE: 2012 UN MDG REPORT UPDATES

2012 MDG UPDATES

On track on stopping the


spread of tuberculosis

SOURCE: 2012 UN MDG REPORT UPDATES

2012 MDG UPDATES

Vulnerable employment
has decreased
marginally
in the last 20 years

2012 MDG UPDATES

Maternal mortality rate


decreases
are far from the
established 2015 targets

SOURCE: 2012 UN MDG REPORT UPDATES

2012 MDG UPDATES

Use of improved sources


of water remains lower
in rural areas

SOURCE: 2012 UN MDG REPORT UPDATES

2012 MDG UPDATES

Hunger remains to be a
global challenge

SOURCE: 2012 UN MDG REPORT UPDATES

2012 MDG UPDATES

Number of people living


in the slums
continues to grow

SOURCE: 2012 UN MDG REPORT UPDATES

HSRA

FOURmula 1
AHA, UHC, KP

Health System
& Structure

Current State of the Philippine


Health System

Based on Speeches given by Health Secretary Ona


from 2010 to present

Current State of the Philippine Health System


What Kills Filipinos?
Filipino Income Quintiles
MDG Targets
Double Burden of Disease
Health Financing Status
Health Facility Status
Strategies and Health Policies

GDP

The Philippine Health System

What is a Health System?


all the activities whose primary purpose is to promote,
restore or maintain health
(World Health Report 2000)

the combination of health care institutions:

human resources,
financing mechanisms,
information systems,
organizational structures that link institutions and
resources,
management structures that collectively culminate in the
delivery of health services to patients
(Lassey et al 1997)

Basic Flow Diagram for the


Health System

Inputs

Personnel
Buildings
Drugs
Supplies

Health
System
Components
Institutions
Health human
resources
Organizational
structures &
mechanisms
Governance &
management
structures
Financing
structures &
mechanisms

Outputs

Surgeries
Vaccinations
Examinations
Medical
treatments
Policies

Intermediate
Outcomes

Access
Quality
Efficiency

Final
Outcomes

Health status
Financial Risk
Protection
Satisfaction/
Responsiveness

99

Fundamental Goals of Health Systems

Improve the health of the population


they serve
Respond to peoples expectations
Provide financial protection against
the costs of ill-health
100

What major health situations drove


health reforms in the Philippines?
Health Status
Improvements in key health status indicators
have slowed down
Health Care Financing
Financing for health care remains inadequate
and inequitable

What major legislations drove health


reforms in the Philippines?
Republic Act 7160 - Local Government Code of 1991

Providing autonomy to local government units and,


in the process, mandating the devolution of health
services to provinces, cities and municipalities
Republic Act 7875 - National Health Insurance Act of 1995

Instituting a National Health Insurance Program


and establishing the Philippine Health Insurance
Corporation (PhilHealth)

Source : AHA (ONA 2011)

The Philippine Health Sector Reform


Agenda (HSRA)
A comprehensive HSRA policy framework was
developed in 1999
Specific components of the reform agenda were
pilot-tested in several provinces from 2000 to
2005
The operational framework known as Fourmula
One for Health (F1) was developed in 2005 and
implemented in the first 16 provinces in 2006

General Guidelines:
Administrative Order 37, s. 2001
Guidelines on the Operationalization of the HSRA
Implementation Plan

Administrative Order 174, s. 2004


Guidelines for Refocusing HSRA Implementation

Health Sector Reform Agenda


Health
Financing

Public
Health
Programs

Health
Regulation

HSRA

Hospital
Systems

Local Health
Systems

What changes in the health sector need to be


introduced?
1.
2.
3.
4.
5.

Hospital System Reforms


Public Health Program Reforms
Local Health System Reforms
Health Regulatory Reforms
Health Financing Reforms

1. Hospital System Reforms


Poorly-equipped and poorly-staffed local
government hospitals (provincial and district
hospitals)
Congested regional and national hospitals
Inadequate hospital networking and patient
referral systems
Heavy reliance on direct subsidies from national
and local governments
Uncoordinated implementation of public health
programs in hospitals

Distribution of Doctors According To Region, 2002 (NSCB)


Region

public

private

total

XIV CAR

85

1968

2053

2.81%

XIII NCR

658

15238

15896

21.78%

158

3659

3817

5.23%

II

175

4053

4228

5.79%

III

297

6878

7175

9.83%

IV

350

8105

8455

11.59%

190

4400

4590

6.29%

VI

226

5234

5460

7.48%

VII

229

5303

5532

7.58%

VIII

IX
X
XI
XII

153 majority
3543 are in 3696
The vast
lucrative5.06%
90
2084
2174
2.98%
PRIVATE99 practice
2293areas in
2392URBAN
3.28%
79
1829
1908
2.62%
settings
84
1945
2029
2.78%

XV ARMM

69

1598

1667

2.28%

XVI CARAGA

79

1829

1908

2.62%

3021

69960

72981

100.00%

Total

Healthworker Distribution

70% of ALL health workers employed in the private


sector serving 30% of the population

30% employed in government services catering to


the majority
of whom many are also engaged in the private sector licitly
or illicitly

2. Public Health Program Reforms


Increasing burden from chronic and
degenerative diseases but still uncontrolled
infectious diseases
Miniscule investment and resources devoted to
public health programs
Highly fragmented health care delivery system
Poor technical and managerial leadership over
decentralized primary care system

Trends of Health Expenditure


by Use of Funds
In billions of Pesos

140
120
100

Personal Health
Public Health
Others

80
60
40
20
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Year

Source: Philippine National Health Account, 2004

Distribution of Health
Expenditure by Use of Funds
Others
12%
Public Health Care
12%

Personal Health
Care
76%

Source: Philippine National Health Account, 2003

3. Local Health System


Reforms

Backlog in capital spending for local health


facilities (pre and post-devolution)
Mismatch between local government share of
Internal Revenue Allotment and local health
responsibility
Fragmentation of the primary care delivery
system (between provincial and municipal
levels)
Lack of DOH capacity to lead and coordinate
inter-local government health programs (eg.
ILHZ)

4. Health Regulatory Reforms


Gaps in specific legal mandates for health
regulation
Inadequate human resources and expertise
for health regulation
Inadequate facilities and equipment in
specific areas of health regulation
Weak regulatory systems and procedures

5. Health Financing Reforms


Heavy dependence on out-of-pocket spending for
health services
Inadequate benefit spending by the National Health
Insurance Program
Low program benefits and bias towards hospitalbased care
Limited population coverage for social health
insurance
Weak benefit delivery and provider payment
mechanisms

FOURMULA ONE FOR HEALTH

General Objective
To undertake critical reforms with speed,
precision, and effective coordination towards
improving the efficiency, effectiveness and equity
of health care delivery.

FOURMULA ONE FOR HEALTH

Source : AHA (ONA 2011)

Why is Successful Reform Difficult?


The consequences of actions are difficult to predict.
Health systems have multiple goals. Doing better on
one goal dimension may mean doing worse on
another. The choices are truly difficult.
Those who benefit from the system are powerful and
resist change. Those who benefit from change are
often less powerful.
Countries are limited by their economic and
administrative capacity.

121

Health Delivery
Structure

Organizational Structure of the Philippine Government


Legislative
House of Reps

Executive

Judiciary

President

Supreme Court

Senate

V-President

Court of Appeals

Major
Commissions
and Offices

Regional Trial
Courts

Natl Sec. Council

Cabinet

Provinces
Municipalities

Cities

Barangays

Barangays

Constitutional Commissions
Local legislatures
Quasi-judicial bodies

Highly
Urbanized
Cities

Barangays

Metropolitan Trial
Courts
Municipal Trial
Courts In Cities
Municipal Circuit
Trial Courts
Municipal Trial
Courts

Organization of the Health Care System


Levels of the Health Care System
Department of Health national health authority, policymaking body, regulatory body, co-provider of specific tertiary
health services
Local Government Units (LGUs) provider of primary,
secondary, & tertiary health care; local policy making bodies
Private Sector - consisting of for-profit & not-for-profit
organizations

125

National Level
Department of Health maintains specialty
hospitals, regional hospitals & medical centers;
has a regional office in every region; has a
provincial health team made up of
representatives to the local health boards &
retained personnel involved in controlling
malaria & other diseases.

126

The Department of Health


MANDATE: Executive Order No. 102
VISION:
The Leader, Staunch Advocate and Model for
promoting Health for All in the Philippines
MISSION:
To guarantee equitable, sustainable and
quality health for all Filipinos, especially the
poor, and to lead the quest for excellence in
health
127

Local Level
The Local Government Units are now responsible
for the direct provision of public health programs
and primary secondary and tertiary hospital care
within their areas of jurisdiction
Local Health Board in every province, city,
municipality & chaired by local chief
executive

128

Office of Secretary of Health


Executive Committee for National
Field Operations
Regional hospital
Medical Centers
Sanitaria

Regional Offices

Provincial Hospitals

Provincial Health Offices

City Health Offices


City Hospitals

Rural Health Unit


Barangay Health
Stations

District Health Offices


District hospitals

Municipal
health offices

Barangay Health
Stations

Devolved to provincial government


Devolved to city government
Devolved to municipal government

129

Private Sector
provides health services in clinics & hospitals,
health insurance, manufacture of drugs, medicines,
vaccines, medical supplies, equipment, etc.

Parting Thoughts

Parting Thoughts

Only You Can Achieve Your Dreams