Medical Governance,
Health Policy,
and Health Sector Reform
in the Philippines
Module I
Introduction: Governance, Policy, Reform
Structured approaches to health development
Reconciling the language gam...
INTRODUCTION: GOVERNANCE,
POLICY, REFORM
Clinical Governance
• Clinicians have the responsibility to monitor and
manage their performance as part of the general
ma...
What is health care?
• In caring for patients, the good physician
dispenses time, sympathy, and understanding
to his patie...
Healthcare Governance:
Scope, Scale, and Stakeholders
Point
of Care
Service Delivery
Networks
National and Local
Governmen...
Quality of Care and Health Systems
• In any country, one of the factors affecting the
health and well-being of individuals...
Measuring Quality of Care (1)
Typically done in terms of structural measures
• Health care inputs
– Availability of drugs
...
Measuring Quality of Care (2)
• Do structural measures have a direct impact
on health outcomes?
• Are structural inputs dy...
Measuring Quality of Care (3)
Three basic elements of quality of care:
• Structure
• Process
• Outcome
Structural measures...
The Service Delivery Network
RECONCILING THE LANGUAGE
GAMES
Declaration of Alma Ata (USSR, 1978)
• Health is a fundamental
human right
• Inequality in health status
is unacceptable
•...
Philippine Constitution (1987)
• The State shall protect and promote the right to health
of the people and instill health ...
Philippine Constitution (1987)
• The State shall establish and maintain an
effective food and drug regulatory system
and u...
UN Millennium Declaration (2000)
• Reduce maternal mortality by
three quarters, and under-five
child mortality by two-thir...
Personal Care vs. Public Health
• Improvement of health through the organized
efforts of society (not individuals), throug...
“Pharmacology” of Public Health
• DYNAMICS and the mechanism of action:
– Will an intervention reduce the risk?
• KINETICS...
Ethics of Prioritization:
The Individual or Society?
• It is important to recognize that at the end of
each decision on a ...
Using Economics to Set Priorities
• Economic approach is to set priorities based on costs
and benefits of health services:...
Demystifying and De-medicalizing
• The allocation of resources must be explicit
• Decision-making at all levels must be op...
Three Fundamental Goals
• Improve the health of the population served;
• Respond to people’s expectations;
• Provide finan...
(Berman, 2012)
Module II
Evidence-based healthcare and the policy cycle
Translating mandated policies
into budgets for execution
EVIDENCE-BASED HEALTHCARE AND
THE POLICY CYCLE
The Epistemology of Public Health
Evidence-based
Epidemiology
Statistics
Aesthetic
Supernatural
Scripture
Reference: Gray,...
The Policy Cycle
Agenda Setting
Policy
Formulation
AdoptionImplementation
Evaluation
Families (specially the poor) have limited access to prenatal care, safe
delivery, immunization, and family planning
Families (specially the poor) have not used modern clinic or hospital
services due to lack of capital investments in facil...
Factors in Health Policy Change
OLD
POLICY
NEW
POLICY
Ideological
inspirations
Change in
circumstances
Evidence
Common sen...
Using Evidence to Craft Health Policy
• Resource reallocation among disease
management systems
• Resource reallocation wit...
Evidence vs. Eminence
• “Experts” commit two sins that retard the
advance of science and harm the young:
– Adding prestige...
Innovations
• Innovation occurs continually
• Promoting innovation may lead to
– Promotion of completely novel interventio...
The Roles of the Scientist
• Ask (and seek to answer) the right questions
• Be clear about the evidence
• Show the balance...
Maternal Mortality Ratio
209
172
162
221
0
50
100
150
200
250
300
1993 NDS 1998 NDHS 2006 FPS 2011 FHS
Numberofdeaths
per1...
Monitoring & Evaluation in Health
MANDATE
•Policies/
Issuances
/ Orders
INPUTS
•Budgets
•Premium
Subsidies
•Supplies and
C...
Ensuring Performance
Reference: Gray, 2004 (p. 327; 367)
MxC
B
P =
Where:
P = performance
M = motivation
C = competence
B ...
STRUCTURED APPROACHES TO
HEALTH DEVELOPMENT
A Structured Approach:
The Results Frame
• Critical Assumptions
• Sound Development Hypotheses
Reference: USAID, 2000
Prog...
TRANSLATING POLICY INTO BUDGETS
AND RESOURCES FOR EXECUTION
History of Philippine Health Reform
• 1960s: Medicare
• 1970s: Population Policy
• 1980s: Generics Act of 1988
• 1990s:
– ...
Continuity in Health Reform
Kalusugan Pangkalahatan
(2010 onwards)
Fourmula One for Health
(2005 – 2010)
Health Sector Ref...
Healthy
Filipinos
Sought
Professional
Care to Address
Illness
Covered by
PhilHealth
Provided
Quality
Care
Inadequate
NHIP ...
Healthy
Filipinos
Sought
Professional
Care to Address
Illness
Covered by
PhilHealth
Provided
Quality
Care
UHC will improve...
Universal Health Care (UHC)
57
Improved Health
especially for
the Poor and
Vulnerable
Secure access to
quality care at
fac...
Disease Management Systems
• A disease management system consists of all
those services and interventions designed to
impr...
The Continuum of Care
Health
Risk
exposure
Risk contact
Latent
disease/inju
ry
Early
disease/
injury
Disease
progression
A...
UHC Strategies and Interventions
UHC
Strategies
Public Health Personal Care Policy and
Standards
Development
Primary
Preve...
Evidence in Primary Care
• In primary care, the provision of healthcare is
undertaken
– Over a large area
– At many scatte...
Advantages of Focusing
on a Discrete/Defined Population
• Facilitates the process of population needs
assessment
• Enables...
Start with the Poor and Vulnerable
Q1 Poorest Q2 Poor
Q3 Middle
Income
Q4 Rich Q5 Richest
39 M poor individuals 59 M non-p...
Purchasers vs. Providers
• In health services world-wide, there is a trend to
separate the function of purchasing healthca...
Behind the Scenes: Unit Costing
Component Significance Actors & Assistants Facilities, Equipment,
Commodities
Admission
Or...
Behind the Scenes: Unit Costing
Component Significance Actors & Assistants Facilities, Equipment,
Commodities
Vital signs ...
Behind the Scenes: Unit Costing
Component Significance Actors & Assistants Facilities, Equipment,
Commodities
Diet Prescri...
Behind the Scenes: Unit Costing
Component Significance Actors & Assistants Facilities, Equipment,
Commodities
Laboratory
s...
Healthcare Financing
• Health systems are not just concerned with
improving people’s health, but also with
protecting them...
Who pays for the cost of health care?
Source: 2010 Philippine National Health Accounts
11.2
15.3
8.9
52.7%
7.1
4.8 Nationa...
Sources of Financing
• The Sources and their Uses
– NG: Policy Support / Management
– LG: Service Delivery (residual claim...
FINANCIAL
PROTECTION
PROVIDED TO THE
POPULATION
AccreditationEnrollment
Claims
Availmentand
Processing
Insurance
Payments
...
The Double Financing Burden of LGUs
Note: This is pre-
NHIA 2013.
The Budget Cycle
and Absorptive Capacity
• Budget Call
• Agency Planning
• Negotiations with DBM
• NEP filed in Congress
•...
Various Aims for Resource Allocation
Actor of Interest Aim for Resource Allocation
Individual patient • More resources to ...
Module III
Implementation arrangements in healthcare
Capacity building, sustainability,
and knowledge management
The Healt...
IMPLEMENTATION
ARRANGEMENTS IN HEALTHCARE
Values (?) Dominate Policy-making
• Politics tends to be driven by beliefs patronage
• It is the values returns on investm...
The Legislation Threshold
Oppositiontolegislation
Reference: Gray, 2004 (Fig 7.9, p. 296)
There is an inverse relationship...
What legal adjustments are needed to
implement UHC?
Restructuring of Excise Taxes of alcohol and
tobacco
Passage of Resp...
Main Determinants of Health
Genetic
inheritance
Health
status
Physical
environment
Biological
environment
Social
environme...
Healthcare Management and Policy,
and Organizational Change
• Health policies relate mainly to the financing
and organizat...
Office of Secretary of Health
Attached Agencies
Regional Offices
Provincial Health Offices
City Health Offices
(Component ...
DepartmentofHealth
PhilippineHealthInsuranceCorporation
(National/CentralOffices)
DOHCentersforHealthDevelopment
PhilHealt...
Secretary of Health
NCR &
Southern
Luzon
Northern &
Central Luzon
Visayas Mindanao
Secretary of Health,
DOH-ARMM
Centers f...
Issues in the Public Sector
• Decentralization
• Devolution
• Public Finance Management
• Procurement
Issues in the Private Sector
• (de)Regulation – big government vs. small
government
• Incentives and Disincentives – Profi...
Public-Private Partnerships
• Frame:
Profit = Revenue – Cost
• Private interest is to maximize profit
• Public interest is...
The Role of Civil Society Organizations
• Churches and Faith-based Groups
• Advocacy Groups
• Academe
• NGOs
• Provider/Pr...
PREVIEW OF A (FULL) POLICY
CYCLE: CASE OF RA 10354
The Reproductive Health Law
• 14+ years of debate in Congress
• 26 years after the 1987 Constitution
• State interest is t...
Carpio
CAPACITY
BUILDING, SUSTAINABILITY, AND
KNOWLEDGE MANAGEMENT
Image from Facebook (Seismologik Intelligence/Occupy Posters)
What is Development Work?
• Official Development Assistance (ODA) /
Foreign Assistance Programs (FAPs)
• Shift from tangib...
Agenda
Setting
Policy
Formulation
AdoptionImplementation
Evaluation
Areas for Management Consulting
Research
Production
Re...
Need for an Institutional Platform (1)
• Implementing health reforms in the
Philippines has become increasingly complex
• ...
Need for an Institutional Platform (2)
• There should be an Institutional Platform (IP)
that will help design, implement, ...
Health Policy Development Program(HPDP2 – Cooperative Agreement No. AID-492-A-12-00016)
• Five-year USAID health policy pr...
INTEGRATION
The Health Value Chain
Policy
Dev’t
Budget and
Expenditure
Plans
Absorptive Capacity of
Local Health Systems
Service
Provi...
The Five-Star Doctor
Roles
• Health Care Provider
• Teacher
• Researcher
• Social Mobilizer
• Manager
Examples of Leaders
...
AlbertDomingo.com
facebook.com/aedomingo
twitter.com/AlbertDomingo
Open Forum / Q&A
Medical Governance and Health Policy in the Philippines
Medical Governance and Health Policy in the Philippines
Medical Governance and Health Policy in the Philippines
Medical Governance and Health Policy in the Philippines
Medical Governance and Health Policy in the Philippines
Medical Governance and Health Policy in the Philippines
Medical Governance and Health Policy in the Philippines
Medical Governance and Health Policy in the Philippines
Medical Governance and Health Policy in the Philippines
Medical Governance and Health Policy in the Philippines
Medical Governance and Health Policy in the Philippines
Medical Governance and Health Policy in the Philippines
Medical Governance and Health Policy in the Philippines
Medical Governance and Health Policy in the Philippines
Upcoming SlideShare
Loading in …5
×

Medical Governance and Health Policy in the Philippines

10,880 views

Published on

An overview of key concepts and present trends in medical governance, health policy, and health sector reform in the Philippines, presented by Dr. Albert Domingo at the De La Salle Health Sciences Institute - College of Medicine on Sep. 26, 2013 for the subject "Perspectives in Medicine".

Includes the broad concept of medical governance as applied to various settings, from the point of care between provider and client/patient, to national and global health systems. Also touches on the practice of evidence-based healthcare as applied to the scale-up of innovations necessary to accelerate reform implementation, with grounding in the operational realities of implementation arrangements faced by sector managers on a day-to-day basis.

Suggested Citation:

Domingo, Albert Francis E. "Medical Governance, Health Policy, and Health Sector Reform in the Philippines: An Overview of Key Concepts and Present Trends." De La Salle Health Sciences Institute (DLSHSI). DLSHSI College of Medicine, Dasmarinas, Cavite. 26 Sep. 2013. Lecture.

Medical Governance and Health Policy in the Philippines

  1. 1. Medical Governance, Health Policy, and Health Sector Reform in the Philippines
  2. 2. Module I Introduction: Governance, Policy, Reform Structured approaches to health development Reconciling the language games
  3. 3. INTRODUCTION: GOVERNANCE, POLICY, REFORM
  4. 4. Clinical Governance • Clinicians have the responsibility to monitor and manage their performance as part of the general management of healthcare organizations. • Decision-making for populations is qualitatively different to that in clinical practice, even though the evidence used for both would be the same. • Clinicians should worry about the quality of care they are performing; let the health system managers worry about resource management. Reference: Gray, 2004 (p. 357-358), with modification
  5. 5. What is health care? • In caring for patients, the good physician dispenses time, sympathy, and understanding to his patients • The physician also scientifically applies principles of diagnosis and treatment • Medical care has become a mosaic of many health and non-health professionals executing the necessary skills Reference: Larson EB, JP Willems, and WC Liles. (2001). Manual of Admitting Orders and Therapeutics. 4th ed. Philadelphia: WB Saunders
  6. 6. Healthcare Governance: Scope, Scale, and Stakeholders Point of Care Service Delivery Networks National and Local Governments Private Sector Dynamics International/Global Health
  7. 7. Quality of Care and Health Systems • In any country, one of the factors affecting the health and well-being of individuals and populations is the quality of care provided within the health service. • In turn, the performance of any health system (including provider quality) is determined by the way in which it is designed, managed, and financed. Reference: Gray, 2004 (p. 288), modified
  8. 8. Measuring Quality of Care (1) Typically done in terms of structural measures • Health care inputs – Availability of drugs – Supplies and technology – Available health manpower • Facility-level characteristics Solon et al. (2009). A novel method for measuring health care system performance: experience from QIDS in the Philippines. Health Policy and Planning 1(8)
  9. 9. Measuring Quality of Care (2) • Do structural measures have a direct impact on health outcomes? • Are structural inputs dynamic and thus responsive to policy initiatives that affect daily clinical practice? • What about the point and period of care? structural measures = inputs Solon et al. (2009). A novel method for measuring health care system performance: experience from QIDS in the Philippines. Health Policy and Planning 1(8)
  10. 10. Measuring Quality of Care (3) Three basic elements of quality of care: • Structure • Process • Outcome Structural measures are too distant to the interface between patient and provider and do not address whether the inputs are used properly to produce better health Solon et al. (2009). A novel method for measuring health care system performance: experience from QIDS in the Philippines. Health Policy and Planning 1(8)
  11. 11. The Service Delivery Network
  12. 12. RECONCILING THE LANGUAGE GAMES
  13. 13. Declaration of Alma Ata (USSR, 1978) • Health is a fundamental human right • Inequality in health status is unacceptable • Economic and social development (“New International Economic Order”) is needed to attain health for all • Governments are responsible for the health of their people • “Primary health care” at the level of communities is key • Policies of independence, peace, détente and disarmament will release additional resources for development, including primary health care Reference: http://www.who.int/publications/almaata_declaration_en.pdf
  14. 14. Philippine Constitution (1987) • The State shall protect and promote the right to health of the people and instill health consciousness among them. (Art II, Sec 15) • The State shall adopt an integrated and comprehensive approach to health development which shall endeavor to make essential goods, health and other social services available to all the people at affordable cost. There shall be priority for the needs of the under-privileged, sick, elderly, disabled, women, and children. The State shall endeavor to provide free medical care to paupers. (Art XIII, Sec 11) Reference: http://lawphil.net/consti/cons1987.html
  15. 15. Philippine Constitution (1987) • The State shall establish and maintain an effective food and drug regulatory system and undertake appropriate health, manpower development, and research, responsive to the country's health needs and problems. (Art XIII, Sec 12) Reference: http://lawphil.net/consti/cons1987.html PNoy’s Social Contract: a promise of increased coverage of social health insurance, and access to health through improved health infrastructure
  16. 16. UN Millennium Declaration (2000) • Reduce maternal mortality by three quarters, and under-five child mortality by two-thirds, of their current rates (MDGs 4, 5) • Halt and begin to reverse the spread of HIV/AIDS, the scourge of malaria and other major diseases that afflict humanity (MDG 6) Reference: http://lawphil.net/consti/cons1987.html
  17. 17. Personal Care vs. Public Health • Improvement of health through the organized efforts of society (not individuals), through social interventions. Examples: – Disease screening programs – Immunization programs – Environmental protection Reference: Gray, 2004 (p. 293)
  18. 18. “Pharmacology” of Public Health • DYNAMICS and the mechanism of action: – Will an intervention reduce the risk? • KINETICS and the response of the system: – Will the intervention for the main concern increase other risks? (i.e., adverse effects) • THERAPEUTICS and delivery: – Is it operationally possible to introduce the intervention? Reference: Gray, 2004 (p. 296), with modification
  19. 19. Ethics of Prioritization: The Individual or Society? • It is important to recognize that at the end of each decision on a health policy, there is an individual. • This is an unpleasant and difficult fact to accept, but those who make decisions about groups and populations must remain continually aware of it. Reference: Gray, 2004 (p. 305)
  20. 20. Using Economics to Set Priorities • Economic approach is to set priorities based on costs and benefits of health services: to do more of some things, we have to take resources from elsewhere • Economists should also consider practical and ethical challenges that managers and doctors face in making rational priority setting decisions • Need to balance clinical autonomy with financial responsibility • Use national guidance, regional and local policy, and the community’s inputs; process should be transparent and accountable Reference: Peacock, 2006
  21. 21. Demystifying and De-medicalizing • The allocation of resources must be explicit • Decision-making at all levels must be open • Medicine must be de-mystified and health de- medicalized, for professionals, patients, the general public and politicians alike • Public health / health policy is thus multi- disciplinary, and multi-stakeholder Reference: Gray, 2004 (pp. 317-318), modified
  22. 22. Three Fundamental Goals • Improve the health of the population served; • Respond to people’s expectations; • Provide financial protection against the costs of ill-health *These are irrespective of the level of resources available and the organization of the health system Reference: Gray, 2004 (p. 289)
  23. 23. (Berman, 2012)
  24. 24. Module II Evidence-based healthcare and the policy cycle Translating mandated policies into budgets for execution
  25. 25. EVIDENCE-BASED HEALTHCARE AND THE POLICY CYCLE
  26. 26. The Epistemology of Public Health Evidence-based Epidemiology Statistics Aesthetic Supernatural Scripture Reference: Gray, 2004 (p. 307-318)
  27. 27. The Policy Cycle Agenda Setting Policy Formulation AdoptionImplementation Evaluation
  28. 28. Families (specially the poor) have limited access to prenatal care, safe delivery, immunization, and family planning
  29. 29. Families (specially the poor) have not used modern clinic or hospital services due to lack of capital investments in facility upgrading
  30. 30. Factors in Health Policy Change OLD POLICY NEW POLICY Ideological inspirations Change in circumstances Evidence Common sense From research From experience Reference: Gray, 2004 (Fig 7.8, p. 291; p. 292) NOTE: Policy makers operate on a timescale that does not generally admit of delays that research will take.
  31. 31. Using Evidence to Craft Health Policy • Resource reallocation among disease management systems • Resource reallocation within a single disease management system • Managing innovation • Controlling increases in healthcare costs without affecting the health of the population Reference: Gray, 2004 (p. 269)
  32. 32. Evidence vs. Eminence • “Experts” commit two sins that retard the advance of science and harm the young: – Adding prestige to opinions gives them greater persuasive power than their inherent science – Reviewers tend to accept or reject new evidence and ideas not based on science, but on their similarity to publicly-declared positions by experts Reference: Sackett, 2000
  33. 33. Innovations • Innovation occurs continually • Promoting innovation may lead to – Promotion of completely novel interventions • e.g., stem cell therapy (?) – Changing the provision of an established service • A purchaser must actively manage the introduction of innovation Reference: Gray, 2004 (p. 273; 276)
  34. 34. The Roles of the Scientist • Ask (and seek to answer) the right questions • Be clear about the evidence • Show the balance of good to harm of an intervention for the population Reference: Gray, 2004 (p. 322; 328), with modification The Roles of the Policymaker • Clarify the relevant societal values • Make appropriate decisions using those values (in relation to the evidence)
  35. 35. Maternal Mortality Ratio 209 172 162 221 0 50 100 150 200 250 300 1993 NDS 1998 NDHS 2006 FPS 2011 FHS Numberofdeaths per100,000livebirths Data Source: FHS 2011 (NSO, DOH, USAID) 260 182 224 120 196 128 MDG Target: 52
  36. 36. Monitoring & Evaluation in Health MANDATE •Policies/ Issuances / Orders INPUTS •Budgets •Premium Subsidies •Supplies and Commodities OUTPUTS •PhilHealth Coverage •Facility Upgrading •Logistics Management •Demand Generation OUTCOMES •Use of quality health services at affordable / no cost IMPACTS •Health •Well-being •Improved productivity Can be tracked through real time operations monitoring
  37. 37. Ensuring Performance Reference: Gray, 2004 (p. 327; 367) MxC B P = Where: P = performance M = motivation C = competence B = barriers Options to achieve change: • Incentives (carrots) • Disincentives (sticks)  hit people with carrots
  38. 38. STRUCTURED APPROACHES TO HEALTH DEVELOPMENT
  39. 39. A Structured Approach: The Results Frame • Critical Assumptions • Sound Development Hypotheses Reference: USAID, 2000 Program Inputs/Interventions Intermediate Results Development Objective Agency Objective
  40. 40. TRANSLATING POLICY INTO BUDGETS AND RESOURCES FOR EXECUTION
  41. 41. History of Philippine Health Reform • 1960s: Medicare • 1970s: Population Policy • 1980s: Generics Act of 1988 • 1990s: – Local Government Code of 1991 – National Health Insurance Act of 1995 • 2000-present: – HSRA, F1, KP Reference: Romualdez, 2011
  42. 42. Continuity in Health Reform Kalusugan Pangkalahatan (2010 onwards) Fourmula One for Health (2005 – 2010) Health Sector Reform Agenda (1999- 2004)
  43. 43. Healthy Filipinos Sought Professional Care to Address Illness Covered by PhilHealth Provided Quality Care Inadequate NHIP coverage High unmet need for public health services Poor infrastructure and low quality of care Low peso support from PhilHealth ? X X X Strategic Thrusts Intend to Eliminate the Barriers
  44. 44. Healthy Filipinos Sought Professional Care to Address Illness Covered by PhilHealth Provided Quality Care UHC will improve the health of beneficiaries Focused public health services Increased peso support from PhilHealth Facility upgrading and quality improvement Increased NHIP coverage
  45. 45. Universal Health Care (UHC) 57 Improved Health especially for the Poor and Vulnerable Secure access to quality care at facilities Achieve the public health MDGs Provide financial risk protection INTERVENTIONS OF CARE Secondary Prevention and Primary Health Care
  46. 46. Disease Management Systems • A disease management system consists of all those services and interventions designed to improve the health of individuals who have a particular disease or a group of diseases • Managed care: all elements of the system are governed by the use of guidelines Reference: Gray, 2004 (p. 270)
  47. 47. The Continuum of Care Health Risk exposure Risk contact Latent disease/inju ry Early disease/ injury Disease progression Advanced disease/injury Chronic disease Impairment or Death Primary Prevention: Reduce risk exposure Secondary Prevention: Detection and intervene early Tertiary Prevention: Reduce progress or complications of established disease PolicyandStandardsDevelopment UHC Interventions
  48. 48. UHC Strategies and Interventions UHC Strategies Public Health Personal Care Policy and Standards Development Primary Prevention Secondary Prevention Tertiary Prevention Achieve the public health MDGs Family Health Programs; Health Promotion Facility-Based Deliveries; Minor Medical and Surgical Management Complicated Deliveries, Medical, and Surgical Management Regulation and Financing Activities (Central and Regional) Provide financial risk protection Primary Care Benefits (PCB) Maternal Care Package (MCP) TB DOTS Package Medical and Surgical Case Rates Case Type Z Membership Services; Provider Services Secure access to quality care at facilities Barangay Health Stations; Rural Health Units Rural Health Units District Hospitals Provincial and DOH-retained Hospitals Facility Management Reforms 60
  49. 49. Evidence in Primary Care • In primary care, the provision of healthcare is undertaken – Over a large area – At many scattered sites • Decision-making covers a wide range of health problems, sometimes in situations where it is not possible to access support • Hence, evidence-based decision-making is more difficult to organize in primary care Reference: Gray, 2004 (p. 265)
  50. 50. Advantages of Focusing on a Discrete/Defined Population • Facilitates the process of population needs assessment • Enables a purchaser to integrate the health services that are purchased with a broad range of public health measures to prevent disease, promote health, and reduce inequalities Reference: Gray, 2004 (p. 270)
  51. 51. Start with the Poor and Vulnerable Q1 Poorest Q2 Poor Q3 Middle Income Q4 Rich Q5 Richest 39 M poor individuals 59 M non-poor individuals Note: Population counts projected for FY 2013 (except for DSWD numbers); rounded off to the nearest million. • Poverty incidence by NEDA/NSO is a statistical estimate without actual names or faces of poor individuals. • DSWD’s NHTS-PR and 4Ps/CCT, while with identification and location data, may not have enlisted all who are genuinely poor and vulnerable (homeless/vagrants, PWDs, prisoners, etc). • The DOH thus uses Q1 + Q2 for planning estimates, with reliance on the DSWD’s NHTS-PR and 4Ps/CCT for targeting/identification. 27 M individuals (NEDA) 30 M individuals (NHTS-PR) 18 M (4Ps/CCT) Identified by DSWD
  52. 52. Purchasers vs. Providers • In health services world-wide, there is a trend to separate the function of purchasing healthcare from that of providing healthcare – Purchasers decide which health services to buy – Providers deliver healthcare to individual patients within the resources available • Purchasers aim to maximize the value obtained from the resources available • Purchasers are not usually asked to reallocate resources on the basis of specific diseases, but for particular patient groups Reference: Gray, 2004 (pp. 269; 272)
  53. 53. Behind the Scenes: Unit Costing Component Significance Actors & Assistants Facilities, Equipment, Commodities Admission Order Initiates the contractual relationships; inpatient health care formally begins. Physical space in the building is designated • Attending Physician • Nursing Service • Hospital Admitting Section • Billing / Accounting Dept • Hospital Ward / Room; Bed • Standard commodities (e.g., cotton, alcohol, gauze, etc) Diagnosis Communicates to team members the working impression; allows actors to plan interventions accordingly • All Physicians • Nursing Service • Pharmacists • Nutritionist-Dietitians • Special equipment as needed (e.g., compression stockings, pulleys, respirators, etc) Condition; Allergies Communicates to team members the level of attention needed as well as precautions • All Physicians • Nursing Service • Pharmacists • Nutritionist-Dietitians • Special considerations for food and drugs Reference: Larson EB, JP Willems, and WC Liles. (2001). Manual of Admitting Orders and Therapeutics. 4th ed. Philadelphia: WB Saunders
  54. 54. Behind the Scenes: Unit Costing Component Significance Actors & Assistants Facilities, Equipment, Commodities Vital signs Initiates the contractual relationships; inpatient health care formally begins. Physical space in the building is designated • Nursing Service • Telemetry (if applicable) • E-cart / Crash cart • Emergency Drugs Activity Indicates what a patient is allowed to do, or conversely restrictions to mobility • Nursing Service • Physical Therapists • Nursing Assistants • Orderlies Special equipment as needed (special beds, wheelchairs, restraints) Nursing Specifies what nursing staff is to do for the patient: I/O, temp, daily weights, incentive spirometry, CBG, etc • Nursing Service • Nursing Assistants • Monitoring equipment (stethoscope, sphygmomanomet er, thermometer, etc) • Special equipment as needed (suction, etc) Reference: Larson EB, JP Willems, and WC Liles. (2001). Manual of Admitting Orders and Therapeutics. 4th ed. Philadelphia: WB Saunders
  55. 55. Behind the Scenes: Unit Costing Component Significance Actors & Assistants Facilities, Equipment, Commodities Diet Prescribes the diet the patient will have (house/regular, low fat, NPO, etc), fluids allowed by mouth, as well as feeding precautions • Nursing Service • Nutritionist- Dietitians • Dietary (kitchen, prep area, etc) • Utensils • Special equipment as needed (NGT, etc) IV orders Prescribes intravenous solutions to be infused • Attending Physician • Nursing Service • IV fluids (NSS, Ringer’s, Dextrose, etc) • IV cannula (needle) and tubing Medication orders Prescribes drugs to be administered, including name (generic preferred), dose, route, and frequency or time • Attending Physician • Nursing Service • Pharmacists • Drugs • Drug delivery equipment (infusion pumps, etc) Reference: Larson EB, JP Willems, and WC Liles. (2001). Manual of Admitting Orders and Therapeutics. 4th ed. Philadelphia: WB Saunders
  56. 56. Behind the Scenes: Unit Costing Component Significance Actors & Assistants Facilities, Equipment, Commodities Laboratory studies Specifies the diagnostic interventions (e.g., bloodwork, urinalysis, x-rays, etc) to be performed • Nursing Service • Medical Technologists • Diagnostic laboratories (chemistry, radiology/imaging, etc) • Special equipment as needed Special orders Specifies ancillary services (respiratory, physical, or occupational therapy), consultations, special preparations for diagnostic studies, etc • Referring Physicians • Nursing Service • Respiratory Therapists • Physical Therapists • Occupational Therapists • etc • Special equipment as needed Reference: Larson EB, JP Willems, and WC Liles. (2001). Manual of Admitting Orders and Therapeutics. 4th ed. Philadelphia: WB Saunders
  57. 57. Healthcare Financing • Health systems are not just concerned with improving people’s health, but also with protecting them against the financial cost of illness (by reducing out-of-pocket expenses). • The sources of financing usually dictates the system of healthcare provision. Two main sources are: – Insurance (risk-pooling)  “pay as you go”; common in low income countries – Taxation (subsidies) Reference: Gray, 2004 (p. 278)
  58. 58. Who pays for the cost of health care? Source: 2010 Philippine National Health Accounts 11.2 15.3 8.9 52.7% 7.1 4.8 National Government Local Government PhilHealth Private Out of Pocket Private Insurance + HMOs Others
  59. 59. Sources of Financing • The Sources and their Uses – NG: Policy Support / Management – LG: Service Delivery (residual claimant) – PhilHealth – single payer – PCSO, etc – catastrophic expenses – PPP – high capital investments – OOP – safeguard against moral hazard • “5% of GDP” – correlation vs. causation issue
  60. 60. FINANCIAL PROTECTION PROVIDED TO THE POPULATION AccreditationEnrollment Claims Availmentand Processing Insurance Payments PhilHealth as a Single Payer/Purchaser • Concept of social health insurance – Pay-as-you-go / “paluwagan” • Leverage resources on behalf of the many clients/patients Source: Joint DOH-PhilHealth Benefit Delivery Review (2010)
  61. 61. The Double Financing Burden of LGUs Note: This is pre- NHIA 2013.
  62. 62. The Budget Cycle and Absorptive Capacity • Budget Call • Agency Planning • Negotiations with DBM • NEP filed in Congress • Congressional Hearings – “Power of the Purse” – PDAF? • Appropriations • Allotments and Obligations References: DBM, 2013; Rappler.com, 2013
  63. 63. Various Aims for Resource Allocation Actor of Interest Aim for Resource Allocation Individual patient • More resources to treat his/her case Group of patients or providers who have the same problem • More resources for the particular patient group • Openness and equity in distribution of resources for that group Representatives of the general public • Openness and equity in distribution of resources across the entire range of patient groups Reference: Gray, 2004 (p. 270)
  64. 64. Module III Implementation arrangements in healthcare Capacity building, sustainability, and knowledge management The Health Value Chain
  65. 65. IMPLEMENTATION ARRANGEMENTS IN HEALTHCARE
  66. 66. Values (?) Dominate Policy-making • Politics tends to be driven by beliefs patronage • It is the values returns on investment (ROI) politicians believe to be important that dominate decision-making about policy. Such decisions will be tempered by the availability of resources. • But, resource allocation can also be based on beliefs and values patronage and ROI • Can a shortage of resources force policy-makers to consider the evidence and alter policy as a result? Reference: Gray, 2004 (p. 287)
  67. 67. The Legislation Threshold Oppositiontolegislation Reference: Gray, 2004 (Fig 7.9, p. 296) There is an inverse relationship between the magnitude of a health problem and the strength of opposition to legislation framed to prevent it. Number of people affected Media interest Strong evidence Opposition by industry Policy has adverse effects High cost of intervention
  68. 68. What legal adjustments are needed to implement UHC? Restructuring of Excise Taxes of alcohol and tobacco Passage of Responsible Parenthood Bill Strengthening of the National Health Insurance Program • Optimization of management of devolved health services • Amendment of selected laws governing practice of health professionals • Laws for corporate governance of hospitals Note: An omnibus law on universal health care that shall contain specific provisions necessary to enact required policies or amend existing laws can also be legislated
  69. 69. Main Determinants of Health Genetic inheritance Health status Physical environment Biological environment Social environment Primary care Reference: Gray, 2004 (Fig 8.1, p. 320) Health services Hospital care Screening
  70. 70. Healthcare Management and Policy, and Organizational Change • Health policies relate mainly to the financing and organization of health services. • Common objectives of organizational change: – Decentralize power; – Involve more people in decision-making; – Encourage cost control; – Reduce the number of managerial staff; – Encourage competition in order to reduce costs and increase quality Reference: Gray, 2004 (p. 290)
  71. 71. Office of Secretary of Health Attached Agencies Regional Offices Provincial Health Offices City Health Offices (Component Cities) Inter-local Health Zones City Hospitals Health Centers Barangay Health Stations District hospitals Municipal health offices/ Rural Health Unit Barangay Health Stations Provincial Hospitals Regional hospital Medical Centers Sanitaria City Health Offices (Chartered Cities) City Hospitals Health Centers Barangay Health Stations References: Kelekar and Llanto, 2013; Khemani, 2010
  72. 72. DepartmentofHealth PhilippineHealthInsuranceCorporation (National/CentralOffices) DOHCentersforHealthDevelopment PhilHealthRegionalOffices LocalGovernmentUnits (ProvincesandCities) Health Care Providers Households Health Outcomes
  73. 73. Secretary of Health NCR & Southern Luzon Northern & Central Luzon Visayas Mindanao Secretary of Health, DOH-ARMM Centers for Health Development Technical Clusters
  74. 74. Issues in the Public Sector • Decentralization • Devolution • Public Finance Management • Procurement
  75. 75. Issues in the Private Sector • (de)Regulation – big government vs. small government • Incentives and Disincentives – Profit?
  76. 76. Public-Private Partnerships • Frame: Profit = Revenue – Cost • Private interest is to maximize profit • Public interest is to ensure (by contract) provision of social services • Not just in infrastructure, but also elsewhere
  77. 77. The Role of Civil Society Organizations • Churches and Faith-based Groups • Advocacy Groups • Academe • NGOs • Provider/Professional Organizations
  78. 78. PREVIEW OF A (FULL) POLICY CYCLE: CASE OF RA 10354
  79. 79. The Reproductive Health Law • 14+ years of debate in Congress • 26 years after the 1987 Constitution • State interest is to save mothers’ lives – Population policy is elsewhere, in the POPCOM PD • The issue is not when life begins, but the “political question” and judicial restraint (institutions affecting policy) • RH Law is social legislation: more in law for those with less in life Reference: Jardeleza, 2013
  80. 80. Carpio
  81. 81. CAPACITY BUILDING, SUSTAINABILITY, AND KNOWLEDGE MANAGEMENT
  82. 82. Image from Facebook (Seismologik Intelligence/Occupy Posters)
  83. 83. What is Development Work? • Official Development Assistance (ODA) / Foreign Assistance Programs (FAPs) • Shift from tangible commodities to technical assistance (TA) Reference: Garrett, 2007
  84. 84. Agenda Setting Policy Formulation AdoptionImplementation Evaluation Areas for Management Consulting Research Production Research Management Marketing / Communication Implementation Monitoring & Evaluation
  85. 85. Need for an Institutional Platform (1) • Implementing health reforms in the Philippines has become increasingly complex • Strategic, operational, and transactional concerns have grown • Staff capacities and time constraints continue to be limited • Budgets are increasing; policies are aligning Reference: USAID/Philippines, 2012
  86. 86. Need for an Institutional Platform (2) • There should be an Institutional Platform (IP) that will help design, implement, monitor, and evaluate UHC initiatives – Accountable to the Secretary of Health, but independent and objective – Funded by various sources (including , but not impaired to provide competitive rates) – Can network and engage with other institutions/individuals contributory to its objectives Reference: USAID/Philippines, 2012
  87. 87. Health Policy Development Program(HPDP2 – Cooperative Agreement No. AID-492-A-12-00016) • Five-year USAID health policy project (2012- 2017) implemented by the UPecon Foundation, Inc. • Supports the DOH-led policy formulation process for scaling up Universal Health Care (UHC) • Goal is to strengthen a supportive policy and financing environment for FP/MNCHN and TB to enable the Philippines to achieve its MDGs in health, as well as expand and sustain its UHC initiative • Two components: (1) establish an institutional platform to help DOH design, implement, monitor, and evaluate the UHC agenda; and (2) remove policy and systems barriers to FP/MNCHN and TB service delivery
  88. 88. INTEGRATION
  89. 89. The Health Value Chain Policy Dev’t Budget and Expenditure Plans Absorptive Capacity of Local Health Systems Service Providers Clients/Patie nts Suppliers Improved Health Information, Feedback, Monitoring
  90. 90. The Five-Star Doctor Roles • Health Care Provider • Teacher • Researcher • Social Mobilizer • Manager Examples of Leaders • Pioneer Practitioners • Deans • Principal Investigators • Politicians/Advocates • DOH Sec / Hospital Chiefs
  91. 91. AlbertDomingo.com facebook.com/aedomingo twitter.com/AlbertDomingo Open Forum / Q&A

×