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Introduction to Improving Municipal Health Systems

  1. 1. Center for Local Health Governance Webinar on Municipal Health Systems by Bien Eli Nillos MD Aug.3 2012
  2. 2. My L e a d e r s h i p J o u r n e y Bien Eli Nillos, MD Former Doctor to the Barrios Municipality of Candoni, Negros Occidental
  3. 3. Bien Nillos, MD M.D. – 2006, University of Saint La Salle BS Biology – 2002, University of Saint La Salle Doctor to the Barrio – 2007 – 2010, DOH/Municipality of Candoni, Negros Occidental. Currently an Associate Professor for Family and Community Medicine (University of Saint La Salle) Fellow, Zuellig’s HLMP Training Alumnus, U.S. State Department (Northern Illinois University) Alumnus, Global Health Course, University of Tampere (Finland)
  4. 4. Candoni, Negros Occidental Population: 21,000 4-hour bus ride from Bacolod City, 1 and half hours away from Kabankalan City Surrounded by other towns and cities (CHICKS)
  5. 5. Problems Encountered Poor Health Indicators Inaccessible health care services Limited Human and Financial Resources Poor Health Seeking Behaviors
  6. 6. Maternal Mortality per 1,000 LBs 6 5.8 5 4 3.6 Candoni 3 Region 6 2 National 0.92 1 0.63 0 2006 2007 Facility based deliveries – 24% in 2007 Skilled birth attendant deliveries – 74% in 2007 Top Causes of MM – post-partum bleeding, Pregnancy Induced Hypertension
  7. 7. Infectious (Pulmonary Tuberculosis) C e D tion R as etec ate 80 60 40 Candoni National 20 0 2006 2007 Cure Rate – 93% in 2007 No med. Tech. – only 1 midwife microscopist Practicing TB DOTS but not Philhealth accredited
  8. 8. Infant Mortality per 1,000 LBs 30 26.5 25 20 Candoni 15 Region 6 10.1 9.2 10 National 5 0 2007 Top Causes of Mortality: Severe Pneumonia, Severe Diarrhea
  9. 9. Compounding Factors “The greatest intelligence is precisely the one that suffers most from its own limitations” – Andre Gide (Nobel Prize for Literature, 1947) POLITICS LACK OF… ACCESS
  10. 10. “We are limited but we can push back the borders of our limitations” – Stephen Covey
  11. 11. “Change will come when those who have the resources learn that they do not have all the answers…they need to learn how to listen.” – Desmund Tutu
  12. 12. Alma Ata Declaration “The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.” - Alma Ata Declaration of 1978
  13. 13. COMMUNITY HEALTH INITIATIVES PARTNERS (CHIP) Members: Barangay Captains, Brgy. Kagawads for Health, SK, BHW Federation Role: Coordinate all health program implementation at the barangay level, initiate community-based health programs through original approaches.
  14. 14. Relations and Advocacy Managers (RAM) Members: Teachers, Faculty-in- charge, church-based organizations, PNP and other NGO’s Role: help in the promotion of health advocacies in schools and communities through integration.
  15. 15. Legislative Action Network (LAN) Members: Political leaders, councilors, department heads, NGO’s Role: provide strong legislative support for health programs, influence policy in favor of health initiatives
  16. 16. MONITORING team (MONITOR) Members: Program coordinators, DOH representative, PHO/CHD/Philhealth, Public health managers, MPDO, Budget Officer Role: Monitor progress of initiatives, plot outcomes and results and provide feedback to community at large.
  17. 17. Engaging the Community  Assembly of hilots and revival of Women’s Health Team  Legislative support – barangay ordinances  Increased advocacy and social awareness  Training of midwives and nurses (refresher’s course)
  18. 18. “There go my people. I must find out where they are going so I can lead them.” ~ Alexandre Ledru-Rollin
  19. 19. “Example, whether it be good or bad, has a powerful influence” – George Washington, quoted from his letter to Lord Stirling (March 1780)
  20. 20. Upgrading A Local Health System Part Two on Candoni Case Bien Eli Nillos, MD Former Municipal Health Officer
  21. 21. Consider this… All 3 components are essential. Hardware = equipments, logistics, physical environment Software = local health system, predominant culture Peopleware = Actors
  22. 22. Why “Upgrade?” Excellent Software Excellent Hardware Excellent Hardware and Literate and Efficient and Software but Peopleware but Poor Peopleware but Poor illiterate Peopleware Hardware Software Slow rendering of Frustrated, Lost, Useless, Impotent output Apathetic
  23. 23. Community Health Initiative Partners (CHIP) Relations Advocacy Managers (RAM) Legislative Action Network (LAN) MONITORing team
  24. 24. Maternal Deaths per 1,000 Lb Infant Deaths per 1,000 Lb in 2007 6 5.8 30 26.5 5 25 4 20 3.6 Candoni Candoni 3 15 10.1 Region 6 Region 6 10 9.2 National 2 0.92 National 5 1 0.63 0 2007 0 2006 2007 TB Case Detection Rate 80 No Botika ng Barangays 70 60 50 Dilapidated RHU 40 Candoni 30 National Low number of deliveries attended 20 10 by skilled birth attendants 0 2006 2007 No indigents enrolled in Philhealth High malnutrition rate
  25. 25. Internal and External Environments Challenge: Motivation to work (feeling of insufficiency, routine work, professional jealousies) Strategy: Treating them as partners, important contributors Activities: Workshops, team building, SOP’s, assignment of program coordinators, trainings and seminars
  26. 26. Internal and External Environments Challenge: direct interest and attention to health (dole-out mentality, political patronage, etc) Strategy: Validation and affirmation of Vision – hopes for Candoni. Approach: Gather influential leaders in the community, and empowering of community through these leaders.
  27. 27. Issue No. 1: Maternal Mortality Ratio “Hardware” – Dilapidated RHU, BHS not capable of handling normal deliveries, lack of supplies, inaccessible puroks, sitios “Software” – poor referral system, lack of tracking system for pregnant clients, policies on hilot delivery, “cultural” “Peopleware” – predominance of TBA, no Women’s Health Team
  28. 28. Assembly of Hilots  Integrating the TBA’s in the “new set-up”.  Important partners and collaborators (WHT)  Support of the Barangay Captains  Barangay Ordinances
  29. 29. New Protocols for RHU Staff  9 barangays with 9 midwives  1 midwife-in-charge of DR  BHW catchment areas (atrition policy)  SOP on referral system  Lifesaving skills and Perineal suturing
  30. 30. Upgrading RHU/ equipping BHS
  31. 31. Selling the Idea to the Community “Alkansiyang Pampamilya” “Buntis Baby Bags”
  32. 32. THE OUTCOMES 90 85 87 80 79 74 70 60 58 50 FBD 40 SBA 30 MMR 24 20 10 5.8 0 0 0 2007 2008 2009 FBD = Facility Based Delivery SBA = Skilled Birth Attendant MMR = Maternal Mortality Ratio
  33. 33. 30 26.5 25 20 21.8 Candoni 15 Region 6 10 10.1 9.2 National 4.14 5 0 2007 2008 2009 Infant Mortality Rate Trend
  34. 34. Issue No. 2: Inaccessibility to Cheaper Medicines Hardware: “geographically challenging” Software: “dole-out mentality” “Credit is good because I don’t have cash” motto Peopleware: “Barangay captains hesitant to start up a BnB due to fear of lack of sustainability”
  35. 35.  Establishment of Botika ng Barangays 9/9  Establishment of Botika ng Barangay Monitoring Team: DOH representative, Municipal Accountant, BnB Operator, Nurse Coordinator, Brgy. Captain  Under the LHB
  36. 36. Issue No. 3: TB or not TB Hardware: “dilapidated RHU, Microscopy lab” Software: “while practicing TB DOTS, lack of aggressiveness in tracking symptomatics” Peopleware: “less motivated(?) staff” “community unaware”
  37. 37.  One additional midwife trained as Microscopist  Aggressive TB awareness campaign  Lung Month Celebrations  Philhealth Accreditation
  38. 38. TB DOTS Program 100 90 80 70 60 50 CDR 40 Cure Rate 30 20 10 0 2007 2008 2009 CDR = Case Detection Rate
  39. 39. My Role, The Pontiff Latin Pontifex – pons (bridge) + facere (to make) = “bridge builder” "I pray that I may never meddle, interfere, dictate, give advice that is not wanted, or assist when my services are not needed. If I can help people, I'll do it by giving them a chance to help themselves; and if I can uplift or inspire, let it be by example, inference and suggestion, rather than by injunction and dictation. That is to say, I desire to be Radiant -- to Radiate Life!" -- Elbert Hubbard
  40. 40. Struggles/Challenges “Anything worth doing is difficult” – Patch Adams
  41. 41. Quo Vadis, Doctor? “I seldom end up where I wanted to go, but almost always end up where I need to be.” – Douglas Adams
  42. 42. “It is the time you have wasted for your rose that makes your rose so important.“ – The Fox (The Little Prince, Chapter 21)

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