Community Medicine in the Philippines. Delivered to newly licensed physicians at the Topnotch Medical Board Review Center last March 11, 2015

1. Hindi Lang
Ubo’t Sipon
Community Medicine in the Philippines for the
Newly Licensed Filipino Physician
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
March 11, 2015
Topnotch Medical Boards Review Center

2. Objectives – Talking Points – Issues to Address
WHAT IS THIS ALL ABOUT???

3. From my experiences as and the perspective of
a Municipal Health Officer, I would like to:
 Contextualize the practice of Community
Medicine in terms of the state of the
Philippine Health Care System
 KEY CONCEPTS:
 Devolution
 Inequity
 Health Systems

4. From my experiences as and the perspective of
a Municipal Health Officer, I would like to:
 Give a discussion on the Challenging
Realities of practicing Community
Medicine in the Philippines
AND AT THE SAME TIME:
 Also show how I dealt with these
CHALLENGING REALITIES in my work on
the “frontlines” of Philippine Health Care

5. Hindi Lang Kuwento Si Rosario…
 I hope to help my newly-licensed physician
colleagues to realize that there is more to Community
Medicine than “Cough and Colds”…
 FORGET THAT Prev Med Exam.
 Hindi benign ang Community Medicine.
 Lalo na dito sa Pilipinas…
 Lalo na para sa milyon-milyong Pilipinong gaya ni
Rosario…
 Lalo’t higit para sa ating Manggagamot na Pilipino

6. In Line with my Personal Advocacy of Filipino Human Health
Resource Capacity Building and Development, I Would Like to:
 Inspire and at the same time, challenge newly-licensed
Filipino Physicians to not only serve the Philippines and its
people; but to serve with MEANING
 Serve the UNDERSERVED
 Go beyond traditional medicine/clinical practice
 Re-evaluate measures of success in the field of medicine/health
care
 Be health systems development practitioners
 Show that beyond the “feels”, a career in Community
Medicine is a viable and vibrant one.
Para saan at kanino ang pagiging duktor mo?

7. INTRODUCTION

8. Who am I?
 Paolo Victor N. Medina, MD
 UPCM Class 2009
 Born and raised in Makati, presently
residing in Las Piñas City
 Municipal Health Officer; Quezon, Quezon
 December 8, 2009 to December 31, 2014
 Direct LGU hiring
 Non-DTTB
 Non-FG, non Pinoy MD Scholar
 Presently:
 Assistant Professor of Community Medicine,
UPCM
 Full-time Public Health and Primary Health
Care Practitioner

9. Where did I work?
 Quezon, Quezon
 1 of 3 municipalities on
Alabat Island, Quezon
 6-10 hours from Manila
(6-9 by land; 1+ hours
by boat)
 Geographically Isolated
and Disadvantaged
Area (GIDA)
 5th class municipality

10. RHU/MHO Quezon, Quezon
 1 MD
 1 RN (Public Health Nurse)
 Rural Health Midwives
 3 permanent
 2 job order
 2 Rural Sanitary Inspectors
 1 of them is also the TB microscopist
 1 Municipal Dentist
 In RHU every other week (serves 2 towns)
 Supplementary Staff (2014)
 6 NDP Nurses
 1 RHMPP Midwife
 1 PhilHealth Nurse- Encoder (job order)
 1 Ambulance Driver (job order)

11. Who did We Serve?
 Only Doctor (only Health
Workers) for:
 15,365 Population (2014
projected, +/- 2,000)
 Significant Proportion Poor
or Near-Poor
 2000+ (out of 3000) are
CCT Families
 Livelihood mainly driven by
subsistence fishing and
farming

12. A Challenging Reality…
THE FILIPINO MD AT THE FRONTLINES

13. The Filipino MD at the Frontlines

14. The Filipino MD on the Frontlines
 Especially in places where there is no
one else
 MDs have to retain and nurture their
unique identities and skillsets as
physicians for their constituents
 Frontliners see the bulk of patients
 BURDEN: Rationalize health care,
management, etc.
 Maximize often very limited resources
 Too Few MDs, Patients simply too many
 No other health workers/MDs because
areas of assignment are dangerous,
remote, too difficult to get to, etc.

15. “Primary Care” ++ on the Frontlines
 “Essential” Health Programs/Services
 Expanded Program on Immunization
 Disease Surveillance
 Control of Acute Respiratory Infections
 Control of Diarrheal Disease
 Nutrition
 Family Planning
 TB Control Program
 STD/AIDS Prevention Program
 Environmental Sanitation Program
 Non-communicable Disease Program
 Cancer Control Program
 Maternal Care
 Plus all other health programs as per DOH
 50++ as of 2014
 Tailored to local needs and situation
(decentralized system of government)
 “Other” Functions
 Social Mobilizer
 Community Organizer
 Activist
 Clinic Manager
 Administrator
 Politician
 Educator/Trainer
 Disease Surveillance
Officer
 Med Tech
 Local Committee Head
 Tourism
 Peace and order
 Gender
 Livelihood
 Planning and
development
 Architect
 Engineer
 Sanitary Engineer
 Policy Maker
 Legislator
 Advocate
 Lobbyist
 Researcher
 Pharmacist
 Student
 Policeman
 Planning Officer
 Leader
 Information Systems
Manager and Analyst
 Epidemiologist
 ETC!

16. Challenging the Reality…
CHALLENGE ACCEPTED!
THE FILIPINO MD AT THE FRONTLINES

17. COLLABORATE…

18. RNs as Primary Care + Providers…
Public Health Nurse/Nurses

19. RHMs as Primary Care + Providers…
Rural Health Midwives

20. Enabling Community Health Workers

21. STAY CONNECTED…

22. BE CREATIVE…

23. TECHNOLOGY…

24. COMMUNITY…

25. A Challenging Reality…
Filipino Doctors ARE NOT Community Medicine READY

26. Current Pinoy MD Education
http://imgkid.com/cartoon-doctor.shtml http://www.wpclipart.com/medical/personnel/surgeon.jpg

27. “Community Medicine”

28. Like A Fish Out of Water…

29. Challenging the Reality…
What I Should Have Learned in Med School… I CAN STILL LEARN NOW!
Filipino Doctors ARE NOT Community Medicine READY

30. To See, You Only Need to Look…

31. Start Asking the Hard Right Questions…

32. Put things into CONTEXT…
“Sixty percentof
ourcountrymen
who succumbto
sicknessdie
without seeing a
doctor.”
-Pres.Noynoy Aquino

33. Remember WHY…
You will never lose your
way if you don’t lose
your WHY…

34. Primary Health Care
 What good does it do
to treat a person’s
illness if he/she will
return to the conditions
that led to the illness in
the first place?
(paraphrasing F. Baum)

35. A Challenging Reality…
THE INEPTITUDE OF GOVERNMENT

36. Mediocrity…

37. Incompetence…

38. Corruption…

39. That Thing Called “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)

40. Devolution
Implementation of Devolution
in 1992:
 Management and delivery
of health services
 From DOH to locally elected
provincial, city and municipal
governments
 ARMM – exception
 Retained its centralized
system
 4 Essential Health
System Functions
 Service provision
 Resource generation
 Financing
 Stewardship

41. Major Features of RA 7160 (LGC of 1991)
Devolved Basic Services
 On Health and Social Services:
1. Implementation of programs and
projects on primary health care,
maternal and child care and
communicable and non-communicable
disease control services;
2. Purchase of medicines, medical supplies
and equipment needed to carry out
services;
3. Social welfare services which include
programs and projects on child and
youth welfare, family and community
welfare, women’s welfare, elderly and
disabled persons welfare
 Negative effects on health
care:
 Vulnerability to patronage and
traditional politics
 Great variability in health care
program planning,
implementation and M&E across
LGUs
 Highly dependent on motivated,
innovative, inspired and morally
upright human resources
 Some LGUs are “more equal
than others”

42. Devolution: Fragmentation of Health System

43. 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 (should be) THE LEAD AGENCY
http://www.mb.com.ph/doh-denies-18-ebola-cases-in-qc/

44. Challenging the Reality…
MAKING THE HEALTH SYSTEM WORK FOR PEOPLE
THE INEPTITUDE OF GOVERNMENT

45. The QQ HSD Framework
Systems thinking for health system strengthening, WHO. 2009.
Adapted from: Building Blocks of a Functional Health System,
WHO by Alliance forImproving Health Outcomes (AIHO)

46. Leadership and Governance
Dynamic RHU Leadership and Staff Active Local Health Board

47. Leadership and Governance
Functional
Interlocal
Health Zone
(ALQUEREZ)
Alabat-Quezon-Perez

48. Leadership and Governance
Active Community and Stakeholder
Participation/Involvement
Regular Barangay Meetings, Assemblies,
Consultations, Local Health Summits, etc

49. Health Information Systems
PIDSR, e-FHSIS, UP-NThC Accurate, Responsive and Useful Data Recording and
Reporting; Regular Health Education Campaigns

50. Health Financing
Full Efforts for RHU Quezon, Quezon to
be a 3-1 PhilHealth Provider (2013)
Local Health Board Efforts, Required
Infrastructure/Services

51. Access to Essential Medicines and Technologies
Policies, Programs, Budgeting, etc to
Ensure Access to Essential Services
UP-NThC, Local and International
Networking, Additional Funding

52. Health Workforce
Skilled, Humane and Dedicated Human
Resources for Health
Regular Staff Meetings, CMEs, Constant
Updates, Skills Upgrade, etc

53. Health Services
High Quality Health Services, Rational
Drug Use, Reproductive Health, etc
Ambulance, Patient Consultations,
Counseling, Patient Education, PHC

54. A few Key Health Indicators and Outcomes for the Municipality of Quezon, Alabat
Island, Quezon (December 2009 – December 2014)
QUEZON, QUEZON AS A FUNCTIONAL HEALTH SYSTEM

55. KEY HEALTH SYSTEM INDICATORS
(December 2009 – December 2014
QUEZON, QUEZON

56. Budget for Health
9.80%
15.38%
13% 13.44%
12.40%
0.00%
5.00%
10.00%
15.00%
20.00%
2010 2011 2012 2013 2014
Percentage of RHU Budget to Municipal Budget
Recommended percentage of Health Budget to LGU Budget: 15%
Spike in 2011 because of budget for Birthing Home (1.5M pesos)
2014 Budget – estimate only (no official figures from MBO; does not include GAD, 20% development fund)

57. • Birthing Home Constructed (LGU, 2012)
• Dedicated DOTS Facility Constructed (2012)
• 2M sourced from DOH for RHU Main Renovation
2013
• Another 5M expected from DOH for 2015
• RHU Presently 2 in 1 PhilHealth Accredited (soon to
be 3 in 1 as soon as MOA w/ GDH finalized
• EMR Utilization (CHITS); RX Box
Health Facility and Services Enhancement
NOON (December 2009) NGAYON

58. Health Services Utilization
4866
7420
6319
10066
11347
12022
14220
16199
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
2007 2008 2009 2010 2011 2012 2013 2014
RHU (Main Health Center)
Consultations
 General improvement of services
and facilities
 Increasing utilization
 Reflects patient trust in services and
personnel
 Excludes BHS data
 Increased utilization seen as well at
BHS level
 RHU Staff were “sent back” to posts
in the different barangays
 More efficient and functional internal
referral system within the
municipality (BHS to RHU)

59. Skilled Birth Attendance
0%
20%
40%
60%
80%
100% 90%
60%
55%
61%
70% 72%
Skilled Birth Attendance

60. Facility Based Deliveries
0%
10%
20%
30%
40%
50%
60%
70%
80%
0% 0%
39%
52%
66%
76%
Facility Based Deliveries
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2009 2010 2011 2012 2013 2014
0 0 0
161
36
0 0 0
13
136
Hospital Delivery RHU Birthing Home

61. Antenatal Care
0%
20%
40%
60%
80%
100% 90%
23%
34%
52%
62% 58%
4+PNCU
Figures are based on actual number of pregnancies during the year.

62. Postpartum Care
0%
20%
40%
60%
80%
100%
80%
65% 65%
81% 85%
2+ Postpartum Visits
Figures are based on actual number of births during the year.

63. Breastfeeding Initiation Within 1 hour
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Target 2010 2011 2012 2013 2014
95%
63% 65%
88%
97%
Breastfeeding Initiated
within 1 Hour

64. Expanded Program of Immunization
95%
57%
43%
67%
83%
69% 68%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Target 2009 2010 2011 2012 2013 2014
Percentage of Fully
Immunized Children
 Sharp drop in 2009
 Lack of DPT vaccine supply from DOH
 Personnel Issues (no MD, RN)
 Upswing in 2011
 Managerial and administrative adjustments
 Reshuffling of RHMs
 Further increase in 2012
 Analysis of Data and Lessons of 2010, 2011
 Drop in 2013
 Adjustment to the new EPI (pentavalent, Hep B vaccine
at birth, etc)
 Implementation of new policy on Pentavalent Vaccine
without adequate supplies in place
 Community Dialogue, Engagement; Advocacy; IECs
 A constant in making efforts for successful FIC
coverage
2014 data as of September only.
FIC accomplishment reported as per projected population.

65. Nutrition
12%
17%
20%
14%
18%
17%
0%
5%
10%
15%
20%
25%
2009 2010 2011 2012 2013 2014
Percentage of PEM among
0-5 year olds
 Sudden Rise in 2010
 Poor reporting in 2009 (no MHO, PHN) – 2009 figure not accurate
 Inactive Municipal Nutrition Action Council (MNAC), no BNS
 2010-2011 Nutrition Program Interventions – resulted in sharp drop in
2012
 Reactivation ng Municipal Nutrition Action Council (PHN as MNAO)
 Community Involvement
 Training and Funding of new batch of BNS
 Barangay Situational Analyses, Validation of Data, Barangay consultations
 Aggressive Breastfeeding and Infant and Young Child Feeding Campaigns
 Rise in 2013
 Political Influence and Instability (Barangay Elections)
 BNS President, other BNS – resigned or removed by Barangay Captains
 Relatively high prevalence in 2014
 Nutrition improvement efforts affected by Typhoon Glenda
 NO FEEDING PROGRAM DONE
National Target: Below 21%

66. Family Planning
0%
10%
20%
30%
40%
50%
60%
70%
Target 2011
2012
2013
2014
65%
30% 31%
43%
39%
Contraceptive Prevalence Rate

67. Control of Communicable Diseases
 Declared Rabies Free (2014
ALQUEREZ)
 Vector-borne Disease Prevalence
 Low Dengue incidence over the last 5
years
 No case of malaria (since 2006)
 Still classified as endemic area
(monitoring)
 Chikungunya Outbreak (2013)
 Filaria endemic area
 Awaiting Mid MDA Implementation NBE
results done November 2014
 Best MDA results in 4 years (97%
actual, 96% projected)

68. Filariasis MDA Accomplishment
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Target 2011
2012
2013
2014
85%
71% 73%
86%
97%
Filariasis MDA Accomplishment

69. Tuberculosis
0%
20%
40%
60%
80%
100%
120%
140%
160%
Target 2011 2012 2013
2014
90%
50% 56%
104%
157%
TB Case Detection Rate

70. Tuberculosis
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Target 2011
2012
2013
2014
90%
77%
100%
91%
100%
TB Cure Rate

71. Enabling People to Make the Health System Work for the People
COMMUNITY MEDICINE AS A CAREER…

72. Family…

74. Health Professions Education

75. Health Professions Education

76. Health Professions Education

77. Health Systems Strengthening through
Health Human Resource Development

78. Health Systems Strengthening through
Health Human Resource Development

79. Health Systems Strengthening through
Health Human Resource Development

80. Health Systems Strengthening through
Health Human Resource Development

81. With you out there, you CAN and WILL make a DIFFERENCE!
THE BOTTOMLINE…

82. The Challenge…
 I am not saying everyone should be
a Municipal Health Officer
 We should respond to the needs of
the country in terms of health
care/health systems:
 Public Health
 Specialized/Clinical Care
 Health Policy
 Health Governance
 Health Financing
 Relevant Health Research
 Dreams and aspirations ARE
compatible with serving the
underserved

83. The Challenge…
 At the end of the day, it’s
all about the principles of
Equity and Justice and
our subsequent role in
ensuring these for every
Filipino
 Whatever kind of doctor
we choose to be.
 Wherever we may find
ourselves in.

84. The Challenge…
 For the Philippines and
the Filipino…
 How much are we
willing TO DO?
 How hard are we
willing TO TRY?
 How far are we willing
TO GO?

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

86. QUESTIONS?