Medical Governance, Health Policy, and Health Sector Reform in the Philippines

Medical Governance,
Health Policy,
and Health Sector Reform
in the Philippines
Updated 24 June 2014

Module I
Introduction: Governance, Policy, Reform
Structured approaches to health development
Reconciling the language games

INTRODUCTION: GOVERNANCE,
POLICY, REFORM

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

Healthcare Governance:
Scope, Scale, and Stakeholders
Point
of Care
Service Delivery
Networks
National and Local
Governments
Private Sector
Dynamics
International/Global
Health

Clinics as part of Health Systems
• 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

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)

The Epistemology of Public Health
Evidence-based
Epidemiology
Statistics
Aesthetic
Supernatural
Scripture
Reference: Gray, 2004 (p. 307-318)

Public Health = Med.Gov
Clinical Medicine Public Health Science / Expertise Needed
Anatomy Organization Organizational Design
Physiology Organizational Dynamics
Social Habits, Rules, and Law
Management and
Administration
Biochemistry Resource Flows
Incentives and Restraints
Budgets and Financing
Logistics
Pathology Monitoring and Evaluation Statistics, Econometrics
Pharmacology Evidence-based Public Health
Innovation
Critical Appraisal and
Application

“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

Public Health Practice
The strategic, organized, and
interdisciplinary application
of knowledge, skills, and competencies
necessary
to perform essential public health
services and other activities
to improve the population’s health.
Reference: Association of (US) Schools of Public Health, 1999

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.

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

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

0 10025 x 1,000 km 75
Parameter 25 75 100
Life Event Manufacture to
Prime
Middle Age Resale / Trade-in /
Scrap
Care Provider “Casa” “Talyer” / Self-repair ?
Dx, Tx, Rx Preventive
Maintenance
(e.g., Oil Changes)
Brake Pad
Replacements,
Recalibrations
Overhauls
Costs of Care + +++ +++++
Financing Co-pay Co-pay, Insurance Co-pay, Insurance
Catastrophe MV “Crash” (Damage)
Regulation LTO, LTFRDB, MMDA, etc.

0 10025 x 1 year 75
Parameter 25 75 100
Life Event Birth to Early
Adulthood
Middle to Old Age (Very) Old Age
Care Provider Clinics
(OB, Pedia, Surg)
Clinics / Hospitals
(IM, Surg)
Hospitals
(IM, Surg, Patho)
Dx, Tx, Rx Outpatient > Inpatient
(Vaccines, Vitamins, etc)
Outpatient = Inpatient
(“Maintenance” Meds,
etc)
Outpatient << Inpatient
(ACLS, Critical Care, etc)
Costs of Care + +++ +++++
Financing OOP vs. Insurance OOP vs. Insurance OOP vs. Insurance
Catastrophe MV “Crash” (Trauma)
Regulation PRC – Board of Medicine, DOH (incl. FDA), PHIC, etc.

RECONCILING THE LANGUAGE
GAMES

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

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

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)
PNoy’s Social Contract: a promise of
increased coverage of social health
insurance, and access to health
through improved health
infrastructure

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)

From MDGs to SDGs
• Sustainable Development Goals (SDGs):
beyond 2015; still being crafted by the UN
Sustainable Development
Social
Environmental
Economic
Reference: South Centre, 2013

Module II
Evidence-based healthcare and the policy cycle
Translating mandated policies
into budgets for execution

EVIDENCE-BASED HEALTHCARE AND
THE POLICY CYCLE

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

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.

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

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

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)

The Policy Cycle
Agenda Setting
Policy
Formulation
AdoptionImplementation
Evaluation

STRUCTURED APPROACHES TO PHL
HEALTH DEVELOPMENT

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
• 2000s: HSRA, F1, Cheaper Meds, FDA
• 2010s: KP, Sin Tax, RH Law, NHIA amendment

A Structured Approach:
The Results Frame
• Critical Assumptions
• Sound Development Hypotheses
Reference: USAID, 2000
Program
Inputs/Interventions
Intermediate
Results
Development
Objective
Agency Objective

The Health Value Chain Approach:
Translating Policies into Budgets and Resources for Execution
Policy Budget
Spending
Plan
Interventions
Securing
Supply
Generating
Demand
Improved
Health
Use of Goods
and Services
Information and Feedback
Reference: HPDP, 2014

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

Epidemiological Transition
0
10
20
30
40
50
60
70
80
90
100
110
0
100
200
300
400
500
600
1954 '57 '60 '63 '66 '69 '72 '75 '78 '81 '84 '87 '90 '93 '96 '99 '02 '05 2008
Deathsper100,000population
(non-communicablediseases)
Deathsper100,000population
(communicablediseases)
Year
Communicable Diseases Malignant Neoplasm Diseases of the Heart
Source: Philippine Health Statistics, various years

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 facility upgrading

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

Improved Health
Outcomes and
Minimal Financial
Risk
PhilHealth
Coverage
Access to
Professional
Healthcare
Use of Quality
Services
Payment of
PhilHealth
Claims
Value of
PhilHealth
Benefits
Reduction of
Exposure to
Health Risks

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

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.
48
• 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

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

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)

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)

Total Health Expenditures as % of GDP
0.50% 0.50% 0.70%
0.60% 0.70%
0.60%
0.40% 0.40%
0.50%
2.20%
2.30%
2.20%
0.50%
0.50%
0.50%
0%
1%
2%
3%
4%
5%
2010 (Actual) 2011 (Actual) 2012 (Estimated)
PercentageofGDP
National Government Local Government
Social Health Insurance (PhilHealth) Private OOP
Others

Who pays for the cost of health care?
National Government
12%
Local Government
15%
Social Health
Insurance
(PhilHealth)
9%Private OOP
53%
Others
11%
Source: 2011 Philippine National Health Accounts

Sources of Financing
• The Sources and their Uses
– NG: Policy Support / Management
– LG: Service Delivery (residual payor)
– PhilHealth – single payer
– PCSO, etc – catastrophic expenses
– PPP – high capital investments
– OOP – safeguard against moral hazard
• “5% of GDP” – correlation vs. causation issue

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

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)

The Supply Side of the Health System

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)

• 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

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

Watch on Youtube
• FP advert: http://youtu.be/H7jq8ccQ450
• TB advert:
http://www.youtube.com/watch?v=-
B8E7uIx19k

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

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

Module III
Implementation arrangements in healthcare
Capacity building, sustainability,
and knowledge management

IMPLEMENTATION
ARRANGEMENTS IN HEALTHCARE

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?

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

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

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

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

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

The Role of Civil Society Organizations
• Churches and Faith-based Groups
• Advocacy Groups
• Academe
• NGOs
• Provider/Professional Organizations

Public-Private Partnerships
• Frame:
Profit = Revenue – Cost
• Private interest is to maximize profit: either
increase revenue, or minimize cost
• Public interest is to ensure (by contract)
provision of high quality social services, which
entails costs
• Not just in infrastructure, but also elsewhere

PPPs in Health Systems
• Main purposes: increase capital finance; improve
the efficiency and quality of service provision
• Note that an across-the-board presumption in
favor of private sector solutions is not evidence-
based; it has to be tailor-made
• Real gains in PPP are not realized upon signing,
but during implementation of the contract which
requires effective monitoring and oversight
Reference: Hellowell, 2012 and Hellowell, 2014

Making PPPs Work
• The procurement process and the structure of
contracts must generate the right incentive framework
• Meaningful competition during bidding is essential so
that the procurer gets high quality at a low price from a
contract
• Government should enforce quality standards, and levy
a financial cost upon the private sector in cases of
underperformance
• Government should have significant financial and
human resources for identifying and mitigating risks
Reference: Hellowell, 2012

PREVIEW OF A (FULL) POLICY
CYCLE: THE RH LAW

OSG: 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

SC: What is the RH Law?
Despite efforts to push the RH Law as a reproductive health
law, the Court sees it as principally a population control
measure.
… the RH Law does not sanction the taking away of life. It
does not allow abortion in any shape or form. It only seeks
to enhance the population control program of the
government by providing information and making non-
abortifacient contraceptives more readily available to the
public, especially to the poor.
Reference: Decision, Imbong v. Ochoa, pp. 34, 101 Emphasis supplied

Indeed, at the present, the country has a population
problem, but the State should not use coercive measures
(like the penal provisions of the RH Law against
conscientious objectors) to solve it.
Reference: Decision, Imbong v. Ochoa, p. 102 Emphasis supplied
SC: What is the RH Law?

SC: Who determines what contraceptives
are abortifacient or not?
While an abortifacient is outlawed by the Constitution and
the RH Law, the practical problem in its enforcement lies in
the determination of whether or not a contraceptive drug
or device is an abortifacient. This is where expert medical
opinion is imperative. The character of the contraceptive as
an abortifacient or non-abortifacient cannot be legislated or
fixed by law and should be confined to the domain of
medical science.
Reference: Concurring Opinion, Leonardo-De Castro, J.,
Imbong v. Ochoa, pp. 7-8 Emphasis supplied

Passing the RH Law
is just the start of the value chain…
Policy Budget
Spending
Plan
Interventions
Securing
Supply
Generating
Demand
Improved
Health
Use of Goods
and Services
Information and Feedback
Reference: HPDP, 2014

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 tangible commodities to technical
assistance (TA)
Reference: Garrett, 2007

Agenda
Setting
Policy
Formulation
AdoptionImplementation
Evaluation
Areas for Management Consulting
Research
Production
Research
Management
Marketing /
Communication
Implementation
Monitoring &
Evaluation

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

HPDP Contact Information
Dr. Orville C. Solon
Chief of Party
Health Policy Development Program (HPDP)
Room 322, Encarnacion Hall, School of Economics
University of the Philippines Diliman
Diliman, Quezon City
upecon.hpdp@gmail.com

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

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Medical Governance, Health Policy, and Health Sector Reform in the Philippines

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