Tuesday, September 18, 2012

Health Transparency 10: Depoliticizing Health, Corporatizing Government Hospitals

Health and education, unlike food and clothing, are among the most politicized services in many countries around the world including the Philippines. The extent of government involvement in healthcare in the Philippines for instance, runs from the barangay or village level (barangay health workers, rural health units, etc.) to the municipality and city to provincial (city and provincial health offices, hospitals) to national (DOH, PhilHealth, FDA, etc.) up to the multilateral and bilateral (WHO, UN, WB, USAID, DFID, etc.) levels.

When we talk about health transparency, we refer not only to all those government agencies and offices of course, but also to the various stakeholders and players in the health sector -- the corporations (pharma manufacturers, wholesalers, drugstores, hospitals, HMOs, etc.), academe and civil society organizations. But unlike corporate entities that are subject to competition among themselves and regulation by the government, the public or government sector is the largest, the most extensive, the most bureaucratic and the most politicized, naturally. So the big challenge in health transparency is how to make the various government agencies be more transparent, be more accountable, and if only possible, be shrinkable if they do not perform their mandate and the various public expectations of them.

I am posting below three recent articles by a friend who also writes a weekly newspaper column, Reiner Gloor of the Pharmaceutical and Healthcare Association of the Philippines (PHAP). Reiner writes in BusinessWorld, a big business newspaper here in the country. His three articles here are on:

1. Governance in Health, August 23, 2012,
2. Health in the Reform Agenda, August 30, 2012, and
3. To corporatize or not to corporatize, September 06, 2012.

All of these topics were tackled under the (DOH) "Secretary's Cup" discussion series in various places and dates.

The first article is about the role of local government units (LGUs) in healthcare delivery; the second is about the linkage and the need for collaboration between healthcare providers including the government, and patients or the public. And the third is about the need for public-private partnership (PPP) in currently government-owned and controlled hospitals that lack resources and managerial skills to make them more financially stable and less dependent on politics and politicians.

Of course I do not believe that public health can be depoliticized. When government implements various healthcare service provision from the barangay up to the national level, involvement and intrusion by politicians and administrators is inevitable.So the move towards corporatizing -- not privatizing as commonly misunderstood -- of certain government hospitals is a move to lessen the politics of healthcare.

Below are the three papers by Reiner. Enjoy.

(1) Governance in health

Posted on 06:16 PM, August 23, 2012

Medicine Cabinet -- Reiner W. Gloor

(First of a series)

IN COUNTRIES where democracy is strong, public discourse is crucial as it provides citizens the capacity and opportunity to talk about and debate relevant issues to spark action and bring about necessary change. This belief that public discourse results in political action is based on the so-called public sphere theory, one which is necessary in realizing comprehensive health reforms in the country.

Towards this end, the Secretary’s Cup has been launched in search for common judgment on proposed reforms in this era of universal healthcare. Apart from the monthly talk series by the country’s health luminaries, town hall meetings and inter-collegiate debates have been put in motion specifically focusing on governance.

However, public discourse operates in opposites, particularly in the health sector. We see this in the ongoing debate on the reproductive health bill and the proposed “corporatization” versus “privatization.”

But does it always have to be “versus”?

Governance, being one of the six building blocks of a health system, is not synonymous to government. Former health secretary Alberto Romualdez explained that governance is “not just about government, but deals with how the government and other institutions arrive at decisions and implement them towards meaningful changes that are beneficial to the people.” The government’s role, thus, is to aim at building consensus and forming partnerships, replacing the operative word “versus” with “and,” paving the way for synergism and constructive, not oppositional, relationships.

In strengthening health governance, it is imperative to discuss the pros and cons of health devolution in the era of universal healthcare, the role of the proposed corporatization of government hospitals in boosting health services at the local government level, and applicability of the no balance billing to local hospitals.

Dr. Gideon Lasco, a member of the Universal Health Care Study Group of the University of the Philippines National Institutes of Health, endeavored to elaborate on these current issues in time for the Secretary’s Cup debate on governance.
In 1991, the Local Government Code drastically altered the bureaucratic landscape by transferring the management of public health program and government hospitals at the municipal and provincial levels, from the Department of Health (DoH) to local government units (LGUs). Not long after, the advantages and disadvantages of this new, decentralized system began to emerge.

While it enabled LGUs to deal with their own particular health needs, it also opened the possibility for LGUs to neglect health care delivery.

In a Universal Health Care scheme, the DoH would have to build strategic partnerships with local governments. While it is clear that there has to be a centralized body to coordinate macro-level functions, such as health information gathering, policy formation, and the operation and management of tertiary hospitals, there are also strengths in empowered local governments.

It must also encourage the strengthening and expansion of Interlocal Health Zones -- adjacent towns and cities that cooperate on health at the district level. These Zones have already demonstrated better health outcomes where they were successfully implemented. Dr. Alberto Romualdez, who spearheaded the Health Sector Reform Agenda in 1998 as DoH secretary, has advanced the notion that the district health system ought to be the level of devolution, and that a referral system must be in place to weave things together: from the smallest rural health unit to the district hospital.

PhilHealth can act as leverage to optimize local-national partnerships, by providing incentives to local governments that perform well, and as well as setting standards in the accreditation of LGU hospitals, ensuring quality and safety, and providing additional capital with which enough human resources and quality health services can be guaranteed.

Finally, by building a constituency on health sector reform, which is what the Secretary’s Cup aims to achieve, political capital on health is built, creating incentives for local and national politicians to work together towards better health outcomes.

(2) Health in the reform agenda

Posted on 05:10 PM, August 30, 2012

Medicine Cabinet -- Reiner Gloor


(Second of a series)

TWO WEEKS ago, I announced in this column that Interior and Local Government (DILG) Secretary Jesse Robredo confirmed that he would participate in a forum we are organizing on health and local governance. I and the Filipino nation hoped for his successful rescue after his accident until things became clearer a few days later.
The media forum series is part of the Department of Health-led "Secretary’s Cup" which aims to increase awareness on the pressing need for health reforms. While Secretary Robredo was not there at the forum opening, DILG Undersecretary Austere Panadero was right when he said that "his legacy shall live on."

Delivering Mr. Panadero’s message, DILG Director Manuel Gotis affirmed Mr. Robredo’s legacy on good governance in health. Following the enactment of the Local Government Code which ushered in health devolution, among others, the DILG took the challenge of capacitating local government units so that health would be on top of their reform agenda.

Union of Local Authorities of the Philippines (ULAP) Executive Director Sonia Lorenzo echoed that health must be a priority and that it could be done, citing the experience of San Isidro, Nueva Ecija which allocated 16.21% of its municipal budget to health.

As an addition to Mr. Robredo’s legacy on health, more and more LGUs are now getting high grades in a health department scorecard which measures health service delivery initiatives, specifically in governance, health financing, regulation and service delivery. The so-called 2011 Scorecard showed promising developments in the performance of LGUs, with 19 cities and 15 provinces consistently performing well in at least four to nine indicators.

In particular, Mr. Gotis revealed that there have been positive developments on malaria, tuberculosis case detection, breastfeeding, and facility based delivery among others. Even better is the report that LGUs have exceeded targets in relation to protein-energy malnutrition and in provincial budget allocation for health.

On the other hand, efforts must be sustained on those relating to TB cure rate, fully immunized children, and doctor-to-population ratio. Also among the challenges of devolution are the salaries and wages of about 46,000 health personnel that became the responsibility of provinces, cities and municipalities. Given this and other concerns, Mr. Gotis cited the need for more resources to deliver basic health services at the local level.

As former health secretary Alberto Romualdez said, the real enemy that we are battling against is inequity in healthcare. At the end of the day, it should be aspired that both the poor and non-poor must have access to same quality healthcare. Governance plays a key role as it relates to how governments and other social organizations interact, how they relate to citizens, and how decisions are taken.

As part of the Secretary’s Cup series, Dr. Gideon Lasco of the Universal Health Care Study Group of the UP National Institutes of Health, explained that health is a product of a synergy among healthcare providers and patients:

Health care must be seen not as an authoritarian imposition of doctors and industry upon patients and consumers; but as a team effort among doctors, nurses, midwives, patients, as well as among producers, regulators, and consumers of pharmaceutical products and health services. In a larger context, this "teamwork" approach mirrors the "social solidarity" concept that rationalizes the social health insurance scheme of PhilHealth.

The community health teams (CHTs) program of the Department of Health is a good move towards this direction. In recognition of the dearth of doctors in rural areas, the CHTs serve to augment the health needs of communities, particularly those that have indigent families. It also mobilizes nurses and midwives, by providing them with experience, training, and also an exposure to community health.

Involvement in health care must likewise extend to the patients themselves, and the community as a whole; the only thing that can beat a "community health team" is a community that works as a health team.

Conversely, patient empowerment can be maladaptive if coupled with mistrust in the health system overlaid with perceptions and experiences of unaffordable drugs and unfriendly health care providers. In line with the DoH strategy of collaborating with other government agencies, the Department of Education can contribute to patient education by strengthening the health curriculum of students. Patient "miseducation," by way of misleading advertisements, should likewise be dealt with.

In addition, patient groups and consumers groups need to be organized. Financial protection should be extended to vulnerable populations, so they will not seek potentially unsafe alternatives. Performance in health must be measured not only in terms of health outcomes or economic gains, but also in terms of patient satisfaction.

(3) To corporatize or not to corporatize

Posted on 06:59 PM, September 06, 2012

Medicine Cabinet -- Reiner Gloor


(Third of a series)

INSTITUTIONALIZING the Aquino Government’s flagship health agenda requires reforms that would aid in strengthening health systems composed of critical building blocks.

On the way to establishing universal healthcare, major issues will be raised and decisions will have to be made. The Secretary’s Cup, was designed by the Department of Health (DoH) and the Universal Healthcare Study Group of the University of the Philippines, along with partners, to tackle these important issues. Through debates, town hall meetings, and roundtables, issues relating to health governance are discussed in the public sphere. These issues include the pros and cons of devolution, no-balance billing policy, oversight functions of the 

DoH over public and private health facilities, and the corporatization of government hospitals.
Legislative proposals to convert 26 government hospitals into corporate entities have been filed in Congress in a bold move to boost health service delivery. The proposed measures seek to allow state hospitals and medical institutions to retain their income or generate revenue, providing opportunities to upgrade facilities and improve services.

In 1991, the Local Government Code took effect so that local government units (LGUs) could fully enjoy autonomy, development, as well as self-reliance, “and make them more effective partners in the attainment of national goals.” Through a system of decentralization, LGUs were given more powers, authority, responsibilities, and resources for them to discharge several functions, including those that are “necessary, appropriate, or incidental to efficient and effective provision of the basic services and facilities.” These health services include the implementation of programs and projects on primary health care, maternal and childcare, and communicable and non-communicable disease control services; access to secondary and tertiary health services; and purchase of medicines, medical supplies, and equipment among others.

At a roundtable organized for the Secretary’s Cup, Department of Interior and Local Government (DILG) Undersecretary Austere Panadero acknowledged that there remain health challenges, specifically lack of public health workers, insufficient funding for medicines and specialized facilities at the local level. Budget remains one of the impediments confronting LGUs. The release of the annual Internal Revenue Allotment is not enough to cover the cost of health services and facilities at the local level.

With these in mind, the DILG encourages public-private partnerships in health to attain local development. The move may result in better facilities and equipment, enhanced staff performance and greater accountability.
On the other hand, Mr. Panadero pointed out that any decisions must not hinder the poor’s access to health services by establishing necessary safety nets. In a corporate setting, the poor must still be able to access quality health services at minimal costs.

In broadening the discussion on corporatization and other governance issues, 40 teams from different schools competed in the first Secretary’s Cup debates.

During the debates at UP Los BaƱos (UPLB), Dr. Lee Yarcia reported that for the Luzon Elimination Rounds, the competing teams argued for or against three motions about health governance. These were: 1.) “That government hospitals should be corporatized and that the local health board be given autonomy”; 2.) “That private hospitals should be exempt from no balance billing policy”; and 3.) “That the DoH should exercise oversight functions over all health facilities both public and private, at local and national level.”

The team of Jake Bustos, Joan Nacorda, and Melchizedek Babilonia of UPLB clinched a spot as finalists after winning all debate rounds, while the team from De La Salle University composed of Mark Escay, Dani Pua, and Brian Chuahiock also secured a spot at the National Final Series after ranking second.

Bustos rejected the proposition on government corporatization and local health board autonomy. He argued that health is a fundamental right that should not be subject to the risks of fluctuating market forces as a consequence of corporatization. He also feared that giving autonomy to the local health board as this may be tantamount to a transfer of government responsibility to the private sector.

In another round, Escay supported the motion that private hospitals should be exempt from no balance billing policy. He contended that the policy would limit the rights of citizens to choose the type of health care they want.
UPLB won the last round when it supported the proposition that the DoH should exercise oversight functions over all health facilities. She asserted that the DoH has the mandate and authority to oversee a national health agenda, and must exert its responsibility of regulating health services all over the country.

For more information, log on to www.phap.org.ph or www.phapcares.org.ph. Join us onwww.facebook.com/people/Pharma-Phap/. E-mail the author at reiner.gloor@gmail.com.

See also:
Health Transparency 5: Forum on Good Governance in Health, March 08, 2012
Health Transparency 6: Physician Protectionism, May 19, 2012
Health Transparency 7: DOH Advisory Council, CHAT, June 04, 2012
Health Transparency 8: Advisory Council on RA 9502, June 11, 2012
Health Transparency 9: Physician Misdiagnosis, Dispensing Medicines, July 20, 2012

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