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

Medical Governance,Health Policy,

and Health Sector Reformin the Philippines

Updated 24 June 2014

Module IIntroduction: Governance, Policy, Reform

Structured approaches to health developmentReconciling 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

ScriptureReference: Gray, 2004 (p. 307-318)

Public Health = Med.GovClinical Medicine Public Health Science / Expertise Needed

Anatomy Organization Organizational Design

Physiology Organizational DynamicsSocial Habits, Rules, and Law

Management and Administration

Biochemistry Resource FlowsIncentives and Restraints

Budgets and FinancingLogistics

Pathology Monitoring and Evaluation Statistics, Econometrics

Pharmacology Evidence-based Public HealthInnovation

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

Soci

al

Envi

ronm

enta

l

Econ

omic

Reference: South Centre, 2013

Module IIEvidence-based healthcare and the policy cycle

Translating mandated policiesinto 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

Ideologicalinspirations

Change in circumstances

Evidence

Common sense

From researchFrom 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/Interven

tions

Intermediate Results

Development Objective

Agency Objective

The Health Value Chain Approach:Translating Policies into Budgets and Resources for Execution

Policy Budget SpendingPlan

Interventions

SecuringSupply

GeneratingDemand

ImprovedHealth

Use of Goodsand 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


(Berman, 2012)

Epidemiological Transition

1954

'55

'56

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2008

0

100

200

300

400

500

600

0

10

20

30

40

50

60

70

80

90

100

110

Communicable Diseases Malignant Neoplasm Diseases of the Heart

Year

De

ath

s p

er

10

0,0

00

po

pu

latio

n

(co

mm

un

ica

ble

dis

ea

ses)

De

ath

s pe

r 10

0,0

00

po

pu

latio

n

(no

n-co

mm

un

icab

le d

isea

ses)

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

1993 NDS 1998 NDHS 2006 FPS 2011 FHS0

50

100

150

200

250

300

Num

ber o

f dea

ths

per 1

00,0

00 li

ve b

irths

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

2

35

6

1

4

The Continuum of Care

Health Risk exposure Risk contact

Latent disease/inju

ry

Early disease/

injury

Disease progression

Advanced disease/injury

Chronic disease

Impairmentor Death

Primary Prevention: Reduce risk exposure

Secondary Prevention:

Detection and intervene early

Tertiary Prevention:Reduce progress or

complications of established disease

Policy and Standards Developm

ent

UHC Interventions

48

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

Advantages of Focusingon 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




Interventions

SecuringSupply

GeneratingDemand

ImprovedHealth




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

2010 (Actual) 2011 (Actual) 2012 (Estimated)0%

1%

2%

3%

4%

5%

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%

National Government Local GovernmentSocial Health Insurance (PhilHealth) Private OOPOthers

Perc

enta

ge o

f GD

P

Who pays for the cost of health care?National Government

12%

Local Government15%

Social Health Insurance (Phil-

Health)9%Private OOP

53%

Others11%

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 Cycleand Absorptive Capacity

• Budget Call• Agency Planning• Negotiations with DBM• NEP filed in Congress• Congressional Hearings

– “Power of the Purse”– PDAF

• Appropriations• Allotments and

ObligationsReferences: DBM, 2013; Rappler.com, 2013

FINANCIALPROTECTION

PROVIDED TO THE POPULATION

AccreditationEnrollmentClaims

Availment and 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)



Interventions

SecuringSupply

GeneratingDemand

ImprovedHealth




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• OutcomeStructural 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




Interventions

SecuringSupply

GeneratingDemand

ImprovedHealth




Watch on Youtube

• FP advert: http://youtu.be/H7jq8ccQ450• TB advert:

http://www.youtube.com/watch?v=-B8E7uIx19k

http://youtu.be/H7jq8ccQ450

http://youtu.be/H7jq8ccQ450





Interventions

SecuringSupply

GeneratingDemand

ImprovedHealth




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)

P =

Where:P = performanceM = motivationC = competence

B = barriers

Options to achieve change:

• Incentives (carrots)• Disincentives (sticks) hit people with carrots

Module IIIImplementation arrangements in healthcare

Capacity building, sustainability,and knowledge management

There is a world

beyond the hospital

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

LEGISLATION THRESHOLD

Opp

ositi

on to

legi

slati

on

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 interestStrong evidence

Opposition by industryPolicy has adverse effectsHigh cost of intervention

What legal adjustments are needed to implement UHC?

Restructuring of Excise Taxes of alcohol and tobaccoPassage of Responsible Parenthood BillStrengthening 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 careScreening

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 qualityReference: Gray, 2004 (p. 290)

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 contraceptivesare 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 Lawis just the start of the value chain…


Interventions

SecuringSupply

GeneratingDemand

ImprovedHealth




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 / CommunicationImplementation

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. SolonChief of PartyHealth Policy Development Program (HPDP)Room 322, Encarnacion Hall, School of EconomicsUniversity of the Philippines DilimanDiliman, Quezon [email protected]

INTEGRATION

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

AlbertDomingo.comfacebook.com/aedomingo

twitter.com/AlbertDomingo

Open Forum / Q&A

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

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