Building Blocks of A Strong Local Health System

Lectured by

Bien Eli Nillos, MD

Project Associate Zuellig Family Foundation Assistant Professor USLS COM, Family and Community Medicine Former Doctor to the Barrios Department of Health

HEALTH FINANCING SUMMIT Nov. 12, 2011 University of Saint La Salle Asian Institute of Management

What is a Local Health System?

All the activities whose primary purpose is to promote, restore or maintain health. (WHO, 2000)

It involves the formal health services such as primary, secondary and tertiary care, public health services, and public, private for profit and private non-profit insurance companies and service providers, as well as traditional healers, over the counter medications, informal or charity home care, health promotion and health enhancing interventions like roads, occupational and environmental safety. It encompasses several political and civil organizations such as health and social committees, working parties, commissioning bodies, patient advocacy groups and consumer protection agencies as well as national licensing and regulatory bodies. (WHO, 2000).

All health systems may be thought of as the articulation to be based on three elements.(Tobar, 1998): A) management model, B) financing model, C) care model. Figure 1 is a diagram showing the components of any health system:

The diagram above shows the complex relationship between the health system and its determinants as well as the different sectors and sub-sectors within and outside the health system which impact health. A health system has the following functions: Financing; Organization and delivery; Regulation; Stewardship; Ability to modify consumer and provider behavior through persuasion; Ethics and values. A health sector is smaller in scope than a health system. It is the part of the economy related to the demand for health services from different individuals, communities, organizations and institutions (Bitrn et al, 2010). The health sector includes policies, service provision, production or import /export of goods, flow of funds, education of providers, etc. At the core of the health sector are the clients for which the health sector exists. Important health determinants outside the health sector include population, environment, education level, behavior, lifestyle, and infrastructure.

To achieve their goals, all health systems have to carry out some basic functions, regardless of how they are organized: they have to provide services; develop health workers and other key resources; mobilize and allocate finances, and ensure health system leadership and governance (also known as stewardship, which is about oversight and guidance of the whole system).

There is mounting evidence that health systems that can deliver services equitably and efficiently are critical to the achievement of national and global health goals, both in terms of communicable diseases and maternal and perinatal health, but also, critically, for the prevention and management of chronic and noncommunicable diseases. Global health initiatives now incorporate attention to health systems strengthening into the support provided to countries. However, there is an urgent need for research on all aspects of health system performance, from understanding the dimensions and nature of health system constraints, to developing innovative strategies for strengthening health systems, translating these into action on the ground and evaluating to assure continuous improvement, enhanced efficiency and effectiveness. A health system, like any other system, is a set of inter-connected parts that must function together to be effective. Changes in one area have repercussions elsewhere. Improvements in one area cannot be achieved without contributions from the others. Interaction between building blocks is essential for achieving better health outcomes.

Health services

Good health services are those which deliver effective, safe, quality personal and non-personal health interventions to those who need them, when and where needed, with minimum waste of resources.

When managing health systems and services, the nature of what has to be managed is remarkably similar across many different settings. All programmes, projects, facilities and area health authorities, whether public or private, have to manage the following 3 things: 1. volume and coverage of services to achieve universal access 2. inputs or resources (e.g. staff, budgets, information, drugs, supplies, equipment, buildings) 3. external relations and partners (e.g. other providers, other sectors, users of services, donors)

 The actions and decisions of health managers influence many things:

where facilities are located when they are open how they are staffed, funded and equipped the range of services provided including support services and outreach activities use of treatment protocols and guidelines use of quality systems referral mechanisms between different services and at different levels of the system.

How to scale up from a pilot project to district or national coverage also entails a wide range of management issues and decisions.

 In many developing countries, people who have the responsibility to manage service delivery often may not have any, or very much, management training. Training to be a doctor, a nurse or a pharmacist, usually does not include how to manage finances, or staff, or how to institute major changes.

Increasing management capacity involves not only building individual management competency, but also, having enough managers in the right places, providing an enabling work environment, and ensuring that managers have suitable functioning management systems to help them to do their job. Thus, focusing primarily on sending managers away for management training will probably not have a significant impact on improving service delivery and health outcomes, if the other aspects of building management capacity are not also improved. (Talked about HLMP of ZFF)

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 Public-private segregation:
70% of ALL health workers employed in the highly resourced private sector serves 30% of the population 30% employed in government services caters to the majority

Emphasis on curative vs. preventive medicine Overspecialization in curative services - Dr. Galvez-Tan (2010)

Fragmentation from several perspectives: public/private segregation over-specialization discontinuities between levels of health care geographic disparities in quality and quantity of services Crowding in tertiary care facilities and underutilization of primary health care facilities due to perceived poor quality and bypassing of the latter.

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Workforce
A well-performing health workforce is one which works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances.

I.e. There are sufficient numbers and mix of staff, fairly distributed; they are competent, responsive and productive.

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 Health workers are INDISPENSABLE the cornerstone of health care delivery system, influencing access, quality and costs of health care, and effective delivery of interventions for improved health outcomes, including progress towards the achievement of the health Millennium Development Goals and Health For All.

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 The World Health Report 2006 estimated a global shortage of 2.3 million physicians, nurses and midwives to meet the workforce levels required to strengthen health systems and accelerate progress towards attaining the health related Millennium Development Goals. An absolute shortage of human resources for health (HRH) was assessed in 57 countries, mostly in subSaharan Africa. Recognizing that pressing health needs across the globe cannot be met without a competent, adequate and available health workforce, urgent and sustained scale-up of health workforce production was called upon for both developed and developing countries to address the health workforce crisis.

Contrary to the tenets of classical economic analysis, as the number of medical professionals in the Philippines has decreased, so has the local wage rate. According to Federico M. Macaranas, PhD, the Executive Director of the Asian Institute of Management's Policy Center, in his remarks, delivered at the Carnegie Council, highlighted the lack of consensus on how to address this problem. , Filipino hospital administrators are keen to avoid over-investing in doctors and nurses that are likely to emigrate. As a result, wages are low and employees see the hospitals as stepping-stones to higher paying jobs overseas. More than 200 hospitals have closed in the Philippines in the last five years. Scaling up the production of health workers means not only increasing the output of health professions education programmes, but also ensuring that the 'pipeline' from recruitment and selection of students to deployment of new graduates in the health labour market - is functional and effective, and that the education and training programmes are adapted to the changing needs of the population. Given the lengthy periods required to see the effects of certain programmatic efforts (e.g. up to six or even eight years in the case of educating physicians), innovative strategies may be required to rapidly increase the capacity of the workforce, notably among mid-level cadres such as medical officers or nursing assistants, and among community health workers. At the same time, increased production must be placed in the broader context of ensuring that the quality, distribution and skill mix of the health workforce meet national health systems goals.

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No. 1 Exporter of Nurses

An estimated 85% of employed Filipino nurses (more than 150,000) are working internationally. (Aiken et al 2004) 70% of all Filipino nursing graduates are working overseas. (Bach 2003)

No. 2 Exporter of Doctors

68% of Filipino doctors work overseas, next to India. (Mejia, WHO 1975)
200 hospitals have closed down within the past two years no more doctors and nurses 800 hospitals have partially closed (with one to two wards closed) lack of doctors and nurses Nurse to patient ratios in provincial and district hospitals now 1: 40 to 1: 60 Loss of highly skilled nurses in all hospitals across the country

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Information System
A well-functioning health information system is one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health systems performance and health status.

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Several countries are making better use of information technology and geographic information systems. Improvements have also been made to disease surveillance systems. In many countries local users are now involved more closely in the design of information systems. Nevertheless, most countries still use a wide range of data collection and analysis tools, some of which collect the same data. An increasing volume of data is available, but coverage and quality are variable. Linking information to policy-making at the national level remains critical, but elusive, goal.

In recent years, WHO and its Member States have placed more emphasis on evidence-based decision-making. Most developing countries in the Region have attempted to enhance their national health information systems, often with the support of partner agencies. However, overall progress has been slow.

(make mention Bago Citys CDSS)

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Problems faced by developing countries in the Region include the following:

weak organizational support for data collection systems; lack of standardization and coherence in attempts to improve health information systems; untimely collection of data; inadequate use of information and evidence for decision-making; inadequate data analysis and communication skills; and overambitious computerization of health information systems that countries are unable to maintain.

Underreporting of deaths by national vital registration systems still needs to be addressed in many countries. If the quality of health information is highly variable, it is unlikely to be widely used. Rudimentary and ministerial despite its usefulness for decision making Error prone pen and paper methods at lower levels despite technological advances Flow is hierarchical with many actors involved Resulting information is distorted, delayed, withheld

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Equitable Access
A well-functioning health system ensures equitable access to essential medical products , vaccines and technologies of assured quality, safety, efficacy and costeffectiveness, and their scientifically sound and cost-effective use.

The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable (Alma Ata)

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LEB under 60 years IMR over 90 MM over 150 LEB over 80 years IMR less than 10 MM less than 15

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Recent essential medicines surveys in 39 mainly lowand low-middleincome countries found that, while there was wide variation, average availability was 20% in the public sector, and 56% in the private sector.

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 An estimated 50% of medical equipment in developing countries is not used, either because of a lack of spare parts or maintenance, or because health workers do not know how to use it.

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Financing

A good health financing system raises adequate funds for health, in ways that ensure people can use needed services, and are protected from financial catastrophe or impoverishment associated with having to pay for them.

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Universal coverage of health services is a widely accepted goal of health-financing policies. Yet despite impressive economic development in the Asia-Pacific region, where growth rates in gross domestic product (GDP) averaged 72% over the period 1999 to 2008, about 105 million people suffer financial catastrophe and over 70 million are impoverished each year because they have to pay for health care Lancet, Health-financing strategy for WHO's AsiaPacific Region

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 Many people in the Asia Pacific region, especially the poor and vulnerable, face severe barriers to accessing quality health care. This is of particular concern during the current global economic crisis. Appropriate health financing policies can help reduce these barriers to access, and thereby extend health gains to those most in need.

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The WHO provides technical support to countries in developing such health financing policies. The ultimate aim is universal coverage, where all people have access to appropriate promotive, preventive, curative and rehabilitative services at an affordable cost. according to National Statistical Coordination Board (NSCB) secretary general Romulo Virola: The Philippine Star Updated August 15, 2010 Pinoy households continued to bear the heaviest burden in terms of spending for their health needs as private out-of-pocket surpassed the 50 percent mark in health expenditure share in 2006, reaching 54.3 percent in 2007. Private households thus contributed an estimated P97.6 billion to the total health expenditure in2005 and P127.3 billion in 2007. Government came in a far second in health spending contribution, with the National Government and the local government units (LGUs) footing almost equal shares of 13.0 percent and 13.3 percent in 2007, respectively. It is worth noting that the LGUs spent more than the national government in 2006 and 2007. Total government expenditure on health care goods and services increased fromP58.5 billion in 2005 to P61.5 billion in 2007, registering an annual growth of only 2.6 percent. Health expenditure from social insurance barely grew from P19.4 billion in 2005 to nearly P20.0 billion in 2007, indicating an average annual growth of only 1.6 percent. Thus, instead of picking up as targeted, the social insurance share in health spending went down from 9.8 percent in 2005 to only 8.5 two years later.

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 The global crisis continues to affect many economies in Asia and the Pacific. Often governments are under pressure to cut health budgets and expand user fees, which would further reduce access, equity, quality, and utilization of health services. The 60th Regional Committee Meeting held in September 2009 discussed the global crisis and its impact on health in the region, including action to help mitigate its adverse effects.

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 Focus: Universal coverage This is defined as securing access for all to appropriate promotive, preventive, curative and rehabilitative services at an affordable cost. 4 target indicators: 1. out-of-pocket spending should not exceed 30%-40% of total health expenditure; 2. total health expenditure should be at least 4%-5% of GDP; 3. over 90% population should be covered by prepayment and risk pooling schemes; and 4. close to 100% coverage of vulnerable population with social assistance and safety net programs.

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 8 strategic areas: 1. increasing investment and public spending on heatlh 2. improving aid effectiveness 3. improving efficiency by rationalizing health expenditures 4. increasing the use of prepayment and pooling 5. improving provider payment methods 6. strengthening safety-net mechanisms for the poor and vulnerable 7. improving evidence and information for policymaking, and 8. improving monitoring and evaluation of policy change.

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 Inadequate: P 180.8 billion in 2005, which is 3.3% of GDP, compared to 5% of GDP as recommended by WHO High out of pocket expenditure: 49% in 2005 Inefficient: 11% for cost effective public health compared to 78.4% for personal health care Greater funding for tertiary facilities at the expense of primary care facilities
- Dr. Galvez-Tan (2010)

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All of us (former health secretaries) began with the promise of universal healthcare. I think we should start getting impatient. The health gap between poor and rich has worsened, has widened, and I dont know anyone else to blame except me, because the fact is that weve all failed. -Sec. Alberto Romualdez (GMA News Online, Nov. 8,
2011)

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Leadership

Leadership and governance involves ensuring strategic policy frameworks exist and are combined with effective oversight, coalitionbuilding, the provision of appropriate regulations and incentives, attention to system-design, and accountability.

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 Governance (or stewardship) is responsible attention to something entrusted to one's care. In the context of health it refers to the wide range of functions carried out by governments in their work to achieve national health goals to improve population health while ensuring equity in access to services, quality of services, and patients' rights. Governance is also concerned with the roles and responsibilities of the public, private and voluntary sectors - including civil society - and their relationships with each other, in the provision and financing of health care in pursuit of national health goals.

Effective governance implies leadership in maintaining the strategic direction of health policy development and implementation; detecting and correcting undesirable trends and distortions; articulating the case for health in national development; regulating the behaviour of actors involved in financing and delivery of health interventions; establishing effective accountability mechanisms and promoting healthy public policy and legislation in other areas of government that impact on peoples' health. In countries that receive significant amounts of development assistance, governance will be concerned with managing these resources in ways that promote national leadership, contribute to the achievement of agreed policy goals, and strengthen national management systems. While the scope for exercising governance functions is greatest at the national level, the concept can also cover the steering role of regional and local authorities.

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Mayor Teodorico Padilla of Sta. Fe, Nueva Vizcaya said learning about Bridging Leadership taught him that real health service goes beyond giving away medicines and building clinics. So he started campaigning to increase his constituents knowledge about health so that they will start to demand their right to receive proper healthcare.

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The values and principles of Primary Health Care remain constant, but there are lessons from the past, which are particularly important when looking ahead. First, despite increased funding, resources for health will always be limited, and there is a responsibility to achieve the maximum possible with available resources. Second, past efforts to implement a Primary Health Care approach focused almost exclusively on the public sector. In reality, for many people poor, as well as rich private providers are the first point of contact, and responsible health system oversight involves taking account of private as well as public providers. Third, while keeping its focus on the community and first contact care, Primary Health Care needs to recognize the problems associated with relying on voluntarism alone.

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HEALTH IS EVERYBODYS BUSINESS

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