“Prevention is better than cure: A four-point action plan”

Recently, my commentary/analysis entitled, “Prevention is better than cure”, was featured in the Opinion page of the Philippine Daily Inquirer. This was my first time to contribute a commentary piece and I felt that it was a great opportunity to be heard. While I initiated to write the article, I wouldn’t like to take full credit for it because the views, opinions and recommendations in my article were collated ideas from the many interactions I had with the people from the communities, represented by their organizations and NGOs. These people were bursting with ideas, wisdom and passion, thus, I owe this piece to them.

Since I was not able to submit the full article due to the space and character limitations of the newspaper, I am going to share with you the complete version. I hope this can help guide health policy analysts, health professionals and policymakers as to the real healthcare needs of the people from all sectors as expressed by them.

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Health advocates rejoiced at the appointment of Dr. Paulyn Jean B. Rosell-Ubial as the new health secretary; moreso, when she said that she will focus on prevention under her watch.  It is not much of a surprise though, since she is known to be a staunch anti-tobacco advocate and on many other preventive health interventions.

With her appointment, it showed President Duterte’s plan to prioritize health in his administration. This policy direction can be observed in his wish to send Ubial to Cuba to study that country’s world-renowned health-care system.

However,  we all know that an advocacy on prevention is easier said than done, especially with all the health destroying industries hovering and lobbying at the policy level. Most have a strong hold over known politicians because of their campaign support.

Therefore, to make this happen, the secretary should have a clear vision targeting the very core of the health system. Packets of changes in several areas will not cut it but interventions need be systemic.

In just a few years of critical health budget engagements, monitorings and researches, this author saw the highs and lows of public health. True, there were improvements with the passages of the Sin Tax and RH Laws, but not enough to even scratch the surface of the country’s health equity problem (particularly “access”) with mass poverty as the root cause. The health system is managing even more diseases and continues to be fragmented much like, the financing of it.

The pharmaceutical companies and health professionals have already enumerated what ought to be the next steps for health in the two-part PDI opinion/editorial series, “Quo Vadis, health,” by Rafael Castillo.

However, for this commentary, the people’s felt needs on health and their corresponding proposals will take the front seat because they deserve to be heard.  After all, they are the ones being served by the health sector. The very foundation of the proposals is primary health care (PHC) of the Alma Ata Declaration and, therefore, emphasis is on the need for a strong people’s participation (the most progressive principle enshrined in the PHC) in implementing a proposed four-point action plan.

Primarily, it is the hope of health advocates that the new Duterte Administration with Dr. Ubial at the DOH helm will reframe/redefine the health system in the next six years. This can be done by using the right keys to untangle the nuts and bolts of the current fragmented health system with the following four-point action plan:

  1. Apply a “Whole-of-Government” (Health in all Policies) direction to be operationalized through a whole budget approach with primary health care as a strategy.

whole of government

Even before answering the call for APEC (Asia-Pacific Economic Cooperation) economies to pursue the “Healthy Asia Pacific 2020 Initiative Roadmap” which includes the “Health in all Policies” and “Whole-of-Government” approaches, the community of health advocates had already previously called for the whole budget approach in the government’s planning and budgetary exercises. By applying such a practice, the DOH would gradually cease to be the manager of diseases and, because it would have in its arsenal the whole government’s resources it can effectively uphold its mandate to ensure the “health” (not only the absence of disease) of the Philippine citizenry. In addition, it will capacitate the department to even lead in addressing the ever neglected direct and social determinants of health (i.e. food, water and sanitation, environment/climate change, transportation and road safety, peace and order, jobs, and education).

Also with this direction, health becomes a tool for development rather than just a by-product of economic progress. Remember that economic growth does not guarantee the health of Filipinos. The June 5, 2016 Talk of the Town article entitled, “Stunting worsens despite GDP growth” by Jocelyn Uy is a perfect illustration of how increases in economic numbers do not matter in terms of health.  The lack of vision and mid-to-long-term solutions to the country’s nutrition problem is quite evident, which cannot be solved by the department alone. A systems’ response to the problem should clearly be in place.

One of the initial steps to make this directional initiative happen is to once and for all evaluate health policies that may come into direct conflict with this action (i.e. The Devolution of the Health System through the lens of the Local Government Code of 1991). Then provide proposals and recommendations for policy development and/or amendment, especially now that talks on Federalism may yet change the course of how the system delivers health care. It is important that the health sector is prepared.

Second, make evidence the basis of policy-making. This does not include the hard sciences alone, but it should be an interdisciplinary and a mixed method approach. Evidences from the academe, government, non-government, and grassroots communities should all come into play in doing evidence-based policymaking. Integral to this endeavor is the prioritization of relevant researches on health, nutrition, science and technology, climate change, etc.

2. Strengthen the frontliners (from health professionals to workers at the grassroots level) towards an integrative health system.

Photo courtesy of http://internationalmidwives.org/blog/2013/11/26/blog-tale-male-midwife/

Photo courtesy of http://internationalmidwives.org/blog/2013/11/26/blog-tale-male-midwife/

According to the Primary Care Coalition, 66 percent of deaths among Filipinos are unattended by a medical doctor or allied health provider.

There are various reasons for this. For one, the pay, benefits and working conditions of health professionals/workers, especially those in the rural areas are inhumanely disturbing.  The recent vetoing of the Comprehensive Nursing Law, that would have implemented the entry level pay for nurses is a big blow to the initiatives to improve the very awful working conditions of young health professionals.

Likewise, the medical and allied health curricula may need some serious overhaul. Again, there are packets of innovations in government SUCs (State Universities and Colleges) to entice young health professionals to serve the country. In a 2005 study entitled, “Physician Migration: Views from professionals in Colombia, Nigeria, India, Pakistan and the Philippines,” (copy of the study is available upon request just send me an email) it discussed that training and practicing abroad provide a high level of social prestige to professionals. It showed that generally-speaking, the medical curricula encourage the exodus of the best and the brightest of physicians.

According to the study, “This is reflected by the fact that nearly a third of all respondents agreed that medical schools judge their success, in part,  by how many of their graduates are accepted by foreign residency programs. Much effort is needed to reorient the medical curricula in developing countries to better address the needs of the population in those countries and to reward physicians, both economically and socially (through awards, honors, and other such acclamations), who choose to devote their lives to treating the underserved in their own countries.”

In addition to these, many physicians become specialists even if the country needs more primary care practitioners. Specialists may be needed in managing certain diseases, however, they are not enough to address the most of the people’s healthcare needs. For one, they do not specifically go to geographically-isolated disadvantaged areas (GIDA) nor do they carry out home visitations because it is simply not their job.

Certainly, the latter types of services from health professionals are wanting but are very much needed by the poor, indigenous peoples (mothers and children) in far-flung areas, the elderly, and people with disabilities who require rehabilitative services in the comforts of their homes. This also partly discusses the problem of maldistribution of health workers. And so clearly, the deployment programs of the deparment need evaluation and rethinking.

On the other hand, other health workers providing services and augmenting the lack of professionals (i.e. midwives and barangay health workers) are most of the time overburdened with work. In the case of the latter (BHWs), they are neither allowed to treat nor provide care to people, even those with the simplest diseases.

Amidst all these, what to do in the short-to-mid-term while addressing the development and retraining of health professionals simutaneously? This is where the primary health care strategy comes in. The questions that might lead the health sector to some of the solutions is this: Is the health system ready to a) make communities (the people) as partners and not just beneficiaries of downloaded health services; b) trust community health workers to care for patients at the household level; and c) use local, indigenous resources and methods in achieving the highest attainable healthcare?

Thus, the current state of the country’s resources is either scarce or maldistributed to properly address the basic requirements to solve health inequity.

3. Manage a complete, accurate, integrated, and up-to-date health information system.

Photo Uploaded from: https://www.searchenginejournal.com/6-aspects-seo-busy-entrepreneur-can-finally-stop-worrying/140905/

Photo Uploaded from:
https://www.searchenginejournal.com/6-aspects-seo-busy-entrepreneur-can-finally-stop-worrying/140905/

The much needed health care services, their efficient delivery and the development and/or improvement of programs both at the national and local levels, can only be effectively facilitated when an information management system is in place throughout the country. This cannot be further emphasized, especially given our more mobile and globalized world where endemics, epidemics and pandemics can emerge at any time.

4. Address the commercialization of health care.

Photo uploaded from https://www.microlinks.org/events/engaging-power-private-sector-development

Photo uploaded from https://www.microlinks.org/events/engaging-power-private-sector-development

In the World Health Report 2008 on Primary Health Care, it identified “commercialization” as one of the current trends capable of undermining a health system’s response. The first two trends: hospital-centrism and fragmentation could already be addressed with the first two actions identified earlier.

In a recent interview, Sec. Ubial said that she wants to talk to advocates about “corporatization.” The advocates are always open to talk about this with the new DOH secretary, however, the author strongly suggests the following to be the bottomline guidelines:

  • Health and healthcare delivery remains to be a common, social good and should largely be publicly funded with the aim of progressively realizing the reduction of out-of-pocket costs until it is free.
  • Definitely, no to privatization of public health facilities and services.
  • Private sector participation should be highly-regulated whether they are companies or not-for-profit NGOs. Effective systems of checks and balances should be put in place. The national government, in partnership with the people, must regularly ensure that the guidelines for the private sector’s participation is always beneficial to the public’s welfare and well-being.
  • Private sector participation should be needs-driven. Only appropriate, needs-based health products (i.e. medicines, vaccines) and technology (i.e. equipment, screening and diagnostics) should be allowed. However, for new medical and technological innovations for health, they must be constantly negotiated at all times to provide long-term benefits for the people.
  • The health sector (both government and advocates) should always encourage and strengthen consumer protection and education (health care beyond commodification).

The author believes that only with the simultaneous, effective and efficient implementation of this four-point action plan will the focus on prevention be realized; not just primary, but from primordial to tertiary prevention. And hopefully, this should be with highest possible participation of the people from planning to the evaluation of programs and budgets.

Inevitably, other health-related policies and programs, such as Philhealth, as a means to reduce financial risk to members, will also have to follow the same direction which the entire DOH will take. Hence, it is already time for the health sector to begin integrating and incentivizing prevention and promotive interventions to health more than just reducing the financial impacts of diseases in the long run.

 

One Response to “Prevention is better than cure: A four-point action plan”

  1. Patricia says:

    I’m super glad that the focus of Dr. Paulyn Jean B. Rosell-Ubial is on prevention! Prevention has always been the best approach to health.

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