Where do the sick go?

By MARYA SALAMAT
Bulatlat.com, Newsbreak-Maggie de Pano Fellow

MANILA, Philippines – Under-funding is not the only reason for the decline in the quality and coverage of local health services. To begin with, some experts say, the devolution of health services started with an inefficient setup, where these services were splintered among different levels of local government.

Before the devolution, there had been efforts by the national government to integrate the public health care and hospital systems. This was interrupted when the Local Government Code of 1991 “splintered services by allocating services for various levels to the national, provincial and municipal institutions,” according to former health secretary Dr. Alberto Romualdez.

Specifically, provincial governments are now responsible for maintaining hospitals and providing tertiary health services. Municipalities are in charge of building and maintaining health clinics, purchasing medicines and equipment and supplies, implementing programs on maternal and child health, and on disease control and prevention. City governments are mandated to deliver the same services as the provincial and municipal governments.

“In the Philippines, the central DOH (Department of Health) had developed a moderately egalitarian distribution of facilities and services, an achievement unlikely to be improved by the local provisioning process set up by the [Code],” a 1994 World Bank study, “Devolution and Health Services: Managing Risks and Opportunities,” noted.

Indeed, the setup “further worsened health inequities” between rich and poor local government units (LGUs), and the gap between the quality of public and private health care facilities, Romualdez said. Rich LGUs can better fund health services and thus register better health indicators. Private hospitals and clinics earn enough to maintain and improve their facilities, equipment, and services, and hire enough skilled personnel.

This also led to LGUs adopting variable practices in addressing common health problems or diseases.

But perhaps one of the costliest effects of devolution has been the disruption of the referral system between health facilities that are under the authority of various levels of local government.

Doctors Bryan Lim and Kenneth Hartigan-Go have video documentation for the Asian Institute of Management (AIM) of how patients had to spend more than necessary when they get “lost in the referral system” between municipal health offices and district hospitals, and then between district hospitals and provincial and higher-level hospitals, before they get the correct diagnosis and treatment.

For example, there was a poor family that coughed up as much as P50,000 on doctors’ fees and tests before they stumbled upon the right doctor, diagnosis, and treatment for a family member’s disease. “It wouldn’t have happened if there were well-coordinated health care services from their village and up,” said Dr. Lim.

In other instances, the “inefficient referral services” between different levels have led some tertiary health facilities to sacrifice its mandate of attending to more advanced medical cases. Instead, they allocate scarce resources to basic services that lower facilities are supposed to be providing, according to an assessment made by the Philippine Institute for Development Studies and the United Nations’ Children’s Fund in 2009. ()

(This article was produced under the Maggie de Pano Fund for Investigative Reporting on Health. The Fund, which is managed by Newsbreak, is funded through a grant from Macare Medicals Inc.)

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