Notes Journalof Philippine Development NumberTwenty-Seven, VolumeXV, No. 2, 1988
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THE PHILIPPINE HEALTH INSTITUTIONS: SOME PROBLEMS, APPROACHES AND POLICY ISSUES
Pilar Ramos-Jlmenez Ma. Elena Chiong-Javier
Introduction Health institutions,typifiedby hospitals,barangayhealth stationsor health centers, and rural health units, continueto carry the major burden of providing health care servicesto the majorityof the Filipinopopulation. Like other types of socialinstitutionsin the countrytoday, they are also badlyaffected by a host of formidableeconomic problemssuch as inflation,prohibitiveinterest rates on borrowedcapital, and dwindlingcapital reservesWhichhave been compounded by recent political upheavals. In the case of private hospitalsalone, a survey done by the PhilippineHospitalAssociationduringthe lasttwo years showsthat over 70 hospitalshad either declaredbankruptcy,had folded up, or were in the processof being foreclosedby theircreditors(Clemente 1986). The situationin the government sector is equally, if not even more pathetic. It is publicly acknowledgedthat governmenthospitalsand health stationshave been operating with inadequatefunds,thereby affectingboththe quantityand qualityof their health service deliverysystem. This paper presents a brief analysis of the current situation of health institutionsin the country using secondary data. Specifically,it aims to: (1) locate the different types of health institutions; (2) describe major problems encounteredby the health institutions;(3) discussrecent approacheswhich the healthinstitutionshave evolvedto improvetheir deliveryof healthcare services; and (4) extricate policy-relatedissues and data gaps from available literature. Distribution of Health Institutions Hospitals. At present, the Philippines has a total of 1,821 licensed hospitals. Of this figure, about one-third are governmentinstitutionswhile the
The authorsare Associateand AssistantProfessors,respectively, Behavioral SciencesDepartment, De La Salle University, Manila. This paperis partof the paperspresented duringthe PIDS-UPSEseminaron "A Programof Researchon HealthPolicyand Development" on December17-18,1986.
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JOURNAL OFPHILIPPINE DEVELOPMENT to implementa hospitaldevelopmentprogramfor each of the district hospitalsin order that these may achieve a progressive level of healthcare (i.e., from a primarytype to secondary and from secondary to tertiary) that will adequately satisfy the community health needs; and c) to establishan inter-referralsystem among government hospitalsas well as between governmentand private hospitals for the promotionof better quality of health care within the region.
At present,the programincludes11 governmenthospitals,sixof whichare operated by the city or municipalityand five by the nationalgovernment. Some of its accomplishmentsare the following: two municipalitieshave been subsidizing beds and servicesin private hospitals;one city districtis being served by a Collaboratingprivate hospital;and five new hospitalsare to be constructedby their municipalgovernmentswith the assistanceof the MMC. District hospitals have substantiallyimproved their service capabilitiesand are on their way to handling higher types of medical care. For example, general hospitals of Caloocan, Pasay, Valenzuela, and ParaSaque were upgraded from S-L-U or sipon-lagnat-ubo primary centers to A-C-H or appendectomy.caesarian-heart secondary hospitals;others like Tondo General, Hospitalng Maynila, Quirino Memorial,and Quezon City General Hospitalare fast developingfrom secondary to tertiary level of health care. Most significantly,inter-hospitalrelationshipshave resulted in the sharing of resources between the governmentand private sector. This has led to the formationof a loose inter-referralsystem with larger medical centers admitting patientsfrom governmenthospitalsfor diagnosticand sophisticatedtherapeutic services. The latter has responded by taking withintheir service those patients who cannot afford the hospitalizationcosts in the private institutions. Their partnership has also been extended to manpower training, with the private institutionssharing their wealth in training materials and technical knowhow. Government hospitals and medical/nursingschools and their training hospitals have both benefited from their linkages, e.g., when the former's residency programsadmit exchange of fellowshipswith the latter. And lastly,service and training are not the only items shared;there is also sharing of equipment(such as oxygen tanks, anaesthesia machines) and even supplies in the spirit of neighborliness. In Iloilo,Ardena (1986) has also found paralleladvantages in the consortium by and between the Iloilo Doctors'Hospital(private)and the IloiloProvincial Hospital(government)which he leads. Thisformal network,whiledifficultat the start, has attained for both hospitals, significant improvements especially in medical education program because of combined manpower utilization and equipment- or sharingof facilities. Primary health care (PHC). This approach has recently emerged as a promisingresponse to the dismal health situation, especially among the poor
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majority, It has been describedby Dr. S.T. Han of the WorldHealthOrganization (WHO) as a practical means for "making essential health care universally accessibleto individualsand families in a community in an acceptable and affordable way and with their full participation"(cited in Salceda 1986). In essence, the approachrequireshealth to be viewed in itstotality (i.e., disease is the effect of both biological,socioeconomicand otherfactors). It also requires both healthprovidersand users to becomeactive partnersin the treatmentof the foundationsof ill health. The PHC is said to have started in the late 1960s, even before the historic 1978 Alma Ata Declaration. Private practitionersfrom hospitals and clinics, healthorganizationsand academicinstitutionsin some parts of the country were the pioneersof this method (Galvez-Tan 1986). It was, however,only in the midseventies, when the Rural Missionariesof the Philippines began their pilot community-basedhealthprograms(CBHP) in three parts of the country with the CatholicChurchNetwork as the conduit,that a nationwidePHC movementwas felt. Their experiences were later adopted by the Protestants through the National Council of Churches and the AKAP, a secular organization. Both institutionsestablishedtheir own nationwidenetworks. At present, the CBHPs are found in 40 provinceswith some 200 health personnel and about 3,000 community health workervolunteers(Galvez-Tan 1986). It was only in 1981 when the governmentimplementedthe PHC on a nationwidescale. By 1985, the Ministryof Health (MOH) reportedthat the PHC is operatingin all barangays except in a few areas where the peace and order situationis unstable. The implementationof this approachlargely rested on the involvementof community members in the delivery of health care services. Thus, residentvolunteerhealthworkershave been trainedby governmenthealth agencies to do health extension work in their respective communities. For example, to date, a total of 365,941 barangayhealthworkers (BHWs) have been mobilized (with a ratio of one BHW to 20 households)and 14,718 Boticas sa Barangay have been established,with almost the same number of pharmacy aides to run these community pharmacies(Galvez-Tan 1986). Policy and Research Issues The review of literature has raised policy and/or research issues which includethe following: 1.
Intersectoral linkages. The experiencesgeneratedby horizontal(i.e., between hospitals)and vertical (i.e., between hospitals and health stations/RHUs)linkagesamong healthinstitutionshave provento be beneficialto these institutionsas well as to their clients. In these times of economicdifficulties,it is imperativethat such linkages are ctrengthened,enhanced, and further institutionalized.To do this, the experiencesof cooperatinginstitutionsneed to be documentedand
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analyzed to draw lessons for the improvementof the linkages. There is also a need to understandthe impact of sharingarrangements on the overall health situation in areas where they are undertaken. Moreover, consideringthe pervasive influence of primary typesof institutionson people'shealth, itmay be worthwhileto cultivatethe vertical linkages. Community participation in health care de/ivety. Given the existing constraintsin resources,there is little doubt on the necessity of tapping sectorsother than those traditionallyconnected with health institutions. The inclusionof communityvolunteerworkers in the health servicedelivery system throughthe PHC programseems to be a promisingstrategy. .However, recent experiences with the government's PHC program have exposed certain difficulties in sustainingcommunityinvolvementbecauseof poorfinances,centralized decisionmakingprocesses,inadequateskillsand proliferationof different types of barangay health workers connected with government line agencies. There is a need to explore the extent to which these difficultiespervade and hamperthe achievementof PHC goals in the country in view of the growing acceptanceof the people's participationamong government health agencies and institutions. There is also a need to comparethe experiencesbetween government and private sectorsemployingthis concept, as well as among government health institutions,to derive better mechanisms for implementation.More importantly,there is a need to review national health policiesin order to determineto what extentthey are congruent and supportiveof communityparticipationin health care.
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