Local governments at the front lines of UHC implementation

FORTY-FIVE-year-old Melodina Hugo is the go-to person when family members and relatives, especially those from the remote Paquibato district, get seriously sick and need to be brought to the Southern Philippines Medical Center (SPMC) in Davao City, the biggest government-owned hospital in Mindanao.

Her know-how of the ins and outs of public health services stems from her sad experience of losing her husband, who was a security guard, in 2009.

He died of prostate cancer, which was already at a late stage when diagnosed.

“That was hard,” she said in an interview, speaking in mixed Visayan and Filipino, “Going back-and-forth to the hospital, sourcing financial assistance, but it was too late for a surgical procedure.”

As a stay-out housekeeper in the city for many years now, she enjoys work schedule flexibility, making her available for emergency situations or to keep watch of a patient overnight, or spend a whole day gathering documents and processing monetary assistance.

There are many funding sources, she says, such as the offices of local government officials and even senators, and the Philippine Charity Sweepstakes Office (PCSO).

But the first place she goes to is the Davao City Lingap Para sa Mahirap center — a program launched in 2001 by then mayor and now President Rodrigo R. Duterte for medical and hospitalization assistance, food supplements, and funeral services to residents, especially indigents and members of the indigenous people communities.

From a small office at city hall, the program now has its own building inside the SPMC that serves as a one-stop-shop for assistance, housing other agencies such as the PCSO and the Department of Social Welfare and Development.

The Lingap program is the model for the Malasakit Center Act, signed by Mr. Duterte in December last year, which mandates the establishment of a similar help desk in all hospitals run by the Department of Health (DoH).

It is intended to complement the Universal Health Care (UHC) law, also passed last year, that automatically makes all Filipinos members and entitled beneficiaries of the Philippine Health Insurance Corp. (PhilHealth).

Implementation of the UHC starts this year, but will not yet be nationwide.

Coverage will initially be in five out of 145 cities (Valenzuela, Parañaque, Dagupan, Baguio, and Cagayan de Oro) and 28 out of 81 provinces (Benguet, Isabela, Nueva Vizcaya, Quirino, Bataan, Tarlac, Batangas, Quezon, Oriental Mindoro, Masbate, Sorsogon, Aklan, Antique, Guimaras, Iloilo, Cebu province, Biliran, Leyte, Samar, Zamboanga del Norte, Misamis Oriental, Compostela Valley, Davao del Norte, Sarangani, South Cotobato, Agusan del Sur, Agusan del Norte, and Maguindanao).

Department of Health Davao Region Director Anabelle P. Yumang said the UHC implementation involves the “managerial integration of province-wide and city-wide systems” within the first three years, and “financial integration” within the next three.

“Because the LGUs (local government units) still need more funds to ensure proper installation and implementation of the integrated health system, to ensure health systems at the local level are more focused, strategically-planned,” she told BusinessWorld.

She said with UHC, the LGU programs can take care of medical costs that are not covered under the PhilHealth system.

PhilHealth’s National Health Insurance Program for UHC guarantees the following: immediate eligibility, no co-payment in basic or ward accommodation, co-payment/co-insurance for amenities in public hospitals, no reduction in current PhilHealth packages, and additional benefits for direct contributors.

Ms. Yumang also said that UHC is not just about access to medical services but making all Filipinos “health literate” in terms of lifestyle, avoiding risks, and knowing that they do not have to suffer the added burden of “financial hardship” in times of sickness.

OUTBREAK
The weaknesses in the health care system become even more pronounced during epidemics, such as in the dengue outbreak last year.

Among the areas with the highest number of cases was the Western Visayas Region, particularly Iloilo province, which has a population of about 2.4 million in 42 towns, Passi as the lone component city, and Iloilo City as an independent city.

Mayor Francis A. Amboy of Maasin, categorized as a 3rd class municipality and one of the most affected towns, recalled the local government’s struggle to respond to the increasing dengue patients at the rural health unit (RHU), which has limited facilities, supplies, and manpower.

“Our RHU cannot accommodate the surge of patients… We also lacked funds to finance the laboratory and monitoring of the patients,” Mr. Amboy told BusinessWorld.

Maasin, home to about 40,000 people, has no hospital. Four died during the dengue outbreak.

One of the response measures taken by Maasin and other towns was setting up temporary medical facilities such as a hydration area in basketball courts and other covered public buildings.

The regional DoH office also sought an arrangement with private hospitals — equally overflowing with patients — to accommodate the more critical ones endorsed by the government hospitals and health units.

Health Secretary Francisco T. Duque III, during his visit to Iloilo at the height of the outbreak in August, said the dengue epidemic is a kind of test on how well local systems can execute UHC.

“UHC is always in the context of the network of service delivery from the barangay health centers to rural health units to city health centers, community, district levels, provincial hospitals linking to your medical center, and all the way to your apex. How well you are doing in the lower delivery of units will be an indicator of how burdensome it will be for your mid and upstream delivery units,” Mr. Duque said.

With this year’s UHC rollout that includes Iloilo, DoH-Western Visayas Assistant Regional Director Dr. Julia Z. Villanueva said households will now be assigned a “primary health care provider,” which would be the front-line unit.

“The primary health care provider (such as RHUs) will navigate the patients or the residents to their needed health care, whether on secondary or tertiary hospitals,” she told BusinessWorld.

With a structured referral system, Ms. Villanueva said, the crowding at hospitals and other facilities like what happened during the dengue epidemic will likely be prevented.

“The outbreak created a panic and people with suspected dengue symptoms rushed to the hospitals and clinics to get tested, and those who tested positive demanded to be admitted in the hospitals when, in fact, they can just be treated in the hydration unit. This kind of referral system will be corrected with the UHC because instead of going directly to hospitals, they will have to be assessed first by their primary care provider,” she said.

“All the municipalities will become a member of a provincial health care network or health system,” she added.

Ms. Villanueva said one of the challenges the department foresees at the local level is the cooperation of leaders.

“There may be indifferences, and mayors might not cooperate with the creation of the network,” she said.

Mr. Amboy, whose two daughters were among the dengue patients, said he will definitely be supporting the UHC.

“We are very willing to cooperate. All the residents should have access to health care. They should be provided with the needed health services,” he said.

As of mid-December, the dengue outbreak alert in Western Visayas was still ongoing.

The region recorded 51,233 dengue cases with 219 deaths as of Oct. 14.

Ms. Hugo, for all her experience in the workings of the Philippine public health care system, has never heard of UHC.

When told about it during the interview, her reaction was a mixture of awe and skepticism.

“There is such a program? Can they do that? Won’t SPMC go bankrupt?” she asked.

At the same time, she said the improvements she has seen over the years at SPMC in terms of facilities and service — as well as the recent establishment of a Botika ng Bayan (government pharmacy dispensing free medicines) in her remote hometown of Paquibato — makes her cautiously optimistic that a comprehensive health care system could eventually be a reality.

“Pasensya lang (We just need patience),” she said, the one main virtue she has learned from getting public medical services.— Marifi S. Jara, Maya M. Padillo and Emme Rose S. Santiagudo