OUT OF REACH
Is the Philippine health-care system as sick as the people it should be helping?
By Mabelle Aban, Contributing Writer
"Filipinos today are suffering from wide disparities in access to health-care facilities, medical professionals, drugs, and health-financing resources," said Prof. Emmanuel Leyco, director of health-care management at the Asian Institute of Management, as he addressed the delegates to the 37th annual convention of the Philippine College of Physicians in May.
Leyco first talked about the imbalance in the distribution of health facilities in the country. For example, 57 percent of all private hospitals in the country are located in Luzon, he said, with 27 percent of them in Metro Manila. "The same situation is mirrored to the public sector which we would have expected to have taken actions to reverse the imbalance," he added. The bulk of heath-care professionals are also found in the National Capital Region (NCR).
This is compounded by the continuing problem of migrating health-care professionals. This problem varies from region to region, said Leyco. There are regions where there is a shortage of nurses, he said; there are also regions with surplus. "The problem with those with a surplus is that they are dealing with a very fast turnover in their nursing staff," he explained. "And for the most part, the first to go are those who are more trained than others."
And so who are left behind? The new graduates, most of whom are also after getting jobs abroad. "Basically you can look at our hospitals and our health-care-service delivery system as a waiting room for airlines before the departure," Leyco quipped.
He added: "I hope that the looming crisis is recognized instead of ironically being applauded as the US$1-billion-a-month savior of the country's economy in the short term. I'm talking about the exodus of the health-care workers, and recognize it as the long-term killer of our health-care system."
Some people have reasoned that the migration of health workers could be a good thing, in that it could force an institution to raise the wages of health workers if it really doesn't want them to leave. But has it actually happened?
"Coupled with poverty, [low wages] serve as push factors that compel health-care workers to leave," said Leyco. "This trend is expected to continue for at least the next five years with its evitable adverse effects. Without econ incentives, it will be almost impossible and impractical to hope that Filipino health-care workers will remain in the country."
Another perennial problem is access to inexpensive medicines. Could parallel importation be the answer to this problem, as heralded by its supporters-or would it only compromise patients' access to safe medicines? Leyco said that even the strict implementation of a parallel-drug-importation policy would lead to some form of shift on quality-monitoring responsibilities, "from the local drug manufacturers and the [Bureau of Food and Drugs] to the hands of the traders, importers, and government customs authorities."
Other possibilities are being explored to improve access to cheaper medicines, in the form of legislation. Before the 13th Congress ended, a bill on affordable medicines (Senate Bill 2263) was passed on third reading in the Senate. Dr. Kenneth Go of the Department of Health, said that the bill sought to address three major obstacles to the people's access to affordable and quality meds. First, it aimed to address the structure of the pharmaceutical industry.
"We must understand that unlike other countries in the world our industry here has some concentration of power," said Dr. Go. Second, "the bill tries to address the behavioral orientation of patients, as doctors and public-health institutions," he said. "Our consumers and patients have to be equally aware and appreciate the value being offered [the] generic substitute." Lastly, it aimed to address the "protectionist provisions of the existing law." (Editor's note: The bill will have to be filed again when the 14th Congress convenes in late July, and will have to go through the whole legislative process.)
So what can be done to rehabilitate the Philippine health-care system? Since the economic conditions that push Filipinos to leave the country cannot be reformed overnight, Leyco stressed that first, the government needs to recognize all these problems. He also added that "the government needs to effectively play the role as the country's biggest buyer of health-care goods and services to invigorate the health sector." This can be done by effectively managing our financial resources, by disposing it toward investments that can stimulate health-care activities.
Providing protection to public health is one of the public's most important concerns. Dr. Encarnita Blanco-Limpin, vice president of the Pharmacovigilance Society of the Philippines, said that strengthening the local pharmaceutical industry could help lower the prices of medicines. "We need to have a pharmaceutical industry that can manufacture the drugs that we need," she said.
She also called for health-insurance reforms, as well as recommended the possibility of putting tax-relief measures in place. She added: "Parallel importation may be part of the solution of the problem but I see it as a short-stop-lock measure only."
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Looking out for outbreaks
Diarrhea-a very familiar illness that each of us may have experienced at some point. It seems to be one of the simple diseases that we know of but it can pose a great danger, as it can lead to dehydration and malnutrition.
Diarrhea remains one of the leading causes of morbidity and mortality in the country, and is included on the watch list of international and local health programs. Thus, it warrants strict monitoring and prompt action during outbreaks.
The National Epidemiology Center of the Department of Health holds the responsibility of carrying out international health regulations in dealing with potential and actual outbreaks. It aims to strengthen its core capacity to prevent and control diarrhea, and share its knowledge and experience with foreign agencies in dealing with diseases that pose local and global threats.
During the 13th annual convention of the Philippine Hospital Infection Control Society (PHICS), Dr. Enrique Tayag of the DOH discussed what the agency does to identify and monitor diarrhea outbreaks. Tayag said that the DOH is in charge of the surveillance of possible outbreaks-"the systematic ongoing collection of data, including [their] analysis and interpretation so that there will be timely dissemination"-to stress the importance of prevention and control.
The DOH uses different surveillance systems-indicator- or case-based surveillance, event-based surveillance, and lab-based surveillance. Tayag explained: "Indicator- or case-based surveillance is where we track down trends from cases that are reported using a standard case definition nationwide." Event-based surveillance, meanwhile, complements case-based surveillance. This allows the agency to receive reports and notifications from the media and from the public, so that same investigations can be immediately done.
After the typhoons
Tayag cited two instances when these tools had proved to be useful in halting the spread of diarrhea. The first one was the cholera outbreak in Albay in 2006, right after two typhoons had hit the area. Here, they used a case-based surveillance system. The typhoons had brought mudslides and flash floods, which killed 734 people, injured 60, and caused 762 to go missing. Major infrastructures were destroyed.
"During these catastrophes or disasters, surveillance systems are put up to monitor the trends of syndromes," said Tayag. "For this case, acute watery diarrhea was included in the indicator-based surveillance system."
Case-control studies were done, records were reviewed, and specimens were examined in labs to document and detect the particular organism that's causing the outbreak. The predominant symptom identified from the majority of the cases is diarrhea. There were also abdominal cramps, vomiting, fever, malaise, and anorexia.
Factors that might have contributed to the emergence of an outbreak were as follows: drinking deep-well water or using it to wash food, and open dumping. This led the DOH to ensure that oral-dehydration solutions were given correctly. This also brought the local government to survey the water sources and to provide rations of potable water.
Dysentery in Bohol
Tayag also cited a dysentery outbreak in Bohol in January. The DOH NEC was alerted on the growing number of people reported to have bloody diarrhea. At first, health providers in the province said that it was likely amoebiasis-related, a common suspect in similar events. However, laboratory tests proved that it was caused by Shigella.
"The environmental survey showed that there was contamination from the deep wells, they get their water from a developed spring," said Tayag. "There was a failure of the chlorinator device."
While this was their conclusion, continuing increase in the number of cases also suggested a possible problem with home hygiene. Tayag said: "In outbreaks of diarrhea in previous years, it has always been the observation that contaminated sources actually contributed to epidemics."
The DOH and the local-government units of Bohol are currently looking into whether improvements in personal and home hygiene improved the situation in Bohol. "Our analyses are not yet complete, and we believe that factors like leaking pipes, flooding rainfall, construction of roads, [and] improvised chlorinators are not enough to explain why this outbreak occurred," he added.
He concluded: "What is very clear is that unless we are able to find out or determine the risk factors responsible for outbreaks, these will occur again and again and again."
M M. Aban
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