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‘HMO has adversely affected medical care and healthcare delivery in the United States.
I have just returned from the 94th Annual Clinical Congress of the American College of Surgeons held in San Francisco, California. Among the hot topics during that convention, besides the various new trends in therapy and in minimally invasive and robotic surgery, was healthcare delivery system. Thirty-five years ago, the United States enacted the Health Maintenance Organization (HMO) Act of 1973 as a solution to massive (billion dollars a day) healthcare expenditures. The Americans thought it was the panacea to their healthcare dilemma, and helped pushed for it. But as it turned out, HMO has led to poorer quality of medical care and a lot of bureaucracy and great delays in access to medical care, especially where surgery was concerned. The Americans now realized they made a big mistake and are vehemently complaining to their legislators about it. HMO has now been proven to be "the deadly treatment that is more fatal than the disease." Today, the US Congress is revisiting the HMO issue. What is HMO? In the traditional patient-doctor arrangement that all of us are familiar with and have been accustomed to, and which is still the predominant existing force in the United States and the Philippine healthcare arena, the patient freely chooses the physician he/she wants to consult. In the HMO system, the patient can only see the physicians who are members of the HMO, even if he/she feels there are other better physicians around, or there is one he/she prefers to see. In some HMOs, the patient cannot even see a specialist directly. He/she has to be referred by the HMO ("Gatekeeper") doctor to a specialist who also belongs to the same HMO. The patient’s freedom of choice is sacrificed. In many cases, even the quality of healthcare, besides the good doctor-patient relationship, suffers. The insurance premium may be cheaper, but it is now apparent to the Americans after that bad experience that indeed, "you get what you pay for." How was HMO supposed to work?
The idea was to cut cost by various methods: requiring pre-certification before a patient is admitted to the hospital, using strict admission criteria; discouraging patients from going to emergency rooms or seeing specialists; mandating physicians to prescribe and use the cheaper generic medications; forcing physicians to use less expensive, and less, diagnostic tests; requiring physicians to discharge their hospital patients sooner, sometimes too soon; decreasing reimbursement to hospitals and physicians by 30 to 50%; refusing to cover and pay physicians and hospitals for certain medical care, illnesses or hospitalization that the company deems "not covered," etc. It also instituted dozens of "strict and somewhat punitive" rules, criteria, and policies for physicians and hospitals to follow in providing healthcare to patients "if they want to participate in the HMO and be paid at all." Did HMO help the people? No. As a matter of fact, the quality of healthcare has suffered and access to care more difficult. Patients feel they have lost their freedom of choice of family physicians and specialists. The wait in the doctor’s office is much longer, and the care much less personalized, since HMO doctors are salaried and are assigned too many patients. Since they get paid the same whether they see 20 or 40 patients anyway, the incentive to do their best is not the greatest. More sophisticated tests (CT Scan, MRI, Heart Angiogram, etc.) are considered "too expensive" by HMOs, whose main concern appears to be their financial bottom line and not the quality of medical care. In subtle ways, they discourage the use of what they consider "too costly tests or medications," handicapping the physician in his service to his patients. Unfortunately, it takes years before people find out the painful truth and complain about it, and another 2 decades or so to have the mistake corrected thru legislature, as in the case of this American experiment with HMO. Has HMO invaded the Philippines? Unfortunately, yes, but fortunately HMO in the Philippines is still in its budding stage. The traditional healthcare delivery system is still the major force in the country, and the people and our medical care are the better for it. Hopefully, the Filipinos, our political leaders, our businesses, hospitals and physicians can unite and prevent the growth and catastrophic onslaught of US-style HMOs on the healthcare system in the Philippines. HMO has adversely affected medical care and healthcare delivery in the United States. The US Congress is now re-discussing the HMO issues and exposing the adverse effects of HMO and the resulting deterioration of the healthcare delivery in the country. Let that painful and inhumane national "experiment" in America be a warning for us Filipinos to be vigilant to protect and preserve our most fundamental privileges: quality medical care, easy access, and the freedom of choice, at a most affordable cost. HMO, as it stands today, is more of a health menace organization and, if allowed to take root and flourish in the Philippines, will clearly be hazardous to the health and well-being of our country and its people. Since the United States experience with HMO has been a catastrophe as the Americans have found out, and most eager to throw it out, wouldn’t it be stupid for us, Filipinos, to adopt it for our country.
Health Care Industry in the Philippines According to the WHO, the Philippines spent US$ 29 per capita on health services (2.9% of the Gross Domestic Product) in 2002. Private hospitals and the health care industry only incur a minimal contribution to GDP. This can be explained by the low percentage share of health care expenditures to an average family’s expenditures. This share amounts to only 2% to 3% of average income. In terms of financing, the private sector has become the major provider in recent years (Figure 2). One reason behind this is the fiscal constraints faced by the government. The second is the apparent increase in the availability of private healthcare companies. External financing is quite limited to donations by international agencies. In private financing, a big portion is still financed by households as revealed by the proportion of out of pocket expenditures to total private sector financing. In 2002, of the total health expenditures, the government expenditures (including social insurance) accounted for 40% of total expenditures (closely approximating the WHO figures). The shares of private sources and other sources were 58.6% and 2.8% respectively. In 2003, share of government increased to 43.7% while private sources declined to 54.9%. Of the total private health expenditures, 1.34% came from private insurance companies, 5.7% came from HMOs and 42.8% were out-of-pocket expenditures by individuals. One can note that almost half of the health care expenditures were either financed independent of any prepaid health care plans or were not sufficiently covered by those plans. Traditionally, the health care industry of the Philippines has been principally financed by taxes and out-of-pocket payments of individuals. Nevertheless, various financing mechanisms, particularly insurance and prepayment schemes are continuously increasing their contributions in the health expenditures of the country recently. Medicare, the compulsory health insurance, is the most established of all insurance schemes because it has been existing since 1972. The actual percentage share of out-of-pocket which falls significantly above the targeted percentage share from the health care reform agenda manifests the dependence of the health care system on the household’s personal disbursements to be able to access health care services. The Figure shows that the health care system is expected to develop the capacity of social insurance to carry the burden of health care financing. The targeted amount also increases other expenses for health care which includes expenditures incurred either by public or private firms on the financing of health care which includes research and development and manpower training. The plan targets an improvement from the current 11% to 18%. The plan does not concretize how an improvement in the funds allotted for research and development and manpower training can be achieved. The data provided by the National Health
Accounts, however, shows that these funds are usually sourced from official development funds which are coursed through the National Government. The accounts do not reflect the purchases of private firms on capital equipment. The research and development funds, however, are targeted towards the improvement of the facilities of government retained health care providers. Purchases of private hospitals for equipment are directly targeted for the improvement of personal health care services. The major health care providers are hospitals, half of which are accounted for by private hospitals and the rest by the government. The former’s ability to engage in social services and their expansion programs are constrained by their relatively unhealthy financial conditions. Private hospitals, for instance, have improved on productivity in the past years but their capacity in terms of number of beds per population has not significantly increased (see Case Study at the end of the paper). The public hospitals likewise need upgrading of facilities. There is a pressing need for the government and the country as a whole to invest on education and healthcare in order to improve the quality of life of the population or our level of human development in general. If financing coming from the local market (particularly from government) is not currently sufficient the country can explore opportunities from exporting health services. Thus, the next section examines the various possibilities by which countries can engage in health services trade and considers the barriers and risks including empirical evidences of such trade Philippine Birthing Centers Help New Mothers, Healthy Infants Posted on: Wednesday, 11 February 2009, 08:23 CST RICHMOND, Va., Feb. 11 /PRNewswire-USNewswire/ -- Access to high quality health care facilities is important for mothers to have healthy newborns. In the Philippines, six new birthing centers have made giving birth much safer and less worrisome for women in Pili, Camarines Sur. "We want to emphasize the importance of bringing pregnant women to health care facilities, which is the most important factor in preventing maternal and newborn mortality," said Dr. Sadia Parveen, Christian Children's Fund reproductive health specialist. Thanks to funding from the CCF's Sky Siegfried Fund, six new birthing centers were officially launched in Pili, Camarines Sur in September. Elisa, 38, was the first resident to give birth in one of the new facilities, delivering a healthy 7-pound baby girl in October at the Kabukludan Birthing Center. The other birthing centers are operating smoothly, according to CCF staff in the region. "The health attendant and the midwife took good care of me before and after delivery," Elisa said. "I will recommend this center to my relatives because I feel at home and safe."
CCF Philippines, partnering with Mt. Zion Family Development Association - Christ the King Center, initiated the project, "Saving Women's Lives Through Improved Maternal Care." Goals of the project include reducing vulnerability of women to the risks related to pregnancy; providing women access to safe maternal and newborn care; and improving community health. "A primary objective of this project is to build partnerships with groups such as the provincial and municipal health offices, local government units and the communities," said Parveen. Plans are under way to make these centers more comprehensive in their primary health care approach, in terms of broadening their reach to cater to not only pregnant women, but also to women and children in general, Parveen said. This would help take comprehensive primary health care to the community level, and thereby bridge the gap between the public health infrastructure and the communities. Pili, Camarines Sur, is located in the Bicol Region of the Philippines. More than half of the pregnant women in this rural area have traditionally received care from traditional birth attendants, also known as hilots. The new facilities allow pregnant mothers quicker access to health care. According to the Rural Health Unit of Pili, only 40 percent of total pregnancies in 2006 were attended by professional health workers. This is consistent with findings from the National Demographic and Health Surveys, which show that women residing in rural areas usually receive little or no care from health professionals and are not informed of the dangers of pregnancy, such as miscarriage and pre-term labor. The facilities offer patients access to trained health care workers. As part of the nearly $200,000 project, pre- and post-natal obstetric and pediatric care training was conducted by specialists from the Bicol Medial Center to 16 health professionals composed of midwives and nurses. Midwives, rural health nurses and volunteer nurses also attended a five-day training workshop on community-managed maternal and newborn care. Five village pharmacies have been formed and are ready to operate as well to provide medicine to mothers and newborns if needed. Assisted delivery by skilled and trained personnel is associated with lower levels of illness and infant mortality, Parveen said. CCF believes that what happens in the first years of life is the cornerstone upon which the child grows and develops. These new birthing centers are critical to CCF's goal of having healthy and secure infants in its programs. The Sky Siegfried Fund is an annual gift from the Siegfried family. The family donates $500,000 and challenges CCF donors to match the gift. The Sky Siegfried Fund supports health initiatives throughout the world. SOURCE Christian Children's Fund
NEW SCHOOL: AMA SCH OF MEDS AND NURSING PARTNERS W/ HARVARD U MANILA, May 4, 2004 (STAR) The AMA School of Medicine and Nursing (ASMN), an institution affiliated with the Harvard Medical International (HMI), will soon open its doors to medical and nursing students, with the best and the latest offerings in healthcare, medical and nursing education in the country based on Harvard’s standards. The new medical school is a product of the tie-up of two reputable institutions. The AMA Education Systems Holdings Inc. (AMA), the pioneer and the largest IT-based education provider in Asia, and Harvard Medical International (HMI), the leading medical education provider in the world, have entered into an exclusive partnership that would raise the standards of ICT-based medical and nursing educational programs in the Philippines. Located in a new and modern, 11-story building along the South Superhighway in Makati City, its facilities and equipment were designed and acquired based on strict specifications of Harvard Medical International to ensure that students will gain world-class quality training based on HMI’s method of teaching.
In addition, a strict teacher-to-student ratio will be observed to guarantee that students get ample attention from their instructors and that they are given sufficient time to use the ASMN facilities and equipment. To ensure that the ASMN meets HMI’s high educational standards, it has embarked on a continuous and rigid faculty training program. This involved faculty exchanges between the two institutions that started last year and which will be implemented on a continuing basis. "We wanted to leverage on the strong expertise on information technology because advances in healthcare comes at speed. With this developing partnership with AMA, we can take advantage of their IT expertise and set a higher standard in medical and nursing education in the Philippines," said Dr. Robert Crone, HMI president and chief executive officer. The medical curriculum is designed in such a way that the first three years will be spent within a classroom setting, while hands-on training in a clinical and contemporary setting will be given during the fourth year. To allow its students access to more opportunities, the ASMN also takes pride in its affiliations with many of the country’s hospitals. The AMA-HMI partnership will also provide students a chance to continue their education in the United States, consequently earning for themselves better chances of gaining employment. "The AMA-HMI partnership will usher in a new trend in medicine and nursing education in the Philippines, and we are very honored to be part of this partnership. While the curriculum and programs will be based on HMI’s standards, it will also be open and flexible culturally so students will easily adjust to the program," said Ambassador Amable Aguiluz V, AMA Education System’s chairman emeritus. Quality Nursing Education Towards Patient Safety Maria Cecilia G. Gatchalian, RN The Association of Nursing Service Administrators of the Philippines, INC (ANSAP), held its mid-year convention last August 15, 2008 with the theme: “Discovering Competitive Paradigms.” ORNAP was among the various health care organizations which attended this historic event. ORNAP officers who attended the said event were Ms. Marilyn Aro, Ms. Cecilia Amontos, Ms. Flor Burgos, Ms. Jeovie Joya, Ms. Cecilia Gatchalian and Mr. Jonah Arguelles. The topics focused mainly on improving safety and quality of patient care not only in the hospital or ambulatory treatment, but also in the community-based care. The most alarming issue that ANSAP wants to address is the remarkable decline in the passing percentage of graduates in Bachelor of Science in Nursing (BSN), not only in the Philippine Nurse Licensure Exam, but also in the Commission on Graduates of Foreign Nursing Schools (CGFNS) and the National Council on Licensure Exam (NCLEX). Certainly, nursing educators play a vital role in improving the quality of education to
assure that graduates are highly competent and prepared to lead effectively at every level of nursing practice and administration. Most importantly, nursing educators develop analytical and critical thinking skills that are essential in the nurse’s ability to identify potential and current problems or at risks that impact upon patient safety. During the open forum, there were diverse reactions given by the participants and the board members especially on the issue of marked decline of quality nursing education. It is certainly a great challenge for the new members of the ANSAP to vie for excellence in producing competent nursing professionals. Jinggoy says Pinoy nurses discriminated in New Zealand By Aurea Calica and Jose Rodel Clapano Updated March 01, 2009 12:00 AM MANILA, Philippines - Senate President Pro Tempore Jinggoy Estrada called on the government to take action against New Zealand Nursing Council’s alleged discrimination of Filipino nurses. Estrada, chairman of the Senate committee on labor and employment, took issue with the Council’s director, David Wills, for allegedly belittling Filipino nurses. Wills reportedly questioned the quality of nursing training programs in the Philippines based on his observation that the number of nursing students in the country boomed from 30,000 in 2004 to 450,000 in 2008. Wills said that New Zealand as well as other overseas nursing authorities had stopped registering Filipino nurses because of concerns over their qualifications. Estrada said the official should be slapped with a diplomatic protest if no public apology would be made. “We should defend our countrymen, especially our overseas Filipino workers, against this affront,” Estrada said. He said his office received a letter-complaint from a Filipino nurse who spent at least $8,000 to process her application and deployment to New Zealand, but was eventually denied registration by the Council, resulting in her current status as an unemployed and overstaying alien in that country. During his radio program on dzRH, Estrada spoke over the phone to Philippine Ambassador to Wellington Bienvenido Tejano, who reported there were about 50 “distressed” overstaying Filipinos in New Zealand, many of them nurses who were denied registration by the Council. Tejano feared that the number of distressed Filipinos in New Zealand would increase following the non-registration of Filipino nurses. Wills was quoted in news reports as saying that “it is easier to get a fresh graduate from Kenya registered than someone from the Philippines.”
“I won’t allow them to treat our nurses that way, with due respect to nurses from Kenya,” Estrada said. He said the number of students taking up nursing should not in any way be viewed as a decrease in the quality of nursing education in the Philippines. Estrada urged the Department of Foreign Affairs to immediately file a diplomatic protest against Wills and demand a public apology from the Council director. According to Estrada, his office also received a letter from New Zealand national Bill Marshall, who said: “Based on my personal experience, having been a patient in Middlemore Hospital heart ward, I can say thank God for nurses from the Philippines. It has occurred to me that our hospital system (in New Zealand) could risk collapse without the contingent of Filipino nurses that we have. Filipino nurses deserve our respect.” The National Nursing Crisis: 7 Strategic Solutions Jaime Z. Galvez Tan M.D., M.P.H. Introduction At the rate we are losing monthly our highly skilled nurses to the United States, the United Kingdom, Ireland and the Netherlands, and with the Philippine government, via the Department of Health raising its hands in helplessness, offering no strategic solutions in sight, expect a worsening of the health crisis already plaguing our country. It is not only the nurses the country is losing, our medical doctors are now enrolling in nursing schools offering an abbreviated course for doctors to become nurses. Why? There is an acute shortage of nurses in the countries mentioned above which became palpable 3 to 4 years ago. The need will not just be for a year or two but for at least the next 10 to 15 fifteen years. So it will no longer be the roller coaster demand for foreign graduate nurses by developed countries which characterized the outflow of nurses from developing countries during the last 35 years but a persistent, chronic need is transpiring. The USA would need around 110,000 nurses a year while the U.K., Ireland, the Netherlands and other European countries would need another 50,000 nurses a year. Austria and Norway have also announced their need for foreign nurses this year. Japan is expected to open its doors to foreign nurses by 2005. The Northern countries of the world are experiencing longer lifespan and the graying of their population. These factors create increasing pressure on their health systems for greater response mechanisms to the health problems of a growing proportion of the elderly. Their youth population no longer take interest in the nursing profession due to relatively difficult and riskier working conditions such as evening duties, care of the chronically ill and exposure to HIV/AIDS. Thus, there is a great demand for foreign graduate nurses.
The Problem The Philippines will never be able to compete with the salary scales of nurses in these Northern countries. The basic monthly pay there is US$3,000-US$4,000 a month compared to the US$150-US$250 that nurses receive in the Philippines. Yes, our Filipino nurses are globally competitive in professional nursing care and practice but our Filipino salaries will never be competitive. Filipino doctors are going through a reversal of health human resource development by becoming nurses. Even specialist doctors are enrolling in nursing schools. The current income of doctors in the Philippines of US$300 to US$800 a month is still a pittance compared to the monthly salary of US or European based nurses.
Hospitals in the USA even offer additional attractive benefits like residency visa status for nurses, their spouse and children plus other perks like subsidized housing and transportation.
In the year 2001, the Philippine Overseas Employment Administration (POEA), reported the departure of 13, 536 Filipino nurses to 31 countries. The majority went to the U.K. with 5, 383 nurses, Saudi Arabia with 5, 045 and Ireland 1,529. The POEA reported only 304 nurses going to the USA. This is definitely gross underreporting since the International Union of Nurses reported that close to 10,000 Filipino nurses were directly hired by US based hospitals in 2001 through their nursing job fairs held in various parts of the Philippines. In 2002, the POEA further reports that a total of 11,911 Filipino nurses left for 33 countries. In 2003, POEA initially reported 8,968 nurses leaving. Again with underreporting of those who left for the USA. Clearly, the trend is here to stay. Sadly, this is no longer “brain drain” but more appropriately “brain hemorrhage” already of our Filipino nurses. These annual outflow of Filipino nurses for Years 2001-2002 is two to three times greater than the annual production of licensed nurses during the same two year period. Since 1999, the Professional Regulation Commission (PRC) through the Board of Nursing gives licenses to only 5, 784 to 8,419 nurses annually. This is despite the increase of nursing schools from 142 to 240 within the last four years. There were only 40 nursing schools in the 1980s. So very soon, the Philippines will be bled dry of nurses. With the proliferation of nursing schools, the quality of nursing education has shown signs of deterioration as measured by the proportion of nursing graduates who pass the Board of Nursing licensure examinations. In 2001, 54 percent (4,430 nurses) passed the nurse licensure examinations. In 2003, only 45 percent (4, 227 nurses)
passed. Compare this with the average proportion who passed the nurse licensure examinations from 1994-1998 which was 57 percent. Will the Philippine government just tolerate this trend of health human resource outflows to other countries? Will we, as Filipinos, just wait, standby and not do something about this health threatening situation now? Will the Department of Health act only when the catastrophe is already beyond resuscitation? Seven Strategic Solutions This national crisis in nursing and medicine is a very complex issue requiring strategic thinking, multidisciplinary approaches and long term goals. Since the problem is both global and national in scope, it also requires solutions that are global and national in nature. A win-win strategic solution between the Philippines and the nursing importing countries of the North must be the ultimate goal in dealing constructively and resolving the crisis in nursing and medical human resources and services. There is no longer room for piece-meal approaches to this issue. But first, President Macapagal-Arroyo, the Cabinet and Congress leaders must accept that this is indeed a serious national problem deserving urgent attention and action. A seven-point policy action agenda is hereby proposed: One. Creation of a National Commission on Health Human Resources Development. Initially, through a Presidential Executive Order, and later as a legislative act, this National Commission will be composed of the leaders from the Executive and Legislative branches of government with participation from the private sector, academe and civil society groups involved in nursing and medical human resources development. With budgetary support and a lifespan of 3 to 5 years, its major tasks include: an intensive review of the past, current and future scenarios of the nursing and medical human resources; completion of a data base of Filipino health human resources; updating of the 25 year National Health Human Resources Policy and Development Plan (1996-2020) formulated with the guidance of Drs. Fernando Sanchez and Dennis Batangan in 1992-95 for the Department of Health; and the development of a unified health human resource development policy and a national policy research agenda on health human resources. Two. Initiation of High-Level Bilateral Negotiations with Northern Countries Importing Filipino Nurses. Led by a team composed of Secretaries of the Department of Foreign Affairs (DFA), Department of Labor and Employment (DOLE), the National Economic Development Authority (NEDA), Commission on Higher Education (CHED), Department of Trade and Industry (DTI) and the Department of Health (DOH), bilateral discussions with the United States, United Kingdom, Republic of Ireland, Netherlands and Saudi Arabia will center on a partnership approach between the Philippines and these countries. The current approach to the importation of Filipino nurses by these rich countries has been lopsided and advantageous only to such countries while the Philippines continue to
wallow in poverty, underdevelopment and inadequate health care. In the negotiations, these rich countries must be made to realize that the agenda and interests of their Departments/Ministries of Health and their Development Agencies can coincide. Thus for example, USAID, in behalf of the US government and DFID, in behalf of the United Kingdom, will include in their aid package to the Philippines, financial assistance to continuously train globally competitive nurses, constantly upgrading nursing education, nursing health services and nurse remuneration and offering nursing scholarships. Such aid will eventually benefit both countries e.g. the US and UK having a regular pool of nurses to serve their needs since many of these nurses will eventually work there, while the Philippines will be ensured also a regular production and supply of nurses for its health care system. The Philippine Cabinet Bilateral Negotiation Team must be able to come up with concrete investment packages for nursing and health human resource development for discussions with these countries at the soonest possible time. Three. North-South Hospital to Hospital Partnership Agreements. While bilateral country negotiations are on-going and the financial aid packages for nursing development eventually actualized, Northern country hospital to Philippine hospital/nursing school agreements should proceed with the same vigor and pace. Such partnership would focus on the provision of a financial grant given by the Northern country hospital for every Filipino nurse that enters its staff. The said financial grant will go to a Nursing Development Trust Fund of the Philippine hospital/nursing school, to be used to improve nurse salaries, training and nursing practice, upgrade hospital and educational facilities and nurse scholarships. Current estimated total cost of educating and producing a nurse that will pass the Philippine nursing licensure examinations are in the range of US$4,000 to US$7,000. Thus for example, the Philippine General Hospital (PGH) will enter into a partnership agreement with the Johns Hopkins University Hospital (JHUH) in Maryland, USA. JHUH will donate a negotiated amount to the PGH Nursing Development Trust Fund, for every nurse that it recruits from the PGH. This is but just since hospitals from countries of the North do not spend a single centavo in the production, development, education and licensure of Filipino nurses. At the very least, they should be able to pay partially if not fully the cost of nursing development since they are going to benefit from the services of that nurse for at least 25 years. Fourth. Institution the National Health Service Act. The Philippines is one of the few countries in SouthEast Asia that does not have a National Health Service Act. This is a compulsory requirement for all licensed health professionals to serve anywhere within the country for a number of years equivalent to the number of years it took them to study their health professions. While in the past there were attempts to have such a law passed, major objections centered on the individual human rights to move freely and practice their profession where each individual
wants, such as in another country. However, with the globalization and active trading of health human resources and the inevitability of the severest brain drain to hit the Philippines, the country’s collective interest and collective rights should now prevail. At best, health professionals graduating from state universities, schools and colleges must be covered by the National Health Service Act. Their education have been heavily subsidized with the taxes paid by the Filipino people. It is but right that they repay the country with their services equivalent to the number of years of subsidy. If the Philippine Military Academy (PMA) has been doing this since its foundation, government health sciences schools should no longer be exempted. Graduates from private health sciences schools can have a modified scheme in complying with the Act, but nevertheless should be covered as well. With the National Health Service Act, the country will be able to program scientifically the exit of our health professionals, thus ensuring a steady maintenance of health human resources in all health facilities, whether rural or urban. Fifth. Establish Philippine Nursing Registries. A nursing registry is corporately run human resource development center that provide hospitals, clinics and other health facilities with their nursing needs. It has management mechanisms that efficiently locates and monitors nursing human resource availability. It actively negotiates for better remuneration and benefits, better working conditions, keeping always nursing welfare high in its agenda. Usually private sector led, nursing registries can be created at the local level covering a specific geographical area. It can start within a local government unit (LGU) service area, either at the city, province or municipality level or a district health system (DHS) level, covering a network of public and private health facilities in various LGU locations. The registry can also center around a tertiary hospital and cover its referral units and catchment areas. While nursing registries are functioning well in the United States and Europe, the Philippines still has to catch-up with this nursing development. The numerous colleges and schools of nursing should complement this service by making sure that their office of alumni affairs keep a regularly updated directory of all their graduates, keeping track not only of where they are but how they are, in terms of their human welfare and professional growth. With the era of advanced computer software systems and global communication technologies, there should be no more excuses for nursing schools to guarantee this. Sixth. Expand Nursing Residency and Nurse Practitioner Training Programs. This strategy was adapted from the Board of Nursing-led policy workshops. Patterned after medical specialist residency training programs, all secondary and tertiary hospitals should start a similar one for nurses. These will also be three year residency training focusing on nursing specialties such as intensive care nursing, operating room nursing, emergency nursing, psychiatric
nursing, neonatal care nursing, geriatric nursing and nurse counseling. There can also be fellowship programs centering on sub-specialty nursing such as cardiac care nursing, neurology care nursing, genetic nurse counseling, chronic care nursing, and palliative and hospice care. A Board of Nursing Specialties, entirely separate from the Board of Nursing of the Philippine Regulations Commission, should be established to regulate the production and development of these nursing residency and fellowship training programs. Another nursing development program is the offering of nurse practitioner post graduate courses. Nurse practitioners are independent, highly skilled nurses that work in solo, group or networks. While the Philippines produces a lot of graduates of Masters in Nursing which focuses more on nursing management, administration and research, it has been lagging behind in developing a nurse practitioner education program. This will give room for clinical skills in the nursing areas of wellness, counseling, public health, community health, complementary and alternative health care. The course can be offered by colleges of nursing and can also be regulated by the Board of Nursing Specialties or another new board as well. Once this course is available, the time will come when Filipinos can benefit from direct nursing care from stand alone nurse clinics, nurse wellness centers and other modalities of nurse practitioners’ facilities. The above mentioned developments in nursing education will become venues for nurses to comply with the National Health Service Act without neglecting their professional growth. These will also ensure better nurse holding mechanisms to maintain a steady pool of nurses to stabilize nursing care in our health care delivery system. Seventh. Create the Philippine National Council for Nursing Concerns. This will be composed of all the major national organizations involved in nursing. Some of these are the Philippine Nurses Association, the Association of Deans of Colleges and Schools of Nursing, the Board of Nursing, the League of Government Nurses, and the Private Duty Nurses Association. The possible functions of this national council are: to develop a 10 year strategic plan for nursing development in the Philippines; to act as an oversight body for the implementation of all nursing policies, legislations and regulations; to be the locus for the national data bank on nurses and nursing; to be the national sounding board for all nursing issues and concerns; and to coordinate all efforts in uplift and upgrade the nursing profession. To ensure funds for its initial three years of operations, a Presidential Executive Order can be issued to create this National Council until it is able to source out its own financing like as was mentioned in strategic solutions #2 and #3, that is, bilateral aid funding or a percentage of the nursing development trust funds of hospitals and nursing schools. The President can also appoint the first ever Undersecretary of Health for Nursing Concerns, who should be a nurse, to chair this National Council. Let us just not hope but act now on these 7 strategic solutions. Let us call upon President Gloria Macapagal Arroyo, Cabinet Members, the Senate and Lower House leadership and the country’s leading personalities in health and nursing for urgent
and immediate actions to solve this current and future crisis in nursing and medicine.
Nancy Joyce R. Fabonan BSN IV- 2 GROUP6
Bernie P. Magallanes
1. Trends and Future Directions in Harmonizing Nursing Education Internationally Nurses have existed in many cultures since ancient times (Sapountzi-Krepia, 2004). In Europe and North America, modern nursing developed in the mid 19th century and spread to much of the world through the globalizing mechanisms of warfare, colonialism, and missionary activities (Basuray, 1997; Nestell, 1998). The roots of nursing in the Middle East, however, can be traced even further back, to the Islamic Period (570-632 AD) and to Rufaida Al-Asalmiya, the first Muslim nurse (MillerRosser, Chapman, & Francis, 2000). From its foundation in 1899, the International Council of Nurses (ICN) has envisioned an international federation of national nursing organizations that would ensure high standards of nursing education and practice globally. Its founders reasoned that principles governing nursing education and practice should be the same in every country (ICN, n.d.). Unfortunately in the early 20th century, as nursing established itself as a profession, globalization waned. Two world wars and the Cold War meant that the profession diversified. This resulted in a great deal of variation in the way nurses were
educated. For example, until recent years, all nursing education in the Soviet Union and the Eastern Bloc occurred exclusively at the secondary school level and was subordinate to medicine (Jones, 1997). In other countries, professional education was increasingly taught at the tertiary level, but curricula content and program length varied. In addition to differences in education, the nursing profession varies by country in how it is regulated. In a number of countries, to protect the public, regulated professions have designated standards for their members and reinforced these standards by withholding registration from individuals lacking appropriate educational or other credentials (ICN/World Health Organization [WHO], 2005). In other countries, regulation has taken a variety of forms; and in some countries, nursing has not yet become an autonomous, regulated profession. Differences in regulatory criteria are barriers to internationalization. Where regulation occurs at the regional or provincial level, mobility within a country is an issue (WHO/Sigma Theta Tau Honor Society of Nursing [STTI], 2007). Yet data collected from the Organization for Economic Cooperation and Development's (OECD's) 30 member countries (listed in the Table 1 ) shows that about 11% of nurses in these countries are foreign educated (2007). This high proportion of foreign nurses indicates that a measure of accommodation exists among the divergent systems of education and regulation allowing nurses to practice outside their countries of origin. Although the ideal of worldwide standards for nurses promoted by the ICN for over a century remains unrealized, the forces of globalization have created an impetus for change. Education of health professionals, specifically nurses, cannot be entirely homogenous given population health issues, such as endemic diseases, along with social, cultural, and economic differences. However, standards for nursing education need to be established throughout the world to provide a guide for local services and to assure a minimum standard for important issues such as essential qualifications for nurse educators. There have been several initiatives to identify and address barriers to achieving global standards. Among the projects focusing on quality of nursing education is the recently formed Joint Task Force on Creating a Global Nursing Education Community. This initiative is designed to share information and promote quality standards. A meeting led by WHO and STTI was held in Bangkok, Thailand, in December 2006. The goal was to initiate the development of global standards for basic nursing and midwifery education and to address patient safety and quality of care issues that result from the large-scale migration of healthcare providers. Major themes included the development of global standards for program admission criteria, program development requirements, program content components, faculty qualifications, and program graduate characteristics (WHO/STTI, 2007). Further work in this area is important and necessary. Aspects of globalization such as professional mobility, health sector reform, and public concern with the quality of healthcare services have led to greater interest in nursing regulation. In conjunction with WHO, the ICN has established a regulation network as both a forum for exchanging ideas, experience, and expertise in regulatory issues affecting nursing and also as a source of information and guidance to deal with emerging issues (ICN, n.d.). Conferences are held at regular intervals,
with the most recent, as of this writing, held in Geneva in May, 2008 (World Health Professions Alliance, 2008). While international and national nursing bodies are focusing on international standards for nurses, more inclusive movements for educational harmonization that involve national governments are under way. One of the most significant is the Bologna process or Bologna accords. The purpose of this undertaking is to make academic degree standards and quality assurance standards more comparable and compatible throughout Europe. The process extends beyond the EU to include some 45 countries (Zgaga, 2006). Clearly, further harmonization is required. Academic records or diploma titles enable European Union (EU) nurses to register and work in any EU country. Currently, nursing programs that enable nurses to practice in the EU have been subjected to two European directives regarding the qualifications of "nurses responsible for general care." Directives 77/453/ECC and 89/595/EEC stipulate that a "registration program should be at least 3 years long or 4,600 hours" (Zabalegui et al., 2006, p. 115). However, a survey of nursing education in the EU indicates programs take place in a variety of universities, colleges, and schools and that curricular and degree structures vary greatly (National Nursing Research Unit, 2007). Despite these differences, entrance examinations are not required when nurses migrate. The Bologna process offers the opportunity to standardize nursing education, with the bachelor's degree as the entry level to the profession, and master's and doctoral degrees recognized in all EU countries (Zabalegui et al., 2006). Some European countries have already adopted a three-year bachelor's degree as the criterion for entry to practice. Other countries, including some in Eastern Europe, are moving toward this standard (Krzeminska, Belcher, & Hart, 2005; Marrow, 2006). The Tuning Educational Structures in Europe project, a component of the Bologna process, builds on previous endeavours to enhance inter-university cooperation and aims to identify generic and specific competencies for nursing graduates at bachelor's, master's, and doctoral levels (for additional information on these specific competencies see Gobbi, 2004). Graduates, academic faculty, and employers participated in the project, which included a method designed to make the different nursing curricula understandable across countries. The process used by these team members led to the identification of 30 generic and 40 specific nursing competences that will serve as a framework for evaluation. Zabalegui et al. (2006, p. 117) noted that "within this new structure, a bachelor in nursing or nursing science will denote achievement of the specified competencies in an academic environment." While the Bologna process directly concerns Europe and its immediate neighbors, it has generated global attention because harmonization of nursing in this large geographical area will have worldwide repercussions (Zabalegui et al., 2006). It has aroused the interest of countries such as Australia and New Zealand, rival providers of educational services (Australian Department of Education, Science and Training, 2006; New Zealand, Ministry of Education 2007), as well as countries in the Far East (Zgaga, 2006).
Schools of nursing in the Philippines, India, and China will need to take the stipulations of the Bologna process and the competencies identified in the Tuning project into account if they wish their graduates to be eligible to work in Europe. Other economic and political partnerships elsewhere in the world may be interested in participating or developing their own harmonization projects. While educators in North America may prefer alternative approaches to nursing education, they will need to address educational equivalences and differences in nursing education and nursing qualifications. Careful comparisons between education systems may be necessary. For example, competencies and hours of instruction or clinical practice may need to be considered when calculating equivalencies. 2. Creating a vision for the future of nursing education: moving toward excellence through innovation.(Guest Editorial) DURING THE LAST SEVERAL YEARS, the NLN Board of Governors, members, and staff have advocated energetically for excellence and innovation in nursing education. While much work is yet to be done, there is cause for hope and celebration. As we speak with faculty around the country, it is increasingly apparent that discussions about innovation in nursing education have become commonplace. Many schools of nursing, inspired by recent NLN position statements, our Centers of Excellence in Nursing Education[TM] program, and our Hallmarks of Excellence in Nursing Education[c], are moving toward excellence by undertaking substantive reform.
Nursing Shortage: Can the Philippines solve the growing nursing crisis in Alberta? April 24, 2008 While Alberta’s economy is certainly healthy, there’s a very real chance its people might not be if things continue the way they have been. Even with workers flocking here to get a piece of the boom pie, the province—along with just about every province in Canada—is experiencing a severe nursing shortage that is leading to surgery cancellations and overloaded health care workers. With nearly a third of Alberta’s 30 0000 registered nurses on the brink of retirement in the next five years, the province’s health care system is facing a mass exodus that won’t be alleviated by the 2000 nursing students promised by Ed Stelmach’s Conservative government to graduate by 2012. Margaret Hadley, president of the College and Association of Registered Nurses in Alberta (CARNA), points out that the instructor shortage in nursing schools is just as severe as the nursing shortage itself, if not worse.
“The average age for nursing instructors is actually slightly higher than the average age for the rest of the nursing population. They’re going to be retiring sooner or potentially sooner,” says Sustrik. “There’s going to have to be a serious look at how we get instructors, what their qualifications are going to be and how we are going to get them in place to teach the students that we need.” To alleviate the nursing shortage, Capital Health is bringing in 600 international recruits, mainly from the Philippines and the United Kingdom, between now and December. Buick quickly asserts that this solution isn’t long-term and that local training programs must ultimately increase to deal with the workforce shortage in the health care system. Sustrik also stresses that hiring foreign nurses must be seen as only a short-term solution. “We need to address our own nursing shortage,” she says. “There’s a nursing shortage worldwide, so poaching from other countries is not helping the overall nursing picture in the world.” While Capital Health, UNA and CARNA all believe that hiring international recruits should only be a temporary solution, Tessie Oliva, founder and current advisor of the Filipino Nurses Association of Alberta (FNAA), which has a partnership with Capital Health in the recruitment of the international nurses, says it could be a long-term solution to the problem. While there are legitimate concerns about the South to North “brain drain/brain gain” when countries such as Canada do mass recruitments of professionals from other, usually developing, countries, Oliva says that in the Philippines the nursing problem is one of oversupply. “[The] number one export in the Philippines is nurses. It produces nurses in the thousands. A lot of nurses [there] don’t even have jobs. A lot of nurses are just volunteering with no pay in order to get experience,” she says.
International Nurse Migration Lessons From the Philippines Barbara L. Brush, PhD, RN, FAAN Division of Health Promotion & Risk Reduction, School of Nursing, University of Michigan, Ann Arbor Julie Sochalski, PhD, RN, FAAN School of Nursing, University of Pennsylvania, Philadelphia Developed countries facing nursing shortages have increasingly turned to aggressive foreign nurse recruitment, primarily from developing nations, to offset their lagging domestic nurse supplies and meet growing health care demands. Few donor nations are prepared to manage the loss of their nurse workforce to migration. The sole country with an explicit nurse export policy and the world's leading donor of nurse labor—the Philippines—is itself facing serious provider
misdistribution and countrywide health disparities. Examining the historical roots of Philippines nurse migration provides lessons from which other nurse exporting countries may learn. The authors discuss factors that have predicated nurse migration and policies that have eased the way. Furthermore, the authors analyze how various stakeholders influence migratory patterns, the implications of migration for nurses and the public in their care, and the challenges that future social policy and political systems face in addressing global health issues engendered by unfettered recruitment of nurses and other health workers.
JAMMIELYN F. FIGUEROA Nursing group rejects 5-year nursing course. Publication: Manila Bulletin Date: Thursday, February 5 2009 The Philippine Nursing Association (PNA) said yesterday that efforts being undertaken by the Commission on Higher Education (CHED) to improve the country's higher education are commendable, except its plan to add a year to the four-year nursing course. "We laud the initiatives of the CHED to make the country's higher education institutions (HEIs) at par with global standards, but lengthening the time allotted especially for nursing education is not the answer to the problem,'' said PNA president Dr. Teresita Barcelo. "Gawin mo mang limang taon ang nursing kung kulang pa rin sa resources at bulok ang mga facilities, nothing will happen,'' added Barcelo. She also expressed reservations over the implementation of the proposed curricular reforms, noting that efforts in the past have yet to be successfully realized. Barcelo echoed the view of some sectors that the proposed five-year curriculum is an additional financial burden to parents and students in the light of the global hard times. CHEd's move to implement a five-year curriculum for nursing education and related programs is centered on the recommendations of the Presidential Task Force for Education (PTFE), co-chaired by the CHEd chairman himself, Dr. Emmanuel Angeles. The PTFE recommendations, including the proposed curricular reforms or the socalled "10+2+3'' scheme are envisioned to make the Philippines a "knowledgebased economy." he other proposals are the establishment of the National Education Evaluation and Testing System (NEETS); establishment of common standards for accreditation per discipline; rationalization within a moratorium period of the creation and conversion of state universities and colleges; and reorientation of the premises of financing public higher education. Angeles told a news conference earlier that a list of these recommendations, submitted to President Arroyo last Dec. 9, are still being studied by all stakeholders concerned.
He also said that tertiary schools will be given a free hand to implement the fiveyear program. But Angeles stressed that the five- year curriculum for nursing is a better option than the existing four years and three summers because the subjects are less crammed and nursing graduates will be recognized globally. The PTFE lamented that many Filipino graduates are not recognized in the international arena because the country adopts a 10- year education system, three years lagging from the education provided in Europe, the United States, and even countries in Asia like Singapore, Malaysia, and Hong Kong. Barceló said the intentions of PTFE and CHEd chair Angeles are noble, but added there are concerns in higher education, particularly in nursing education, that are far crucial. She urged CHed to strictly monitor existing nursing schools to ensure they continuously abide by the CHEd's mandate to produce quality nursing graduates. She also asked the CHEd to lobby for more funds to address the deficiencies in laboratory facilities and equipment. CHEd data showed that only 12 nursing programs are recognized as excellent, while 18 are performing highly in board exams. There are 460 nursing schools nationwide. The report likewise noted there is a deficiency in the training capacity of students as only about 20 per cent of the country’s 2,000 hospitals has a 100- bed capacity. Nursing students comprise nearly a quarter of the 2.5- million college enrollees last school year, Angeles said.
Phase-out of poor nursing schools pushed; To improve Philippines nursing education, Bicol lawmaker says. Publication: Manila Bulletin Date: Sunday, January 22 2006 LEGAZPI CITY a" To improve the quality of nursing education in the country, the Commission on Higher Education (CHED) should phase out substandard nursing schools instead of forcing prospective nursing students to undergo a special college entrance test, lawmakers said here yesterday. "Nursing students go to school and pay tuition, in many cases, sky-high tuition, precisely because they expect to obtain adequate instruction," Catanduanes Rep. Joseph A. Santiago said.
"If deficient nursing colleges cannot provide students their moneyas worth in training, then the schools concerned have no business staying in business," Santiago said. Santiago said the CHED should promptly raise the bar for nursing schools and compel them to quickly shape up or risk being shut down. "Many young Filipinos aspire for a good-quality nursing education because it offers them a way out of poverty and the opportunity to work in greener pastures," he said. "We must safeguard this hope and dream by seeing to it that inferior schools are phased out." Starting next year, the CHED plans to require all high school graduates to take a new National Nursing College Admission Test before they are allowed to enroll in a nursing course. Santiago, however, said the entrance test would not necessarily improve the quality of nursing education. "The admission test will be of little help if after passing the test, nursing students will still get mediocre schooling over the next four years. As a result, many students may still fail miserably in the licensure examinations," Santiago said. "So we definitely still need a system of attrition, if you will, to get rid of low-grade nursing schools," Santiago added. Santiago previously disclosed to the public, through the media, the performance of various nursing schools nationwide based on the achievement ratings of their graduates in the licensure examinations from 1999-2004. Even the Professional Regulation Commission (PRC) has expressed alarm over the deterioration of the quality of nursing education. This year, 26,000 nursing graduates took the PRC-administered nursing eligibility test, but only 49 percent of them passed. Ten years ago, 24,600 nursing graduates took the eligibility test and 62 percent of them passed. (PR)
MADEL V. LANCETA Health Care Quality and the Delivery System: The Forgotten Issue Concern about the state of the American health care system has reached a slow boil. Health care consistently ranks among the top three issues that the American public wants policy makers to address, and it is increasingly intertwined with growing worries about economic insecurity. High costs, gap-ridden coverage, and sporadic quality are the health care problems that most concern Americans. Yet most of the policy discussion is focused on the issue of coverage. To ensure that the other problems are not forgotten, the Center for American Progress and the Institute for Medicine as a Profession partnered to develop the book, The Health Care Delivery System: A Blueprint for Reform , which offers recommendations and pathways to systemically promote efficiency, quality, patient-centeredness, and other characteristics of a high-performing health system. Its blueprint includes the vision for how different parts of the system should be structured and should function. It also proposes specific policies that the next administration and Congress could adopt to set change in motion over the next five years. This event and book will ensure that when the opportunity presents itself, the next administration will be ready with grounded policies that are more than patches and can serve as pathways toward the high-performing health system that is not just possible, but essential, to better health and a prospering economy. Nursing woes. Publication: Manila Bulletin Date: Wednesday, May 28 2008
Seeking greener pastures in foreign lands, Filipino nurses leave the comfort of their homes and their families in order to be given the opportunity they never had in their own country. It is not surprising then that nursing schools have sprouted like mushrooms everywhere. Often raised along this ballooning number of nursing schools in the country is the quality and standard of nursing education they provide. Even well established colleges and universities offering nursing education are being periodically checked by the Commission on Higher Education (CHED) in order to inform them of the latest innovation and trends in nursing education as well as to assess the colleges/universities' compliance with CHED directives relative to nursing education. Just last week, CHED announced the nationwide implementation of the new nursing curriculum which would add twenty eight (28) units to the current one hundred sixty nine units (169) curriculum for nursing education. Further, the order (CHED Memorandum Order No. 5) will increase the hours of related learning experience (RLE) to 2,730 from the originally required 2,142. That's an additional 588 hours of hospital and community exposure. This likewise means additional expenses and painstaking study for nursing students. The Commission on Higher Education argues that the implementation of the new curriculum aims, among others, to upgrade the quality of nursing education in the Philippines. It has been observed, according to reports that the quality of nursing education had steadily declined in the recent years, as reflected in the performance of nursing graduates in the Licensure Examination. With CHED Memorandum Order No. 5, the Commission hopes to address this problem. The new policy likewise eliminates "special courses" for other professionals lured to enter nursing schools because of the prospects of employment abroad. This, according to CHED, contributes to the declining competency of our Filipino nurses. The new nursing curriculum also integrates board review to ensure that graduates who take the licensure exam are well prepared. At this early stage, vehement oppositions have been raised regarding the implementation of CHED's new rule. The Coordinating Council of Private Educational Associations (COCOPEA), which consists of around 2,500 educational institutions, for example, immediately appealed for CHED to halt of the order's implementation claiming it "disastrous" to students, parents and schools. Amidst the objections raised against the directive, we ask: Is CHED's argument for Memorandum Order No. 5 really plausible? Is standard and quality truly ensured by the additional subjects and extra RLE hours? How does the new policy impact students and parents, as well as the innumerable nursing schools in the country? In the People's Republic of China, for example, their previous five-year nursing curriculum was even shortened to three years. In the United States on the other hand, emphasis was made in upgrading the quality of teaching professionals in nursing schools as well as in using state-of-the-art equipment and facilities in order to hone the skills of nursing students. Both did not find the lengthening of study as a prerequisite to producing competent and highly skilled health professionals.
RAIZA Q. LAGAYA Pacific Bridge Medical- Asian Medical Publication Analysis of Asia’s Changing Health Care Delivery System Published in Spectrum: Health Care Delivery and Economics By: Ames Gross and Elaine C. Conavay August 5, 1997 Business Implications • Throughout Asia, changing health care needs, along with strong economic and population growth, are forcing countries to address staggering increases in health care demands and costs and to shift some of the burden of those costs from governments to the private sector. Also, improved access to quality health care has increased demand for numerous medical products and services. • One consequence of Asia’s economic success has been a significant change in disease patterns. As living standards improve, many Asian countries are dealing less with problems such as malnutrition, associated with developing countries, and more with diseases like cancer, associated with prosperous nations. In response, health care providers must adapt products (diagnostic and therapeutic) and facilities to meet these needs. • Singapore has earned a reputation as Asia’s health care center and is drawing growing numbers of patients annually. In addition, Singapore, with its central
location and strong infrastructure, is used by many foreign medical firms as a base of operations in Southeast Asia. Singapore’s government has tried to build the country’s biotech industry by offering incentives to biotech companies. • Increasing demand will drive the medical device and pharmaceutical industries by more than 10% a year in many Asian nations through 2000. Background: Asia’s Changing Health Care Demands and Policies Over the past decade, Asia has been one of the fastest-growing regions of the world. The World Bank estimates that over the next decade, East Asia (excluding Japan) will grow twice as fast economically as any other region in the world. And by the year 2020, seven of the top ten world economies will be in Asia—China, South Korea, Japan, India, Indonesia, Taiwan, and Thailand. With the economies of many Asian countries experiencing double-digit growth rates, increasing numbers of middle- and upper-class citizens have begun to demand the high-quality health care they can now afford. In response to this demand, various nations in Asia are creating systems that most effectively address the unique health care needs of their citizens. One consequence of Asia’s economic success has been a significant change in disease patterns. As living standards improve, many countries are dealing less with problems of malnutrition and cholera, associated with developing countries, and more with diseases like cancer and heart disease, associated with prosperous nations. In response to these changing disease patterns, health care providers must adapt products (both diagnostic and therapeutic) and facilities to meet the needs of newly developed nations. Another consequence of Asia’s growing prosperity is rising health care expenditures, as health care facilities are modernized and as more medical products and services are used. To help control rising costs and to shift some of the burden of paying for medical care from governments, many Asian countries are moving away from health care that is subsidized or controlled by the government and toward private-sector solutions, such as insurance programs. These programs (found in Singapore, Thailand, and even China, among other countries) are typically paid for by employers or through a joint contribution from employers and employees. At the same time that many Asian countries are shifting more of the burden of paying for health care to the private sector, the growing ranks of affluent Asians are choosing to receive medical care from nongovernment services, where they believe they can get the best treatment. This demand has further fueled the growth of private-sector health care in the region, leading to large increases in the development and utilization of private hospitals. In addition, some Asian governments are trying to improve health care within their borders by working to attract foreign medical product manufacturers with tax breaks and other incentives. Although many Asian countries face similar challenges in restructuring their health care systems, these countries should not be treated as one homogeneous region. Clearly, the wealth and economic growth of Singapore, Hong Kong, and South Korea
separate those nations from developing countries like Vietnam and Thailand, especially when total health care expenditures are considered. This report examines the health care delivery systems of several Asian countries that are developing rapidly and that hold the most promise for future medical device and pharmaceutical sales. In particular, it discusses how countries are restructuring their health care systems to meet the increased demand for medical products and services and describes the role that foreign manufacturers of medical products are playing in the region’s growing economies. Philippines After more than 20 years of a corrupt and unstable political environment, the democratic election of President V. Fidel Ramos in 1992 was evidence of a new beginning for the Philippines, whose economic growth lagged behind that of its Asian neighbors in the 1980s. The election of Ramos has given rise to some economic stability in the Philippines; for example, inflation rates are under control and interest rates are lower. Although the Philippine’ per capita GDP ($1,055 in 1995) is one of the lowest in Southeast Asia, the economic growth rate nearly doubled from 1993 to 1994, reaching 5.1%—a sign that the country is on the right track to sustained economic development. Despite this progress, poverty is still a serious problem in the Philippines. Health Care Trends and Policies The Philippines’ health care system differs considerably from those of its Southeast Asian neighbors in that most of the country’s medical services are delivered by the private sector. In 1991, the national government decided to take an even smaller role in the delivery of health care by leaving most of the responsibility for delivering medical services to local governments. Nevertheless, the Filipino government, through the World Health Organization (WHO), is increasing its services to the poor, many of whom still lack access to adequate health care. For the most part, the private health facilities in the Philippines provide curative services, while public health facilities provide preventive services. In 1994, the Philippines had 1,068 private hospitals and 503 public hospitals; the country also has a wide variety of specialized hospitals. In quantity, Filipino hospitals are on par with those in the more developed Hong Kong and Singapore, but they will need serious upgrading to reach the same level of quality. In 1995, the nation’s personper-doctor ratio was 1,062:1 and the person-per-hospital-bed ratio was 683:1. Accompanying the trend of dominant private-sector health care, the number of health maintenance organizations (HMOs) in the Philippines is growing. Most of the 17 HMOs currently operating in the country specialize in group and company health services. (Private health insurance in the Philippines is primarily funded by a combination employer and employee contributions.) Despite its decreased role in health care delivery, the Philippines’ Department of Health plays an important role in overseeing the entire health care sector; for
example, it sets and enforces standards for medical services and facilities and promotes health initiatives. Another main responsibility of the Department of Health is to make sure that all citizens—especially the poor and those living in rural areas— receive basic health services. The department has set seven specific goals for improving public health, including controlling disease, establishing child survival programs, improving women’s health and maternity services, and expanding health service capacity. Expenditures for public health services in the Philippines increased by 400%, to $386 million, from 1985 to 1991. Because of population growth and the need to serve the poor with basic health services, this growth is not expected to taper off anytime soon. The Role of Foreign Medical Companies The growth of the Philippines’ population and economy has sparked a demand for health care services and products that foreign companies are helping to meet. In fact, foreign medical companies control approximately 85% of the medical device market and almost 70% of the pharmaceutical market in the Philippines, where much of the domestic production of pharmaceuticals involves mixing and preparing drugs rather than creating new agents. U.S. companies have a particular edge because many Filipino doctors study in the United States and are familiar with the country’s products. Despite competition from larger foreign medical firms, the Filipino company Unilab has been especially successful and now commands more than 20% of the pharmaceutical market in the Philippines and approximately 8% of the pharmaceutical market in Southeast Asia. One of the reasons for Unilab’s success is its powerful joint ventures with foreign medical companies such as Schering-Plough, Roussel-Uclaf, Fujisawa Pharmaceuticals, and Yamanouchi Pharmaceuticals. These alliances have helped Unilab get ahead by giving the company access to new developments and technologies. Another reason for Unilab’s success is its highly developed distribution network in both the Philippines and throughout Southeast Asia. Conclusion The effects of Asia’s tremendous economic and population growth over the past decade have been widespread. This growth has created a need to change and improve the various health care systems of the region and has led many Asian countries to build and modernize hospitals and clinics as well as adapt diagnostic and therapeutic products. To help control the staggering costs of these improvements and adaptations, many countries are moving away from governmentsubsidized health care and towards private-sector solutions. As living standards continue to improve throughout Asia, citizens are demanding greater access to higher-quality health care. Many who can afford high-priced medical services do not hesitate to bypass government-sponsored care and instead use the more advanced and expensive services of private hospitals within their own countries and even in other nations in the region. To meet the growing demand for sophisticated medical treatment, the number of private hospitals has increased dramatically in recent years. Because care at these private hospitals is frequently covered by private health insurance, which often places few limitations on treatment, costs have increased with the quality of care.
The improved access to quality health care in many Asian countries has sparked a boom in the demand for all sorts of medical products and services. Companies marketing medical devices and pharmaceuticals in the region have benefited from this increased demand, and the growth rates for each of these industries is expected to exceed 10% annually in many Asian nations through 2000. Between 1996 and 2000, Vietnam is expected to register the highest annual growth rate (20%) in pharmaceutical sales, followed by China (15%), Indonesia (13%), and Thailand (12%). Furthermore, because health care spending as a percentage of GDP is relatively low in most Asian countries, when compared with such spending in the United States and other Western nations, Asia’s health care markets have plenty of room for growth. Foreign companies have responded to this opportunity by investing heavily in pharmaceutical, medical device, and biotechnology facilities in Asia, often with encouragement from local governments. With predictions that, by 2020, seven of the ten largest economies will by in Asia, companies are diving into the market, hoping to cash in on this expected growth.
Lack of Nurses Burdens an Ailing Healthcare System By: Chit Estella
This month, some 20,000 nursing students will graduate from about 350 schools throughout the country. The best of these students will likely go abroad. A good number of them, however, will fail the nursing board exams. (The failure rate in the last few years has been close to 60 percent.) The first part of this series examines the export of nurses and its impact on Philippine health care, where the shortage of skilled nurses has meant deteriorating hospital care and even the closure of many hospitals. In the last 10 years, the Philippines exported close to 90,000 nurses overseas. In addition, in the last four years alone, 3,500 doctors left the country to take on nursing posts abroad. We are now exporting more nurses than we are producing, resulting in substandard patient care and a real crisis in hospitals. The second part of the series looks at how the nursing export boom has also resulted in a boom in nursing education. Many substandard schools have been set up, and many of these play on the dreams of those who aspire for a job abroad. Nursing education in fact has been retrofitted to meet the demands of the global market. Courses like transcultural studies being included in the curriculum and new, shortened designer courses are being offered for doctors and other professionals who want to take up nursing. In these new curricula, the compassionate and caregiving values that are supposed to be inculcated among healthcare professionals are being overlooked; instead nursing is treated as primarily a passport to the good life.
This month, some 20,000 nursing students will graduate from 350 schools in the country. As the global health industry opens itself up to more migrant health workers, many of the new graduates will be making a beeline for jobs overseas. But many more of them will not pass the qualificatory exams for nurses, thanks to a boom in nursing schools that has led to a decline in the quality of education and also of students being accepted into nursing programs. In the last few years, less than half of those taking the nursing board exams passed. The best among the graduates, however, are often bound for abroad, many of them skipping the one or two-year experience YEAR that is usually required by hospitals. In the last 10 years, the Philippines sent close to 90,000 nurses overseas. Today it is 1994 exporting more qualified nurses than it is producing, leading to a nursing crisis that has already diminished the quality of hospital 1995 care and even forced the closure of a number of hospitals. 1996 TABLE 1: Deployment of Filipino Nurses, 1994-July 2003 1997 SOURCE: POEA, Institute of Health Policy and Development Studies, 2004 1998 The impact of the nursing drain is compounded by the fact that 1999 doctors are also now taking nursing courses in the hope of going abroad, worsening the shortage of healthcare workers in many 2000 parts of the country. In the last four years, 3,500 Filipino doctors 2001 have left the country to take on nursing jobs overseas. 2002 A study by the National Institutes of Health (NIH) describes migrant health workers (nurses, physical and occupational July therapists and midwives) as generally young, from 20 to 30 years 2003 old. Migrant doctors are between 31 and 40 years old. But these figures can deceive. Now and then, hospital staffers would speak TOTA of doctors who have retired or are about to retire and taking up L nursing. Age is not a hindrance to working abroad, especially in the United States where one can work for as long as one wants to. VOLUM E 6,699 7,584 4,734 4,242 4,591 5,413 7,683 13,536 11,911 5,628 84,843
Although the number of male nurses has been observed to be on the rise, the migrant health workers are still predominantly female, meaning more families are losing their traditional caregivers—the wives, mothers, and sisters. According to a 2004 Asian Development Bank report, 65 percent of Filipino workers overseas are already women. The NIH study also warns that because the migrating nurses are usually the ones with training, experience and skill, patients in hospitals and other health institutions in the Philippines can expect a higher incidence of cross-infections, adverse events after surgery, accidents, injuries and even increased violence against the staff. With the best among nursing students often leaving as soon as they graduate, the less skilled are taking the place of senior or relatively more experienced nurses who have also left for other shores. In a year or two, they too would be gone. The void
would be filled once more by fresh graduates who would repeat the same cycle: get a few years experience in a local hospital, apply for work abroad and then leave. It is, say many health professionals, a cycle that leaves local hospitals in a state of perpetual displacement—and patients in constant danger. Next to India, the Philippines is already the second largest source of doctors in hospitals abroad. The country also supplies 25 percent of all overseas nurses worldwide. Not surprisingly, about 10 percent of the Philippines’ 2,500 hospitals have closed down in the past three years mainly because of the loss of doctors and nurses to jobs overseas. As more nurses leave and as fewer are qualifying for the job, the situation in hospitals can only deteriorate. But to Rita Tamse, deputy director for nursing of the Philippine General Hospital (PGH), “That worse situation is happening right now.” “Our problem is unskilled, untrained nurses,” says Dr. Irineo Bernardo, executive officer of the Philippine Hospital Association and owner of a primary care community hospital in Tanay, Rizal. He notes that the turnover of nurses has been particularly high in the last five years. “In a small hospital, we’d expect one or two to leave for abroad in a year,” says Bernardo. “Last year, we had five who left.” Even the PGH, the country’s premier government hospital, is also seeing an exodus, with up to a quarter of its 2,000-nurse workforce leaving in the last few years. The preferred country of destination is the United States because of the possibility of acquiring U.S. citizenship and all its privileges. But 57 percent of Filipino nurses abroad are in Saudi Arabia and only 14 percent are in the United States, while 12 percent are in the United Kingdom. But that may soon change. Figures vary but the United States is said to need about a million nurses over the next few years; Canada, 10,000; the Netherlands and the United Kingdom, 7,000; other countries, 27,000. In 2001, the Philippine Overseas Employment Administration (POEA) reported that 13,536 Filipino nurses went overseas, almost double the previous year’s exodus of 7,683 nurses. The 2001 figure is the highest ever recorded. The same year, only 4,430 students passed the Nursing Board Examination. The pattern would be repeated in 2002 when 11,911 nurses chose to work abroad as against a much smaller number of nursing students—4,228—who passed the Board. Clearly, the country has been exporting more nurses than it was producing.
TABLE 2: Nursing Board Performance YEAR 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 June 2004 NO. OF NO. OF PASSING EXAMINEES PASSERS RATE (%) 41,459 38,689 25,163 19,546 17,101 13,152 9,270 8,269 9,449 15,606 13,194 25,477 22,532 13,643 9,776 9,541 6,558 4,601 4,430 4,228 7,526 7,371 61.45 58.24 54.22 50.02 55.79 49.86 49.63 53.57 44.75 48.23 55.87
SOURCE: Professional Regulation Commission Tamse, who is also a member of the Technical Committee on Nursing Education of the Commission on Higher Education (CHED), notes that the latest Nursing Board Exam last December registered its lowest passing rate ever at 43 percent. Of the about 12,000 students who took the Board, only about 5,000 made the grade. Thus, while PGH used to accept only the top graduates of the country’s nursing schools, it can no longer afford to stick to such standards, says Dr. Jaime Galvez Tan, vice chancellor of the University of the Philippines in Manila that is in charge of the hospital. So long as a nurse makes the minimum passing grade, an apparently desperate PGH will take the applicant. Bernardo points out that the shortage of skilled nurses compromises the quality of patient care. He says, “It takes years for a new graduate, even for someone with good grades, to be trained.” It is not enough that a nursing graduate knows the theories, says the doctor, adding, “He or she must know the culture inside a hospital as well.”
Skilled and trained nurses are a requisite of proper health care. In some towns, small hospitals are run by nurses, not doctors. Bernardo says that if the only nurse available “is an idiot, then better not open the ward altogether. You’ll be putting the patients at risk.” One need not even go to distant barangays to find unskilled nurses. In a top hospital in Metro Manila, Tan recalls asking for a spittoon for a patient. “The nurse,” he says, “came back with a urinal.” This writer also witnessed a nurse at a government hospital using her cellphone’s calculator to compute the intake and outflow of fluid of a patient, only to come up with the wrong numbers, which were recorded in the patient’s chart. Doctors base their diagnosis and course of treatment on the patient’s chart and wrong data could lead them to make wrong conclusions. But even doctors are fast disappearing. On the fifth floor of a busy hospital in Manila, for example, hundreds of doctors congregate from Friday to Sunday in the early evening to “learn nursing.” Tan says that 5,500 doctors are now enrolled in 45 nursing schools in courses that were tailor-made for them. Two thousand doctors have already taken up the Nursing Board Exams, topping the test in 2003 and 2004. Last year, the topnotcher in the medical board exam announced his plans to work overseas as a nurse. Thus, even as more nursing schools pop up each year, medical schools are getting less popular. Of the 39 medical schools in the country, three have ceased operating because of steeply declining enrollment. One report says that only six medical schools out of 25 that it studied registered an increase in enrollment. The highest increase in enrollment, registered by Mindanao State University, was 29 percent. This, however, is hardly encouraging when compared to the decline in enrollment experienced by most schools. The Iloilo Doctors College of Medicine, for instance, reported a 74-percent decrease in enrollees. Except for the University of Sto. Tomas, nearly every medical school covered by the study reported a shortfall in its enrollment quota. Among the reasons cited by health workers bound for abroad are political instability, corruption and the need for political backing in order to get a job or a promotion. They also deplore the long hours of work required of them. The most common reason they give, however, is economic. Tamse recalls that one nurse came back from the United Kingdom with P500,000 after just six months there. For those bound for the United States, there is even a signing bonus of anywhere from $2,000 to $10,000. These figures, she says are “a far cry” from what nurses are paid here. Those in the provinces, for instance, get as low as P2,000 a month. Ironically, government hospitals pay more than private hospitals. Nurses in public hospitals receive at least
P9,000; in private hospitals, it could go down to P4,000 a month. Under the Nursing Law of 2002, an entry-level nurse should get about P13,300 a month. “It’s such a small amount and yet the government is unable to give that,” Tamse says, citing “unavailability of funds” as the constant reason being given by the Department of Budget and Management. In the meantime, a contractual nurse without experience gets P9,930 a month; with experience, the pay goes a bit higher at P12,000. Even recruiters are handsomely paid for every nurse they bring to a foreign health institution. Tan says a recruiter once offered him $7,000 for every nurse that he could find for a U.S. hospital. When the disbelieving doctor finally got the chance to talk to staff members of that hospital, he was even more surprised. “They denied it!” cries Tan. “They weren’t giving $7,000 for every nurse. They were giving $14,000!” Tan worries that doing nothing to stop the flow of Filipino doctors and health workers to other countries could only lead to a “health human resources disaster.” Based on the results of a project he has been conducting in the last several years, he thinks the lack of good role models is partly to blame for the exodus of health workers. Some teachers, he says, tell their students there is no hope in this country. The medical curriculum, he adds, gives premium to grades and competencies rather than values. Globalization of labor has also contributed to a materialistic attitude even among those whose profession is supposed to serve others. Yet Tan says that medical students generally start off with the right attitude and values. But somewhere on their way to becoming doctors, something seems to happen to them, changing their goals and plans, he says. Over the years, Tan has been monitoring the attitudes of medical students, asking them three questions: How do you describe yourself? How do you see yourself 10 years from now? What country do you want to serve? During the first and second years, he says, a medical student would usually describe himself as “compassionate” and “humane.” The student would also see himself working in public health, community medicine, or with a nongovernmental health organization. Those years also see all medical students replying that they would like to serve in the Philippines. Change, however, comes by the third year onward. With students invariably describing themselves as “competent” and “skilled,” many now want to become super-specialists. And by the time they graduate, only 25 percent said they would stay. But Tan says the outward flow of health workers, however strong it is right now, can be “tamed” and lead to a “win-win situation” for the Philippines and the importing countries.
He suggests the initiation of bilateral negotiations with countries that import Filipino health workers that would lead to the allocation of development aid or compensation to the Philippines in exchange for sending health workers abroad. He also advises the government to create a national commission to oversee the planning, production, deployment, retention and development of health professionals. He deplores the fact that there is no single body taking charge of these matters, which explains why figures concerning health matters vary depending on which government agency is consulted. For now, however, Filipinos who fall ill will find less skilled professionals attending to them SCHEMONETTE F. CELISPARA
Oversupply of Nurses in the Philippines Confirmed: 150K Unemployed Filipino Nurses Two nights ago, news on TV confirmed the oversupply of nurses in the Philippines. Statistics on unemployment of Filipino (Pinoy) nurses hit a whooping 150,000 (estimated count). According to government sources, this figure is actually lower than the previous estimate of 400,000 unemployed (and underemployed) nurses in the Philippines but still confirms that there really exists an oversupply of nurses in the country. An article about unemployment of nurses is directly related to the number of board exam takers (see Complete List of Nursing Board Exam Passers for June 2008). Another article I have written about this topic was “Oversupply of Nurses in the Philippines Largely Contributes to the Philippine Unemployment Rate” where the discussion focused on the rate of unemployment in the Philippines in general and the contribution of nursing graduates and registered nurses in the rate of unemployment in the Philippines in particular. One of the threats of the Commission on Higher Education (CHED) was closure of nursing schools if their performance in the Nursing Board Exam will not improve. This threat remained a word-of-mouth because so far, there had been no reports on schools ordered by CHED for closure. If there had been schools ordered by CHED to stop offering Bachelor of Science in Nursing, this author did not know about it. If there were schools, I doubt if their number is significant to minimize the enrollment of students in the degree program (BS Nursing). The oversupply of nurses in the Philippines should be addressed right from the home level. This is because parents/relatives of the students are the ones forcing their child/ren to enroll in BS Nursing because of the “bright future” this course could bring someday. While this is true in some cases, majority of our Filipino nurses have not been that lucky in their quest for a greener pasture and overall success in their chosen field of specialization.
Hospital administrators and academician agree that the quality of Nursing graduates have long been declining. Quality of nursing education could also be blamed. Quality of nursing education is becoming lower each year and adding another year to the New 5-Year Nursing Curriculum in the Philippines is not a practical solution if the primary objective of this new curriculum is to control the growing number of enrolees per year. Quality teachers (clinical instructors) should be employed and stringent screening of nursing students should be done because I strongly believe that to overcome the oversupply of nurses in the Philippines, quality education should be improved by way of improving the quality of educators as well as the quality of educands. This way, the population of nursing enrollees will go down and good clinical instructors will educate better a manageable number of students, making the teaching-learning process more effective.
Philippine hospitals suffer as workers leave MANILA: The Philippine health care system, already compromised by the massive migration of Filipino medical workers to other countries, could worsen if the United States ends its capon the number of foreign nurses it can hire, health experts warn. The Philippines sends more nurses to the United States than any other country. While health experts said the increase of migration could benefit the Philippine economy, which relies heavily on the billions of dollars of remittances from Filipinos overseas, the health care system could collapse. "Filipino nurses will definitely be ecstatic if the bill is passed," said George Cordero, the president of the Philippine Nurses Association. But, he said, "the Filipino people will suffer because the U.S. will get all our trained nurses." Modesto Llamas, the president of the Philippine Medical Association, said health care "is deteriorating in many areas, where there is lack of professionals and lack of facilities." He warned that this could result in "the medical crisis that we dread." Government records show that, in the last three years, more than 50,000 nurses have left the Philippines, mainly for Asia, the Middle East, Europe and the United States.
The demand for Filipino nurses is such that some doctors, most of them from government hospitals, enroll in nursing courses so that they, too, can work abroad as nurses. As a result, several hospitals have closed or are scaling down their operations. According to the Private Hospital Association of the Philippines, 687 private hospitals have stopped operating since 1998, mainly because of a lack of personnel. Four years from now, this number is projected to increase to 1,000, said Antonio Almonte Chang, the group's president. Chang said there were only 1,071 private hospitals in the country and 682 government hospitals, several of which have closed sections and departments because they lacked medical workers. These closures, Chang said, already had a severe impact on health care. "All that are left now, especially in the provinces, are government hospitals, which are overloaded and overcrowded but are staffed inadequately," he said. The lack of personnel and funds have forced many government hospitals to demand payments from patients, Chang said. In some cases, he said, some government hospitals practically detain patients who cannot pay. "This is an outrage," Chang said. "Government hospitals should give free services." The turnover of nurses in government hospitals is frequent. Beatriz Sawal, a nurse who runs a nursing training program at the government-run Jose Reyes Memorial Hospital, said that up to 90 percent of the nurses there did notlast longer than six months. Gov't to strengthen health care delivery system
The Macapagal-Arroyo administration will strengthen its public health delivery system in the coming three months, Health Secretary Manuel Dayrit said today. During the Cabinet meeting presided by Executive Secretary Alberto Romulo at Malacanang, Dayrit said the government will issue a family health card to replace
President Gloria Macapagal-Arroyo on Tuesday issued Executive Order 276 expanding the coverage of the Philippine Health Insurance Corp. (PhilHealth) to include an additional five million families, or 25 million people, as new beneficiaries.
The expanded PhilHealth program, called Universal Family Health Insurance, was launched amid observations that the costs of medical treatment and hospitalization were beyond the reach of ordinary Filipinos.
Dayrit said the government is embarking on a free hospitalization program in conjunction with the implementation of a nationwide anti-measles campaign called "Iwas Tigdas."
The Secretary revealed that the government has earmarked P3 billion for the implementation of its strengthened public health delivery programs this year. Of this amount, P1.5 billion would come from the Department of Budget and Management, while the remaining P1.5 billion would be shouldered by the Philippine Charity Sweepstakes Office.
In a press briefing in Malacanang, Deputy Spokesperson Ricardo Saludo said the Cabinet also reviewed the funding requirements of vital government programs for the coming months to ensure that whatever happens to the May 10 elections, the budget for these programs would be sustained.
Saludo cited the programs for food sufficiency, notably the hybrid rice program, the delivery of clean water, basic health services and quality education.
MARY CATHERINE R. DUBLA Nursing: The 5-Year Curriculum: The problem or the solution? The 5-Year Curriculum: The problem or the solution? Source:mb.com.ph Overloaded subjects. Insufficient time for practical training. Graduates who lack in skills and preparedness for the workplace. These are the main reasons why the Commission on Higher Education (CHEd) had proposed to add another year to the four-year curriculum in Nursing and Education courses, purportedly to improve the quality of education and produce globally competitive graduates. But even before CHEd could rally support for its controversial proposal, they already got flak from the public and the academe, all doubtful whether this proposal would really solve the problem. GLOBAL COMPETITIVENESS?
CHEd chairman Emmanuel Angeles said the Presidential Task Force for Education (PTFE) came up with this proposal in a bid to improve the current curriculum by adopting the Bologna Accord, the system of education being used in Europe. “The five-year curriculum will give a better study structure for students. We are the one of only two remaining countries in the world with a 10-year basic education. The other is Botswana in South Africa. The rest have 12, 13 years of basic education. But we have a solution for that without adding one year in elementary and one year in high school. By adopting the Bologna Accord which requires a total of 15 years of education to obtain a bachelor’s degree, we will be globally at par with our neighbors,” Angeles explains in an interview with the Students and Campuses Bulletin. At present, freshmen Nursing students are using the CHEd Memorandum Order (CMO) 5 curriculum of “four school years plus three summer sessions’’ which was just implemented in the summer of 2008. The three other levels are using the old four-year curriculum. PTFE has recommended the 10+2+3 scheme (10 years basic education, two years pre-university, and three years specialization) which was approved by the Cabinet in a meeting with President Arroyo last December. “It’s a better curriculum because it complies with the global standards and gives Nursing students more time for clinical training, and Education students more time for practice teaching,’’ Angeles says. 10+2+3 Angeles also clarifies that contrary to perception, this new curriculum will be more cost efficient for students and parents. “The subjects will be distributed over the five-year period. So what you save for the overloaded subjects and the three summers is more than enough. The ideal is 18 units per semester. Right now they have 28 to 30 units and they cram them into four years, that’s why they require in Nursing three summers. That’s the reason why we are trying to restructure our curricular offerings.” Under Phase I (AY 2009-2010) of the program, all existing five-year courses (Accountancy, Occupational Therapy, Physical Therapy and Pharmacy) with PRC licensure examinations, as well as Education and Nursing shall follow the 10+2+3 system. Engineering and Architecture programs, on the other hand, shall follow the 10+2+(3 or 4) in accordance with the Washington Accord, APEC Registry for Engineers and Architects and other international accrediting bodies. Phase II (AY 2010-11) covers all four-year board and non-board programs which shall follow the 10+2+3 system in accordance with the Bologna Accord.
Angeles says they will conduct series of consultations with students, parents, faculty and school administrators starting March. If they are able to reach an agreement during this period, he reveals that they intend to implement the new curriculum for Nursing and Education this coming school year. “We’re doing it gradually. Hopefully before 2020, which is the globalization, we would already be implementing Phase 2 and fulfill our ultimate goal of 10+2+3 in all courses,” Angeles adds. To effectively carry out this new education scheme, the PTFE said in its report that it will undertake several measures including the training of school administrators and teachers and conduct negotiations to urge schools to offer a Study-Now-Pay-Later and other financial programs to help bright but financially hard-up students cope with the demands of the new curriculum. TOO MANY CURRICULA Some people in the academe however do not believe that this is the solution to the prevailing problems in education. For instance, Eduardo Fabella, academic coordinator of Manila Doctors College (MDC) says the issue of too many curricula may cause greater confusion. “We were surprised that media got hold of the information before the schools. There was no consultation made. We are also at a loss as to what curriculum to implement. Right now there are two curricula being implemented — the CMO 5 that is being used by the first year students, and the older curriculum used by the second, third and fourth levels. Does this mean we will have a third curriculum running in the College of Nursing all at the same time?” he asks. MDC Level 3 coordinator Niño Listones says that as it is, they have yet to see the effectivity of the CMO 5 which was just implemented in School Year 2008. “I would recommend that the CMO 5 be continued since the competencies in the subjects are better. The problem lies on the schedule for the three summer sessions that they are required to take,” Listones adds. ESCALATING TUITION FEES Moreover, Listones thinks the new five-year curriculum may decrease enrolment because of additional fees required for an additional year. As it is, the cost of pursuing a Nursing course has escalated over the years, according to Related Learning Experience (RLE) clinical coordinator Cynthia Quintana. “The five-year course is really enough for the competencies of the professional nurse, but during this time hindi na siya applicable because of the cost. Noon mura lang, ngayon quadruple na ang cost. When I graduated my tuition was R500
including our review. Ngayon about R50,000 per sem including miscellaneous fees,” Quintana says. Emilie Lopez, dean of MDC’s College of Nursing, points out that even if the government claims that tuition fee will remain the same under the new curriculum, there are still miscellaneous and incidental expenses that the parents, schools and students need to shoulder. National Teachers College (NTC) dean of Instruction Dr. Leonisa Del Rosario says their students, mostly in the average to below average socio economic level, will suffer. “Although we are a private university, we offer one of the lowest tuition fees (R340 per unit or R12,000 per sem) to cater to our students who come from average to poor families. They may not pay extra for the tuition fee with the new curriculum but they still have to pay for their board and lodging, transportation, materials, meals and this will definitely be a burden for them,” Dean Del Rosario says. The teacher education curriculum was last revised in 2005, to include more actual teaching work over and above practice teaching. Del Rosario says several one-unit subjects had been integrated into the new curriculum, with units almost doubling from 36 to 60. This, she adds, truly improved the Teacher Ed curriculum as it became stronger in content. With the five-year program, Dean Del Rosario believes that fewer students would be enticed to take up the Education because this will mean longer time to start working and help their families. At present, there are around 2,000 students taking the three Teacher Education programs in NTC, a significant decrease from the past years. On the other hand, NTC president Dr. Priscilla Arguelles says she is more in favor of a lengthened curriculum in Basic Education which is considered the formative years of a child. The number of students in a classroom should also be reduced to make it more conducive to learning. “It’s the way you bring out the subject matter, in the way you teach. It’s not in the length but it’s in the quality of education that you deliver to the students. The additional number in years is not a guarantee that we will produce more qualified, competent graduates. What happens between the four and five years will make the difference.”
LOW PASSING RATE, MORE NURSING SCHOOLS MDC Level 1 coordinator Monique Espinosa shared that the very low national passing rate (approximately 50 percent or less) in the Nursing board exams and the
proliferation of smaller nursing schools (400 plus and still counting) may also be the reasons why CHEd is pushing for a reform in the Nursing curriculum. “CHEd also has to consider their role in strictly implementing policies when it comes to Nursing curriculum, specifically in the area of RLE where students are able to hone their skills. Kahit gaano kaganda curriculum mo, kung ang estudyante walang venue or sites for learning like hospitals or any clinical affiliates they won’t be able to practice what they have learned in the classroom. They should also be strict in monitoring nursing schools with poor board exam outcome. If they don’t deliver, they should be closed. Kailangan quality, hindi puro curriculum ang laging papalitan,” says MDC Level 2 coordinator Elisa Hubac. But Ricarte Gapuz Jr., licensed nurse and owner of the R.A. Gapuz Review Center, the country’s largest review center, does not think that closing down the smaller nursing schools is a solution. “We can find diamonds even in the smaller schools. Based on my own experience of running a review program for the past 15 years, six of those who emerge as topnotchers are coming from small schools in the provinces,” says Gapuz who also provides scholarships to deserving students in various courses through his foundation. What needs to be done, Gapuz recom-mends, is to change the core curriculum, remove the subjects which are not relevant; bring back the three safeguards for those who want to take up Nursing; and extensively train administrators in both big and small nursing schools. PRACTICE MAKES PERFECT To prepare nurses for the workforce, more practical subjects should be integrated in the curriculum, Gapuz says. For instance, “Transcultural Nursing’’ which tackles the health problems of foreign patients should take the place of World Civilization. Filipino subjects, he adds, should also be lessened to allow students more time and give them energy to study the major subjects. “Instead of Filipino grammar, why don’t we include the study of foreign language such as Nihonggo, Spanish or Italian to make graduates more adept when they apply for work in Japan, Spain and Italy where there is a high demand for nurses,” he stresses. English subjects, Gapuz adds, should also be related to Nursing. “Since there are requirements for IELTS, TOFEL, TWE in getting nursing licensure exams abroad, why can’t we do it in such a way that English 1 would be TWE, English 2, TOFEL, English 3 IELTS? So that ang requirement mo sa students the moment they finish the subject they have to pass the actual IELTS test so yun ang grade nila. Kung hindi sila nakapasa ibig sabihin failed din sila sa subject. This is needed if they really want to address the issue of globalization,” he points out.
BRINGING BACK THE SAFEGUARDS Meanwhile, he said the low national passing rate for nursing maybe also be attributed to the removal of three safeguards (NCEE, school entrance exam and nursing requirement of belonging to the upper 40 percent of class) which used to serve as excellent guidelines for the selection of aspiring nursing students. “During our time katakot takot na requirements para makapagtake ng Nursing. May NCEE. Pag pumasa ka pa pero mababa sa 95 percentile ayaw ka pa kunin ng good school. May entrance exam pa sa school na papasukan mo. And with the old Nursing law, hindi ka puede mag Nursing kung wala ka sa upper 40 percent of the graduating class. Because you are dealing with lives, there’s no second chance,” he says. Gapuz stresses that it’s not in the school, in the lengthening of the curriculum but in the quality of the curriculum, in the graduates we produce and in the teachers that teach them. Gapuz also called on the government to give the students the chance to speak up, voice their opinions and include them in decision-making, in drafting policies that they themselves will benefit. “The young should be given a chance to say their piece. They can best decide for their future,” he concludes.
EUNICE GRACE C. EVANGELISTA Integrated Health Care Delivery Systems' Challenges June 2000 by Bonnie Boone Willis Health Care Practiceand Robin Maley Maley HealthCare Consulting There are more than 850 integrated health care delivery systems in the United States today, and they face many unique challenges and loss exposures. This article highlights some of the important issues that must be considered in managing their risks and structuring their insurance programs. Close to 850 integrated health care delivery systems (IDSs) exist in the United States today. Currently, most systems are considered to be in an evolving state of integration as they attempt to provide a full continuum of services in a user-friendly, one-stop-shopping environment that eliminates costly intermediaries, promotes wellness, and improves health outcomes. Markers of integration include strong physician-hospital links, coordinated systems of care, geographic reach, quality management, contractual capabilities, utilization controls, financial strength, organized oversight and economies of scale. An honest evaluation of just how integrated each component of a system is will determine the strategies necessary to contain its risks. The typically large size of organizations, the geographical distances and structural differences among components, and the differences in services and staff involved create formidable challenges to those responsible for risk management. Skeptics have questioned the value of many integration efforts. The financial performance of hospitals affiliated with systems suggests only small gains in many instances. Proponents believe that attention to community health needs has improved but that new risks have been created as health care providers’ roles and degrees of authority have changed, immediacy of access to health care has been reduced, and providers’ freedom of choice has been restricted. As a result of these events, new avenues for potential errors and litigation to occur have emerged. Discussions surrounding the value and accountability of IDSs and the necessity for health plan regulation overall have emerged rapidly as priority issues on the President’s current agenda. The review of the intended provisions of the Federal Employee and Income Security Act of 1974 (ERISA), in regard to states’ rights to regulate the “business of insurance” and patients’ rights to sue their managed care providers, complicates risk evaluations at this time. Medical malpractice risks, antitrust issues, negligent credentialing risks, employment practices liabilities, shareholders derivative suits, and directors and officers liabilities are among those areas that must all be carefully reviewed with the disadvantage of not knowing the clear direction of the law.
From a risk management perspective, the challenge within the IDS is to institute an integrated risk management plan. A good starting point in the risk assessment of an IDS is to be familiar with determinants of their success. For an IDS to be and remain successful, several actions must be taken by IDS leaders. Specifically, they should be engaging in the following strategies.
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Identifying and aligning the key economic initiatives and incentives of the participating provider organizations Expanding upon health system choices available to consumers and accurately gauging their preferences of delivery mechanisms Partnering with an array of inpatient and ambulatory care support services such as home care, hospice, medical transportation companies, and wellness centers Managing patients’ care “from cradle to grave” along a continuum of care versus treating episodic illnesses Providing strong operational management of the IDS by highly skilled personnel Recruiting physician leaders Evaluating information exchange capabilities Identifying and resolving culture clashes Analyzing financial integrity Keeping on top of legislative developments impacting reimbursement policies, medical practice patterns, distribution of healthcare services, and tort reform Identifying risks and handling claims Developing and implementing quality of care and patient satisfaction measurements
As gaps in the potential for success are noted, measures to bolster weaknesses can be put in place. To do this, however, it is imperative that the risk manager is provided with the authority to effect change and that he or she is fully supported by the board of directors, top administration, and medical leadership of the IDS. Recognition of the risk manager’s authority should be stated clearly in a formal, written statement that supports the quality initiatives of the organization and that is circulated throughout the IDS. While all of the above activities are critical for the success of the IDS and the containment of risks, those discussed in this article include the evaluation of management strengths and weaknesses, physician support, financial integrity, and information exchange capabilities. Following a discussion of these topics, information will be provided regarding means to control risks via various insurance mechanisms. Evaluating Management Strengths and Weaknesses To form and operate integrated health care delivery systems successfully requires a great deal of commitment, leadership, and business savvy and can pose major challenges to even the most experienced health care executives. During IDS formation, many persons are asked to perform functions and tasks for which they
have never been previously responsible. Activities may be handled awkwardly at first and, as a result, risks usually not present may emerge. To decrease the risk, it is important that empowered leaders begin to focus on the system as a whole rather than a conglomeration of independent organizations, e.g., physician practices, home care agencies, hospital clinics, etc. Flexibility and the ability to respond quickly to change is important and will continue to be so in the future as capitation and other new managed fee structures drive executives to redesign health care delivery systems to follow industry mandates and trends. Buy-in to compatible goals and objectives and the ability for the mission of the organization to be carried out across all components will impact risks related to the management of the network. A critical determinant of success will be the ability of leadership to secure the participation of others to work toward the benefit of the entire system. Risk management professionals can be helpful in evaluating the strengths and weaknesses of each network component based on the managers’ credentials, past performances, commitment, attitude, and leadership skills. Suboptimal performers and persons uninterested in being team members can be replaced with personnel with stronger skill sets, if it is determined that their performance is not likely to change. From a risk management point of view, it is important to remember that even high performers may feel threatened by uncertainty and change and will be apt to perform at a subpar level. This reemphasizes the critical need for open lines of communication and ample dissemination of information to place workers at ease to the greatest degree possible in order to avoid accidents. The extent of control the majority of physicians have had over their working environments and their degrees of autonomy has been severely impacted since the introduction of managed care. In prior years, doctors routinely developed very individualistic, independent styles of practicing medicine. These practice methods contrast significantly with those that are necessary to practice within the health care delivery system. Conforming to new rules and working in foreign environments are difficult adjustments for physicians to make. These changes require them to be flexible and adopt a new outlook on the delivery of health care. Evaluating the mind frames of the physicians involved in the formation of an integrated health care delivery system is paramount to the establishment of a strong risk management program. Angry, confused physicians burdened by tasks they have had limited training to perform or desire to manage increases risks. Advising key executives of the potential for risk under this scenario falls within the realm of the risk manager’s responsibility. Following the identification of this risk should be a recommendation for physician education addressing the advantages to them of joining forces with other network components. Advantages physicians may benefit from include cost-effective administration, improved access to other providers and support systems, access to a broader range of support services, financial strength and security, increased customer satisfaction, access to educational resources, ownership potential, increased market share, increased access to data and information systems, group purchasing discounts, strategic planning, and enhanced image in the community.
Analyzing Financial Integrity The historic financial experiences of each component part of the integrated health care delivery system should be taken into consideration during the due diligence, financial forecasting, and budgeting processes. Premiums, products, managed care enrollments, mix of services, and provider and customer shifts then need to be analyzed and adjusted within financial reporting systems. Ongoing versus one-time expenditures need to be distinguished from one another and a means for benchmarking financial performance against quality indicators established. The risk manager should take an interactive role in identifying and analyzing risk factors that could follow the implementation of strategic imperatives. Unchecked, these areas of potential liability could negatively impact the bottom line. Evaluating Information Exchange Capabilities Inferior, incompatible, or duplicative information systems can pose serious risks within organizations providing health care services. The complexities of and variations among integrated health care delivery components exacerbate the potential for system problems, which can lead to the incomplete transmission of critical patient information. Analyzing information systems and their ability to reach and serve IDS components is an overwhelming and expensive task but one that is critical for the system to operate optimally from financial, quality, and utilization standpoints. Lack of data is a significant obstacle to the development of a sound risk management program. Outlined below are several of the functions that information systems within IDSs should be designed to perform in order to yield information that will subsequently help to preserve financial assets and promote patient and practitioner satisfaction.
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Facilitate member enrollment and determination of plan eligibility. Demonstrate the proper administration of defined benefits. Document the medical necessity of care including how, when, where, and how long it is given. Measure the impact of cost sharing arrangements. Maintain provider credentialing information. Yield information regarding providers’ adherence to payment policies and their responses to payment incentives. Track the effects of treatment provided by measuring clinical outcomes. Support member and provider relations by providing access to data that is necessary to answer member questions and that promotes the easy transfer of information among providers. Produce management reports. Provide decision support tools. Collect and categorize adverse incidents and claims.
Structuring an Insurance Program We have reviewed some of the risk management issues facing IDSs in the new millennium. What we will examine in this section are some of the professional
liability/errors and omissions (E&O) and risk financing issues that are important to IDSs. Traditional lines of coverage that are a part of the IDS’ portfolio are the following.
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Workers compensation Property General liability Automobile liability Aircraft
Some of the less traditional coverages include the following.
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Managed care liability Directors & officers liability Employment practices liability Punitive damages wraparound Managed care stop loss
Emerging exposures raise new coverage issues. Some examples include the following.
MSOs, PHOs, PPOs, IPAs, and other entities that have been formed to provide contracting leverage with managed care organizations (MCOs) require E&O coverage that is somewhat different from that required by a general acute facility. Their practices include peer review, utilization review, marketing, actuarial consulting and claims handling, and some other exposures. Are these all covered by the E&O wording? Antitrust exposures, denial of benefits, bad faith claims, and punitive damages all need to be addressed. Recent legislation in Texas and several other states consider utilization review as a form of practicing medicine. In an age of technology, is the Web site that gives medical advice a media liability/telecommunications risk or an E&O risk with contingent and vicarious liability exposures? Are physicians covered for their administrative duties within a managed care entity as well as their work at the hospital/facility?
The Integrated Product as an Option Health care providers integrate for many reasons. Some have been mentioned above. From the insurance and liability perspective, risk financing for these entities has also been integrated. The motivating forces behind this integration include the following.
Overcoming the difficulties in segregating the liabilities within the system. There are gray areas and the exposures and liabilities are blurred. Reduced administration. It is easier to negotiate with one insurer, to have one common expiration date, and to pay one premium.
The ability to leverage the marketplace. There may be one line of coverage that may not be as desirable to the market. Supporting business may make this line more palatable. Premium credits based on the economies of scale. More creativity on the risk retained, e.g., with a captive or trust.
Risk Financing There are many ways an IDS can choose to secure its liabilities as it becomes more diverse. Most of the major health care insurers offer a comprehensive product to IDSs. Some examples include ERC’s Hercules, AIG’s Med Elite and PROCAP, Zurich Americas’ Corporate Risk Solutions, and Zurich UK’s All Lines Combined Aggregate. Some of those products have been more successful than others. Commercial primary first dollar insurance is available where IDSs do share in the risk. Other risk financing methods include captives, risk retention groups, and self-insured trusts. Captives and self-insured trusts appear to appeal most to IDSs. Questions that need to be addressed when considering these options include the following.
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Should we be writing third-party business? Is the basket aggregate the most appropriate option for an IDS in an integrated product? Should we consider a loss portfolio transfer for past liabilities or incorporate them in our ongoing program? Can we assume the excess exposure of our capitation contracts?
There are other nontraditional ways of risk financing. One example would be equity put warranty transactions. This method would be available for a publicly traded forprofit entity. The insurer and the insured enter into a transaction where the insured’s stock and warranty value are negotiating elements. As we move into the new millennium, IDSs are rethinking their approach to risk, as are most other organizations in the United States. Rather than focusing solely on hazardous forms of risk, enterprise liability seeks to address all forms of contingencies, events, and actions that might adversely impact the performance of the company. Some issues to consider regarding risk financing options are the following.
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Flexibility Regulatory requirements Tax implications The inclusion of all lines of coverage
A thorough evaluation or risk assessment of the IDS’ exposures and emerging liabilities should be a part of any risk management strategy. Here some of the points that should be on an exposure review checklist.
Before starting any physician program for your attending physicians, be aware of Stark or inurement laws.
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Perform due diligence on all mergers and acquisitions. Work and communicate with all risk managers or persons responsible for risk management. You will need to relay the risk strategy, policies on defense cost, etc., to all new entities. Make sure policy wordings dovetail. Definitions and terms are important, in particular the definition of ultimate net loss, definition of occurrence, or when a claim is considered first made. Make sure your claims management philosophy is adapted by each entity. Check all contractual agreements and hold harmless agreements on all entities. On the telemedicine risk, make sure there is a wrongful act coverage part as well as a medical professional section providing some form of bodily injury coverage. Make sure your managed care wording provides contingent and vicarious medical malpractice. Do you have consent to settle on the institutions’ policies (given on most physician policies)? Are the primary and excess coverages on concurrent forms? Be aware of dates of reporting and the dates of occurrences when there are different forms. Be aware of regulatory issues that may affect the coverages needed. If you have a health plan, you need continuation of benefits coverage in the event the health plan is declared insolvent. Make sure your insurer can accommodate your growth plans. Be aware of fraud and abuse issues and compliance issues.
Conclusion These are a few issues associated with an integrated delivery system from the risk management and risk financing perspective. New liabilities will continue to evolve. Health care providers are forging ahead into a challenging year 2000 with physicians in unions, fewer dollars to work with and technological innovations continuing to raise costs. Despite that background, many opportunities remain to turn risk into an advantage.
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