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THE PHILIPPINE HEALTH CARE DELIVERY SYSTEM HEALTH CARE SYSTEM - an organized plan of health services (Miller-Keane, 1987) HEALTH CARE DELIVERY - rendering health care services to the people (Williams-Tungpalan, 1981). HEALTH CARE DELIVERY SYSTEM (Williams-Tungpalan, 1981) - the network of health facilities and personnel which carries out the task of rendering health care to the people. PHILIPPINE HEALTH CARE SYSTEM - is a complex set of organizations interacting to provide an array of health services (Dizon, 1977). MAJOR PLAYERS The Philippine healthcare delivery system is composed of two sectors. The public sector, and the private sector. The public sector is largely financed through a tax-based budgeting system at both national and local levels. It is consist of the national and local government agencies providing health service. At the national level, the DOH is mandated as the lead agency in health. It has a regional field office in every region and maintains specialty hospitals, regional hospitals and medical centers. The private sector is for profit and non-profit providers which is largely market-oriented and where healthcare is payed through user fees at the point of service. Their involvement in maintaining the peoples health is enormous. This includes providing health services in clinics and hospitals, health insurance, manufacture of medicines, vaccines, medical supplies, equipment and other health and nutrition products, research and development, human resource development, and other health-related services.

COMPONENTS Health care delivery system incorporates four functional componentsfinancing, insurance, delivery, and payment thatthat are necessary for the delivery of health services. The four functional components make up the quad-function model. 1. FINANCING Health care often requires costly diagnostic tests and procedures and lengthy hospital stays. Financing is necessary to obtain health insurance or to pay for health care services. 2. INSURANCE

Insurance protects the insured against catastrophic risks when needing expensive health care services. The insurance function also determines the package of health services the insured individual is entitled to receive. It specifies how and where health care services will be received. The insurance company or MCO also functions as a claims processor and manages the disbursement of funds to the providers of care.

3. DELIVERY Refers to the provision of health care services and the receipt of insurance payments directly for those services. Common examples of providers who deliver care and services include physicians, dentists, optometrists, and therapists in private practices, hospitals, diagnostic and imaging clinics, and suppliers of medical equipment 4. PAYMENT The payment function deals with reimbursement to providers for services delivered. Reimbursement is the determination of how much to pay for a certain service. Funds for actual disbursement come from the premiums paid to the insurance company or MCO.

HISTORICAL ROOTS DOH through the Years Before 1898 During the pre-Spanish period, traditional ways of healing (i.e., herbs and rituals) were widely used. Public health services in the Philippines began in 1577 when a Franciscan friar, Fr. Juan Clemente, established a dispensary for Manila indigents. In 1659, the dispensary became the San Juan de Dios Hospital. The Spaniards instituted a hospital system with 13 hospitals and intensified public health work with the creation of the Central Board of Vaccination and a Board of Health and Charity. Before the Americans came to the Philippines, there were already Medicos Titulares, which corresponds to todays provincial health workers.

1898 On June 23, 1898, the Department of Public Works, Education and Hygiene (currently known as Department of Public Works and Highways, Department of Education, and Department of Health, respectively) was formally proclaimed by President Emilio Aguinaldo. Aguinaldos proclamation was not continued for they lost to the Americans. Through General Order No. 15, the Americans created a Board of Health for the City of Manila on September 29, 1898. Dr. T.H. Pardo de Tavera and Dr. Aristone Bautista Lim, together with three American surgeons, comprised the provisional

board. Being that General Order No. 15 is American in nature, it aimed to protect the health of the American troops. Nevertheless, this American order started the institutional development of the current Department of Health (DOH).

1899 On August 26, 1899, the Board of Health was abolished while Dr. Guy Edie was appointed as the first Commissioner of Health. Registration of births, deaths, and marriages began during this time.

1901 The Philippine Commission created the Board of Health for the Philippine Islands, which served as the local health board, through Act No. 157 dated July 1, 1901. It became the Insular Board of Health when the provincial health boards and municipal health boards were created on December 2, 1901 through Act No. 307 and Act No. 308, respectively.

1905 With Act No. 1407, the Insular Board of Health and its functions were abolished and replaced by the Bureau of Health, being under the Department of Interior. Dr. Victor Heiser was the first Director of the Bureau of Health.

1906 Repealing Act No. 307, Philippine Commission Act No. 1487 ordered that the provincial boards of health be replaced with district health officers.

1912 Act No. 2156 of 1912, also referred to as Fajardo Act, consolidated municipalities into sanitary divisions and instigated todays Health Fund.

1915 In 1915, the Bureau of Health was renamed into Philippine Health Service, and later reverted back to its previous name. Dr. Vicente de Jesuswas the first Filipino Director of Health.

1932 The Reorganization Act of 1932or Act No. 4007 created the Office of the Commissioner of Health and Public Welfare with Dr. Basilio J. Valdez as its first Commissioner.

1941 On January 7, 1941, the Executive Order No. 317 formalized the Department of Public Health and Welfare with Dr. Jose Fabella as its first Department Secretary. The Department included the following: Bureau of Quarantine; health department of chartered cities; provincial, city, and municipal hospitals; dispensaries and clinics; public markets and slaughter houses; health resorts; and all charitable agencies.

1947 In October 1947, Executive Order No. 94 regulated reorganization in the Department of Public Health and Welfare. The Bureau of Public Welfare and the Philippine General Hospital (PGH) were transferred under the Office of the President of the Philippines. From then on, the Department was called Department of Health (DOH). Under DOH were Office of the Secretary, Bureau of Health, Bureau of Quarantine, Bureau of Hospitals, and all City Health Departments.

1950 Just three years after, the second reorganization of the Department was implemented through Executive Order No. 392. The Institute of Nutrition, Division of Biological Research, and Division of Food Technology were transferred from the Institute of Science to DOH. The Medical and Dental Services unit under the Bureau of Public Schools was transferred as the Division of School Medical and Dental Services under the Bureau of Health. There were also changes within the Department, namely: integration of the National Chest Center and TB section into a Tuberculosis Division; conversion of the Division of Laboratories into an Office of Public Health Research Laboratory; and conversion of the leprosy control section into a Division of Sanitaria under the Bureau of Hospitals.

1958 After a threat from the US Operations Mission to the Philippines, the most sweeping reorganization was implemented. Two Undersecretaries of Health the Undersecretary of Health and the Medical Services, and the Undersecretary of Special Services were created. Eight regional health offices were formed as the health services were decentralized to the regional, provincial, and municipal levels.

1969 Republic Act No. 6111, or the so-called Philippine Medical Care Act of 1969,authorized hospitalization, surgical, and medical expense benefits for the people.

1970 In 1970, health services were classified into primary, secondary, and tertiary levels through the Restructured Health Care Delivery System.

1972 At the onset of Martial Law, DOH was renamed to Ministry of Health and the regional offices increased from eight to twelve. The first Minister of Health was Dr. Clemente Gatmaitan.

1982 Under the Executive Order No. 851, the Integrated Provincial Health Office was created to reorganize the Ministry of Health. The Health Education and Manpower Development Service was also created.

1986-1987 The Ministry of Health regained its former name (Department of Health) with the Executive Order No. 119. Also, five (5) offices, headed by an undersecretary and an assistant secretary, were placed under the Secretary of Health. These offices are the Chief of Staff, Public Health Services, Hospital and Facilities Services, Standard and Regulations, and Management Service. Three regions (i.e., NCR, CAR, and ARMM) were added to the 12 regional health offices. A National Health Facilities, consisting of seven (7) special research centers and hospitals and eight (8) medical centers, was also created.

1991-1993 The Republic Act 7160 or Local Government Code of 1991 was fully implemented. The Office for Special Concerns was formed from the branching out of the Office of Public Health Services. The Office of Hospital Facilities, Standards and Regulation was created from the merging of two big offices.

Health projects were intensified. Among these projects are National Micronutrient Campaign, Disaster Management, Urban Health and Nutrition Project, Traditional Medicine, Doctors to the Barrios Program, and "Lets DOH It"!

1999 Through the Executive Order 102, the functions and operations of DOH were to be aligned with the provisions of Administrative Code 1987 and RA 7160. This year, the Health Sector Reform Agenda of the Philippines 1999-2004 was launched. Reforms include: fiscal autonomy to government hospitals; funding for priority health programs; promoting the development of local health systems and assurance of effective performance; strengthening of capacities of health regulatory agencies and expanding coverage of the National Health Insurance Program (NHIP). The National Objectives for Health 1999-2004, which indicates the Philippines objectives to eradicate and control infectious diseases, major chronic illnesses and injuries, was also launched. This encourages healthy lifestyle and health-seeking behaviors towards the prevention of diseases.

4 ESSENTIAL FUNCTIONS of Health System 1. 2. 3. 4. Service Provision Resource Generation Financing Stewardship

HEALTH CARE SYSTEM MODELS 1. Private Enterprise Health Care Model Purely private enterprise health care systems are comparatively rare. Where they exist, it is usually for a comparatively well-off subpopulation in a poorer country with a poorer standard of health care-for instance, private clinics for a small, wealthy expatriate population in 2. Social Security Health Model Where workers and their families are insured by the state Refers to Social Welfare Service concerned with social protection, or protection against socially recognized conditions, including poverty, old age, disability, and unemployment. Social Security may refer to: Social Insurance, where people receive benefits or services in recognition of contributions to an insurance scheme. These services typically include provision for retirement pensions, disability insurance, survivor benefits, and unemployment insurance. Income Maintenance, mainly the distribution of cash in the event of interruption of employment, including retirement, disability and unemployment. Services provided by administrations responsible for social security. In different countries this may include medical care, aspects of social work and even industrial relations.

3. Publicly funded Health Model Where the residents of the country are insured by the state. Health care that is financed entirely or in majority part by citizens tax payments instead of through private payments made to insurance companies or directly to health care providers. 4. Social Health Insurance Where the whole population or most of the population is a member of a sickness insurance company (SHI) is a method for financing health care costs through a social insurance program based on the collection of funds and contributed by individuals, employers, and sometimes government subsidies. Characterized by the presence of sickness funds which usually receive a proportional contributions of their members wages. With this insurance contributions these funds pay medical costs of their members Affiliation to such funds is usually based on professional, geographic, religious/political and/ or non-partisan criteria.


Health Status Birth Death Morbidity Mortality Nutrition Population

Demographic Characteristics Socio-Cultural Factors The majority of Filipinos are Roman Catholics High functional literacy rate of 83.8% Folk beliefs, misconceptions and practices detrimental to health are still rampant. The family is the basic unit of Filipino society

Political Factors The Philippines is a democratic country Local Government Units (LGUs) comprise the political subdivisions of the Philippines Health Sector Refers to the groups of services or institutions in the community or country which are concerned with the health protection of the population May be public (government), private, and non-government organizations Functions: Direct provision of health services: Promotion, Prevention, Diagnosis and Treatment, and Medical Rehabilitation Development and provision of health manpower, drugs and medical supplies; financing support Research Development Coordinating, controlling and directing organizations and activities associated with other functions Health-related Sector Social organization of the health care

THE DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH Is the principal agency in the health in the Philippines A Policy and Regulatory Body for Health Provides the direction and national plans for health programs and services Vision: The leader of health for all in the Philippines. Mission: Guarantee equitable, sustainable and quality health for all Filipinos, especially the poor, and to lead the quest for excellence in health. E.O. No. 119, Sec 3: The primary function of the Department of Health is the promotion, protection, preservation or restoration of the health of the people through the provision and delivery of health services and through the regulation and encouragement of providers of health goods and services. DOH Offices: composed of about 17 central offices, 16 Centers for Health Development located in various regions, 70 hospitals and 4 attached agencies

CENTER FOR HEALTH DEVELOPMENT Responsible for field operations of the Department in its administrative region and for providing catchment area with efficient and effective medical services. It is tasked to implement laws, regulation, policies and programs. It is also tasked to coordinate with regional offices of the other Departments, offices and agencies as well as with the local governments. Acts as main catalyst and organizer in the Inter Local Health Zone (ILHZ) DOH HOSPITALS

Provides hospital-based care; specialized or general services, some conduct research on clinical priorities and training hospitals for medical specialization.

ATTACHED AGENCIES The Philippine Health Insurance Corporation is implementing the national health insurance law, administers the Medicare program for both public and private sectors. The Dangerous Drugs Board on the other hand, coordinates and manages the dangerous drugs control program. Philippine Institute of Traditional and Alternative Health Care Philippine National AIDS Council DISTRICT HEALTH SYSTEM Defined by World Health Organizations as, A contained segment of the national health system which comprises a well-defined administrative and geographic area either rural or urban and all institutions and sectors whose activities contribute to improve health. Levels of Health Care and Referral System 1. Primary Level of Care Primary care is devolved to the cities and the municipalities. It is health care provided by center physicians, public health nurses, rural health midwives, barangay health workers, traditional healers and others at the barangay health stations and rural health units. The Primary health care is usually the first contact between the community members and the other levels of health facility. 2. Secondary Level of Care Secondary care is given by physicians with basic health training. This is usually given in health facilities either privately owned or government operated such as infirmaries, municipal and district hospitals and out-patient departments of provincial hospitals. This serves as a referral center for the primary health facilities. Secondary facilities are capable of performing minor surgeries and perform some simple laboratory examinations. 3. Tertiary Level of Care Tertiary care is rendered by specialists in health facilities including medical centers as well as regional and provincial hospitals, and specialized hospitals such as the Philippine Heart Center. The tertiary health facility is the referral center for the secondary care facilities. Complicated cases and intensive care requires tertiary care and all these can be provided by the tertiary care facility.

Pyramidal Health Structure

National Health Services Regional Health Services District Health Services Rural (Local Hospital) Services Rural Health Units Barangay Health Stations

Tertiary Health Care

Secondary Health Care

Primary Health Care

TWO-WAY REFERRAL SYSTEM (Niace, et. al. 8 edition 1995) A two-way referral system need to be established between each level of health facility e.g. barangay health workers refer cases to the rural health team, who in turn refer more serious cases to either the district hospital, then to the provincial, regional or the whole health care system. Public P Barangay Health nd O Health Worker Nurse 2 3rd P HF HF U EA EA L Barangay RHU AC AC A Health Midwife Physician LI LI T Stations TL TL I HI HI O T T N RHS Sanitary Y Y Midwife Inspector


Three Levels of Primary Health Care Workers 1. VILLAGE OR GRASSROOT HEALTH WORKERS First contacts of the community and initial links of health care. Provide simple curative and preventive health care measures promoting healthy environment. Participate in activities geared towards the improvement of the socio-economic level of the community like food production program. Community health worker, volunteers or traditional birth attendants.

2. 3. -

INTERMEDIATE LEVEL HEALTH WORKERS represent the first source of professional health care attends to health problems beyond the competence of village workers Provide support to front-line health workers in terms of supervision, training, supplies, and services. Medical practitioners, nurses and midwives. FIRST LINE HOSPITAL PERSONNEL provide backup health services for cases that require hospitalization Establish close contact with intermediate level health workers or village health workers. Physicians with specialty, nurses, dentist, pharmacists, other health professionals.

INTER LOCAL HEALTH SYTEM Created by clustering municipalities into Inter-Local Health Zones through inter-LGU cooperation INTER LOCAL HEALTH ZONE (ILHZ) Unit of health system created for local health service management and delivery in the Philippines. Applied in many developing countries where responsibility for health services has been decentralized from national to local health authorities. Has defined population within a defined geographical area and comprises a central or core referral hospital and a number of primary level facilities such as RHUs and BHS Includes all stakeholders involved in the delivery of health services including community-based NGOs and private sectors (foreign and/or local) Composition of ILHZ People Community members, CHWs, NGOs, peoples organizations, local chief executives, other government officials and private sector Boundaries Clear boundaries between ILHZ to determine the accountability and responsibility of health service providers, geographical locations and access to referral facilities Health Facilities Health Workers Importance of Establishing ILHZ To re-integrate hospital and public health services for a holistic delivery of health services To identify areas of complementation of the stakeholders. CORE REFERRAL HOSPITAL Main hospital for ILHZ and its catchment population. Main point of referral for hospital services from the community, private medical practitioner and public health services at BHS and RHUs. NATIONAL HEALTH PLAN The blue print which is followed by the Department of Health It defines the countrys health problems, policy thrusts, strategies and targets. Policy Thrusts and Strategies 1. Information, education, and communication programs will be implemented to raise the awareness of the public, including policy makers, program planners and decision makers. 2. An update of the legislative agenda for health, nutrition and family planning (HNFP), and stronger advocacy for pending HNFP related legislations will be pursued.

3. . Integration of efforts in the health, nutrition and family planning sector to maximize resources in the delivery of services through the establishment of coordinative mechanisms at both the national and local levels. 4. Partnership between the public and the private sectors will be strengthen and institutionalized to effectively utilize and monitor private resources for the sector. 5. Enhancement of the status and role of women as program beneficiaries and program implementers will be pursued to enable them to substantially participate in the development process.

MAJOR HEALTH REFORMS IN THE PHILIPPINES, 1979-2009 1979: Primary Health Care Prioritizes the eight essential elements of health care including education on prevalent health problems and their prevention and control; promotion of adequate food supply and proper nutrition; basic sanitation and adequate supply of water; maternal and child care; immunization; prevention and control of endemic diseases; appropriate treatment and control of common diseases; and, provision of essential drugs. As an approach, PHC encouraged partnership of government with various segments of civil society; incorporated health into socioeconomic development; and, advocated the importance of health promotion and preventive aspects of health care. 1982: Executive Order 851 Directs the regional health offices to be responsible for the field operations of the ministry in the region by utilizing the primary health care approach in delivering health and medical services that are responsive to the prioritized needs of the community as defined by its members, and by ensuring community participation in the determination of health care requirements. 1987: Executive Order 119 Creates the District Health Office (DHO) as one of the component structures of the Ministry of Health. The DHO provides supervision and control over district hospitals, municipal hospitals, rural health units, and barangay health centers. Moreover, this Order creates the Community Health Service under the Office of the Minister to provide services related to the formulation and implementation of health plans and programs in coordination with local governments and nongovernment organizations. 1988: RA 6675 The Generics Act of 1988 Aims to promote and assure adequate supply, distribution and use of generics drugs and medicines. This law also emphasizes increased awareness among health professionals of the scientific basis for the therapeutic effectiveness of medicines and promotes drug safety 1991: RA 7160 Local Government Code of 1991 Paves the way for the devolution of health services to local government units. The process of transferring responsibility to the local government units breaks the chain of integration resulting in fragmentation of administrative control of health services between the rural health units and the hospitals 1995: RA 7875 National Health Insurance Act

Seeks to provide all Filipinos with the mechanism to gain financial access to health services, giving particular priority to those who cannot afford such services.

1999: Health Sector Reform Agenda Aims to improve the way health care is delivered, regulated and financed through systemic reforms in public health, the hospital system, local health, health regulation and health financing. Executive Order 102 Redirects the functions and operations of the DOH to be more responsive to its new role as a result of the devolution of basic services to local government. 2004: RA 9271 The Quarantine Act of 2004 Aims to strengthen the regulatory capacity of the DOH in quarantine and international health surveillance by increasing the regulatory powers of its Bureau of Quarantine (BOQ). This includes expanding the Bureaus role in surveillance of international health concerns, allowing it to expand and contract its quarantine stations and authorizing it to utilize its income. 2005: FOURmula ONE (F1) for Health Implements the reform strategies in service delivery, health regulation, health financing and governance as a single package that is supported by effective management infrastructure and financing arrangements, with particular focus on critical health interventions. 2008: RA 9502 Universally Accessible Cheaper and Quality Medicines Act Allows the government to adopt appropriate measures to promote and ensure access to affordable quality drugs and medicines for all. 2009: RA 9711 Food and Drug Administration Act Aims to 1) enhance and strengthen the administrative and technical capacity of the FDA in regulating the establishments and products under its jurisdiction; 2) ensure the monitoring and regulatory coverage of the FDA; and 3) provide coherence in the regulatory system of the FDA. f