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the Role of LGU Officials in Health Sector Development
Building Partnerships for Health Clark Special Economic Zone August 2010
Health in the context of overall local development
± Role of government in the health sector ± Health sector goals ± Means of achieving health sector goals
Strengthening local governance in health Health sector reform (FOURmula ONE) Province-wide investment planning
Finding the Money to Finance Health Programs USAID technical assistance Key ideas for local policy action
HealthGov August 2010 thank you 2
Health and Local Development
HealthGov August 2010
Two ways of looking at health
Health as a component of development that is valued in its own right. Health as an asset that generates wealth.
HealthGov August 2010
Health as a component of development
Development is the sustained capacity to achieve a better life. Better life includes the length of life and the quality of life that people succeed in living Quality involves capabilities ³to do´ and ³to be´
± ± ± ± To be free from premature death To be free from preventable illness To be free from avoidable disability To be free to achieve one¶s fertility goals (desired family size ± number and spacing)
Hence development is also about expanding freedom and the range of choices.
Adapted from Amartya Sen (1988) HealthGov August 2010 5
HealthGov August 2010 6 .Development is freedom from premature death Life expectancy at birth is lower than neighboring countries Male Singapore South Korea Malaysia Thailand Vietnam Philippines Indonesia 77 74 72 68 69 66 66 Female 81 81 76 75 73 71 70 Source: Estimates from UN ESCAP (2006) Life expectancy at birth is the average number of years that a person can expect to live from birth given the mortality conditions of the time.
000 births Sources: 1993 and 1998 NDHS. and 2006 FPS But it still remains high compared to other countries Estimates for other countries in 2006: ± South Korea: 20 ± Malaysia: 41 ± China: 56 ± Thailand: 24 ± Vietnam:130 ± Indonesia: 230 Source: UN ESCAP 2006 Status HealthGov August 2010 7 .Development is freedom from premature death Maternal mortality has declined in the past 20 years Maternal mortality ratio (MMR) estimated for Philippines ± NDHS (1987-1993): 209 ± NDHS (1991-1997): 172 ± FPS (1999-2006): 162 MMR = maternal deaths per 100.
Development is freedom from premature death Infant and child mortality rates are still high compared to other countries in 2006 Infant Singapore South Korea Malaysia Thailand Vietnam Philippines Indonesia 3 4 9 17 18 25 36 Child 4 5 12 21 24 29 45 Source: Estimates from UN ESCAP (2006) Infant mortality is the number of infant deaths per 1.000 births. HealthGov August 2010 8 .000 children under five years. Child mortality is the number of deaths of children under five years per 1.
2003 NDHS. 2003 Wealth status Indicator Total fertility rate Desired fertility rate Difference (total less desired) Low Second Middle Fourth High 5.5 3.Development is freedom to achieve one¶s fertility goals (The poor are less able to achieve their fertility goals than the rich) Total fertility and desired fertility rate by wealth status.8 2.6 2.9 2.6 0.9 3.1 4.7 0.2 0.5 2.0 1.6 3.5 2.1 1.3 Total 3.0 9 Source: NSO and ORC Macro.8 2.5 1. 2003 HealthGov August 2010 .
education. higher education. Non-health sector outcomes Key idea 1: Better non-health sector outcomes. HealthGov August 2010 . agriculture. contributing to better health 10 outcomes.. e. environment. agriculture and industry contributing to better non-health outcomes. infrastructure.g. Health outcomes Key idea 2: Better health increases the productivity of investments in non-health sectors.g.. higher incomes. e.Health as an asset: its role in local development Health sector Economic resources Non-health sectors: Education. etc. facilitate healthy behavior and access of health care services. better infrastructure.
Health as an asset: recent scientific findings High economic cost of TB: productivity losses in the Philippines due to premature deaths from TB estimated at PhP 26B yearly (Peabody. cited in NOH 2005) Nutrition and health in early childhood affect future success of children in education. 2003. and health in later life (Studies in Bukidnon and Cebu) Unforeseen large spending for health care reduces consumption of other goods and services that promote well-being. employment and productivity. HealthGov August 2010 11 .
The Health Sector and the Role of Government HealthGov August 2010 12 .
. treatment of infectious disease HealthGov August 2010 13 .. disease surveillance. sanitary regulations immunization.Local Health Sector What is the role of government? Insurance market failure PhilHealth. child Providers/ dispensers: Public and private Public goods. e. e.g. other financing agents premium Local and national government reimbursements. capitation funds premium taxes subsidy Imperfect information Consumers/ households: economic & social groups services Unequal distribution of income user charges Services with large externalities.g.
Role of government in health care markets: efficiency and equity To correct for market failure arising from (and the nature of possible response): ± ± ± ± Imperfect information (public information) Public goods (public financing and/or production) Externalities (public subsidies or regulation) Insurance market failure (development of social health insurance) Improve equity .provision of cost-effective services to the poor as an effective and socially acceptable approach to poverty alleviation HealthGov August 2010 14 .
capitation funds premium taxes subsidy Consumers/ households: economic & social groups services user charges Providers/ dispensers: Public and private Outline HealthGov August 2010 15 .Local Health Sector PhilHealth. other financing agents premium Local and national government reimbursements.
Part II Health Sector Development and the Role of Local Governance HealthGov August 2010 16 .
other financing agents premium Local and national government Strengthen local governance for health Implement health sector reform reimbursements.Local Health Sector How do we achieve our goals? PhilHealth. capitation funds premium taxes Consumers/ households: economic & social groups subsidy services user charges Providers/ dispensers: Public and private Adopt province-wide investment planning for health 17 Outline HealthGov August 2010 .
Local officials as the stewards of the health sector Stewardship = the careful and responsible management of something entrusted to one¶s care HealthGov August 2010 18 .
Strengthening Local Governance for Health through evidence-based participatory local decision making process Management information system (field services. Sanggunian) Policies Budgets Systems Services Health sector performance and outcomes Stakeholder participation LGU officials Public/private providers NGOs/CSOs HealthGov August 2010 19 . hospital. quality improvements. program reviews. M&E) PIPH MIPH ILHZ CSR plan Nutrition plan HIV/AIDS plan PHIC plan Facility rationalization plan Systems (logistics. local surveys. financing. LCE. income & expenditures. etc. procurement.) LGU decision making: (LHB.
procurement. partners PIPH MIPH ILHZ CSR plan Nutrition plan HIV/AIDS plan PHIC plan Facility rationalization plan Systems (logistics. M&E) DOH. income & expenditures. financing. 20 . Sanggunian) Policies Budgets Systems Services Health sector performance and outcomes Stakeholder participation LGU officials Public/private providers NGOs/CSOs HealthGov August 2010 Achieving . LCE.) LGU officials LGU decision making: (LHB. etc. PHIC. local surveys. CHD.. quality improvements. hospital. program reviews.Strengthening Local Governance for Health through evidence-based participatory local decision making process Management information system (field services.
Health Sector Reform An implementation framework that consists of strategies. and governance HealthGov August 2010 21 . organizational and policy changes. service delivery. regulated. and financed It has four instruments: financing. and public investments needed to improve the way health care is delivered. regulation.
better and sustained financing for health) 2. Governance (improved health system performance) HealthGov August 2010 Goals: Better health outcomes Equitable health care financing More responsive health system Achieving« 22 . Service delivery (ensured access and availability of essential basic health packages) 4. Financing (more.Health Sector Reform Reform instruments: 1. Regulation (assured quality and affordability of health goods/services) 3.
A plan prepared and adopted by LGUs within a province and agreed to be supported by DOH and its development partners in health.Investment Plan for Health (PIPH/MIPH/CIPH) The IPH provides the framework for the development of public investment plans in health covering utilization. DOH and development partners. capabilities. mobilization and rationalization of the LGU¶s resources. and stronger institutions to attain health system goals. HealthGov August 2010 23 . that defines local health systems improvements to be attained in the province through the proposed application of public investments jointly funded by LGUs.
PIPH: Key Features and Steps HealthGov August 2010 24 .
2007 HealthGov August 2010 Achieving ..Key features of Province-Wide Investment Plan for Health (PIPH) Health sector perspective Planning using a health sector/F1 frame Province-wide* with component LGUs and ILHZ Medium-term strategic time frame Well-defined critical interventions and targets Sound financial plan Implementation through performance-driven agreements *Region-wide in the case of ARMM Source: DOH Guidelines in PIPH Development. 25 .
2009.Where are you now? Provinces have completed their PIPH Municipalities/Cities have their MIPH Preparation of the Annual Investment Plans for Health (AOP) for 2011 Completion of the Health Facility Rationalization Plans as a subplan of the PIPH Utilization of the MNCHN grants (2008. 2010) HealthGov August 2010 26 .
Finding the Money to Finance Health Programs .
IRA will be too crowded 3. The LGC provides opportunities to generate sustainable resources 6.Reality Check at the LGU Level 1. PIPH/MIPH increase health budget 2. MHOs/PHO will need assistance 4. Lots of advocacies will be required Local Budget Regular Health Budget PIPH Budget 5. Hard decisions have to be made by the LGU HealthGov August 2010 28 .
Health Stakeholders Office LGU Health Office Governor / Mayor Sangguniang Planning and Development Office Treasury Budget Office Accountant¶s Office General Service Office Role Proponent and Main Driver Issuance of Mandate and Authority to Implement Provision of Supportive Ordinances Integration to the Plan and Overall Development Strategy Raising of Revenues/Cashiering Preparation of Funding Allocation Identify fund support/ Rendering of Financial Reports Administration of Procurement and Distribution Systems HealthGov August 2010 29 .
Develop financing sources for Health ± Improve the collection of local taxes.Approaches to Sustainable Financing Track 1-. fees and charges ± Create new sources for health ± Access grants and other forms of assistance ± Develop facilities into an economic enterprise ± Take advantage of private sector support HealthGov August 2010 30 .
etc«) Internally Sourced Revenues ± ± ± ± ± Local Taxes Regulatory and Fees Charges Economic Enterprise Other Taxes. Fees and Charges (sec 186) Philhealth Capitation & Reimbursements HealthGov August 2010 31 .Sustainable Local Funds Central Transfers ± Internal Revenue Allotment ± Others (share from wealth.
S. 60% E.S. Intra LGU Allocation 50% Population (NSO) 25% Land Area (LMB) 25% Equal Sharing (1) Total BRGY. LGU Allocation Provinces 23% Cities 23% Municipalities 34% Barangays 20% D.INTERNAL REVENUE ALLOTMENT A. 60% Pop.S 40% E.Share (2) Net Brgy.Share 1992 1993 1994 forward 40% Pop. 50% E. HealthGov August 2010 32 .SHARE ± BRGYs. 50% Pop. Base Gross Internal Revenue Collections based on third preceding Calendar Year B. Level 1992 = 30% 1993 = 35% 1994 & succeeding years = 40% C. with 100 inhabitants = NET Brgy.
2) Section 186 of the LGU allow LGUs to impose other taxes. fees and charges under certain limitations HealthGov August 2010 33 .Local Taxes Provinces Real Property Professionals Franchise Amusement Places Printing & Publication Transfer of Real Property Idle Lands Sand. Gravel & Quarry Delivery Vans & Trucks Business Taxes Municipalities Community Tax Cities All taxes which can be imposed by the Provinces and Municipalities combined and the rates can be 50% higher Note: 1) Tax Rates can be increased once every five (5) years at the rates not exceeding 10%.
Fees and Charges Building Permit Electrical permit Mechanical Permit Plumbing Permit Demolition Permit Sanitary Permit Fire Certification Annual Inspection Caretela and Calesa Storage of Flammable Materials Agricultural Machinery Other Heavy Equipment Carts and Sledge Cockpits Special Cockfighting Gaffers and Cockpit Pers. of Large Cattle Parking Tax Clearance Civil Registry Fees Exhumation of Cadaver Firearms Permit Police Clearance Holding of Benefits Fee on Occupation or Calling Fishing Permit Hawkers Mineral Lands Video Tape Rental Secretary¶s Certification Tuition Fees for LGU Colleges Garbage Fees Overnight P. Fees Toll Fees & Charges Physical Exam &Medical Certification Market Hospital fees Health Services Terminal Fees Traffic Violations Towing Charges Water and Power Slaughterhouse & Corrals Bus Terminals Rental of Facilities 34 HealthGov August 2010 . Filmmaking Bicycle Permit Boats Permit Marriage Permit & Solemnization Mayors Permit Mining Claims Parades Pedicab Operations Tricycle Franchising Weights and Measures Court Fees Sheriff¶s Fees Fiscal¶s Clearance Impounding of Stray Animals Burial Permit Reg.
Revenue Reforms Coverage Assessment Collection HealthGov August 2010 35 .
Expanding Coverage Updating Local Revenue Codes General Revision of Real Property Assmt Explore Section 186 Revalidate Exemptions Investment Incentives Code Fiscal Cadastre/GIS Mapping Special Levies and Variants HealthGov August 2010 36 .
Improving Assessment Methods Examination of Books of Accounts Technical Trainings Use Presumptive Income Levels Market Based Valuation in RPT HealthGov August 2010 37 .
Remedies One Stop Shops Billing Through Barangays Computerization HealthGov August 2010 38 .Improving Collection Tax Information Issuance of Demand Letters Field Collections Enforcement of Civil & Adm.
Support of MHO/PHO to Revenue Collections MHO/PHO can be actively involved in supporting revenue collections. Public Hospitals HealthGov August 2010 39 . User fees for cost recovery Strict enforcement of health fees Requiring CTC to those seeking health care in RHUs.
Earmarking Funds for Health Budgetary Share from Proceeds of Collection of Taxes and Fee Retention of Income (user fees) from Operations of Health Facilities Convert Health Facilities to Economic Enterprises Note: LGUs may need to pass a specific ordinance allocating share of the proceeds to health and putting the proceeds to a special account under the general fund HealthGov August 2010 40 .
Bond Float) ± External Public-Private Partnership HealthGov August 2010 41 .External Support Grants ± NGAs ± Donors ± Other Sources Borrowings ± Internal (GFIs. MDFO. PFIs.
medicines and medical supplies etc«) ± MNCHN. drugs. FP and other forms ± Technical Assistance Philhealth ± Capitation fund for enrolment of indigents in the sponsored programs ± Reimbursements of health facilities for the conduct of benefit packages HealthGov August 2010 42 .Grant Assistance (NG) DOH (wide range of health support in cash and kind through CHDs) ± Regular assistance (vaccines.
health systems development . CSR. capability building of providers. NGOs and Private Individuals HealthGov August 2010 43 . public finance management. monitoring and evaluation. identification of the poor. advocacy and promotion.Grant Assistance (Donors) Foreign (USAID. AusAID) ± Technical assistance (e. EU.g. etc) ± Commodity support Charitable Institutions (PCSO) Congressional Funds ± Premium payment of families to Philhealth sponsored programs ± Other grant support Corporations.
Critical Steps for External Support Knowledge on the coverage and rules of assistance Proposal/applications Approval Written instrument Delivery report/Impact assessment Liquidation of Funds HealthGov August 2010 44 .
Borrowings LGUs can borrow funds from any of the following sources: ± Government Financial Institutions(GFIs) ± Private Financial Institutions (PFIs) ± Municipal Development Fund Office (MDFO) ± Other LGUs Maximum debt service shall not exceed 20% of annual regular income HealthGov August 2010 45 .
Municipalities Prov. Other max 15 years with grace period Max of 20 years MBUSSP Urban Services 9% fixed DMAF Climate Change Adaptation 0%-5% PWRF Prov. Sanitation Project Preparation and Contingency To be prepared HealthGov August 2010 Variable rate PTACF 0%-1. Cities. Municipalities Prov.MDFO-Facilities Windows HSRA Eligible LGUs Provinces Focus Health Terms 11% Repayment With grant depending on income class Max of P200M PROLEND Provinces Policy Development. Municipalities Max of 10years MDFP 15 years with 3 yrs grace period on the principal 15 years with grace period of principal 3 yrs for category 1. Cities. Municipalities Prov.5% Full payment during the term of LCE Other Windows 46 . Cities. Municipalities Prov. Municipalities Prov. Cities.5%-8. Municipalities Water Supply. Cities.0% fixed interest 9% fixed MDGF Prov. Cities. Infrastructure Support to MDG Goals Urban Infra Fixed interest based on 10 year T-bond 7. Cities.
Public-Private Partnership Arrangements BOT and its Variations Joint Venture Service Contract Management Contracts Lease or ³Affermage´ Concession Arrangements Combinations HealthGov August 2010 47 .
Approaches to Sustainable Financing Track 2 ± Lessen expenses and optimize effectiveness of the health budget ± Focused Service Targets ± Enhance Efficiency of Operations ± Additional Support from lumps sums and other departments¶ budgets ± Results oriented allocation HealthGov August 2010 48 .
Location of the LGU Funds Internal (Province and Component LGUs) Regular Budget Lump Sum Appropriations Supplemental External (Assistance passing the LGU) DOH/NGAs Support Projects Direct Assistance (e.PDAF.g. private sector) HealthGov August 2010 49 .
clear indicators of indigents) Policy Initiatives (e.g. Tie-up instead of outright purchases to support accreditation of facilities.g.g. population vs poor only. time sharing or job orders instead of plantilla positions) HealthGov August 2010 50 . requiring tricycle drivers to enroll to philhealth as a requisite for renewal of franchise) Cost Efficiency in Operations (e.Focused Costing Service Targetting ± (e.
Lump Sums and Parallel Appropriations 20% Development Fund 5% Gender and Development Fund 5% Calamity Fund 10% Sangguniang Kabataan RPT Special Education Fund 2% RPT Discretionary Fund Funds for the Elderly Others HealthGov August 2010 51 .
Justifying for Lump Sum While the slant is health. Vit A. feeding program SEF ± School Based IEC activities However. charging from lump sums will always require negotiations HealthGov August 2010 52 . FP Promotion gender sensitive activities SK ± Adolescent and Youth Health Programs on FP. charging from the lump sums will be possible if the focus for its creation can be retained such as the following: GAD ± purchase of FP commodities.
Support from other Departments The other departments may have health oriented programs which the MHO/PHO can support: ± Traffic enforcement and engineering ± Potable water supply ± Sanitation and cleanliness drives ± Support to healthy lifestyle Outline HealthGov August 2010 53 .
Conclusion HealthGov August 2010 54 .
) 2. (Additional rationale for policy to invest in health.) HealthGov August 2010 55 .Key ideas for local policy action 1. Health as an asset generates wealth. The poor are more handicapped by poor health.) 3. (Policies to better target government subsidies towards the poor. Health as a component of well-being is valued in its own right. (People have basic right to health and government has the responsibility to make essential health services available. Ill health contributes to income poverty.
it requires participatory decision-making for it to succeed.) 5. (Implement an integrated package of mutually supporting interventions ± health sector reform.Key ideas for local policy action 4. Large unforeseen household out-of-pocket payments for health care reduces consumption of other goods and services that promote well-being.) 6.) Outline HealthGov August 2010 56 . (Policies to provide financial protection to the poor. Health sector reform is a complex undertaking. (Strengthen stakeholder participation in local decision making. Individual interventions implemented in isolation will not work. it might even do more harm.
has hope.Arabian Proverb HealthGov August 2010 57 . And he who has hope. has everything .Health is not valued until sickness comes ± Dr. Thomas Fuller He who has health.
Thank You and Mabuhay HealthGov August 2010 58 .
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