Health Systems in Developing Countries - The University of Sydney

Health Systems in Developing Countries The Frontline of Rural Health Systems Strengthening in the Philippines

Lewis Austin Keane University of Sydney – School of Public Health Master of International Public Health – Classroom in the field Program

Classroom in the Field Placement Philippine Government- Department of Health – Health Human Resource Development Bureau ›  Objective: ›  1- Analyze human resource strengthening in rural Philippines through the ‘Doctor to the Barrios’ Program. ›  2- Provide feedback and recommendations for improvements. ›  3- Examine Doctors aren’t staying after the program… ›  Activity: 2 week placement in both: ›  1- Quezon, Nueva Ecija ›  2- Argao, Cebu ›  Assigned with Doctor to the Barrios in both municipalities.

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Doctor to the Barrios (DTTB) What is it? In very basic terms.… ›  Incentivized rural service program. (salary, employment, scholarship, masters) ›  New medical school graduates. ›  Sent out to Poorer, rural or isolated regions of the Philippines.. ›  2 year assignment.. ›  Launched in 1993 after DOH realized that 271 towns hadn’t had municipal physician for over 10 years or more. ›  Paid by the DOH, alleviates financial burden of doctors on lower class municipalities. 3

Department of Health 3 day Pre-departure Preparation ›  In 1992 the Philippine Government decentralised the Philippine health system. ›  Due to 7107 islands, the workload regarding budgetary allocation on the DOH central office (Manila) was too high. ›  Took complete decision making control away from DOH and transferred it all the way to the Local Governments. ›  Philippine National Government gives each municipality (1491) a lump sum budget. ›  This budget gets divided at the discretion of the Mayor to the Police force, road building, infrastructure, sporting teams and health care. ›  Looks good in theory, bad in practice. 4

Filipinos really love to sing.. No matter how badly..

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Assignment (2 weeks): Quezon, Nueva Ecija Demographics ›  Population: 35,559 ›  Class: 4th class ›  Barangays: 16 ›  Avg family income: $1300 AUD/ year. ›  Industry: 74% Agriculture ›  Rural Health unit (RHU): 1 ›  Doctors: 1 (LGU), 1 DTTB ›  DTTB: Doctor Joel Parungao

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First day..

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Geography Flat farmland areas with comparatively good roads

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Health Indicators Dengue: 11 cases – 0 deaths. TB: 100% cure rate, 3.8% case detection rate. Rabies: 37 bites, 36 given post-exposure, 0 deaths. No cases of Malaria for several years. Leading Causes of Mortality: 1- Heart Attack

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2- Stroke

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3- Diabetes

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4- Cancer

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Activities for Research… Family planning and Pre-natal checks in farthest Barangays..

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Activities for Research… Visited Barangays for DOH 4 P’s (CCT) assessment and EPI vaccination program

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Activities for Research… Installed Dengue traps in local schools..

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Activities for Research… Joined Barangay health worker monthly meeting..

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Activities for fun… RHU Team building exercises

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Activities for fun… RHU Christmas party

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Challenges for Quezon Health System Qualitative data collected from DTTB, nurses, midwives, barangay captains etc… ›  1- Family Planning falling far behind DOH national targets. ›  2- Need for second RHU as population rises and lack of political will to build one. ›  3- Huge increases needed in health budget from local government unit (LGU). ›  4- Only half of RHU staff at any one time are supplied by LGU, the rest are sent from DOH to fill in gaps. ›  5- Budget was election focused dole-out activities instead of sustainable longterm projects. 16

Christmas in the Philippines December 22- December 27

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Christmas in the Philippines The Filipino experience…Dr Giselle and Dr Angelo Manalo

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Christmas in the Philippines The Village Surgical Clinic…Iligan City, Mindanao

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Christmas in the Philippines Zip-lining in Iligan….

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Christmas in the Philippines Tinago Falls, Iligan, Mindanao

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3rd January- Assignment (2 weeks): Argao, Cebu Demographics ›  Population: 70,000+ (35,000) ›  Class: 1st Class

(4th Class)

›  Barangays: 45

(16)

›  RHU: 2

(1)

›  Doctors: 2 LGU & 1 DTTB ›  DTTB: Dr Hayce Famor

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Geography Mix of flat coastal area and isolated treacherous mountainous region

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Activities for Research Post-natal Vaccinations under DOH EPI program..

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Activities for Research.. Makeshift pharmacy for consultations in mountain Barangay Colawin...

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Activities for Research… Visited Isolated Barangay Balaas for consultation, EPI… everything!

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Activities for fun.. 23km jungle trek, mining, table tennis and fishing..

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Lesson’s on Public Health from the mountains of Argao Number 1: Innovation is essential

Nebulization of infant (pneumonia) in mountainous Barangay with oxygen hood made by RHU driver….. 28

Lessons on Public Health from the mountains of Argao Number 2: Improvisation is everything

Treatment of asthma patient without oxygen masks 29

Lesson’s on Public Health from the mountains of Argao Number 3: Task shifting is fact of life..

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Lesson’s of Public Health from the mountains of Argao Number 4: Passion of staff is vital

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Lesson’s of Public Health from the mountains of Argao Lesson 5: Space is luxury

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Challenges of the Argao Health System Input collected from DTTB, nurses, midwives, stakeholders, barangay captains 1- Need for increased capacity of district hospital in Argao by provincial Health office. 2- Need a rural Health unit for the mountains. 3- Improvement of road conditions between future 3rd RHU and Argao town Centre (District Hospital). 4- Increase transport (ambulance) for complicated cases down to district hospital and on to DOH referral hospital.

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Development of the Doctors to the Barrios Program

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Doctors to the Barrios Top Factors that would make the DTTB Want to stay… ›  1. Local government support ›  2. Good salary ›  3. Family ›  4. Career advancement opportunities ›  5. Sustainability of health projects ›  6. DOH support ›  7. Needs of the poor and undeserved ›  8. Ease of transportation ›  9. Passion for public health ›  10. Personal reasons ›  ›  Leonardia et al. BMC Health Services Research 2012 12:411 35

Thank you to everyone.. University of Sydney Research supervisor: Dr Joel Negin Head of School of Public Health: Professor Glenn Salkeld Mentor: Eric Aguila

Classroom in the Field staff: ›  Dr Giselle Manalo

Dr Angelo Manalo

›  DJ Calla

Dr ‪Allison Gocotano

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