Typical rural scene of the health department’s Ligtas-Tigdas campaign
ALLAN EVANGELISTA of Quezon City signed up with the Doctors to the Barrio program last year despite suffering from dilated cardiomyopathy, an incurable disease of the heart muscle that actor Aga Muhlach introduced to Filipinos through his 2004 movie “All My Life.”
This “walking time bomb” has had four attacks since being assigned in September to Catigbian, Bohol, an interior town 34 kilometers from Tagbilaran City. He has also experienced working under a mango tree for two months while his rundown health center was being repaired.
But the young doctor still counts himself lucky, and not only because he finds his work fulfilling. Last November, he asked and got a whopping 230 percent increase in the budget of his rural health unit.
The local government had been determined to impose austerity measures, and what ensued was the longest budget hearing the town ever had. Evangelista, however, was able to convince the town officials just how badly Catigbian needed health programs, including the appropriate medicines, for its people. His RHU was the only unit in the local government that was granted an increase.
Many of Evangelista’s colleagues in similar posts across the country have not been as fortunate. In fact, local governments often give low priority to health, and allot health services and programs sums so paltry that health centers practically have to beg for donations from patients, most of whom are indigent but still give anywhere from P1 to P10 each.
Combined with corruption and shameless politicking by local officials, the meager budgets for health have led to a frequent lack of medicines in health centers, among other things. Local health workers have also been denied many of the benefits they are entitled to under the law because of the lack of attention paid by local governments to health.
Mayors and governors have long given the more visible and more corruption-prone infrastructure projects top priority. To the dismay of public doctors and other health workers, the devolution of health services in 1993 hasn’t altered that mindset. Nine surveys of 80 towns and 301 barangays done in 2000 by the U.S.-based Center for Institutional Reform and the Informal Sector (IRIS), show local officials still emphasizing infrastructure over health, new jobs and aid to the poor.
First- and fifth-class municipalities alike complain about the lack of funds for health, according to a 1998 study done for the World Health Organization. Note the authors of the study: “There seems to be a lack of political will to allocate additional funds for health since it is commonly perceived that additional expenditures for health are not capable of turning in the votes. People normally consider the infrastructure record of candidates as basis for solid achievement.”
They further surmise, “Because of the old centralized setup where health is the responsibility of the Department of Health, people are not used to making health an issue during elections. Local political candidates who are re-electionists normally cite their public works record as measure of their performance. Even barangay officials use their local funds to construct waiting sheds, basketball courts instead of spending them for health.”
Doctors also complain of what they describe as the “narrow perspective” of local officials toward health. “It must be curative rather than preventive,” says a paper of the nonprofit Institute of Public Health Management, quoting doctors who have attended its health and governance conferences. “The notion that health is merely the absence of disease still prevails among the local chief executives and their constituents.”
Almost always, a town’s budget for the RHU is quickly eaten up by salaries of health personnel. In 2003, personal services accounted for nearly 80 percent of the towns’ combined P4.68 billion appropriations for health centers. Maintenance and other operating expenses or MOOE, which fund health programs and the purchase of medicines and supplies, made up only a fifth of the budget.
The budget of an RHU, especially those that have been doctorless for some time, could be as small as P50,000 a year, says Maritona Labajo, assistant director for field operations of the Leaders for Health Program, which allows barrio doctors like Evangelista to earn a master’s degree in community health management from the Ateneo de Manila University. Yet, points out Labajo, the same town may allot P500,000 to P1 million to buy medicines but put this not in the health budget but in the mayor’s discretionary fund, over which the local physician has no control.
This has resulted in municipal and urban health doctors being forced to innovate because of lack of medicine. A doctor in Laguna, for example, has resorted to giving tablets in place of suspension fluids as an antibiotic for toddlers. “I tell the mothers to cut the tablet into half,” says the doctor, “and mix it in glass of water with sugar.”
Other physicians recommend the use of herbal plants like oregano, a substitute for cough syrup, or lagundi for treating boils because their RHUs do not have the manufactured medical treatments.
Pork-barrel allocations of congressmen sometimes enable RHUs to have the medicines they need. The Department of Health (DOH) also distributes drugs in line with national health programs, aside from the usual anti-tuberculosis drugs, vaccines and micronutrients. But local health units rely mainly on their internal revenue allotment and locally generated funds to purchase medicines and supplies.
Yet since many doctors are hardly involved in the local budgeting process, it is difficult for them to lobby even for just the basic things needed by their RHUs. A Central Visayas-based municipal health officer remembers getting this instruction from his mayor when he was preparing the budget: “Just make sure na maswelduhan kayo (you all get your salaries). Don’t worry about the programs.” And, indeed, hardly any money went to the health programs of the fourth-class town.
An RHU in Rizal province, meanwhile, was given a budget so tiny it couldn’t even buy cotton. A Bicol RHU’s budget had no money allotted for soap, disinfectant, even writing paper.
The physical condition of RHUs is sometimes a good indicator of how much — or little — importance the mayor attaches to health. Richard Lariosa, who signed up with the Doctors to the Barrio program in 2001, was assigned to Tagapul-an, Samar, where he found himself seeing patients in a tiny room in a building that had windows that were falling off and a leaking roof.
The first thing Lariosa had done shortly after he arrived in Tagapul-an was to ask the mayor to repair the RHU while awaiting a P3-million new health center the Japanese government had pledged to build. When Lariosa was pulled out of remote Visayan town late last year, the mayor had yet to act on his request, and Japan had not released the promised funds. “We tried to patch the roof, but Vulcaseal didn’t work well,” Lariosa says.
But that was not all Lariosa had to put up with. The solar-powered vaccine refrigerator at his RHU kept breaking down, causing the vaccines to spoil. Exasperated, Lariosa stored them in a canteen operator’s fridge. “It wasn’t ideal because you shouldn’t be opening the ref as much as possible,” he says. “But I didn’t have a choice.”
Lariosa also found he was entitled to only P5,000 a year for travel and RHU’s midwives, P3,000 a year. As the RHU did not have its own boat, it had to rent one for P500 a day to visit the barangays. To stretch the budget, Lariosa and his staff pooled their travel allowances and conducted team visits so they could make regular rounds of Tagapul-an.
But it is the failure of many provinces, cities and towns to fully implement the Magna Carta for Public Health Workers that has convinced local doctors and health workers of the local governments’ neglect of the health sector.
Passed in 1992, Republic Act 7305 mandates a host of benefits not only for government doctors, nurses, midwives, dentists, barangay health workers, and sanitation inspectors at both the national and local levels. The benefits include hazard pay, laundry allowance, subsistence allowance, holiday pay, and even remote allowance or medico-legal allowance.
Health personnel in the national government’s payroll, including volunteers under the Doctors to the Barrio Program who are also known as rural health physicians, enjoy the full benefits provided by the Act. Majority of local health workers, however, do not.
For municipal health officers in poor towns, failure to fully implement the law has resulted in a bigger discrepancy between their pay and that of the DOH-hired rural health physicians. As things stand, many of them receive just more than half of the P20,824, basic monthly salary received by rural health physicians.
A number of barrio doctors fielded by the DOH have ended up fighting for the benefits of their RHU staff. Dorie Lynn Balanoba, who was in the first batch of 46 doctors sent to the countryside under the program in 1993 and now works at the DOH central office, led her staff in Jipapad, Eastern Samar in going on a two-week sick leave in 1996 to force the town treasurer to release the benefits due them.
In some towns, health personnel have filed administrative or court cases against their mayors. Alas, the courts have junked some of these cases, including the one initiated against the former mayor and treasurer of Catigbian by the municipal health officer who preceded Evangelista, the doctor with the heart disease. With the case under appeal, the new mayor has elected to observe the status quo. This leaves Evangelista in a bind whenever his RHU’s nurse and midwives pressure him to work for the release of their benefits.
Most, if not all, of the towns in Bohol have yet to fully implement the law, observes Evangelista. This appears to be the case for most parts of the country, he says.
Last September, the Association of Provincial Health Officers of the Philippines (APHOP) issued a manifesto addressed to President Gloria Macapagal-Arroyo, complaining that the Magna Carta has yet to be fully implemented.
Health workers complain that mayors and governors often mouth the famous line “subject to availability of funds” to justify the Act’s partial implementation. Yet they note that many local governments violate a Department of Budget and Management circular for mayors and governors to first appropriate the Magna Carta benefits in their budget before providing other nonmandatory salary items.
“The problem with devolution is that health personnel were not trained to deal with the (local governments),” says Nemecia Mejia, former provincial health officer of Pangasinan. Still, not everyone has had to just grin and bear the dire consequences of decentralization.
Municipal health workers in Pangasinan, for example, have had an easier time coping with the changes because some hospitals maintained an informal relationship with the rural health centers after devolution. Pangasinan was also among the pioneer provinces that enforced the DOH’s Health Sector Reform Agenda (HSRA). Implemented in 1999, the HSRA sought to improve the financing and delivery of health services.
The HSRA, among others, encourages the creation of “inter-local health zones,” or districts or catchment areas composed of neighboring municipalities with the aim of improving cooperation among themselves on health matters. In Pangasinan, a core hospital is in charge of one health zone. Mejia says the chief of hospital helps municipal doctors advocate for local programs and reforms to their mayors.
The HSRA, which has reforms in hospitals as one of its components, also allows for a systematic pooled procurement in provincial hospitals. Mejia says the bidded price in Pangasinan went down by more than half through bulk procurement.
The hospital and provincial therapeutics committees in the province oversee the procurement of drugs starting from the annual procurement plans of the 14 hospitals. This is to ensure quality of drugs and the procurement of drugs at lower costs. But Mejia explains they have yet to convince the municipalities to adopt a similar system. With money involved, she says, procurement has become a very sensitive issue.
The least the hospitals could do, says Mejia, is to refer the winning bidders to the municipalities and have them adopt the bidded price. “They don’t have to undergo another bidding because it was already bidded out in the provincial level,” she says. “We would like this to be implemented in the lower-class municipalities with very meager budgets.” — with Avigail M. Olarte