BloogerGAN-Personal

     By Alexander Villafania
INQ7.net

DUTCH electronics company Philips will soon be
offering an online diagnosis project aimed at offering free specialist
diagnosis to rural communities in the Philippines.
 
The
project would allow medical practitioners to send via the Web the MRI
(magnetic resonance imaging) scans of patients from rural areas to
available medical specialists in other cities.
 
Philips
Group of Companies Philippines President Med Mateo said in an interview
that the project is aimed at providing expert diagnosis for MRI scans
in areas where there are no specialists available.
 
“There
is an obvious lack of medical specialists in the country and those that
are here are mostly concentrated in bigger cities. The availability of
MRI scans does not solve the problem of correct diagnosis and this is
what the web-based diagnosis will try to address,” Mateo said.
 
Philips will partner with the Department of Health to provide the
specialists who would offer free diagnosis to medical practitioners in
rural areas.
 
Philips will invest 300,000 euros for the
project, which is expected to span three years. It is expected to start
in August this year.
 
The web-based diagnosis project is a
follow-up to a previous community health project called ORET, jointly
conducted by Philips Electronics and the Dutch Government.
 
ORET is a loan 22-million-euro loan from the Dutch government to hospitals in the Philippines.
 
The loan will be used to acquire new equipment such as MRIs, ultrasound and CT scans to 11 beneficiary hospitals.
 
According to Mateo, five hospitals in Quezon City, Bicol, Davao and
Iloilo will be the first beneficiaries of the ORET project.
 
He said the web-based project would start once three ORET beneficiary
hospitals have completed the acquisition of their equipment.
 
Philips is a manufacturer of various electronics products, among which
includes audio-video home appliances, lighting devices and medical
equipment.

(1 euro = 68.13 pesos)

     By Christian V. Esguerra
Inquirer News Service

   

TOUGH
luck for poor and pregnant moms. They may not all be welcome at Fabella
Hospital in Manila, which is known for delivering babies at low cost.

Two
health workers and a nurse said they witnessed some cases of inhumane
treatment of women in the throes of childbirth at the old, dilapidated
hospital.

In separate interviews with the Inquirer, the three
sources admitted to seeing pregnant women in labor, being cursed and
scolded by some doctors and nurses, purportedly for failing to practice
birth control.

Fabella Hospital is known as the facility to go to
for pregnant women who can’t afford to go to private hospitals. It
handles at least six births at any given time on ordinary days. The
number usually rises to 15 during the "peak season," usually in
September, according to one source.

"Ikaw na naman? Taun-taon ka
na lang nanganak! Pagkatapos nito, magpa-ligate ka na! (It’s you again?
Every year you give birth! After this, you should have a ligation!)"
one health worker recalled hearing a male doctor scold a mother in the
delivery room.

Getting no reply from the helpless woman, the
doctor allegedly was heard mumbling to his assistants: "Sana patay ang
bata, sana patay ang bata (I hope the baby is dead)."

"He got even more angry when he saw that the baby was alive," the source told the Inquirer.

The
same doctor, a graduate of a top medical school in Manila, had also
performed "total abdominal hysterectomy" on an unsuspecting mother
after she delivered her sixth baby by ceasarian section, the source
said.

He had removed her uterus.

When the mother woke up,
the doctor told her he had to perform hysterectomy because she was
bleeding profusely, the source said. "But she was never bleeding."

First order of the day

The
case shocked incoming Health Secretary Francisco Duque III who said he
would immediately order an investigation when he assumes office on
Wednesday.

"Really? Wow!" he told the Inquirer in an interview.
"I will immediately have it investigated. It’ll be the first order of
the day."

Duque was particularly shocked with the doctor who
removed the patient’s uterus without her consent. "That’s not right.
That’s illegal. He can’t do that," he said.

He was surprised that
these things were happening at Fabella Hospital, considering that
Manila Mayor Lito Atienza was a fierce enemy of artificial
contraception.

Perennially pregnant

Lawyer
Carolina Ruiz Austria of the Reproductive Health Advocacy Network told
the Inquirer that she was aware of similar incidents occurring at
Fabella Hospital, as well as in another institution in the city.

She
said some of the people in these two government hospitals were
particularly harsh with patients who tried to have their pregnancies
aborted.

"I know of one instance when a woman was made to wear a sign which read, ‘I tried to get an abortion,’" Austria recalled.

But
while this purported case condemned abortion, some of the health
workers in the Manila hospital demonstrated outright disdain for
"perennially pregnant women."

No anesthesia

These
patients who have ignored the constant badgering were usually in for
some form of "punishment" during labor, according to the Inquirer
sources.

One source cited an instance when a mother was refused
anesthesia during episiotomy, a procedure which involves cutting the
vaginal opening of a woman in labor.

The cut is usually an inch or two long.

Besides
the common bedside rebuke, perennially pregnant mothers would get more
scoldings during the pelvic exam usually the day after delivery, the
source said.

"For once, use your brain! Be responsible! How will
you feed so many children?" health workers allegedly told mothers
lining up for checkups.

Not-so-special delivery

A
third source, a former nursing trainee at the hospital, said he
witnessed similar cases while working there for a month last year.

"I
was shocked," he told the Inquirer on Saturday. "It wasn’t what we were
taught in school about patient care. It was completely the opposite."

He
recalled one instance when a mother delivered her eighth baby on a
stretcher before she could be transferred to the delivery table.

"The nurses got mad and said, ‘Why didn’t you tell us the baby was about to come out?’" he narrated.

To punish the woman, the nurses allegedly told her to move to the delivery table by herself.

"Imagine the pain. You’ve just delivered [a baby] and you’re asked to move with no assistance whatsoever," the source said.

No qualms

In contrast, some doctors were allegedly more accommodating of women seeking what could almost be considered an abortion.

The
former nursing trainee said he saw one female doctor perform dilation
and curettage, more commonly known as raspa, to a pregnant entertainer
in her 20s.

"She was pregnant, I think for several weeks already,
and she didn’t want the baby because she had to return to Japan," he
recalled. "The doctor had no qualms about doing the procedure. She
killed the baby simply because the mother didn’t want it."

I’ve finally made the decision, I’m ending my stint outside the medical field. When, I’m still figuring out when and how I could gracefully exit. I’m sent feelers to my supervisor and my officemates. I just hope my other options would push thru as soon as possible.

      THE YOUNG
mother was frantic. A seven-month-old baby was burning with fever in
her arms, barely able to breathe. The doctor at the rural health unit
quickly attended to the child, who was suffering from serious
respiratory tract infection. But she had no medicine to give the baby:
her supply of Ventolin or salbutamol, which would have given the infant
instant relief, had run out.

The
doctor, who ministers to the needs of residents of a poor municipality
in Bulacan, could only wring her hands. It took two weeks before the
poor mother could scrape together P50 to buy the drug. Fortunately, the
baby survived, although it had to suffer the fever and cough longer
than it should have.

The
doctor sees 90 to 100 patients a week and the medicines the local
government buys for her clinic always run out. Worse, she says, the
drugs she is supplied with are overpriced by sometimes over 100
percent, with the difference lining the pockets of local officials.

Since
the Local Government Code devolved public health centers and other
health programs and facilities from the Department of Health (DOH) to
local government units in 1993, local officials have had more
discretion on how health budgets should be spent. While there are some
bright spots, evidence suggests that a culture of waste, corruption and
patronage pervades health care in many local governments.

Doctors,
suppliers and local officials and employees interviewed for this report
estimate that kickbacks from the purchase of drugs — also known as
standard operating procedures (SOPs), rebates, internal arrangements
and "love gifts" — given to mayors, governors and other local officials
range from 10 to 70 percent of the contract price.

The
result: a system that can barely answer the needs of the poorest
one-third of the population that relies on local-government-funded
health care centers.

"Before
the devolution, all the corruption was happening in Manila," says Juan
A. Perez III, who was a DOH official when Juan Flavier was still
secretary. Transferring resources to local governments should have
directly helped communities, he says, but in far too many instances,
corruption has thrived instead. Devolution, says Perez, seems to have
resulted only in "democratizing corruption."

"Increases
in discretion enjoyed by local governments lead to increase in
local-level corruption," says a 2000 study on decentralization in the
Philippines by the U.S.-based Center for Institutional Reform and the
Informal Sector (IRIS). "When officials enjoy more discretion, they
have greater opportunities to demand bribes."

Decentralization
was expected to reduce corruption, especially in drug procurement. Yet
for the most part, such practices as overpricing, rigged biddings,
short and ghost deliveries, and the purchase of substandard drugs
remain pervasive.

These
problems are demoralizing the ranks of doctors assigned to the more
than 1,600 rural health units (RHUs) and urban health centers. Too
often, these doctors find themselves battling with local officials who
divert precious resources to corruption and patronage. "The doctors are
leaving," says a municipal health officer from the Calabarzon region.

Problems
have dogged the devolution of health services from the start.
Unprepared local governments had trouble paying for the salaries and
benefits of about 70,000 health workers and to run local health centers
and hospitals now under their jurisdiction. The problem persists, but
the national government and international agencies have come to their
aid.

All
these imperil the delivery of frontline health services. The 2003
National Demographic and Health Survey found more Filipino households
visiting public health facilities than private clinics and hospitals.
Barangay health stations, which are supervised by the RHUs and urban
health centers, had the most clients, followed by the RHUs and urban
health centers themselves.

A
survey done by the Social Weather Stations for the World Bank in 2001
also shows the country’s poorest 30 percent seeking help mostly from
the local health units for their aches and pains.

These
health centers are the poor’s primary source of medicines as well. Yet
many local governments are allotting less money for health services,
choosing instead to spend tax money on fancy municipal buildings,
basketball courts and waiting sheds.

Moreover,
many local officials see health as another source of illicit income and
demand hefty shares from suppliers of drugs and hospital equipment. Of
the nearly P1 billion allotted in 2003 for the maintenance and other
expenses of all rural health units, P100 million to P700 million could
have been lost to graft.

Such
amount could have been used to purchase at least 100 million pieces of
500-mg. tablets of paracetamol, which is prescribed for simple fevers
and aches, or more than 62,000 tablets per health unit.

TABLE 1: Selected Medicine Purchases of Quezon City, 2000

      

       
       
         

         

         

         

         

       

       

         

         

         

         

       

       

         

         

         

         

         

         

         

       

       

         

         

         

         

         

         

         

       

       

         

         

         

         

         

         

         

       

       

         

         

         

         

         

         

         

       

       

PARTICULARS	QUANTITY	PRICE               AS PURCHASED		PRICE               PER AUDIT		DISALLOWANCE
		Unit               Price	Total               Cost	Unit               Price	Total               Cost
Amoxicillin               Suspension 125 mgs (btl x 60 ml)	7,525	83.73	630,068.25	18.39	138,384.75	491,683.50
Mefenamic               Acid Tablet 250 mgs (box x 100s)	1,488	255.00	379,444.00	56.54	84,131.52	295,308.48
Paracetamol               Syrup 125 mgs (btl x 60 ml)	9,636	59.93	577,485.48	7.22	69,571.92	507,913.56
Cotrimoxazole Suspension 200 mgs/40 mgs (btl x 60 ml)	5,007	69.90	349,989.30	17.05	85,369.35	264,619.95

SOURCE: Commission on Audit 

Today
most RHUs and urban health centers have little or no medicine for their
patients. Too often, the deliveries — if they were made at all — fall
short of what had been promised, in both quality and quantity. A
municipal health officer in Laguna recalls an instance when she issued
a prescription, only to be told by her staff that their RHU had run out
of the needed medicine. Yet the doctor knew that two weeks before,
there had been a delivery of supplies.

"I went to the supply closet, and there was indeed no medicine," she says. "So I went to the police (and told them), ‘Papuntahin mo ‘yung ahente dito at ihatid ang gamot ko kung ayaw niyang maghalo ang balat sa tinalupan (Get that agent to deliver my medicine if he doesn’t want the sh__ to hit the fan)!’"

The
doctor who had no medicine to give to the feverish baby recalls that in
the past, she would order 10 boxes of assorted medicines every two
months. But there came a time when only four boxes arrived at her
office. When the confused doctor was asked to sign the payment voucher,
she noticed that the prices had been "adjusted."

The
doctor says she had copied onto the requisition voucher the prices of
the medicines based on the handwritten list given by the medical
representative. Later, she saw a typewritten copy of that list with
figures twice the actual price. This served as the basis of the payment
voucher. Since then, the doctor has been leaving the price column
blank, reasoning, "They’ll just change it anyway."

Heidi
Mendoza, auditor at the Commission on Audit (COA), says overpricing of
supplies is the most common form of fraud. "One city mayor told an
auditor casually that where price difference falls within the range of
50 percent to 100 percent, that is not overpricing," Mendoza says.
Drugs can be overpriced by as much as 700 percent, COA records show.

A
drug distributor admits having sold to a local government in northern
Luzon the antibiotic amoxicillin for three times more than its actual
price of P280 per box of 100 tablets. "Does it affect the health
system?" she asks. "Yes, because I can sell it for P380 per box. I’m
already okay with that P100 markup. Even P50 per box is fine. So that
(should have been) 300 boxes instead of (just) 100."

TABLE 2: Price Comparison of Cainta’s Drug Purchases from January 1 to June 30, 2001

   
      

      

      

      

      

      

      

      

   

      

      

      

      

      

      

      

      

   

      

      

      

      

      

      

      

   

   

      

      

      

      

      

      

      

   

   

      

      

      

      

      

      

      

   

   

      

      

      

      

      

      

      

   

   

      

      

      

      

      

      

      

   

   

MEDICINE	UNIT	QUANTITY	PRICE PER HEALTH OFFICE	PRICE PER RHO IV (plus 10% allowable price variance)	DIFFERENCE	PERCENTAGE (%)
Amoxicillin               capsule, 500 mg.	box	454	1,100.00	203.50	896.50	440
Amoxicillin               suspension	bottle	2,160	92.00	17.60	74.40	421
Cotrimoxazole               tablet, 400/80 mg.	box	50	720.00	82.83	637.17	769
Salbutamol syrup	bottle	1,152	55.00	14.85	40.15	270
Salbutamol tablet, 2mg.	box	50	245.00	46.47	198.53	427
Rifampicin, 450 mg.	box	20	1,756.50	382.91	1,373.59	358

According
to the supplier, 30 percent of the contract went to bribes, or P256 per
box. But she says the share of the contract price going to "love gifts"
now starts from 50 percent up. Other suppliers and health officers,
meanwhile, say that 30 percent of the contract amount goes to the mayor
while 15 percent goes to accountants, budget officers, and to whoever
else has to sign or approve the contract. Five percent, meanwhile,
sometimes goes to the doctor at the health center.

Under
Republic Act 9184 or the Government Procurement Reform Act, all
government purchases must go through competitive bidding to ensure the
best quality at the least cost. The Local Government Code, meanwhile,
says that each town or city is supposed to have a Committee on Awards
composed of the mayor, treasurer, accountant, budget officer, general
services officer, and the department head, which in cases involving
medical supplies is the RHU or urban health center doctor.

But
Mendoza says the procuring official and the bidder always find
"creative" ways to avoid public bidding. There are also instances where
a winning contract is almost already decided even before the conduct of
actual bidding.

Suppliers
say members of the awards committee are the key people in "bagging" a
contract. The amoxicillin supplier says the contract is practically
guaranteed as a done deal once one has settled the "sharing" of the
spoils. According to the supplier, the doctors are the starting point:
"If you can make them your friends, then you can have (the contract)."

"When a doctor doesn’t cooperate, there will be no medicines," another supplier explains. "The budget will be realigned. Bubuwisitin nila yung doctor (They will pester the doctor)."

The
next people to talk to would be the mayors, treasurers or general
services officers to negotiate the contract and settle the "love
gifts."

Delivery
of 20 to 50 percent of the negotiated amount is done early on as
downpayment. The rest of the money comes after the collection to
guarantee the processing of the papers. The amoxicillin supplier says
mayors prefer cash, since checks leave a trail.

To
make it appear as if a bidding had taken place, the amoxicillin
supplier says she borrows her friends’ company names and registration
papers, promising them a five-percent share later on, and adds two
other fictitious competitors for good measure.

The
supplier says she sometimes has to "adjust" some more to meet the
demands of increasingly greedy local officials while ensuring she still
gets a profit. Such "adjustments" could mean substandard drugs,
confesses the supplier. Sometimes, wracked with guilt, she tells
officials that a higher kickback would mean medicine of lesser quality.

One
doctor says she took one of the medicines available at her health
center when she was having stomach trouble. The drug didn’t work, she
says, making her worry about her patients. She laments, "What can I do?
That’s the kind of drugs they deliver."

This
doesn’t happen only in the provinces. In 2000, the Quezon City
government bought some P8 million worth of medicines in three batches.
Of these, medicines totaling P1.8 million — including 6,028 bottles of
multivitamins with lysine syrup and 740 boxes of amoxicillin capsules —
failed Bureau of Food and Drugs (BFAD) tests conducted as part of a
special audit. Despite the BFAD finding, the local government still
paid the contractor, La Croesus Pharma Inc., in full. The supplier did
pull out questionable medicines, but the replacements it delivered
again failed BFAD tests.

When
COA verified the prices of the medicines that passed the tests, it also
found these to have been overpriced by P4.3 million. City officials,
however, maintained that La Croesus Pharma’s bid was the lowest
competitive bid. COA argued that the city should not have limited its
evaluation to the submitted bids, but could have compared them with
prevailing market prices. Three hospitals in Quezon City, in fact, were
able to purchase similar medicines at lower prices during the same
year.

Some
provinces have also shown that a systematic pooled procurement can
drastically bring down costs. In Pangasinan, which is one of the
pioneer provinces that have enforced the Health Sector Reform Agenda
(HSRA) of the health department, bidded prices went down by 52 percent
through bulk procurement.

TABLE 3: Household Utilization of Health Facilities (%)

SOURCE: 2003 National Demographic and Health Survey

      

   

   

      

      

   

   

      

      

   

   

      

      

   

   

      

      

   

   

      

      

   

   

      

      

   

   

      

      

   

   

      

      

   

Barangay health station	22.4
Rural health unit/urban               health center	16.3
Municipal hospital	3.8
District hospital	3.4
Provincial hospital	4.9
Regional hospital/public               medical center	3.3
Private clinic	14.0
Private hospital	9.4
Other	2.0

State
auditors say the absence of a procurement plan is a red flag. Take the
case of Cainta, Rizal, which COA says circumvented rules six years ago
because it had no annual procurement program for medicines. The Local
Government Code, which then governed the system of procurement,
requires that projects be in line with the procurement program of an
office before any purchase is made, except in cases of emergency.

According
to COA, Cainta avoided public bidding for medicines from January 1999
to October 2000 by purchasing in separate and smaller batches, each
below P60,000. At one point, Cainta’s local health office made up to 11
purchases in just a month’s time.

Cainta’s
then municipal health officer said they did this because the local
government didn’t have funds to conduct public biddings. But COA noted
that the frequency of the purchases indicated that Cainta did not
suffer from any financial lack. The absence of specifics on the
purchased medicines made the transactions even more questionable.

As
a rule, before any procurement takes place, the doctor prepares a
requisition voucher on which he or she lists the medicines, specifying
the quantity and cost for each drug. In Cainta’s case, the municipal
health officer provided no such thing although she was obviously privy
to the purchase.

In
some instances, however, the health-center doctor could be clueless
about the local government’s procurement of medical supplies. A doctor
in the Visayas says some local governments there just make the heads of
health units sign the payment vouchers. Many of the doctors sign just
so their RHUs can have supplies. But there are those who refuse-and
later face the wrath of local officials.

One
young doctor left his post at an RHU in Mindanao after the fuming mayor
jabbed a finger at him at the town hall and berated him as the entire
municipal workforce looked on. The doctor — the town’s first in more
than a decade — was almost reduced to tears, and all because he had
refused to sign the delivery receipt of medicines bought by the mayor’s
office. The doctor said the medicines had been overpriced by more than
100 percent. He knew the real price because he had met the supplier
just weeks before.

After
his public humiliation, the doctor, then just 26, packed his bags and
left the town. Corruption, he says, has mired that fifth-class
municipality in poverty. The doctor has sworn never to be a community
physician again.

      by Yvonne T. Chua PCIJ.org

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

      By: Yvonne T. Chua, PCIJ.org

WHEN BARRIO
doctor Richard Lariosa arrived in Tagapul-an, Samar in 2002, he was
surprised to learn that medicines for the town were being kept at the
mayor’s office. "When you gave a prescription to a patient not of the
same political color as the mayor, he’d be told by the people at the
mayor’s office there was no medicine even when they were still a lot,"
the doctor says. "Color coding."

The
mayor was later persuaded to turn over all the stocks to the rural
health unit, after being assured the people would know the medicines
came from him. But months before the May 2004 elections, newly
delivered medicines again wound up with the mayor. He agreed to let go
of half the medicines only after Lariosa paid him a visit.

The
young doctor’s relationship with the mayor, however, was already quite
strained. At one point, Lariosa had objected to the removal of trained
health workers and their replacement by untrained supporters of the
mayor and the barangay captains. The mayor was in turn displeased when
Lariosa changed caterers for a health-training course because the food
served by the first caterer caused the trainees to have diarrhea.
Apparently, the former caterer was the mayor’s ally.

Last
December, Lariosa was pulled out of Tagapul-an after the Doctors to the
Barrio-Leaders for Health program, which had sent him there, concluded
that the mayor was not very concerned about health. Now assigned to
Uyugan, Batanes, Lariosa hopes local politics would not again become a
hindrance to his work.

Corruption
and official neglect are not the only problems plaguing the health
system in local government units. Traditional politics is also
compromising the delivery of health services to the people who need it
most, and discouraging health workers who would otherwise not even mind
the low pay and long hours their jobs entail.

"Confidently,
we can say that partisan politics is the number one problem at the
RHU," says Maritona Labajo, assistant director for field operations of
the Leaders for Health program that allows barrio doctors to earn a
master’s degree in community health management. She also concedes,
"Politicians….are really difficult to work with. The (health) program
can be sabotaged by the mere fact that the mayor does not cooperate."

This
has led to disillusionment even among the most idealistic of doctors,
some of whom had volunteered for the much-vaunted Doctors to the Barrio
program begun more than a decade ago by then health secretary Juan
Flavier. The program has already sent more than 400 physicians to about
300 doctorless fifth- and sixth-class towns, but medical practitioners
are still badly needed in the countryside, even by wealthy towns.

While
some of the volunteer doctors eventually stay as municipal health
officers in the towns they are assigned to, several wind up swearing
off working for local governments ever again. One barrio doctor
assigned to a remote town in Mindanao can hardly wait until her
four-year contract is up. "I can’t stand the politics," she says.

Yet
Pascualito Concepcion, an Ateneo de Zamboanga alumnus assigned by the
Doctors to the Barrio program to Talusan, Zamboanga Sibugay in 2002,
has shown just how much a community doctor can accomplish when the
local government is health-friendly.

With
help from the mayor and the town council, Concepcion transformed a
dusty warehouse-like building into an air-conditioned health center. He
got Philhealth to accredit his rural health unit and enrolled 500 poor
families in the program in 2002 alone. His RHU’s pharmacy also sells
paracetamol for as low as 50 centavos each; usually the cheapest a
tablet of the medicine can get is 90 centavos.

Concepcion
convinced local officials to increase the RHU’s share from the
development fund (from P200,000 in 2002 to P1.2 million in 2003) and
even persuaded them to let it keep the Philhealth payments for the
upkeep of the health center and its programs. The local government has
since created more positions for the RHU and has been fully
implementing the Magna Carta for Public Health Workers. The health
center laboratory is comparable to a medical center lab with pap smear,
blood sugar and other blood chemical.

Concepcion
was given the Grand Distinction Award in the Department of Health’s
annual recognition of outstanding doctors to the barrio. Other RHU
doctors, however, are probably more jealous of his luck with his local
government rather than of his award.

Many
of the doctors interviewed for this story recounted story after story
about clashing with local officials-primarily the mayor-over such
seemingly trivial things as the hiring of barangay health workers and
the safekeeping and distribution of medicines. These, however, have
serious implications, and affect the continuity of services and
effectiveness of treatment.

In
most of the cases, patronage politics was involved, with the officials
using employment and medical supplies as a means of garnering support
for themselves and clinching votes for the next election.

Lariosa’s
experience in Tagapul-an is but one illustration of this. The
frustrated doctor in western Mindanao also recounts that when she was
the municipal health officer of another poor town in the southern part
of the region, she had displeased the mayor when she dispensed medicine
to every patient needing treatment instead of just the mayor’s
followers. She didn’t win points either when she refused to sign
procurement forms that she deemed questionable. When she resigned
sometime last year, the mayor replaced her with a favored midwife,
instead of the nurse, the RHU’s second in command.

Now
the doctor is in yet another impoverished town, this time under the
Doctors to the Barrio program. But she says it feels like she hadn’t
moved at all. The first-term mayor in her new assignment has taken to
appointing unqualified people as barangay health workers, for one. For
another, says the doctor, patients must have their RHU-issued
prescriptions signed by the mayor’s office before the medicines are
released.

"There
is a common practice in many LGUs (local government units) where RHU
patients get their drugs from the municipal hall rather than from the
RHU," notes a study by the Department of Health (DOH) and the
Management Sciences for Health (MSH), a nonprofit international
organization working in public health areas.

The
study describes the practice in a town in northern Luzon: The RHU
doctor prescribes the drugs, the patient goes to the social welfare
office to get an approval of indigency, and then proceeds to the office
of the sangguniang bayan (town council) chair on health committee where
the drugs are dispensed. To assure safety and regulate the validity of
drug dispensing, the patient is asked to go back to the RHU for further
instructions on the intake of medicine.

The
risks involved in the practice, the study says, are "when the patient
does not go back to the RHU for final… approval and when the wrong,
inappropriate drug is given to the patient." RHU doctors themselves say
that those who happen to support the opposition also do not bother to
go to the town hall for their medicine, knowing the chances of being
given some are small anyway.

Many
of the doctors also complain that a change in local administration
means a change in health workers. Unfortunately, the newcomers are
often unqualified for the job that had taken their predecessors years
to learn.

A
doctor in Eastern Visayas says barangay captains removed barangay
health workers who didn’t belong to the same party and replaced them
with untrained ones. Another tactic was hiring new workers while
keeping the incumbents "floating."

When
the doctor offered to train the new workers, he was spurned and even
accused of meddling. "I was building a good referral system, so there
should be no breaks. Barangay health workers are important," he
explains. "The mayor also hired midwives as casuals."

Labajo observes that a lot of barangay health workers are "nonfunctional": They do things other than deliver health services.

Months
before the 2004 elections, for instance, the mayor and political
candidates of the Eastern Visayas town fielded the barangay health
workers, midwives and casual employees to conduct "data gathering."
They went around the island to survey who the residents were voting
for. "It’s that strategic," the doctor says. "Politicians paid P500 per
voter, and more for those who may not vote for them."

Labajo
says even governors have recognized that barangay health workers are a
political force in elections and offer to pay half their salaries or
make them casuals or contractuals of the provincial government. "As
casuals, they get P2,500 to P3,000 a month. That’s a lot of money in a
poor town," says the doctor from Eastern Visayas.

In
many places, barangay health workers don’t even report for duty but
still draw their pay. "Mga ‘15-30′ sila," the Mindanao doctor says,
referring to employees who don’t work but show up at the town hall or
capitol every 15th and 30th of the month to claim their paycheck.

Labajo
says a town with 24 barangays could have as many 184 barangay health
workers. But she notes, "The number of barangay health workers doesn’t
necessarily mean that you have a good ratio of barangay health workers
to the population or that the barangays are being serviced."

Some
mayors do not stop at hiring and firing barangay health workers at a
whim. In some towns, mayors have demoted doctors who disagreed with
them or had somehow displeased them and appointed nurses and midwives
in their stead as officers in charge of municipal health offices.

Doctors
whose relationships with their mayors become strained but continue to
stay in their posts often lose effectiveness in carrying out health
programs. For instance, the RHU in a northern Mindanao town hardly had
any local health programs to speak of because the mayor and the RHU’s
staff were not on speaking terms.

Community
doctors who butt heads with local officials find to their
disappointment that other government agencies can hardly come to their
aid. In many towns, the local health board rarely or never meets, or is
under the mayor’s control, says one doctor assigned in Mindanao. The
board consists of the mayor, president of the barangay health workers,
the rural health physician, and one representative each from the DOH
and the sangguniang bayan.

Much
as he had wanted to engage the mayor and sanggunian officials to push
Tagalpul-an’s health program, Lariosa had realized there was little he
could do. The mayor was in town just once a month, staying for about a
week; most of the time he was in Calbayog, where he also kept a house,
supposedly following up with other government agencies.

Lariosa
couldn’t turn to the sanggunian for support either, since it hardly
ever convened sessions. "The resolutions are passed around the barangay
where they happen to be for their signature," he says.

But
things came to a head when the mayor’s nephew sought treatment at the
RHU and found it empty. The doctor and his staff were out implementing
a DOH campaign and the staff assigned to man the health center had
failed to report to work. The angry mayor nailed the RHU shut. Recounts
Lariosa: "The following morning I told the mayor what he did was
unfair. Hindi kami naglalakwatsa (We weren’t out having fun)."

It
may take some time before the DOH sends another barrio doctor to
Tagapul-an. The town would first have to convince the national
government that its local officials and community leaders are
cooperative enough to deserve another barrio doctor.

Lariosa
was actually the second barrio doctor to become a casualty of local
politics in Tagapul-an. Danilo Reynes, the town’s first physician after
a doctorless decade, belonged to the Doctors to the Barrio program’s
first batch. He stayed there for four years, but left because incumbent
officials perceived him to be allied with their political opponents.

Lariosa
was not the only barrio doctor withdrawn from their places of
assignment. Two doctors from the Western Samar towns of Matuguinao and
Jiabong were pulled out for the same reason: The mayors refused to
abide by the agreement that full support for health be given that are
within their very limited resources.

A
few years ago, two of seven barrio doctors assigned to a northern
Mindanao province cut short their stint, saying they could not stand
the treatment they were getting from their mayors. Says one of the
doctors: "I left feeling really bad. I didn’t even want to be
reassigned. My idealism had been shattered, I had been disillusioned. I
go to another local government unit, and there would be yet another
mayor who would be controlling my life."

Doctors
who have lodged complaints against their mayors to their governors, the
DOH, the Department of Interior and Local and Governments and the
Department of Budget and Management say many of these remain
unresolved.

Still,
when the local government puts importance on health, success stories
like that of Concepcion are possible. Robert Briones, who gave up a
lucrative private practice to become a barrio doctor in the island town
of Loreto in Surigao del Norte, also says he does not regret his
decision, even if it has meant being away from his wife and three young
children, aged six, four, and two.

"I
frequently wonder….what is happening to them," he says. "But in my
journey as a doctor to the barrio, a doctor in a far-flung
community…one thing is apparent. This (has) made me affirm that ‘it is
not the end of the journey that matters most but the journey itself is
what matters in the end.’"

Even
Lariosa has not junked the idea of serving communities despite his
rather tumultuous experience in Tagapul-an. He admits mulling over the
idea of residency training in internal medicine or surgery after
finishing his contract as barrio doctor. "But I’m having second
thoughts," he says. "The work of a public health practitioner is
challenging."

Lariosa’s
younger sister has just graduated from medical school and plans to go
straight to residency training. "But I’ll try to expose her to the
Doctors to the Barrio program when she visits me in Batanes in the
summer," says Lariosa. "There are bits of ugliness, but I think my type
of work is beautiful."

Well, at least I was able to migrate all of my personal blogs from BloogerGAN to this Friendster Blog. Now, I can focus on my Tech Blogs in the BloogerGAN Blogsite.

Here I go again, still undecided on what to do. Other options have been decided on to, the only thing left is if those "options" will accept my decision. Working in a call center is a bomb, liked it very much, but the problem is, it doesn’t give me the satisfaction I have when I was working in a hospital. The adrenalin rush is really not there.

The other day, we had our first meeting with our Team Sup, he asked us about our goals, asked us what’s our purpose why we were there? Of course most of them replied with the usual, I want to be this and that, but for me, what else can I ask for, professionally, I’m at the top of the heap, I’m already a Doctor, so what more can one ask for, be a Lawyer? Hehehe

I guess, the pay is a big factor when decision comes, especially for those who has a family to think about. But there’s always that factor of self-satisfaction. There should be balance, as most of us will say, but when you’re in that situation, it’s hard to get that balance. A friend of mine said, for her, at this time, it’s self-satisfaction first, she’s not looking for that big fat pay check first. She said, perhaps, it’s becuase she’s a girl, because, when and if she finds her guy, worrying about the finances would be his problem. Perhaps she’s right, I can’t compare her with me, since we’re too different person with two different situation.

I’ve been contemplating of resigning my current job, but what will I do if I quit? Well, I’ve never been a quitter, but with my current situation in the office, well, it’s affecting my team. The reason? I don’t know how to sell, they told me it’s part of the job, then I guess, this is not the job for me. Going back to hospital work is always an option, it’s always there, waiting for me to come back, but when?

I really don’t know  what’s wrong with me, although I know that I’m wierd in most sorts, but the other night, while on my way to work, I felt sad. Don’t what’s it was about, but I guess it’s the work. Before, I was so proud of getting or having this job, then again most of my friends told me that I will never stay long in this new found job of mine. But I said no, I told them and myself that I’ll be able to survive the pressures this will bring me, I was wrong. It’s really not the pressure of the job, but the lack thereof perhaps is what makes me feel this way. Eversince, all of the "jobs" I had have the adrelin rush feeling. There’s that sting that I feel everytime I go to "work", there’s excitement and the hoope that a new thing will come out of this new day. But with my current job, I guess the excitement is not there. It’s sooooo BORING! Then I think the only thing that’s making me stay with this job is the pay. None of my preevious "works" did pay this much, even so, I was happy with it before. Perhaps I would just convince myself just a little bit more to stay a little bit longer. Then have a self evaluation after it.

Tomorrow I got my BRAND NEW Headset, I think this indicates that there’s no more turning back from this new found career of mine. Anyways, I’m still holding on with my schedule, although this is just half of the wake up hours I spent in a hospital duty.

I’m nearing the end of my shift and so far, everything’s doing fine, hopefully this thing goes all the way ’til the end shift. And hehehehe I’ll just be waiting for the day’s evaluation hahaha, GOOD LUCK TO ME!