introduction to improving municipal health systems
DESCRIPTION
Webinar on Local Health SystemsTRANSCRIPT
Center for Local Health Governance
Webinar on Municipal Health Systems by Bien Eli Nillos MD
Aug.3 2012
M y
L e a d e r s h i
p J o u r n e yBien Eli Nillos, MD
Former Doctor to the Barrios
Municipality of Candoni, Negros Occidental
Bien Nillos, MD
M.D. – 2006, University of Saint La Salle
BS Biology – 2002, University of Saint La Salle
Doctor to the Barrio – 2007 – 2010, DOH/Municipality of Candoni, Negros Occidental.
Currently an Associate Professor for Family and Community Medicine (University of Saint La Salle)
Fellow, Zuellig’s HLMP Training
Alumnus, U.S. State Department (Northern Illinois University)
Alumnus, Global Health Course, University of Tampere (Finland)
Candoni, Negros Occidental
Population: 21,000
4-hour bus ride from Bacolod City, 1 and half hours away from Kabankalan City
Surrounded by other towns and cities (CHICKS)
Problems Encountered
Poor Health Indicators
Inaccessible health
care services
Limited Human and
Financial Resources
Poor Health Seeking
Behaviors
Maternal Mortality per 1,000 LBs
3.6
5.8
0.92
0.63
0
1
2
3
4
5
6
2006 2007
Candoni
Region 6
National
Facility based deliveries – 24% in 2007
Skilled birth attendant deliveries – 74% in 2007
Top Causes of MM – post-partum bleeding, Pregnancy Induced Hypertension
Infectious (Pulmonary
Tuberculosis)
0
20
40
60
80
2006 2007
Case Detection Rate
Candoni
National
Cure Rate – 93% in 2007
No med. Tech. – only 1 midwife microscopist
Practicing TB DOTS but not Philhealth accredited
Infant Mortality per 1,000 LBs
26.5
10.1 9.2
0
5
10
15
20
25
30
2007
Candoni
Region 6
National
Top Causes of Mortality: Severe Pneumonia, Severe Diarrhea
Compounding Factors
“The greatest intelligence is precisely the
one that suffers most from its
own limitations” – Andre Gide (Nobel
Prize for Literature, 1947)
POLITICS
ACCESS
LACK OF…
“We are limited but we can push back the borders
of our limitations” – Stephen Covey
“Change will come
when those who
have the resources
learn that they do
not have all the
answers…they need
to learn how to
listen.” – Desmund
Tutu
Alma Ata Declaration
“The people have the right and duty to participate individually and
collectively in the planning and implementation of their health care.” -
Alma Ata Declaration of 1978
COMMUNITY HEALTH INITIATIVES
PARTNERS (CHIP)
Members: Barangay Captains,
Brgy. Kagawads for Health, SK,
BHW Federation
Role: Coordinate all health
program implementation at the
barangay level, initiate
community-based health
programs through original
approaches.
Relations and Advocacy Managers (RAM)
Members: Teachers, Faculty-in-
charge, church-based
organizations, PNP and other
NGO’s
Role: help in the promotion of
health advocacies in schools
and communities through
integration.
Legislative Action Network (LAN)
Members: Political leaders,
councilors, department heads,
NGO’s
Role: provide strong legislative
support for health programs,
influence policy in favor of
health initiatives
MONITORING team (MONITOR)Members: Program coordinators,
DOH representative,
PHO/CHD/Philhealth, Public health
managers, MPDO, Budget Officer
Role: Monitor progress of
initiatives, plot outcomes and
results and provide feedback to
community at large.
Engaging the Community
Assembly of hilots and revival of Women’s Health Team
Legislative support –barangay ordinances
Increased advocacy and social awareness
Training of midwives and nurses (refresher’s course)
“There go my people. I must find out where they are going so I can lead them.” ~ Alexandre Ledru-Rollin
“Example, whether it be good or bad, has a powerful influence” – George Washington, quoted from his letter to Lord Stirling (March 1780)
Upgrading A Local Health System
Part Two on Candoni Case
Bien Eli Nillos, MD
Former Municipal Health Officer
Consider this…
All 3 components are essential.
Hardware = equipments, logistics, physical environment
Software = local health system, predominant culture
Peopleware = Actors
Why “Upgrade?”
Excellent Hardware
and Software but
illiterate Peopleware
Excellent Software
and Literate
Peopleware but Poor
Hardware
Excellent Hardware
and Efficient
Peopleware but Poor
Software
Slow rendering of
outputUseless, Impotent
Frustrated, Lost,
Apathetic
Community Health Initiative Partners (CHIP)
Relations Advocacy Managers
(RAM)
Legislative Action Network (LAN)
MONITORing team
3.6
5.8
0.920.63
0
1
2
3
4
5
6
2006 2007
Maternal Deaths per 1,000 Lb
Candoni
Region 6
National
26.5
10.1 9.2
0
5
10
15
20
25
30
2007
Infant Deaths per 1,000 Lb in 2007
Candoni
Region 6
National
0
10
20
30
40
50
60
70
80
2006 2007
TB Case Detection Rate
Candoni
National
No Botika ng Barangays
Dilapidated RHU
Low number of deliveries attended
by skilled birth attendants
No indigents enrolled in Philhealth
High malnutrition rate
Internal and External Environments
Challenge: Motivation to
work (feeling of insufficiency,
routine work, professional
jealousies)
Strategy: Treating them as
partners, important
contributors
Activities: Workshops, team
building, SOP’s, assignment
of program coordinators,
trainings and seminars
Internal and External Environments
Challenge: direct interest and attention to health (dole-out mentality, political patronage, etc)
Strategy: Validation and affirmation of Vision –hopes for Candoni.
Approach: Gather influential leaders in the community, and empowering of community through these leaders.
Issue No. 1: Maternal Mortality
Ratio
“Hardware” – Dilapidated RHU, BHS not
capable of handling normal deliveries, lack
of supplies, inaccessible puroks, sitios
“Software” – poor referral system, lack of
tracking system for pregnant clients,
policies on hilot delivery, “cultural”
“Peopleware” – predominance of TBA, no
Women’s Health Team
Assembly of Hilots
Integrating the TBA’s in the “new set-up”.
Important partners and collaborators (WHT)
Support of the Barangay Captains
Barangay Ordinances
New Protocols for RHU Staff
9 barangays with 9 midwives
1 midwife-in-charge of DR
BHW catchment areas (atrition policy)
SOP on referral system
Lifesaving skills and Perineal suturing
Upgrading RHU/
equipping BHS
Selling the Idea to the Community
“Alkansiyang
Pampamilya”
“Buntis Baby Bags”
24
58
5.8
7479
0
85 87
00
10
20
30
40
50
60
70
80
90
2007 2008 2009
FBD
SBA
MMR
FBD = Facility Based Delivery
SBA = Skilled Birth Attendant
MMR = Maternal Mortality Ratio
THE OUTCOMES
26.5
10.19.2
21.8
4.14
0
5
10
15
20
25
30
2007 2008 2009
Candoni
Region 6
National
Infant Mortality Rate Trend
Issue No. 2: Inaccessibility to
Cheaper Medicines
Hardware: “geographically challenging”
Software: “dole-out mentality” “Credit is
good because I don’t have cash” motto
Peopleware: “Barangay captains hesitant to
start up a BnB due to fear of lack of
sustainability”
Establishment of Botika ng
Barangays 9/9
Establishment of Botika ng
Barangay Monitoring
Team: DOH
representative, Municipal
Accountant, BnB Operator,
Nurse Coordinator, Brgy.
Captain
Under the LHB
Issue No. 3: TB or not TB
Hardware: “dilapidated RHU, Microscopy
lab”
Software: “while practicing TB DOTS, lack of
aggressiveness in tracking symptomatics”
Peopleware: “less motivated(?) staff”
“community unaware”
One additional midwife trained as Microscopist
Aggressive TB awareness campaign
Lung Month Celebrations
Philhealth Accreditation
TB DOTS Program
0
10
20
30
40
50
60
70
80
90
100
2007 2008 2009
CDR
Cure Rate
CDR = Case Detection Rate
My Role, The PontiffLatin Pontifex – pons (bridge) + facere (to make) = “bridge builder”
"I pray that I may never meddle, interfere, dictate,
give advice that is not wanted, or assist when my
services are not needed. If I can help people, I'll do
it by giving them a chance to help themselves; and
if I can uplift or inspire, let it be by example,
inference and suggestion, rather than by injunction
and dictation. That is to say, I desire to be Radiant
-- to Radiate Life!"
-- Elbert Hubbard
Struggles/Challenges
“Anything worth doing is
difficult” – Patch Adams
Quo Vadis, Doctor?
“I seldom end up where I wanted to go, but almost always end up where I need to be.” – Douglas Adams
“It is the time you have wasted for your rose that makes your rose so important.“
– The Fox (The Little Prince, Chapter 21)