|
By Avigail M. Olarte and Yvonne T. Chua, Philippine
Center for Investigative Journalism
Second of Three Parts
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 the 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. In 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
health unit was the only one in the local government that was
granted an increase.
Giving low priority to health
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 for 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 US-based Center for Institutional Reform and the Informal
Sector, 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 reelectionists
normally cite their public works record as a measure of their
performance. Even barangay officials use their local funds to build
waiting sheds, basketball courts instead of spending them for
health.”
Curative, not preventive
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, which fund health programs and the
purchase of medicines and supplies, made up only a fifth of the
budget.
The budget of a rural health unit, 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, Labajo
points out, 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.
Medical innovations
This has resulted in municipal and urban health
doctors being forced to innovate for 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 a 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 rural health units 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 also distributes drugs in line with national health programs,
besides the usual antituberculosis drugs, vaccines and
micronutrients. But local health units rely mainly on their internal
revenue allotment and locally generated funds to buy medicines and
supplies.
Yet since many doctors are hardly involved in
local budgeting, they find it hard to lobby even for just the basic
things needed by their RHUs. A municipal health officer based in
Central Visayas 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.
A good indicator
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 tiny rooms 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 a
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 medicolegal allowance.
Discrepancy in salaries
Health personnel on 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. Most of the 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 rural health
physicians hired by the Department of Health. 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 health
department 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 health department’s 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 dismissed 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.
In September the Association of Provincial
Health Officers of the Philippines issued a manifesto addressed to
President 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 Pacita 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.
Health Sector Reform Agenda
Pangasinan was also among the pioneer provinces
that enforced the health department’s Health Sector Reform Agenda.
Implemented in 1999, the agenda sought to improve the financing and
delivery of health services.
The agenda, among others, encourages the
creation of “interlocal health zones,” or districts or catchment
areas composed of neighboring municipalities, to improve 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 espouse local programs and reforms to their
mayors.
The agenda, which has reforms in hospitals as
one of its components, also allows for a systematic pooled
procurement in provincial hospitals. Mejia says the bid 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 the quality of drugs and their procurement at lower costs.
But Mejia says they have yet to persuade the municipalities to adopt
a similar system. With money involved, she says, procurement has
become a very sensitive issue.
--With Avigail M. Olarte )
(To be continued)
Part 1 |
|
