Good day everyone. This is Dr. Ela Mi Tabura and I will be discussing about the health care system services and development. For the objectives of this lecture, first is to describe the concept of a health system from a global, national and local viewpoints. Second is to recognize the goals and functions of a health care system. Third is to gain an understanding of the organization of the health care system in the Philippines. And lastly is to acquire a broader understanding on health financing, health governance and regulations and health system performance within the context of the Philippines. So we will be discussing four topics um under the health care system services and development. So first we will be talking about the health care system in general. Next we will be focusing on the Philippine health systems and services. Third are the health sector reforms and lastly we will be talking about the strengths and weaknesses of the Philippine health care system. So first let us talk about the health care system in general. According to Bertilani in 1968, a system is an arrangement of parts and their interconnections that come together for a purpose. ROR in 1991 defined health system as the combination of resources, organization, financing and management that culminate in the delivery of health services to the population. The world world health organization also um defined health system as all the organizations, institution and resources that are devoted to producing health actions. As you can see in this diagram, the health system, it consists of many parts such as the community, pharmaceutical companies, the department of health and other organizations related to health. So the goals and function of a health system um it includes improving the health of the population, improving the responsiveness of the health system itself and providing fair health financing. So first let us discuss the goal of improving the health of the population. So the overall achieving goal of our health care system is the improvement of health to the population across different social economic groups. So as you can see slide no please read nang but to summarize since different countries have different health systems. So meaning disparities even within the country itself. So factors disparities. So like we have income, the ethnicity, the location, sexual orientation etc. So the system should recognize and make the reduction of these disparities a central goal in healthcare planning and imple implementation to improve the overall health of the population. So next goal is improving the responsi responsiveness of the health system. So responsiveness. So responsiveness in health care system represents the concept that the health system provides services in a manner that people want or desire and engages people as active partners. So it should embodies m values like respectfulness, non-discrimination, confidentiality and humaness. So our a responsive health care system empowers individuals by promoting their autonomy and involvement in the decision making ultimately placing them at the center of the health care system. So the third main goal is providing fair health financing. The WHO definition of a fairly financed health system is one that does not deter individuals from receiving needed care due to payments required at the time of service and one in which each individual pays approximately the same percentage of their income for needed services. So ideal healthare system should provide social and financial risk protection so So now let's talk about the functions of a health system. We have four vital functions of a health system. First is health care provision. Health service professional. So this refers to the delivery of health care to individual and communities. It encompasses all activities aimed at promoting, restoring and maintaining health. Health service provision is the delivery of health care at various levels. So we have the primary um which is your first point point of contact. This includes the prevention diagnostic um therapeutic services and etc. Next is the secondary care where specialists stepped in. So if primary care usually um your general practitioners we go to the specialist. This is shortterm and um uh it needs now the input of a specialist like the gastroenterenterologist um cardiologist, neurologist etc. And lastly the tertiary care which are um conditions that are relatively uncommon and it uses um highly specialized equipments or the treatment is highly specialized. Quality and safety are the heart of health service provision. This means following best practices, ensuring patient safety and continuously improving care provided. Next function is health service inputs. This refer to the resources and components that a health system needs to function. from the people delivering care to care to the facilities, medicine and technologies they use to fund and datas that supports them. These inputs are what makes a health system work. So as you can see no um for a health care system to function hospital it also needs funding um information system which is very useful hospital and lastly the healthcare workers. The third function of a health system is stewardship. This is all about the overall system oversight and setting the context in which the health system operates. It's typically the responsibility of the government and it involves creating the policy framework that guides the entire health system. So we have four core functions of stewardship for one of the key responsibilities of stewardship is identifying the health priorities that the public resources should target. This means determining which health issues are more important to address and ensuring that funds and resources are directed to those areas. Stewardship also involves establishing the institutional framework within which the health system operates. It also requires coordination with other systems external to health care such as education, environment and social services. And this uh to ensure that the health policies are aligned with broader societal goals. So lastly, stewardship also involves monitor monitoring trends in health priorities and resource generation. By understanding these trends, policymakers can anticipate future needs and challenges ensuring that health system remains responsive, responsive and sustainable. The last function of a health system is health financing. So this involves three key components. So uh first collecting revenues, next is pooling financial risks and third is allocating resources effectively. Revenue collection is a process of gathering money to pay for healthcare services. So revenue collection. So through tax, mandatory payroll contributions, donor financing or direct out-ofpocket payments and even personal savings. Risk pooling involves collecting and managing financial resources in a way that spreads financial risks across all members of a pool. This is the core function of health insurance systems like Phil Health. The third component is strategic purchasing. This refers to how poolled finance financial resources are used to finance or buy health care services for its members. Now let us focus on the Philippine health system and services. So the Philippines is an archipelago archipelago in the Southeast Asia with a population of 104.9 million as of 2017 making it the 13th most populous country globally. So the majority of the Filipinos are Christian males and we have a literacy rate of uh 96.5. So life expectancy in the Philippines has risen from 62.2 years in 1980 to 69.1 years in 2016. Um this is basically um due to the improved living conditions per We still face um health challenges like tuberculosis which is very endemic there is a um at country pneumonia heart disease um neoplasms and diabetes. We also are very exposed to disasters ranking third globally frequent with frequent strong typhoons. The country's most pressing health issues are inequalities in health status and access to health care services stemming from structural flaws in the health care system prompting recent health reform efforts. So the current population um of the Philippines as of August 17, 2024 um is uh 115 millionaud compared to 2017 no um the population is equivalent to 1.42 of the total world population. we still rank 14 um list of countries and the median age is 25.7 years. So in this table you can see that Filipinos tend to live longer now than in the previous decades with life expectancy at birth increasing from 62 years in 1980 to 69 years in 2016. The life expectancy trend is reflective of the improving living condition in recent years. However, mortality rates declined from 291 and 29 per 1,00 men and women respectively. So based on the Philippine statistics office, the top three causes of death in the country from January to May 2003 I 2023 rather were es schemic heart disease, neoplasms and cardiovascular disease. So in this figure the darker colors um show show strong increase in the impact while lighter colors indicate decreased impact between 2010 and 2019. So can blue ones um non-communicable diseases such as eskeemic heart disease and stroke. can orange or red ones. They they comprise the the communicable diseases with a growing impact on um TB, respiratory tract infection, a neonatal disease and the green one although gam portion no um these include the common injuries per they should not be neglected this is also a growing category um organization of the health care system. So the Philippine health system is a dual health system composed of the public and private sectors. So health services in the public sectors are provided by the health facilities run by the national and um local government units and are large largely financed through tax base. So gigani sa to ang tax guys. On the other hand, the private sector is largely marketed oriented I sorry market oriented where health services are generally paid for through user fees at the point of service. So as you can see private healthcare facilities they include m specialty clinics uh general private hospitals and private clinics. So in 2022 about 23,000 Baranga health stations provided healthc care services to about 42,000 barangis in the Philippines. Meanwhile there were 277 municipal health centers, 638 city health centers and 1,75 rural health units. So actually I work under Cebu City Health Department deployed in Bulako Health Center. So I can say personally having a doctor in health centers especially lowerconomic groups one doctor per baranga health center big impact healthare system. So in this slide you can see the functional structure of the department of health health in the Philippines in 2017. So the DOA structure shown reflects the major organizational changes brought brought about by the strategic review and rationalization of government agency agencies and functions under the executive order number 366. Um this executive order was affected by the DO in 2013 and the major organizational change includes number one they standardize standardize the nomenclature of bureaus services and regional offices. Next they streamline the functions divisions and staffing pattern of the entire agency. And third they emphasize the do leadership and policy setting role for the whole health sectors. So besides the do you can see other organizations like the depth ed state colleges universities or do even do provide direct health services with within their respective legal mandates. So first let us discuss the public health care system. So previously our health care system was used to be a highly centralized health system run by the do. So with the passing of the different bills and law, our health care system became a fragmented system consisting of more than a thousand autonomous local health system run by provinces, cities and municipalities. Although the DO still maintained its role as a steward of national policies, plans, standard standards and regulations on health while the local government units were given the responsibility of being managers and providers of direct health services at a local level. So as you can see in this figure, it shows the different units retained in the do. this one with a color darker blue green and those that devolve to the LG use mga gray colors. So next is the private private health care system. So the private sector consists of thousands of for-profit or nonprofit health providers which are largely market oriented where health care is generally paid for through user fees at the point of service. So usually hospital or private clinic after what's consultation to pay the doctor. Then um we should also remember private healthcare se sectors is still regulated by the government through a system of standards and guidelines implemented through the lensure procedures of the do and accreditation procedures of Phil health. So as you can see this figures comprise private health sectors no we have the clinics infirmaries laboratories drug manufacturers etc. Um the JCI or the Joint Commission International is an independent notfor-profit organization. Um they best identify, measure and share the uh best practices in quality and patient safety around the world. So we have in the Philippines we have five hospitals that hold accreditation from the joint commission international and one is in Cebu City which is the Chongwa hospital. So other hospitals accredited are the Asian hospital and medical center, the medical city, St. Luke's Medical Center and Makati Medical Center. So we have the nonformal private health sectors which include the traditional healers or the albularios, the healots or the traditional birth attendants which are not covered by any licensing or accreditation system by the government. So other relevant private organizations and non-government organizations include the Philippine Medical Association, Philippine Dental Association, and Integrated Midwives Association of the Philippines. So next are the services that the national and local government provide and pay for. So the public and private healthc care facilities exist for all levels of care primary to tertiary. In this table you can see the responsibilities of the national and local governments in the provision of healthcare. We should take note that there are three categories of local governments. So the provinces, the cities and the municipalities all of which are political jurisdictions with elected officials. So on municipality facilitates mainly in providing primary care through the health centers on provinces they provide primary care level in infirmaries and secondary care level in district hospitals and cities they may provide primary and secondary services. However cities they may operate on a tertiary level hospital. So as you can see in this table, the average hospital size measure by the number of beds is 83.1. The average size increases to 109 for public hospitals and a decrease in 68.8 in um private hospitals. So we can conclude now higher number of people to public hospitals because public hospitals run and some services are free of charge. So let's now talk on financing healthcare. So based on the n Philippine National Health Accounts as reported by the Philippine Statistics Authority, the 2022 total health expenditure or the THE comprise 93.3% in current health expenditure and 6.7% in health capital formation expenditure. So in figure 2, the government schemes and compulsory contribute contributo healthcare financing schemes corner the highest share of the CHE or the current health expenditure in 2022 at 44.8% amounting to 52.9 billion. However, this is almost as the same level as household out of pocket payment which is at 501.8 8 billion 40 44.7% of the CHE. So the financing schemes include the country's health financial system groups that direct their revenues to pay for or purchase healthcare goods, services and activities. So in this um data you can see that the yellow portion or the non-communicable diseases had the highest rate in the current health expenditure in 2022 amounting to 449.2 billion or 40% of the um the budget. So it was discussed earlier non-communicable diseases which includes the eskeemic heart disease. It's a top three reason for the morbidity and mortality of the people here in the Philippines. For the next four slides, I will be discussing a brief overview l of the Phil health. The national health insurance program or NHIP is managed by Phil Health which receives premiums from households, firms and governments. Established in 1995, Phil Health is the largest health insurance risk pool in the country and has the largest network of accredited medical professionals and health facilities. Phil Health reimbures health care costs at both public and private facilities per it only matches a part of the total healthcare cost ranging between 30 to 70% maximum. This is to ensure allocation every time we use our healthare and minus or deduction gives healthcare total bill diagnosis. So the more complicated diagnosis the bigger deduction s health the role of Phil health is limited due to the skewed distribution of health facilities limitations in type of care covered and limited depth of financing services or the share of the health care costs reimbured. So diagram but I will discuss it thoroughly. This diagram provides a simplified overview of how Philippine health care is financed in a system involving household firms, government and insurance providers like Phil and health maintenance organizations or HMO. So first column you can see household and firms. Both households and firms contribute to the health care system through pre premiums paid to insurance entities like Phil Health and HMOs. Households may also make out-ofpocket payments directly to healthcare providers. In the next column, as you can see, the government it plays a dual role in the system. It collects tax or general taxation from households and firms and allocates these funds through budget appropriations to Phil health and directly to healthcare providers. This helps in subsidizing health care costs and ensuring broader access. Next is the Phil and private insuranceances. These entities collect premiums from households and firms and use the funds to make insurance payments to healthcare providers. And lastly, the healthcare providers. They receive payments from both insurance companies and out-ofpocket payments from households, thereby providing the necessary health services. In the essence of this flow, it shows the flow of funds in this system that ensures health care is financed through combination of taxation, premiums, and direct payments allowing more accessible and sustainable health care system. Now let us understand Phil health whatever field or what wherever you are whether working here s Philippines or in abroad health deduction. So the Philippine health insurance corporation or Phil health is a government-owned and controlled corporation that administer the national health insurance program. Its primary goal is to ensure that all Filipinos have access to affordable health care services. Phil Health operates under the principle of social solidarity pooling resources through member contributions and government subsidies meaning but in return access to a range of health benefits. Moreover, Philippine supports the Universal Health Care Act, which aims to provide comprehensive health coverage to all Filipinos, ensuring that no one is left behind. Now, let's talk about how Phil Health works. Membership in Phil Health is mandatory for all employed individuals with contributions automatically deducted from their payroll and employers also share the cost. So deduction may appeal voluntary payers. No. So it includes the self-employed, the overseas Filipino workers or or OFWs and those who who choose to join voluntarily fixed premium amount that is paid directly sil health. Additionally, the government subsidizes contributions for indigents and senior citizens. So usually ifenior citizens before age of Philatically they are enrolled to Phil and admit total bill health deduction. So once you're a member of Phil Health, you can avail um yourself of various benefits which includes inpatient care, outpatient services, and preventive care. Phil Health covers a significant portion of medical expenses, reducing the out-ofpocket costs for members. This is managed through case rate system where specific illnesses or procedures have a fixed amount of coverage. So procedure diagnosis deduction to Phil health. This helps me know exactly how much support they will receive for their medical needs. So in summary, Phil health is an essential part of the health care system in the Philippines, ensuring that Filipinos has access to necessary medical services without without the burden of excessive cost. As of December 2017, the top four categories of health professionals working in health institutions are the nurses, followed by the doctors, next their midwives, and then the medical technologist. So unlike doctors, more nurses, midwives and medical technologists work in public institutions because we all know public institution. So this hospital ccentric distribution of doctors and nurses in health institutions is reflective of a model of care that diverges from the ideal setup of a first point of contact at the primary care level. So the Philippines is known to be the the highest labor exporting country despite many different policy efforts to reduce the flow. In recent years, an average of 13,000 nurses migrate every year. So blame no especially the nurses because um as a personal experience I I have worked in a public hospital and the ratio nurses to patients overwhelming for the nurses around one nurse 40 patient then per procedures. Very underpaid. So that is the reality of our healthare system in the Philippines. Now let's talk about the health sector reforms. We will be talking about the legislative milestones in our health system for the past 30 years. The major areas of the following health reform initiatives are the health service delivery, health regulation and health financing. These health reforms targeted addressing issues about um poor accessibility, inequity and inefficiencies in our healthcare system. To start in 1970, primary health care for all was developed. Um during this time, our country developed a largely centralized fund um centralized government funded and operated healthcare system. In 1979, there was an adaptation of the primary health care which promoted participatory management of the local health care system. In 1982, there was a reorganization of the department of health for the integration of publicos public health and hospital services. In 1986, uh milk code act was uh made which regulates the marketing of infant milk formulas and other milk products. It also promotes uh breastfeeding. In 1988, the generics act um through this act prescriptions are written using generic name of the drug in attempt to lower the expenditures on drugs by promoting and purchasing um not branded medicines. In 1991 or the Republic Act 7160 the local government code there was a transfer of responsibility of health services provisions to the local government units. In 1995 the n national health insurance act which aims to provide all citizens a mechanism for financial protection with priority given to the poor. In 1996, health sector reform agenda was made and the major organizational re restructuring of the department of health which improve the way healthcare is delivered, regulated and financed. In 2005, Formula 1 or F1 for health was made. There was an adoptation of the operational framework to undertake reforms with speed, precision, and effective um coordination. In 2008 or the Republic Act 9502 or the access to cheaper and quality medicine act was made which promotes and ensures access to affordable and quality drugs and medicines for all. In 2010, the administrative order 2010-000036 or the Kalugang Pang Kalhhatan was made um which promotes um universal healthc care coverage for all in 2013. Sin taxes for health generating extra revenue for the department of health by discouraging harmful consumption of alcohol and tobacco. So during this time cigarettes and tobacco. And as you can see, pictures of the consequences of long-term um smoking. Although um last 2019, President Duterte signed the universal healthc care law enrolling all Filipino citizens automatically to the NH NHIP program administered by Phil which goal uh goal of this law is that all Filipinos are guar guaranteed equitable access to quality and affordable healthcare services. So let us first talk about the universal health care. This is also referred to as kosugan pang kalahhatan. This is the provision to every Filipino of the highest possible quality of health care that is accessible, efficient, equitably distributed, adequately funded, fairly financed, and appropriately used by an informed and empowered public. It is a government mandate aiming to ensure that every Filipino shall receive affordable and quality health benefits. So angusto is that all Filipinos have access to quality health care regardless of their socioeconomic status. So three strategic thrusts corresponding to the main goals have been formulated to achieve theatan. So first is financial risk protection through expansion in enrollment and benefit delivery of the national health insurance program. Second is improved access to quality hospitals and healthcare facilities by upgrading to expand capacity and quality services. And lastly, attainment of the health related millennium development goals by focusing public public health programs on reducing maternal and child morbidity, reducing morbidity and mortality from TB and malaria, reducing prevalence of HIV or AIDS, prevention and control of non-communicable diseases, and lastly, preparation for emerging diseases. So the universal healthc care law of 2019. In March 2019, President Duterte signed the universal healthc care bill into law which is also called as a republic act number 11223. The major step is to enroll all all Filipino citizens automatically in the NHIP administered by the Phil health. So in the universal healthc care bill stricter delionation and mandates between the do and Phil health were emphasized. So number one the do to focus on population based health services like health promotion disease surveillance and vector control. Phil Health to focus on individualbased health services like services that can be accessed within the health facility or remotely and can be traced to one recipient only. Now let us talk about the issues in healthcare reform. So first is the oral disease. Oral disease is a serious public health problem creating an epidemic and heavy burden on school children. So dentists play a very limited role in education and prevention of oral diseases and generally see no role for themselves in this area. Another issue in the health reform is the lack of resources or in inequity in health and care. There are there were several factors why there are disparities across socioeconomic statuses. So factors like maternal health um access to health care services and regional allocation. So personal experience is that especially in maternal care no cuz I'm working in a um government institution. So mothers and most of us especially healthare how important prenatal is congenital anomalies help mother baby most parents especially lower soio economic groups aware how important important that is. So that's why mothersational problem so like gestational hypertension gestational diabetes. So I think uh one of the most important things improve is um patient education. Another issue in the healthcare reform is the e- health. So e- health e- health uses digital technologies and telecommunications such as computers, the internet and the mobile mobile devices to facilitate health improvement and health care services. It is often used alongside the traditional offline or non-digital approaches for the delivery of information directed to the patient and the healthcare consumers. So familiar word tele medicine. This was very useful during the pandemic allowed to go out can do check up. So what the government and the doawag to certain hotlines and your health problem. This was very useful and until now So we are down to our last last topic. So the strengths and weaknesses of the Philippine health sector. So the strengths adoption of the universal health care law reforms increasing insurance coverage significant growth in health expenditure stable precoid precoid economy projected growth large young population with a skilled workforce and continued financial support from the IFIs. However, our weaknesses include fragmented health care system due to decentralization, diversity of health systems varying from advanced to basic, slow and substantial governmental bureaucracy, chronic understaffing due to health worker migration, quality of care below regional standards, corruption issues affecting business cost and uncertainty, poor conditions of health infrastructure particular particularly in rural areas and substantial inequality with people paying substantial amounts for health services even in the public sectors. The following are the important government organizations with their specific activities. So first the department of health with which is the main body in healthcare in the government. Next is the public private partnership center national economic and development authority which is mandated to facilitate the implementation of the country's PPP program and projects. The food and drug administration which which is the main regulatory agency for registration of drugs, medical equipment, supplies and cosmetics. Phil health which is a single government health insurance agency. the Kits or the knowledge management and information technology service which is a do unit in charge of digital health applications. We also have the NAST or the National Academy of Science and Technology which advises the president and the cabinet on matters related to science and technology. the UPN NIH or the University of the Philippines National Institute of Health which was created on January 26 by the UP board of regions to strengthen the re strengthen the re research facility of UP Manila and serve as an institutional home of a network of researchers and research institutions. We also have the University of the Philippines which is the country's national university. This premier institution of higher learning was established in 1908 and is now a university system composed of eight constituent universities spread throughout the 17 campuses in the archipelago. And lastly, the Philippine General Hospital which is the country's leader in transforming the lives of the people through excellent health care, education, research and and it is accessible to all. So just go over an slide langu no need to memorize this one. So these are my references. Thank you everyone for listening. I hope you learned something a lecture and if you have questions regarding the topics please message your president and whoever is president section kindly collect the questions gives a you can message me through teams and I will try my best to reply to your questions as soon as possible. Again thank you all for listening and have a great day everyone.