introduction to improving municipal health systems

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)