Webinar on Local Health Systems

1. Center for Local Health Governance
Webinar on Municipal Health
Systems by Bien Eli Nillos MD
Aug.3 2012

2. My
L e a d e r s h i
p J o u r n e y Bien Eli Nillos, MD
Former Doctor to the Barrios
Municipality of Candoni, Negros Occidental

3. 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)

4. 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)

5. Problems Encountered
Poor Health Indicators
Inaccessible health
care services
Limited Human and
Financial Resources
Poor Health Seeking
Behaviors

6. Maternal Mortality per 1,000 LBs
6
5.8
5
4
3.6
Candoni
3
Region 6
2 National
0.92
1 0.63
0
2006 2007
Facility based deliveries – 24% in 2007
Skilled birth attendant deliveries – 74% in 2007
Top Causes of MM – post-partum bleeding, Pregnancy Induced Hypertension

7. Infectious (Pulmonary
Tuberculosis)
C e D tion R
as etec ate
80
60
40 Candoni
National
20
0
2006 2007
Cure Rate – 93% in 2007
No med. Tech. – only 1 midwife microscopist
Practicing TB DOTS but not Philhealth accredited

10. Infant Mortality per 1,000 LBs
30
26.5
25
20
Candoni
15 Region 6
10.1 9.2
10 National
5
0
2007
Top Causes of Mortality: Severe Pneumonia, Severe Diarrhea

12. Compounding Factors
“The greatest intelligence is precisely the
one that suffers most from its
own limitations” – Andre Gide (Nobel
Prize for Literature, 1947)
POLITICS
LACK OF…
ACCESS

13. “We are limited but we can push back the borders
of our limitations” – Stephen Covey

14. “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

15. 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

17. 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.

18. 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.

19. 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

20. 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.

21. 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)

22. “There go my people. I must find out where they
are going so I can lead them.” ~ Alexandre
Ledru-Rollin

23. “Example, whether it be good or bad, has a powerful
influence” – George Washington, quoted from his letter
to Lord Stirling (March 1780)

24. Upgrading A Local
Health System
Part Two on Candoni Case
Bien Eli Nillos, MD
Former Municipal Health Officer

25. Consider this…
All 3 components are essential.
Hardware = equipments, logistics, physical environment
Software = local health system, predominant culture
Peopleware = Actors

26. Why “Upgrade?”
Excellent Software Excellent Hardware
Excellent Hardware
and Literate and Efficient
and Software but
Peopleware but Poor Peopleware but Poor
illiterate Peopleware
Hardware Software
Slow rendering of Frustrated, Lost,
Useless, Impotent
output Apathetic

28. Community Health Initiative
Partners (CHIP)
Relations Advocacy Managers
(RAM)
Legislative Action Network (LAN)
MONITORing team

29. Maternal Deaths per 1,000 Lb
Infant Deaths per 1,000 Lb in 2007
6 5.8 30
26.5
5 25
4 20
3.6 Candoni Candoni
3 15
10.1 Region 6
Region 6 10
9.2
National
2 0.92 National 5
1 0.63
0
2007
0
2006 2007
TB Case Detection Rate
80
No Botika ng Barangays 70
60
50
Dilapidated RHU 40 Candoni
30 National
Low number of deliveries attended 20
10
by skilled birth attendants 0
2006 2007
No indigents enrolled in Philhealth
High malnutrition rate

30. 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

31. 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.

32. 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

33. Assembly of Hilots
 Integrating the TBA’s
in the “new set-up”.
 Important partners
and collaborators
(WHT)
 Support of the
Barangay Captains
 Barangay
Ordinances

34. 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

35. Upgrading RHU/
equipping BHS

36. Selling the Idea to the Community
“Alkansiyang
Pampamilya”
“Buntis Baby Bags”

37. THE OUTCOMES
90 85 87
80 79
74
70
60 58
50 FBD
40 SBA
30 MMR
24
20
10 5.8
0 0 0
2007 2008 2009
FBD = Facility Based Delivery
SBA = Skilled Birth Attendant
MMR = Maternal Mortality Ratio

38. 30
26.5
25
20 21.8
Candoni
15
Region 6
10 10.1
9.2 National
4.14
5
0
2007 2008 2009
Infant Mortality Rate Trend

39. 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”

40.  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

41. 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”

42.  One additional
midwife trained
as Microscopist
 Aggressive TB
awareness
campaign
 Lung Month
Celebrations
 Philhealth
Accreditation

43. TB DOTS Program
100
90
80
70
60
50 CDR
40 Cure Rate
30
20
10
0
2007 2008 2009
CDR = Case Detection Rate

44. My Role, The Pontiff
Latin 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

45. Struggles/Challenges
“Anything worth doing is
difficult” – Patch Adams

46. Quo Vadis, Doctor?
“I seldom end up
where I wanted to
go, but almost always
end up where I need
to be.” – Douglas Adams

47. “It is the time you have wasted for your rose that makes your rose so important.“
– The Fox (The Little Prince, Chapter 21)