Medical Governance and Health Policy in the Philippines

Medical Governance,
Health Policy,
and Health Sector Reform
in the Philippines

Module I
Introduction: Governance, Policy, Reform
Structured approaches to health development
Reconciling the language games

INTRODUCTION: GOVERNANCE,
POLICY, REFORM

Clinical Governance
• Clinicians have the responsibility to monitor and
manage their performance as part of the general
management of healthcare organizations.
• Decision-making for populations is qualitatively
different to that in clinical practice, even though
the evidence used for both would be the same.
• Clinicians should worry about the quality of care
they are performing; let the health system
managers worry about resource management.
Reference: Gray, 2004 (p. 357-358), with modification

What is health care?
• In caring for patients, the good physician
dispenses time, sympathy, and understanding
to his patients
• The physician also scientifically applies
principles of diagnosis and treatment
• Medical care has become a mosaic of many
health and non-health professionals executing
the necessary skills
Reference: Larson EB, JP Willems, and WC Liles. (2001). Manual of Admitting Orders and Therapeutics. 4th ed. Philadelphia: WB Saunders

Healthcare Governance:
Scope, Scale, and Stakeholders
Point
of Care
Service Delivery
Networks
National and Local
Governments
Private Sector
Dynamics
International/Global
Health

Quality of Care and Health Systems
• In any country, one of the factors affecting the
health and well-being of individuals and
populations is the quality of care provided
within the health service.
• In turn, the performance of any health system
(including provider quality) is determined by
the way in which it is designed, managed, and
financed.
Reference: Gray, 2004 (p. 288), modified

Measuring Quality of Care (1)
Typically done in terms of structural measures
• Health care inputs
– Availability of drugs
– Supplies and technology
– Available health manpower
• Facility-level characteristics
Solon et al. (2009). A novel method for measuring health care system performance:
experience from QIDS in the Philippines. Health Policy and Planning 1(8)

• Do structural measures have a direct impact
on health outcomes?
• Are structural inputs dynamic and thus
responsive to policy initiatives that affect daily
clinical practice?
• What about the point and period of care?
structural measures = inputs

Three basic elements of quality of care:
• Structure
• Process
• Outcome
Structural measures are too distant to the
interface between patient and provider and do
not address whether the inputs are used
properly to produce better health

RECONCILING THE LANGUAGE
GAMES

Declaration of Alma Ata (USSR, 1978)
• Health is a fundamental
human right
• Inequality in health status
is unacceptable
• Economic and social
development (“New
International Economic
Order”) is needed to
attain health for all
• Governments are
responsible for the health
of their people
• “Primary health care” at
the level of communities
is key
• Policies of independence,
peace, détente and
disarmament will release
additional resources for
development, including
primary health care
Reference: http://www.who.int/publications/almaata_declaration_en.pdf

Philippine Constitution (1987)
• The State shall protect and promote the right to health
of the people and instill health consciousness among
them. (Art II, Sec 15)
• The State shall adopt an integrated and
comprehensive approach to health development
which shall endeavor to make essential goods, health
and other social services available to all the people at
affordable cost. There shall be priority for the needs of
the under-privileged, sick, elderly, disabled, women,
and children. The State shall endeavor to provide free
medical care to paupers. (Art XIII, Sec 11)
Reference: http://lawphil.net/consti/cons1987.html

Philippine Constitution (1987)
• The State shall establish and maintain an
effective food and drug regulatory system
and undertake appropriate health, manpower
development, and research, responsive to the
country's health needs and problems. (Art XIII,
Sec 12)
PNoy’s Social Contract: a promise of
increased coverage of social health
insurance, and access to health
through improved health
infrastructure

UN Millennium Declaration (2000)
• Reduce maternal mortality by
three quarters, and under-five
child mortality by two-thirds, of
their current rates (MDGs 4, 5)
• Halt and begin to reverse the
spread of HIV/AIDS, the scourge
of malaria and other major
diseases that afflict humanity
(MDG 6)

Personal Care vs. Public Health
• Improvement of health through the organized
efforts of society (not individuals), through
social interventions. Examples:
– Disease screening programs
– Immunization programs
– Environmental protection
Reference: Gray, 2004 (p. 293)

“Pharmacology” of Public Health
• DYNAMICS and the mechanism of action:
– Will an intervention reduce the risk?
• KINETICS and the response of the system:
– Will the intervention for the main concern
increase other risks? (i.e., adverse effects)
• THERAPEUTICS and delivery:
– Is it operationally possible to introduce the
intervention?
Reference: Gray, 2004 (p. 296), with modification

Ethics of Prioritization:
The Individual or Society?
• It is important to recognize that at the end of
each decision on a health policy, there is an
individual.
• This is an unpleasant and difficult fact to
accept, but those who make decisions about
groups and populations must remain
continually aware of it.

Using Economics to Set Priorities
• Economic approach is to set priorities based on costs
and benefits of health services: to do more of some
things, we have to take resources from elsewhere
• Economists should also consider practical and ethical
challenges that managers and doctors face in making
rational priority setting decisions
• Need to balance clinical autonomy with financial
responsibility
• Use national guidance, regional and local policy, and
the community’s inputs; process should be transparent
and accountable
Reference: Peacock, 2006

Demystifying and De-medicalizing
• The allocation of resources must be explicit
• Decision-making at all levels must be open
• Medicine must be de-mystified and health de-
medicalized, for professionals, patients, the
general public and politicians alike
• Public health / health policy is thus multi-
disciplinary, and multi-stakeholder
Reference: Gray, 2004 (pp. 317-318), modified

Three Fundamental Goals
• Improve the health of the population served;
• Respond to people’s expectations;
• Provide financial protection against the costs
of ill-health
*These are irrespective of the level of resources
available and the organization of the health
system

Module II
Evidence-based healthcare and the policy cycle
Translating mandated policies
into budgets for execution

EVIDENCE-BASED HEALTHCARE AND
THE POLICY CYCLE

The Epistemology of Public Health
Evidence-based
Epidemiology
Statistics
Aesthetic
Supernatural
Scripture
Reference: Gray, 2004 (p. 307-318)

The Policy Cycle
Agenda Setting
Policy
Formulation
AdoptionImplementation
Evaluation

Families (specially the poor) have limited access to prenatal care, safe
delivery, immunization, and family planning

Families (specially the poor) have not used modern clinic or hospital
services due to lack of capital investments in facility upgrading

Factors in Health Policy Change
OLD
POLICY
NEW
POLICY
Ideological
inspirations
Change in
circumstances
Evidence
Common sense
From research
From experience
Reference: Gray, 2004 (Fig 7.8, p. 291; p. 292)
NOTE: Policy makers operate on a
timescale that does not generally admit
of delays that research will take.

Using Evidence to Craft Health Policy
• Resource reallocation among disease
management systems
• Resource reallocation within a single disease
management system
• Managing innovation
• Controlling increases in healthcare costs
without affecting the health of the population

Evidence vs. Eminence
• “Experts” commit two sins that retard the
advance of science and harm the young:
– Adding prestige to opinions gives them greater
persuasive power than their inherent science
– Reviewers tend to accept or reject new evidence
and ideas not based on science, but on their
similarity to publicly-declared positions by experts
Reference: Sackett, 2000

Innovations
• Innovation occurs continually
• Promoting innovation may lead to
– Promotion of completely novel interventions
• e.g., stem cell therapy (?)
– Changing the provision of an established service
• A purchaser must actively manage the
introduction of innovation
Reference: Gray, 2004 (p. 273; 276)

The Roles of the Scientist
• Ask (and seek to answer) the right questions
• Be clear about the evidence
• Show the balance of good to harm of an
intervention for the population
Reference: Gray, 2004 (p. 322; 328), with modification
The Roles of the Policymaker
• Clarify the relevant societal values
• Make appropriate decisions using those values
(in relation to the evidence)

Maternal Mortality Ratio
209
172
162
221
0
50
100
150
200
250
300
1993 NDS 1998 NDHS 2006 FPS 2011 FHS
Numberofdeaths
per100,000livebirths
Data Source: FHS 2011 (NSO, DOH, USAID)
260
182
224
120
196
128
MDG Target: 52

Monitoring & Evaluation in Health
MANDATE
•Policies/
Issuances
/ Orders
INPUTS
•Budgets
•Premium
Subsidies
•Supplies and
Commodities
OUTPUTS
•PhilHealth
Coverage
•Facility
Upgrading
•Logistics
Management
•Demand
Generation
OUTCOMES
•Use of quality
health
services at
affordable /
no cost
IMPACTS
•Health
•Well-being
•Improved
productivity
Can be tracked through real time
operations monitoring

Ensuring Performance
Reference: Gray, 2004 (p. 327; 367)
MxC
B
P =
Where:
P = performance
M = motivation
C = competence
B = barriers
Options to achieve change:
• Incentives (carrots)
• Disincentives (sticks)
 hit people with carrots

STRUCTURED APPROACHES TO
HEALTH DEVELOPMENT

A Structured Approach:
The Results Frame
• Critical Assumptions
• Sound Development Hypotheses
Reference: USAID, 2000
Program
Inputs/Interventions
Intermediate
Results
Development
Objective
Agency Objective

TRANSLATING POLICY INTO BUDGETS
AND RESOURCES FOR EXECUTION

History of Philippine Health Reform
• 1960s: Medicare
• 1970s: Population Policy
• 1980s: Generics Act of 1988
• 1990s:
– Local Government Code of 1991
– National Health Insurance Act of 1995
• 2000-present:
– HSRA, F1, KP
Reference: Romualdez, 2011

Continuity in Health Reform
Kalusugan Pangkalahatan
(2010 onwards)
Fourmula One for Health
(2005 – 2010)
Health Sector Reform Agenda
(1999- 2004)

Healthy
Filipinos
Sought
Professional
Care to Address
Illness
Covered by
PhilHealth
Provided
Quality
Care
Inadequate
NHIP coverage
High unmet need
for public health
services
Poor infrastructure
and low quality of
care
Low peso support
from PhilHealth
?
X
X X
Strategic Thrusts Intend to Eliminate the Barriers

Healthy
Filipinos
Sought
Professional
Care to Address
Illness
Covered by
PhilHealth
Provided
Quality
Care
UHC will improve the health of beneficiaries
Focused public
health services
Increased peso
support from
PhilHealth
Facility upgrading
and quality
improvement
Increased NHIP
coverage

Universal Health Care (UHC)
57
Improved Health
especially for
the Poor and
Vulnerable
Secure access to
quality care at
facilities
Achieve the public
health MDGs
Provide financial
risk protection
INTERVENTIONS OF CARE
Secondary Prevention and
Primary Health Care

Disease Management Systems
• A disease management system consists of all
those services and interventions designed to
improve the health of individuals who have a
particular disease or a group of diseases
• Managed care: all elements of the system are
governed by the use of guidelines

The Continuum of Care
Health
Risk
exposure
Risk contact
Latent
disease/inju
ry
Early
disease/
injury
Disease
progression
Advanced
disease/injury
Chronic
disease
Impairment
or Death
Primary Prevention:
Reduce risk exposure
Secondary
Prevention:
Detection and
intervene early
Tertiary Prevention:
Reduce progress or
complications of
established disease
PolicyandStandardsDevelopment
UHC
Interventions

UHC Strategies and Interventions
UHC
Strategies
Public Health Personal Care Policy and
Standards
Development
Primary
Prevention
Secondary
Prevention
Tertiary
Prevention
Achieve the
public health
MDGs
Family Health
Programs;
Health
Promotion
Facility-Based
Deliveries;
Minor Medical
and Surgical
Management
Complicated
Deliveries,
Medical, and
Surgical
Management
Regulation
and Financing
Activities
(Central and
Regional)
Provide
financial risk
protection
Primary Care Benefits (PCB)
Maternal Care Package (MCP)
TB DOTS Package
Medical and
Surgical Case
Rates
Case Type Z
Membership
Services;
Provider
Services
Secure access
to quality care
at facilities
Barangay Health
Stations;
Rural Health
Units
Rural Health
Units
District Hospitals
Provincial and
DOH-retained
Hospitals
Facility
Management
Reforms
60

Evidence in Primary Care
• In primary care, the provision of healthcare is
undertaken
– Over a large area
– At many scattered sites
• Decision-making covers a wide range of health
problems, sometimes in situations where it is
not possible to access support
• Hence, evidence-based decision-making is
more difficult to organize in primary care

Advantages of Focusing
on a Discrete/Defined Population
• Facilitates the process of population needs
assessment
• Enables a purchaser to integrate the health
services that are purchased with a broad
range of public health measures to prevent
disease, promote health, and reduce
inequalities

Start with the Poor and Vulnerable
Q1 Poorest Q2 Poor
Q3 Middle
Income
Q4 Rich Q5 Richest
39 M poor individuals 59 M non-poor individuals
Note: Population counts projected for FY 2013 (except for DSWD numbers); rounded off to the nearest million.
• Poverty incidence by NEDA/NSO is a statistical estimate without actual
names or faces of poor individuals.
• DSWD’s NHTS-PR and 4Ps/CCT, while with identification and location
data, may not have enlisted all who are genuinely poor and vulnerable
(homeless/vagrants, PWDs, prisoners, etc).
• The DOH thus uses Q1 + Q2 for planning estimates, with reliance on the
DSWD’s NHTS-PR and 4Ps/CCT for targeting/identification.
27 M individuals (NEDA)
30 M individuals (NHTS-PR)
18 M (4Ps/CCT)
Identified by DSWD

Purchasers vs. Providers
• In health services world-wide, there is a trend to
separate the function of purchasing healthcare
from that of providing healthcare
– Purchasers decide which health services to buy
– Providers deliver healthcare to individual patients
within the resources available
• Purchasers aim to maximize the value obtained
from the resources available
• Purchasers are not usually asked to reallocate
resources on the basis of specific diseases, but for
particular patient groups
Reference: Gray, 2004 (pp. 269; 272)

Behind the Scenes: Unit Costing
Component Significance Actors & Assistants Facilities, Equipment,
Commodities
Admission
Order
Initiates the contractual
relationships; inpatient
health care formally
begins. Physical space in
the building is designated
• Attending Physician
• Nursing Service
• Hospital Admitting
Section
• Billing / Accounting
Dept
• Hospital Ward /
Room; Bed
• Standard
commodities (e.g.,
cotton, alcohol,
gauze, etc)
Diagnosis Communicates to team
members the working
impression; allows actors
to plan interventions
accordingly
• All Physicians
• Nursing Service
• Pharmacists
• Nutritionist-Dietitians
• Special equipment
as needed (e.g.,
compression
stockings, pulleys,
respirators, etc)
Condition;
Allergies
Communicates to team
members the level of
attention needed as well
as precautions
• All Physicians
• Nursing Service
• Pharmacists
• Nutritionist-Dietitians
• Special
considerations for
food and drugs

Commodities
Vital signs Initiates the contractual
relationships; inpatient
health care formally begins.
Physical space in the building
is designated
• Nursing Service • Telemetry (if
applicable)
• E-cart / Crash cart
• Emergency Drugs
Activity Indicates what a patient is
allowed to do, or conversely
restrictions to mobility
• Nursing Service
• Physical Therapists
• Nursing Assistants
• Orderlies
Special equipment as
needed (special beds,
wheelchairs,
restraints)
Nursing Specifies what nursing staff is
to do for the patient: I/O,
temp, daily weights,
incentive spirometry, CBG,
etc
• Nursing Service
• Nursing Assistants
• Monitoring
equipment
(stethoscope,
sphygmomanomet
er, thermometer,
etc)
as needed
(suction, etc)

Commodities
Diet Prescribes the diet the
patient will have
(house/regular, low fat, NPO,
etc), fluids allowed by mouth,
as well as feeding
precautions
• Nursing Service
• Nutritionist-
Dietitians
• Dietary (kitchen,
prep area, etc)
• Utensils
as needed (NGT,
etc)
IV orders Prescribes intravenous
solutions to be infused
• Attending
Physician
• Nursing Service
• IV fluids (NSS,
Ringer’s, Dextrose,
etc)
• IV cannula
(needle) and
tubing
Medication
orders
Prescribes drugs to be
administered, including name
(generic preferred), dose,
route, and frequency or time
• Attending
Physician
• Nursing Service
• Pharmacists
• Drugs
• Drug delivery
equipment
(infusion pumps,
etc)

Commodities
Laboratory
studies
Specifies the diagnostic
interventions (e.g.,
bloodwork, urinalysis, x-rays,
etc) to be performed
• Nursing Service
• Medical
Technologists
• Diagnostic
laboratories
(chemistry,
radiology/imaging,
etc)
as needed
Special orders Specifies ancillary services
(respiratory, physical, or
occupational therapy),
consultations, special
preparations for diagnostic
studies, etc
• Referring
Physicians
• Nursing Service
• Respiratory
Therapists
• Physical Therapists
• Occupational
Therapists
• etc
as needed

Healthcare Financing
• Health systems are not just concerned with
improving people’s health, but also with
protecting them against the financial cost of
illness (by reducing out-of-pocket expenses).
• The sources of financing usually dictates the
system of healthcare provision. Two main sources
are:
– Insurance (risk-pooling)  “pay as you go”; common
in low income countries
– Taxation (subsidies)

Who pays for the cost of health care?
Source: 2010 Philippine National Health Accounts
11.2
15.3
8.9
52.7%
7.1
4.8 National Government
Local Government
PhilHealth
Private Out of Pocket
Private Insurance +
HMOs
Others

Sources of Financing
• The Sources and their Uses
– NG: Policy Support / Management
– LG: Service Delivery (residual claimant)
– PhilHealth – single payer
– PCSO, etc – catastrophic expenses
– PPP – high capital investments
– OOP – safeguard against moral hazard
• “5% of GDP” – correlation vs. causation issue

FINANCIAL
PROTECTION
PROVIDED TO THE
POPULATION
AccreditationEnrollment
Claims
Availmentand
Processing
Insurance
Payments
PhilHealth as a Single Payer/Purchaser
• Concept of social health insurance
– Pay-as-you-go / “paluwagan”
• Leverage resources on behalf of the many
clients/patients
Source: Joint DOH-PhilHealth Benefit Delivery Review (2010)

The Double Financing Burden of LGUs
Note: This is pre-
NHIA 2013.

The Budget Cycle
and Absorptive Capacity
• Budget Call
• Agency Planning
• Negotiations with DBM
• NEP filed in Congress
• Congressional Hearings
– “Power of the Purse”
– PDAF?
• Appropriations
• Allotments and
Obligations
References: DBM, 2013; Rappler.com, 2013

Various Aims for Resource Allocation
Actor of Interest Aim for Resource Allocation
Individual patient • More resources to treat
his/her case
Group of patients or providers
who have the same problem
• More resources for the
particular patient group
• Openness and equity in
distribution of resources for
that group
Representatives of the general
public
• Openness and equity in
distribution of resources
across the entire range of
patient groups

Module III
Implementation arrangements in healthcare
Capacity building, sustainability,
and knowledge management
The Health Value Chain

IMPLEMENTATION
ARRANGEMENTS IN HEALTHCARE

Values (?) Dominate Policy-making
• Politics tends to be driven by beliefs patronage
• It is the values returns on investment (ROI)
politicians believe to be important that dominate
decision-making about policy. Such decisions will
be tempered by the availability of resources.
• But, resource allocation can also be based on
beliefs and values patronage and ROI
• Can a shortage of resources force policy-makers
to consider the evidence and alter policy as a
result?

The Legislation Threshold
Oppositiontolegislation
Reference: Gray, 2004 (Fig 7.9, p. 296)
There is an inverse relationship between the magnitude of
a health problem and the strength of opposition to
legislation framed to prevent it.
Number of people affected
Media interest
Strong evidence
Opposition by industry
Policy has adverse effects
High cost of intervention

What legal adjustments are needed to
implement UHC?
Restructuring of Excise Taxes of alcohol and
tobacco
Passage of Responsible Parenthood Bill
Strengthening of the National Health Insurance
Program
• Optimization of management of devolved health
services
• Amendment of selected laws governing practice
of health professionals
• Laws for corporate governance of hospitals
Note: An omnibus law on universal health care that shall contain specific
provisions necessary to enact required policies or amend existing laws can
also be legislated

Main Determinants of Health
Genetic
inheritance
Health
status
Physical
environment
Biological
environment
Social
environment
Primary care
Reference: Gray, 2004 (Fig 8.1, p. 320)
Health services
Hospital care
Screening

Healthcare Management and Policy,
and Organizational Change
• Health policies relate mainly to the financing
and organization of health services.
• Common objectives of organizational change:
– Decentralize power;
– Involve more people in decision-making;
– Encourage cost control;
– Reduce the number of managerial staff;
– Encourage competition in order to reduce costs
and increase quality

Office of Secretary of Health
Attached Agencies
Regional Offices
Provincial Health Offices
City Health Offices
(Component Cities)
Inter-local Health Zones
City
Hospitals
Health
Centers
Barangay
Health
Stations
District
hospitals
Municipal health
offices/ Rural
Health Unit
Barangay Health
Stations
Provincial
Hospitals
Regional hospital
Medical Centers
Sanitaria
City Health Offices
(Chartered Cities)
City
Hospitals
Health
Centers
Barangay
Health
Stations
References: Kelekar and Llanto, 2013; Khemani, 2010

DepartmentofHealth
PhilippineHealthInsuranceCorporation
(National/CentralOffices)
DOHCentersforHealthDevelopment
PhilHealthRegionalOffices
LocalGovernmentUnits
(ProvincesandCities)
Health Care
Providers
Households
Health
Outcomes

Secretary of Health
NCR &
Southern
Luzon
Northern &
Central Luzon
Visayas Mindanao
Secretary of Health,
DOH-ARMM
Centers for Health Development
Technical
Clusters

Issues in the Public Sector
• Decentralization
• Devolution
• Public Finance Management
• Procurement

Issues in the Private Sector
• (de)Regulation – big government vs. small
government
• Incentives and Disincentives – Profit?

Public-Private Partnerships
• Frame:
Profit = Revenue – Cost
• Private interest is to maximize profit
• Public interest is to ensure (by contract)
provision of social services
• Not just in infrastructure, but also elsewhere

The Role of Civil Society Organizations
• Churches and Faith-based Groups
• Advocacy Groups
• Academe
• NGOs
• Provider/Professional Organizations

PREVIEW OF A (FULL) POLICY
CYCLE: CASE OF RA 10354

The Reproductive Health Law
• 14+ years of debate in Congress
• 26 years after the 1987 Constitution
• State interest is to save mothers’ lives
– Population policy is elsewhere, in the POPCOM PD
• The issue is not when life begins, but the
“political question” and judicial restraint
(institutions affecting policy)
• RH Law is social legislation: more in law for
those with less in life
Reference: Jardeleza, 2013

CAPACITY
BUILDING, SUSTAINABILITY, AND
KNOWLEDGE MANAGEMENT

Image from Facebook (Seismologik Intelligence/Occupy Posters)

What is Development Work?
• Official Development Assistance (ODA) /
Foreign Assistance Programs (FAPs)
• Shift from tangible commodities to technical
assistance (TA)
Reference: Garrett, 2007

Agenda
Setting
Policy
Formulation
AdoptionImplementation
Evaluation
Areas for Management Consulting
Research
Production
Research
Management
Marketing /
Communication
Implementation
Monitoring &
Evaluation

Need for an Institutional Platform (1)
• Implementing health reforms in the
Philippines has become increasingly complex
• Strategic, operational, and transactional
concerns have grown
• Staff capacities and time constraints continue
to be limited
• Budgets are increasing; policies are aligning
Reference: USAID/Philippines, 2012

Need for an Institutional Platform (2)
• There should be an Institutional Platform (IP)
that will help design, implement, monitor, and
evaluate UHC initiatives
– Accountable to the Secretary of Health, but
independent and objective
– Funded by various sources (including , but not
impaired to provide competitive rates)
– Can network and engage with other
institutions/individuals contributory to its
objectives
Reference: USAID/Philippines, 2012

Health Policy Development Program(HPDP2 – Cooperative Agreement No. AID-492-A-12-00016)
• Five-year USAID health policy project (2012-
2017) implemented by the UPecon
Foundation, Inc.
• Supports the DOH-led policy formulation
process for scaling up Universal Health Care
(UHC)
• Goal is to strengthen a supportive policy and financing environment
for FP/MNCHN and TB to enable the Philippines to achieve its MDGs
in health, as well as expand and sustain its UHC initiative
• Two components: (1) establish an institutional platform to help DOH
design, implement, monitor, and evaluate the UHC agenda; and (2)
remove policy and systems barriers to FP/MNCHN and TB service
delivery

The Health Value Chain
Policy
Dev’t
Budget and
Expenditure
Plans
Absorptive Capacity of
Local Health Systems
Service
Providers
Clients/Patie
nts
Suppliers
Improved
Health
Information, Feedback, Monitoring

The Five-Star Doctor
Roles
• Health Care Provider
• Teacher
• Researcher
• Social Mobilizer
• Manager
Examples of Leaders
• Pioneer Practitioners
• Deans
• Principal
Investigators
• Politicians/Advocates
• DOH Sec / Hospital
Chiefs

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Medical Governance and Health Policy in the Philippines

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