|ORIGINAL RESEARCH PAPER
|Year : 2007 | Volume
| Issue : 2 | Page : 51
Lessons from a Local Government Unit - Health Academic Partnership
College of Medicine, University of the Philippines, Ermita, Manila, Philippines
|Date of Submission||16-Jun-2007|
|Date of Web Publication||21-Aug-2007|
E R Paterno
College of Medicine, University of the Philippines, Ermita, Manila
Source of Support: None, Conflict of Interest: None
Context: The devolution of health services from the Department of Health to the Local Government Unit in the Philippines in 1992 led to the deterioration of the management of local health services. The UP College of Medicine (UPCM) has forged a partnership with a Local Government Unit of a rural municipality to implement a community based health program geared towards the development of local health systems.
Objective: Program objectives were: (1) to provide learning opportunities for UPCM faculty, medical residents and students in community medicine; and (2) to assist communities develop their health systems.
Interventions: In July, 2004, the UPCM jointly drafted a municipal health plan with its partner municipality. Before the actual planning session, the rural health midwives were assisted by the UPCM students in determining the health needs of their communities and in drafting community health plans. The plans were then presented by the midwives in a 2-day planning workshop, and became the basis of the municipal health plan.
Main Outcomes: The outcome of the workshop was the first municipal health plan that this health office had drafted. Main outcomes from the implementation of the plan included the organization of the Local Health Board, improved health service provision by the municipal health office, active health committees in selected villages and better learning opportunities for medical residents and interns.
Conclusion: Colleges of Medicine in the Philippines can and should play a role in the development of local health systems within the overall framework of Alma Ata Primary Health Care. National health planners should seriously consider this role of the health academe.
Keywords: academic community medicine; partnerships in health; academic community programs; community-based health programs; participatory community health programs; primary health care
|How to cite this article:|
Paterno E R. Lessons from a Local Government Unit - Health Academic Partnership. Educ Health 2007;20:51
The devolution of health services from the Department of Health to the Local Government Unit in the Philippines in 1992 led to the deterioration of the management of local health services. Most Municipal Health Officers are graduates of a medical education that heavily emphasizes clinical medicine, with no further training in public health or health management.
The UP College of Medicine forged a partnership with a Local Government Unit of a rural municipality to create programs geared towards the development of health systems in the municipality and to help medical students acquire skills and perspective in managing rural health systems. In this particular rural municipality, the government health team was composed of a physician (the Municipal Health Officer), a public health nurse, nine midwives, a sanitary inspector and a municipal nutrition officer. This team was in charge of the health of a population of 80 000 in 30 villages. The Municipal Health Officer was also the Public Health Officer, though he stayed in the town center attending to clinics at least 90% of his working time. One rural health midwife took care of 3-4 villages or a population ranging from 5,000-8,000. Rural health midwives were assisted by a team of village health workers (VHWs) in each village. The UP team, on the other hand, was composed of four Community Medicine professors of the College of Medicine, 1-2 rotating residents of the Department of Family and Community Medicine (FCM), and rotating medical interns. There were 30 interns immersed in 12 villages in the municipality at any given time. They rotated in the program for six weeks.
The program was maintained to provide learning opportunities for the faculty, FCM residents and medical students in the principles and practice of community medicine through activities that directly addressed expressed local needs, and in the process assisted these areas attain increasing capacities in their own health systems.
In July, 2004, the UP community medicine professors requested the Health Office of its partner municipality for a joint planning session to map out activities that could be jointly implemented by the UP and the Municipal Health Office (MHO) to improve health services in the municipality. In the process, the UP team discovered that there was no drafted health plan in the municipality, and that the health office was merely implementing programs prioritized by the National Department of Health. Before the actual planning session, the midwives were assisted by FCM residents and medical interns in determining the health needs of their villages and in drafting village health plans through small group discussions with the Village Council and VHWs. FCM residents assisted the midwives in collating the data, which were then presented by the midwives in a 2-day planning workshop conducted jointly by the MHO and the UP professors and FCM residents. During the workshop, the UP professors facilitated the MHO’s formulation of its mission and vision, and based on this and the data collected by the midwives, a joint 2-year health plan was drafted.
The outcome of the workshop was the first municipal health plan that this MHO had drafted. The workshop was also the first formal municipal health planning session that the whole MHO staff had participated in. The following were the main outcomes that resulted from the drafting and implementation of the plan:
- Strengthening of the Municipal Health Organization:
- The Local Health Board formally met for the first time so that the Municipal Health Officer could present the Municipal Health Plan. After this meeting, the Mayor issued an administrative order defining the duties and functions of the Local Health Board.
- In succeeding months, meetings of the MHO staff became a common event, albeit irregular, with or without the presence of the UP team. Prior to the planning session held with the UP team, midwives reported that there had never been any formal meeting held among the MHO staff. Information or instructions for new programs were passed onto each MHO personnel individually. Midwives’ reported needs were discussed individually.
- Following the approval of the Municipal Health Plan by the Local Health Board, the midwives became emboldened to request for funds from the village level government executives to upgrade the village health stations in order to comply with the minimum standards defined in the plan. At least 80% of their requests were granted.
- Village health committees became active in 10 villages where the village level government executives worked well with the rural health midwife and the UP team. The medical interns, together with the UP preceptor guiding the students, were considered part of the village health committees for the duration of the program. Regular village health committee meetings were conducted to address problems identified during the village consultations. Relevant plans were drafted and implemented during the past two years.
- Improvement in health services:
- The municipal plan to conduct an awareness campaign against Dengue Fever was implemented in all of the villages. However, only one village that was especially hit by a number of cases earlier in 2004 started a comprehensive program to eradicate the disease. The health committee in this village drafted a 2-year eradication program. As a result of the implementation of the drafted program, the village did not register a single case of Dengue Fever from 2005-2006. The municipality had no mortality from Dengue Fever for the same period. [Mortality Trends in Sto. Tomas, Batangas from 1999-2006, compiled from Municipal Mortality Records.]
- Hypertension was one of the diseases targeted in the municipal health plan. Complications of Hypertension (Myocardial Infarction and Stroke) had been the leading causes of death for the past few years in the municipality. A group of interns drafted a training module on hypertension in the vernacular for midwives and VHWs, based on The US Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Using this module on hypertension, rotating FCM residents gave the initial training of the municipal midwives in December 2004. Six months later, the midwives, assisted by the FCM residents and medical interns, in turn trained the VHWs. Before this, midwives had never given formal trainings to their health workers. Public health lectures were subsequently conducted by VHWs, usually followed by hypertension screening among those who attended the lectures. In some villages, health committees opted to do house-to-house screening to identify those with hypertension. In an effort to address the hypertensive patients’ problems and to create a sustainable hypertension program, 5 villages have organized Hypertension Clubs, presently in different stages of organization. Among the mainstay activities of these clubs are regular group exercises, education sessions on hypertension and BP monitoring by the village health workers. In the village with the most organized hypertension club, a hypertension specialist practicing in a nearby city agreed, through the facilitation of the UP team, to conduct clinic consultations once a month for all the club members. For this effort, he is receiving a fixed fee from the village government unit.
- Village drug stores or Botika ng Barangay were set up in some strategic villages to address the need to provide essential drugs to the villages. The setting up of village drug stores has been a Department of Health program for the past decade. However, it was not implemented in this municipality. After the plan was drafted, the MHO requested the Department of Health for assistance in the implementation of the program in the municipality and was assured funding for five village drug stores. At present, three villages have set up drug stores and trained assistant pharmacists have been successfully running these pharmacies for the past two years. The UP team assisted the villages in the setting up and maintenance of the village drug stores.
- VHWs acquired skills in the recognition and primary management of diseases common in the area. Medical interns were oriented to regard regular clinics in the village health stations as opportunities for training midwives and VHWs in primary care.
- The plan helped the Municipal Health Office define what they should and can do to improve health services in the municipality without UP’s help. Examples of these were:
- the need to improve dental services. At the time of planning, there was no full time dentist in the municipality. Clinical dental needs were addressed by the Provincial Dentist who came once a week. To date there is a dentist who now works full time in the municipal health office, while the Provincial Dentist still visits the area at least once or twice every month.
- the training of traditional birth assistants. A problem discussed during the planning session was the recent increase in complications in deliveries assisted by traditional birth assistants in the area. The MHO, in coordination with the Provincial Health Office and the Department of Health Representative, planned and implemented a training seminar for traditional birth assistants on proper birthing methods.
- Better learning opportunities for medical interns.
Not the least of the outcomes of the implementation of the program is the appreciation of the discipline of community medicine by the rotating interns, and a realization among many of them that community medicine is a viable option for a future career as doctors. [Quotes from Interns’ Community Journals from 2002-the present. Compiled by E. Paterno, ongoing and unpublished.] Many of the students who rotated under this set-up expressed their appreciation of the program in their journals, and claimed they had acquired a good orientation to the work that needs to be done should they eventually become Municipal Health Officers. These statements have yet to be validated by their performance after graduation.
The drafting and the implementation of the health plan jointly by the UP team and the municipality paved the way for a strong partnership between the municipality and the College of Medicine, and provided a framework for the medical interns’ immersion program. The partnership was in the form of collaborative projects at the village level. Medical interns who were immersed in the communities were considered members of the village health committees. Upon entry, interns studied the municipal health plan and received endorsements regarding what had been completed and what needed to be done to attain the objectives set in the municipal and village plans, both from the previous rotators and the VHWs of the village they were assigned to. The medical interns’ role as facilitators in the empowerment of the village health committees was especially stressed during pre-rotation orientation sessions. Respect for the leadership of the midwives was emphasized. As a result of this arrangement, village health committees became more competent in addressing their own health needs.
At the municipal level, the partnership was of the ‘ad hoc’ type (Boelen, 2000). Meetings between the municipal health office and the UP team occurred at least twice in a year, with regular consultations between the Municipal Health Officer and the UP program coordinator at least once a month. Program monitoring was done at the end of the year. In this manner, communication between the UP team and the MHO greatly improved and problems in program implementation were easily addressed. Long term commitment of the MHO staff to the vision they defined, however, is yet to be proven.
The drafted municipal and village health plans were far from perfect. There were too many goals set, many objectives were not clearly stated and the identified problems that needed to be addressed were not prioritized. They were, however, truly a product of people’s efforts and through the implementation of the municipal and village health plans, the UP team has come to the following realizations:
- Learning is minimal when students perceive that what they are doing is mainly an academic requirement and does not significantly contribute to the improvement of the communities they are working in. On the other hand, learning becomes significant and the experience satisfying when students realize that the communities benefit from their efforts and that community people are willing to spend time, effort and money to obtain the objectives they had made jointly with the students. The two program objectives, namely student learning and community development therefore should be considered of equal importance and interdependent.
- The 1978 Alma Ata Declaration defining Primary Health Care, together with the Network: Towards Unity for Health’s four values of quality, equity, relevance and cost-effectiveness (Boelen, 2000) have served as the main guide of the UP team. As such, the team realizes the need to approach each community or municipality with an open outlook, and with no rigid model to follow. Following the above principles, the partner municipality and the community people are treated as equals and their decisions on what and how programs should be implemented in their areas are respected. Community participation and ownership of the projects are considered among the most important indicators of the program’s success.
- The involvement of the university clinical faculty is important in ensuring the quality and soundness of programs designed to combat priority illnesses, for example, the hypertension program.
- One of the important responsibilities of the UP team is the creation of a network that will support the village programs long after the UP team has left the area. Since the University of the Philippines is considered a prestigious institution in the country, many individuals (including health professionals) and organizations or institutions are willing to assist in programs started by the UP.
- There are local and political issues that are beyond the capability of the UP team alone to address. The UP team realizes that health development is dependent on and should be a part of total community development. For this to be a reality, a multidisciplinary/multisectoral approach is necessary (WHO, 1978; Palaganas, 2003). The whole university needs to be eventually involved in the community programs (Lathem, 1978). This is a subject of much debate and experimentation within the university at present. Another important issue is the rampant corruption present in all segments of municipal and village government that contributes to the difficulty in achieving many of the goals set in the program and continues to pose a moral dilemma for the UP staff.
- Areas where the UP team needs to improve its skills include documentation and health information management. Information management is a major weakness of most rural health units, making monitoring and evaluation of programs difficult. Conflict resolution and the ability to attract funding to improve the programs are other areas for improvement.
Health academic institutions in the Philippines, especially those supported by people’s taxes can and should play a role in the development of local health systems within the overall framework of Alma Ata Primary Health Care. As an initial effort towards this goal, student exposure programs should be improved to prepare health professionals who will be willing and able to perform functions geared towards this end. National health planners should seriously consider this role of the health academe.
BOELEN, CHARLES (2000). Towards Unity for Health: Challenges and Opportunities for Partnership in Health Development. A Working Paper. Geneva, World Health Organization.
CASTRO-PALAGANAS, ERLINDA (2003). Health Care Practice in the Community, First Ed. Manila, Educational Publishing House.
LATHEM, WILLOUGHBY, ed (1979). The Future of Academic Community Medicine in Developing Countries. USA, The Rockefeller Foundation.
WORLD HEALTH ORGANIZATION (1978). Alma-Ata : Primary Health Care. Report of the international conference on primary health care, Alma-Ata, USSR, 6-12 September 1978. Geneva, World Health Organization (“Health for All” Series, No.1).