|Year : 2007 | Volume
| Issue : 2 | Page : 77
Towards Unity for Health: Integrating purpose and action - The story of Estelita
M Millar Dayrit
World Health Organization, Geneva 27, Switzerland
|Date of Submission||12-Jul-2007|
|Date of Web Publication||30-Aug-2007|
M Millar Dayrit
20 ave Appia, 1211 Geneva 27
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dayrit M M. Towards Unity for Health: Integrating purpose and action - The story of Estelita. Educ Health 2007;20:77
As a public health practitioner, I have always believed that the success of any health initiative, any health programme, any attempt to improve the health status of people had to begin and proceed with integrity of purpose and action. Without this unity, success would never be achieved.
How do we cultivate this unity of purpose and action? In my case, it began with a dream, shared in common with many of my generation who believed that poor people in my country (the Philippines) deserved better. The dream was simple - by living and working closely with them, learning from them, teaching them, we could transform their health situation.
And so we went to live out our dreams in the late 1970s at a time when Halfdan Mahler and WHO had made primary health care the battle cry of global health, and the world was enamored with the idea of village health workers and their potential powers of transformation.
I left urban Manila to live in a small town in Southern Philippines, commuting distance from the rural villages where we set up our village health programme. My colleagues and I immersed ourselves in community organizing and steadily trained successive batches of CHWs (community health workers). We were quite successful in doing that and the numbers of our CHWs grew.
In one of the villages was a frail, emaciated lady in her late twenties named Estelita (her name meant “little star”). Estelita had rheumatic heart disease. Shortly after we got to know her, she became acutely ill with congestive heart failure.
We knew she needed treatment in the hospital but her family had no money to pay for hospital care. With the help of the CHWs, we were able to raise some money to pay for transportation and a 3-day hospital stay. She actually stayed in the hospital for 7 days, with the hospital subsidizing the unpaid days and accepting the chickens and vegetables contributed by the villagers.
We tided Estelita over that episode of heart failure but our efforts and community resources were not enough to keep her alive for very long.
Reflecting on that situation, it became clear to me that efforts to improve people’s health in rural villages could not be dependent entirely on the efforts and resources at the village level - something that we naively and romantically wanted to believe. Even efforts to set up a community-based self-help fund from voluntary contributions could not do much to finance hospital expenses of other villagers who needed hospitalization.
Fifteen years later (1994), the Congress of the Philippines passed national legislation promoting social health insurance. But seven years after the passage of the law, coverage of social insurance in the country had included only those who were employed - only 30% of the population - and the very few self-employed who were up to date on premium payments. This meant that poor farmers and fishermen, people like Estelita and her co-villagers, could still not avail of the safety net of social insurance.
As Minister of Health, I presided over government efforts to raise the coverage of social health insurance - by encouraging local governments to contribute to the premiums needed for their indigent population. The campaign was successful and over the next three years, it was estimated that an additional four million families (24 million people) received social insurance cards. This meant that theoretically, more Filipinos had access to hospital care. However, as we tracked the insurance payments, we realized that utilization rates were low and flat, a sign that people who received the cards were not using them. Despite having gotten the cards, people were either unaware of its potential benefit or refusing to use them. Perhaps it was too much to expect that people’s attitudes and health care seeking habits would change overnight, despite a health insurance card in hand. Also there were observations that in many places, there were no accredited health facilities which could provide services to people who presented the cards.
The lessons derived from the above anecdote are well known today. For health care to work for people, people and health systems have to be in synchrony and in unity throughout their various levels - from household to hospital, from village to health care center, from Congress to local government. Everything must come together - patient, caregivers, payors, support from family and community.
Today, the fragile systems that have been set up are threatened by the loss of health workers, particularly doctors and nurses who are migrating abroad. Just recently, a scandal has broken out that the national licensure examination for nurses had been tainted by leakage of exam questions. Finger-pointing, public outrage, acrimonious debate, and investigations have followed this scandal all with the backdrop of thousands of eager nurse examinees waiting to be recruited to migrate.
The scandal will pass. The problems of providing better health care to millions of Filipinos, both rich and poor (but particularly the poor!), insured and uninsured will remain.
But the dream to provide health care to the poorest Filipino - people like Estelita - must live on. In order to do that, everything must come together in unity and synchrony. The purpose must be clear and pure, and the actions must be comprehensive, effective and sustainable in the face of a complex world.