Best Practices INTER-LOCAL HEALTH SYSTEMS
An inter-local health zone refers to a district or a catchment area composed of a number of neighboring municipalities which main function is to improve networking and strengthen cooperation among themselves with regard to health matters. Several stakeholders play a role in the ILHZ, which includes national health organizations represented by the Center for Health Development of the DOH, provincial government, NGOs/POs and the private sector. The key actors are the neighboring municipal LGUs with their RHUs and BHS, district hospital and the district health office. The intended functions of the ILHZ are to formulate, implement and evaluate: 1) local health plans, 2) health information system, 3) two-way referral system, 3) health resources management and development system, 4) health care financing, 5) hospital regulation and management, 6) community mobilization, and 7) benefit monitoring and evaluation. Several provinces and cities were selected to have pilot ILHZs. These areas include Negros Oriental, Misamis Occidental, Capiz, South Cotabato, Bulacan, Pangasinan, Nueva Vizcaya and Pasay City. This document describes the best practice in the inter-local health zones using the following criteria agreed upon during the research team’s meeting in June 2002: Presence of letters of intent/ memorandum of agreement for ILHZ • • Number of ILHZ vs. targets • • Organization of district health board and evidence of leadership and governance • • Evidence of resource sharing • • Evidence of functional referral system • • Evidence of networking • • Cost sharing • • Common fund • • Integration with non-health systems/development initiatives Best Practice / Most developed ILHZ- Negros Oriental The inter-local health zones in Negros Oriental were viewed as the most developed ILHZ in the country following the criteria earlier. As early as of 1999, the Negros Oriental Provincial Health Board passed Resolution No. 5, which recommended the development of six district health systems and the formation of the corresponding inter-LGU District Health Board. Thus, the organization of the six ILHZs called “Inter-LGU Health Systems” was a local initiative established even before EO 205. Number of ILHZ
Negros Oriental targeted six ILHZs to be established in the province. These six ILHZs have now been organized. The ILHZs and their corresponding catchment areas are as follows: CVGLJ District Health System Canlaon City Vallehermoso Guihulngan 1 Guihulngan 2 La Libertad Jimalalud Sta. Bayabas District Health System Sta. Catalina Bayawan City 1 Bayawan City 2 Basay
Binata District Health System Bindoy Ayungon Tayasan Mama Bata Pa District Health System Mabinay 1 Mabinay 2 Manjuyod Bais City Tanjay 1 Tanjay 2 Pamplona NOPH District Health System Dumaguete City Dauin Bacong Valencia Sibulan San Jose Amlan SIAZAM Inter Local Health Zone Siaton Zamboanguita
Among the six ILHZs, the CVGLJ District Health System was the first to be established as an inter-local health zone followed by STA. BAYABAS and BINATA. CVJLG and STA. BAYABAS are the most active in implementing the inter-local health zone. Except for the adoption of the PhilHealth social health insurance, STA. BAYABAS ILHZ was found to be the most advanced in terms of health reforms leading to HSRA convergence. Member-LGUs in STA. BAYABAS ILHZ have strengthened their health service networks and collaboration. They contributed their share to establish a common health fund from their respective budget allocation. Cost sharing and contribution to a common fund is also happening in CVJLG and BINATA. In the area of social insurance, BINATA is most advanced, since member municipalities have enrolled indigents into PhilHealth and two RHUs are currently implementing the outpatient benefit package of PhilHealth. This paved BINATA ILHZ as the lead in implementing the four components of HSRA convergence strategy. What is most notable in Negros Oriental, however, is that the concept and implementation of the zones occurred through local initiatives and efforts way before the HSRA was set as a policy.
Legal Framework for ILHZ ILHZs in Negros Oriental are established within a legal framework as evidenced by the numerous resolutions formulated in the Sangguniang Panlalawigan and Sangguniang Bayan. The MOA signed by the member LGUs spelled out the responsibilities of each LGU and their expected gains in forming an ILHZ. These include sharing of resources (e.g. money, facilities, manpower), integrated health service delivery, easy access to the hospital and increased opportunity in getting foreign grants. Resource Sharing Participating LGUs complement each other’s resources in terms of manpower and health facilities. They also contribute to the common fund that supports the activities of the health district system. Member LGUs share an equivalent of 1% of the 20% economic development fund taken from the budget for the general fund of the preceding year. The common health fund is deposited under one collaborating LGU upon agreement by participating LGUs and managed by the ILHZ Technical Management Committee. Expectedly, LGUs that share more in the common funds by virtue of their classification (e.g. Class 1) will also get the most benefits mainly because they have the larger population to be served by the ILHZ. In addition, a community health financing scheme called “Peso for Health” was established to make health services more accessible and affordable to the community members. The participating members’ contributions and benefits are categorized as follows: Peso for Health Premium Schedule and Benefit Package.
BRACKET
PREMIUM/MONTH BENEFITS
Category A
PhP 1.00
PhP200 benefit package for drugs/medicines plus discount in diagnostic services and other medical facilities PhP1,000 benefit package for drugs/medicines plus discount in diagnostic services and other medical facilities PhP2,000 benefit package for drugs/medicines plus discount in diagnostic services and other medical facilities
Category B
PhP 5.00
Category C
PhP 10.00
Discussions are underway for PhilHealth to recognize this community-based financing scheme.
Organizational structure and governance There is an organizational structure for the ILHZs with the establishment of an ILHZ board composed of the following representatives, all of whom have voting rights. • • • • • • • • • • • • • • • • • • • • Provincial LGU representative Sangguniang Panlalawigan (SP) representative of the health zone IPHO Municipal LGU Association of Barangay Captains (ABC) President DOH representative Health insurance organization COH MHO NGO/PO representative
The ILHZ board has financial and policymaking functions to supplement existing LGU policies. An ILHZ technical committee composed of the technical staff from the RHU and hospital, DOH representative, patient group representative and assisted by the administrative staff designated by member LGUs was also organized. With technical assistance from DOH and MSH, the ILHZ technical committee takes charge of the information needs of the integrated zonal plan, health service standards and the system of pooling human resources. There is a District Hospital Health Board that is responsible for quality of care and services in the district hospitals. The Inter-District Hospital conference and the bi-annual review led by the PHO have become the inter-zonal conference. ILHZ related issues and problems are discussed through this venue. Networking The ILHZs work closely with NGOs, GOs, academe and foreign donors like the Goretti Foundation, Belgian Integrated Agrarian Reform Support Program (BIARSP) and USAID. NGO and POs are active members in the various boards. NGOs and POs help in the monitoring and evaluation of the district health activities. Referral system
The referral systems from the RHUs to the district hospitals and provincial hospital are being strengthened. The draft of the new referral system is currently being deliberated. Distinctive features of other convergence sites While Negros Oriental as a whole has the most developed ILHZs, some laudable achievements, distinctive practices and important push factors can be cited in other convergence cites. South Cotabato The second most developed ILHZ are those of South Cotabato. During the LPP Provincial Health Summit in June 1999, 5 Local Area Health Development Zones (LAHDZ) were organized to improve the health care system in the province. Support from agencies such as AusAID, the province and DOH was secured. The province has well laid out health plans where the roles and responsibilities for each level of care and each level of management are carefully defined. A Referral Manual containing the policies, guidelines, procedures and forms needed for the referral process are disseminated to the RHUs, LAHDZ and provincial levels. An important push factor in South Cotabato is the creativity, innovativeness and persistence displayed by the PHO. SP members were given important roles in health decision-making and activities. An SP member is designated as the head of each LADHZ, with the District Hospital Chief as the coordinator. SP Board members are also encouraged to participate in study tours to “broaden their horizons.” The PHO makes it a point that health is always in the news to sustain interest of stakeholders. The LAHDZ system resulted in a better referral system, integration of services and closer links between the health sector and other stakeholders. According to the PHO, the “secret is in maintaining strong links with the LGUs.” Unlike Negros Oriental, the LAHDZ system has yet to implement the management of a common fund at the zone level. Hence, financial support for zonal activities needs to come from the PHO or ICHSP. Pasay City The health system in Pasay City may not be comparable with those in the other convergence sites because of its urban character and administrative distinctiveness, but it can be cited as one of the most efficient and functional local health systems in the country. The city is divided into zones, each of which has a local health center that serves a well-defined catchment area. All households are registered and Barangay Volunteer Health Workers take charge of the health of a specified number of households. The local health system has also a well-defined referral system. Health centers would only entertain patients who belong to their catchment areas. A patient from a catchment area consulting in another health center will be given initial treatment, but are encouraged
for follow-up in their respective health facility. Should a patient need a higher level of care, the patient is referred to the Pasay City General Hospital. A MOA has also been signed by the Mayor with the Philippine General Hospital for cases that need tertiary care. The local health system is also anchored on a strong partnership among health workers and the local leaders. As a city, Pasay has been autonomous in its operations even prior to devolution. Many of its systems have been in place and were relatively insured from the effects of the transition to local governance. Nueva Vizcaya In Nueva Vizcaya, there was a careful assessment about the number of ILHZs to be established considering the topography and financial capabilities of the LGUs. Currently, a province-wide ILHZ has been established with the Expanded Provincial Health Board (EPHB) as the governing body. The EPHB has 45 members, which include the chiefs of hospitals, PHO, president of the League of Mayors, MHOs, PhilHealth, NGOs, professional societies and other relevant departments and government agencies in the province. There is no formal MOA among the LGUs, but the EPHB has been proven to be an effective mechanism in establishing linkage and cooperation among various stakeholders. The provincial political leadership is perceived as strong, committed and is well respected. The partnership among the governor, lone congressman and the president of the League of Mayors of the province is also commendable. Bulacan Two ILHZs have already been organized in Bulacan; the Baliuag Unified Local Health System (BULHS) and the Sta. Maria Unified Local Health System. Between the two ILHZs, the BULHS is more mature. It was organized in 1999 by virtue of a memorandum of agreement with the Baliuag Unified Local Health System Board as the governing body. So far, the accomplishment of the BULHS are; the sharing of resources among member municipalities in terms of equipment and ambulance, a referral system and the implementation of locally initiated programs like the Zero Waste Management Project, Friendly Hearts’ Club for the Cardiovascular Disease Control and Prevention Program, Stress Management, and the Prince and Princess of Nutrition, which is a fund-raising campaign. Misamis Occidental Misamis Occidental has established 2 ILHZs; the Oroquieta ILHZ and the Calamba ILHZ. As early as 1999, Misamis Occidental has already formed its District Health Boards. The more advanced between the two ILHZs is the Oroquieta District Health Zone (ODHZ). It was established in March 2002 with the signing of the MOA that indicates sharing of health resources and allocation of funds for the operations of the
district health zone. Members of the District Health Board who are also members of the Technical Management Committee formulate the health plans and monitor the implementation of the health activities. Examples of local initiatives are the implementation of vegetable gardening/ FAITH program, a barangay self-sufficiency program and a drug cost sharing scheme where LGUs share in the cost of drugs used by their own constituents who are admitted at the Misamis Occidental Provincial Hospital. One thing commendable about the Misamis Occidental is that it has a multi-sectoral and inter-agency approach to health development within its ILHZs. The Oroquieta City Health Board includes representatives from other government agencies, namely; Agriculture, Social Welfare, Budget and Department of Environment and Natural Resources. Pangasinan Even before the HSRA convergence, the district health system in Pangasinan has already been working, albeit without the benefit of a MOA and with funds coming from the provincial budget. So far, only one ILHZ, the Bayambang District Health Zone has been identified. A MOA has already been drafted, but it is still under study by the Office of the Governor. The establishment of ILHZs was delayed mainly because of the prudence exercised by the provincial government in deciding about the nature of ILHZ to be established, taking into consideration the local culture and LGU capabilities. Realizing that the Negros Oriental model might not work in the province, discussions are underway to develop a more appropriate ILHZ framework for Pangasinan. Capiz All five ILHZs in Capiz are already organized. The Bailan district is the pilot area for ILHZ. While the management structure has already been in place, much has still to be done with regard to its implementation. A distinctive feature in Capiz is the strong support provided by the provincial government and private donors like the Roxas family to the ILHZs.