Health metrics that matter

By the end of the Aquino administration, the Department of Health (DoH) would already have a budget almost five times more than it began to receive at the start of President Benigno S. C. Aquino III’s term, should the proposed P122.7-billion health budget be approved this year. This is a record high in the history of the DoH budget.

At a glance, the steep rise in the DoH budget is a testament to the administration’s commitment to advance Universal Health Care (UHC), which envisions a health system that leaves no one behind. It is also a strong indicator that the Sin Tax Law is working, given that bulk of the law’s incremental revenues are earmarked for UHC, and that the substantial increase happened soon after its passage, from P53.2 billion in 2013 to P83.7 billion in 2014. The entire health community, both at the local and international level, recognize the budget increase as an important milestone in health financing.

WITH MORE MONEY COMES GREATER RESPONSIBILITY
Indeed, the Philippines has been so far successful in securing resources for health, yet the more difficult task of ensuring that resources actually translate to health outcomes still remains. Even the latest figures for some of the most basic health-specific Millennium Development Goals (MDGs), which culminates this year, such as maternal mortality and incidence of HIV/AIDS, are still far below the targets despite the seemingly MDG-focused programs of DoH. Add to that the double burden of non-communicable and communicable diseases, which has only been slightly tackled by the Department, and you get a grim picture of the challenges ahead.

Perhaps the most obvious reason why the impact on health outcomes is not as dramatic as the spike in the health budget is the huge mismatch between DoH programs and the primary causes of mortality and morbidity. The top three causes of deaths in the Philippines, namely diseases of the heart, diseases of the vascular system, and malignant neoplasms, have been the same for more than a decade and are continuously increasing the number of deaths every year, yet none of DoH’s well-funded programs deals with the prevention of these conditions. While most of the top 10 causes of mortality and morbidity may only be completely addressed by involving other agencies and employing a whole-of-government approach, it is still imperative that DoH leads in setting this health agenda.

KEY STRATEGIC THRUSTS AND ITS PERFORMANCE INDICATORS
Consequentially, there is also a gap between the Department’s performance indicators, and the service delivery and health outcomes that really matter. We can start by looking at “financial risk protection improved,” a key strategic thrust of the Aquino Health Agenda that has been getting a lion’s share of the DoH budget since 2012. Here, coverage rate and benefit payments have been the primary measures of progress whereas the measures that really matter should have been the amount of out-of-pocket expense and the number of people who were not able to access needed quality health services due to financial hardship.

The next thrust — access to quality health care services, is also masked with indicators that do not necessarily improve access to health care. For example, under the health facilities enhancement program, the most common performance measures such as the number of facilities established, upgraded, and accredited, are useless if they do not inform about their actual catchment areas — the number, socio-demographic profiles, and health conditions of the people they serve. The number of facilities also need to be accompanied by the number and types of health providers who will render service in each facility, for what good will a facility do in the absence of the health care workforce.

The third thrust, which aims to address the MDGs on health, specifically maternal health, child health and HIV/AIDS, may have the most number of indicators that are more directly linked with health outcomes, but even so, some of its targets still need to be refined. For instance, in reducing maternal mortality, the single most effective intervention is to ensure that deliveries are attended by skilled health personnel, yet, this is not included in the official performance measures for maternal mortality. Instead, what has been adopted as a key measure is the proportion of facility-based deliveries or pregnant women delivering in facilities.

Moreover, although some of the MDG indicators used are reflective of important health outcomes, what is being measured barely scratches the surface. Even the indicators of access to quality health care services which touch on communicable and non-communicable diseases, reflect a hodgepodge of data.

While some are actual health outcomes — malaria or filaria-free provinces or deaths due to malaria, others are outputs or interventions completed — number of senior citizens immunized against influenza, provinces with noncommunicable diseases registries, or cessation clinics established, or are clumped together such as in HIV/AIDS cases diagnosed and given treatment. Furthermore, critical health outcomes remain missing, such as access to skilled health personnel, despite the inclusion of annual targets on the number of health human resource deployed.

All of the indicators measured by the DoH are important. But the missing data, the uneven, intermittent, and selective analyses, and failure to track progress gravely affects the understanding of the complete health picture across time.

MISSED MEASURES, LOST OPPORTUNITIES
To the extent that DoH’s selection of its measures and targets is a function of its capacity to collect and produce various types of data, its failure to pay attention to the metrics that matter may partially be a result of the existing poor health information system. The obvious solution then would be to invest in a comprehensive health information system and to boost DoH’s information management capacities. After all, the development of a national health information system is crucial to effectively aid policy formulation, which is why it is also one of the six building blocks to achieve UHC. Particularly, DoH needs to generate new data that will capture alcohol prevalence, and sexual and reproductive health outcomes, among others.

Nevertheless, even with the available limited data, much can still be done to sharpen DoH’s policy formulation. The underutilization of the DoH budget is definitely a huge disappointment given that many targets have yet to be achieved, but it also provides room to maneuver towards more evidence-based planning. An urgent task for the Department is to complete the Evidence-based Human Resources for Health Master Plan, which provides the blueprint for determining, attaining, and retaining the standard number of skilled health professionals and other allied health professionals across the country, as specified in the Implementing Rules and Regulations of the Sin Tax Law. The mapping and connection of the service delivery network, which includes the geotagging of health facilities across the country, can also be achieved before 2015 ends. Disaggregated data on the utilization of PhilHealth benefits, by package, income group, sector, type of facility, and geopolitical divisions, should already be generated and released to effectively guide the development of packages.

The legacy of the MDGs is that what is measured counts, as it shapes policy and determines where resources will go. As Congress deliberates the 2016 DoH budget, may they ensure that the measures that really matter are addressed. Ultimately, health outcomes that are missed, deliberately or not, means lives lost.

Jo-Ann Latuja-Diosana is a Senior Economist at Action for Economic Reforms. May-i Lactao-Fabros is the Young Women Collective Coordinator of WomanHealth Philippines. Action for Economic Reforms and WomanHealth Philippines are members of the Alternative Budget Initiative — Health Cluster, which proposes alternative budget recommendations to the Department of Health annually.

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