 and health issues. I'm Dr. Teddy Herbosa, a trauma surgeon, an academic, and faculty of the College of Medicine of the University of the Philippines, Manila. From 2010 to 2015, the university lent me to the Department of Health as an undersecretary as we implemented health reforms for the Philippine health system. This educational series on health systems, health policies, and health reforms are critical as our country is aiming to provide health equity and quality healthcare to our citizens from all socioeconomic sectors through a robust and efficient universal health coverage system that all governments aspire to attain. Our health system has long mirrored the health system in the United States of America, which has now become the most expensive healthcare system in the world. In the early 1990s, our government officials decided that we can no longer copy the American model of an expensive healthcare for a high-income economy, but must develop our own system through one involving greater health equity for our poor and the disadvantaged. After our government decided to follow the Bismarck model of social protection and created the National Health Insurance Act of 1994, which eventually formed the Philippine Health Insurance Corporation. It was also health secretary Alberto Cuasi Romaldes that initiated health reform agenda in an environment of a decentralized health system that predated the creation of the National Health Insurance Program. By 2010, which was supposed to have been the deadline for universal health coverage by Phil Health, only 54% of the population had health insurance. Also, the support value of Phil Health remained a low 30% of the total cost of healthcare, making our citizens spend a ton of money from out-of-pocket expenses. It was in this environment that we formulated the Department of Health's program of Kalusugan Pang Kalahatan, directly translated as health for all, and we passed the financing by revising the syntax law that allocated 85% of revenues to healthcare system. This was a critical reform in health financing that fueled the resurgence of better health outcomes for our people. Recently, we have passed a comprehensive universal healthcare law, and the office of the president is due to sign this. What our series would like to do is to discuss the many complex issues of health reform in our health system. For this episode, we have our first guest, former health secretary, Polin Jean-Rosell Obyal, to help us understand one of the important elements of health reform, which is good governance, together with health leadership. Polin, let's start by talking about your life experience in the public health system. Let us know how you ended up in the Department of Health and eventually become the highest health official of the land and an alter ego of the president on matters about health. Well, Ted, I started my career in public health as a rural practice volunteer after my internship at UPPGH. So we finished in May. I entered Kidapawan Health Center. Your family is from Mindanao, right? That is North Kotobato, right? North Kotobato. August. So I worked there for six months. Volunteer, no salary. As a volunteer. So I was able to see firsthand how a rural physician actually worked. We went to the mountains. We went to indigenous peoples. So you were a rural doctor? Yes. Rural doctor and a volunteer of the Department of Health. That's right. So it was really a transition in my life thinking about doing residency. But after the six months that I was in North Kotobato, I then decided that public health or rural practice is what I want to do rather than. You fell in love with the public health and rural practice. That's true. Rather than hospital or clinical practice. Which is my track. I ended up in a hospital, yes. So after passing the board exam, I think the results came in February and we ended our rural practice in March. I had an offer from the regional director of Region 12 to stay on. The Java region, right? No, that's Kotobato. Kotobato, Kotobato. Yes. And Maginda now and some of the ARMM provinces were still part of Kotobato region. Correct, correct. So I stayed on as maternal and child health program coordinator. And during the time that I was there, I was again noticed by the mayor of Kotobato city and he appointed me assistant city health officer. Okay. You moved from the department of health to a local government. From the regional office. I joined, at that time we were not yet devolved. Yes, yes. So it was still with the department of health but working in the local government. Correct, correct, correct. So that was the time that I saw how really policy leadership, because I was at a leadership position in the city health office, can really influence how the health system would. So it's the city health officer is the pilot for how the local health system happens in the city and coordinates with the department of health and the other agencies of government, correct? And then you also have to coordinate with all the other departments of the local government. You have to present the budget, you have to defend your budget in the Sangunian. So it's like a mini national government. So you learned governance at the early part of your career. You are already learning governance and leadership in a small community. Community. And I think my most unforgettable experience as assistant city health officer of Cotabato city was when my mayor came back from a conference sponsored by UNICEF and he said, you know, doctora, I don't want to go back to that conference anymore. Do you know where the lowest in the entire country in fully immunized child? FIC. At that time I didn't even know what FIC was. Yes, this is a marker for how many of the children in the community have full immunization of all the vaccines related diseases. Yeah, so at that time I didn't know and I told him I will make sure mayor that we will not be the lowest before the end of the year. What was the rate at that time? Must be less than 50%. When I came in, that was 1988, our rate was 1818. Oh my God. And the whole country was already at the 80% mark. So I told the mayor, at least we will not be the lowest. So I did a lot of programs, we did campaigns, like we talked to the schools, health promotion, we talked to... But we didn't call it health promotion then. Yes. We called it public health. Actually it was then called social mobilization. Social mobilization was the old term. So you engage all the stakeholders and then you implement a program. So the good news was that after about six months doing that, we got 82% FIC. Wow, in six months. So did you do house to house? Or they went to your health center? No, we did the campaign. Every first Saturday they come to a health post. It's not the health center. We established so many health posts and we had nurses, student nurses, student midwives. So you had an army as well. So you got all other stakeholders in the health community to have the idea let's improve FIC and vaccinate all the children. Interesting. So that's how governance can work and succeed. So that was actually... Six months from 18% to 84%. Wow. That's why I was telling myself because that was my first experience. Little did I know that after five years we would be doing the National Immunization Days of Secretary Flaviere. With Secretary Flaviere. So with my background in Cotabato doing that mass vaccination campaign and catch up immunization, I was prepared for the much bigger role of being the head of the Polio Eradication Unit. Oh yeah. And I was the one stage. So you were involved in that in the Polio Eradication Unit? Actually we were on top of staging the whole National Immunization Days campaign. We were sent by the DOH, me, Maritel, Costales, and Agnes Benegas, the three of us to Vietnam for the technical advisory group meeting on Polio Eradication. You never told me this story when we were in the Department of Health. We were sitmates in the Ex-ACOB. But Polio is one of the examples of a successful partnership between the private sector, the rotary clubs of the world to eradicate Polio. And we succeeded. When did the WHO declare that we were polio free? We were declared polio free in 2000. Actually, Secretary Ramaldes was the one who accepted the award in Japan at that time. So indeed, public health had had successes. Yes. So how did you end up in central office? Or were you assigned in regional offices before? So after my success in Kotabato, I was already noticed by program managers of the central office. So they were saying, oh, there's a good doctor, a very... Good public health... Public health doctor in Kotabato. And we can recruit her to the central office. Battle tested with medals. So they recruited you to the central office, IC. So your success in local governance brought you to the central office. How was life like in central office? I mean, you know we're in central office. Yeah, you have many bosses. We don't have only one boss. It's a matrix organization. You have a matrix there in central office and many people assistant secretaries. Undersecretaries, directors. Even people from other agencies imposing their will on you. So how was that life like that in the central office? It was really much more busier in central office because in the field, you really can take your time or make your own schedule. But in central office, everybody is pulling you left and right. For meetings and for projects. And then you cannot make your own schedule because you have to adjust to the schedule of other offices, the bosses, your network, UNICEF, WHO. So it was a culture shock. It was a culture shock from rural medicine, rural public health, to central office governance and leadership. But I was also exposed to making policy because when I was city health officer, we were implementing programs. I had somebody write all the orders, the directive in central office because I was the program manager. I wrote administrative order, department order and all that. Correct, correct. So we're really very involved in central office. Maybe for the benefit of viewers, they should understand that laws in the Philippines can be created through Congress and Senate as republic acts. The president can act the executive, can issue executive orders. But the secretary of health can issue administrative orders and department orders which will involve the whole health sector or the whole department of health or any focus group for specific policies. Yes, that's right. So you were involved in crafting many of the policies written in the past. What is one you remember and you're proud of? It's crafting the administrative order for the national immunization days. The one that Flabberg used. Flabberg used to reach about 95% that was the most successful implementation for immunization program of the country. And I believe the WHO used our model as a pattern and became a case study for other countries to improve immunization. After our national immunization days, actually, WHO was pushing us to be the first country in Western Pacific to do national immunization days because it was already being done only in Paho. Correct. In the South American. Pan-American health organization. Yeah, but they did it in South America. North America, they didn't do mass vaccination or national immunization days. So they were pushing us. And the biggest promoter there of the health day was Secretary Flavier himself. He was in these jokes. We were able to stage it successfully with Secretary Flavier, with all the logistical dilemma. At that time, we didn't even have the vaccines in the country. So we're monitoring. We get it from WHO, right? UNICEF and WHO. It's a global purchase. And then we just give their money and then they deliver when our program will be, right? So it was really logistically nightmare for all of us. Big operation. It was a big operation. Requiring good leadership and governance. It was done in April and May 1993. So you're really a local Philippine expert. In fact, a global expert on implementation of immunization program. So after that, that's when the Philippines became known in the Western Pacific as really a trailblazer in terms of mass vaccination campaigns, in terms of social mobilization. So we were invited to a meeting in Vietnam for the technical advisory group on polio eradication. And our main role there was to convince all the other countries of the Western Pacific to do it. That was also doable to eradicate polio in their countries. And then when they saw our list of stakeholders and collaborators, I think we have around 45 and we had, can I mention, private sector and Galibi, McDonald's. So the private sector also helped out. Coca-Cola and they were all wondering, how did you get all this private sector to help you? We just asked them to print our posters to deliver our materials like Coca-Cola trucks. They were all over the country. They were in the public. So it was an early form of public-private partnership. It wasn't called then at that time public-private parties. But stakeholder engagement. You engage all stakeholders and were able to implement polio eradication program. And then we had DHL, we had PAL, they delivered all our logistics for free. Wow. So that was how we were able to make it despite a very low budget. Government only came out with the budget for the vaccines but all the information education materials were donated. Interesting. Yes. So after that, well it's the rest is history. It became assistant secretary. Because China, the biggest country in western Pacific actually did their national immunization. I saw that and I said, oh, China is copying the Philippines. Yes. So let me ask you now, based on your wealth of experience as a health leader, understanding health governance and how to make immunization programs happen, how does the health reform occur in a particular health system? You've lived through a centralized health system converted into a devolved and decentralized and then through the creation of field health, through Kalusugan Pankalahata and then you became health secretary. And tell me a story. How does a country or a system, a government implement reform in the health sector? I think I would like to believe that I went through in my 29 years in the Department of Health, through the major, three decades of Department of Health. Of the health sector in the Philippines. So you did mention about field health, the introduction of the Social Protection. National Health Insurance Program. I think that was one of the, shall we say, turning point, tipping point of the health system in the Philippines because we changed the way we financed health from a purely tax base, meaning we get taxes from people and then give it. With a public health, public health and public hospital funded by tax money. Tax money. And then private health funded by out of pocket. Yes. So if you're poor, you go to the public system. So it's a dichotomous health system. The field health covered everybody. Yes. Poor and rich. So it was a paradigm shift so that really, the intention was that people, even if you are poor, you can access health services in the private hospital. Even if you are rich because of the quality of health services in public hospitals, you can access health services. So we wanted a shift from a dichotomous health system to a single payer. In fact, at that time that started, I remember my colleagues in clinical medicine was ignoring field health for the very small reimbursement. But today, everybody is trying to line up with you and get field health accreditation. I think that was the way we started with very low, shall we say, support value. But as things improve, then we increase the support value. Correct. And right now, because as you mentioned, private sector is trying to get the national health insurance because we now have about 92% covered. About 90 million people have health insurance. So it's actually now, in terms of volume, you can get more payments if you get more patients. So it's more sustainable to deliver low cost but quality health care. So that's how we are. And I think the turning point again was the syntax law. Yes, the financing. Because after that law, I think the funds for health increased quadruple. That's why when... You know, we only won that law by 10 to nine, by one vote. Yeah, by one vote. By one vote. In fact, when Secretary Duque came in, he was my health secretary before Secretary Onah. The first time, the first time, yes. And then when he came in now as health secretary, when I left the DOH, he said, Pao, you are awash with cash. Because during his time, the budget of the DOH, and including field health, was 26 billion in all. And when I was endorsing to him, the budget of the DOH and field health was already 160 billion. So he was really going crazy about the amount of money that was invested in health. And you know what happened? The absorptive capacity wasn't there. So DBM started to cut again. No, but I told DBM at that time, you know, health is an investment. Correct. And at that point in time, when President Duterte came in, I'm very glad that he in fact mentioned it in his state of the nation address, that we, of course, when the president says something, it came from the health secretaries or the secretaries. Yes, yes, yes. But he mentioned the state of the nation. And then we feed his speech. Speech writers. And then he mentioned that health is an investment. It is not an expense. Therefore, we will, this administration will ensure greater investments in health. So I was very glad that he did mention that. And I, in fact, lobbied for the biggest budget of health during my administration. In the history of the Philippines. In the history of the Philippines. Because I was presenting to the president health development plan that looked at an ideal model of human resource to population of health facilities to population. And we saw that there were 42,000 hospital beds. Correct. Gap. That's the infrastructure gap for hospitals, correct. And then he wanted, the president in his campaign wanted one barangay health station or one health worker per barangay. I told the president we cannot do that because we don't even have a house. The barangay health station in every barangay. And he said, how many are we missing? I said, we have 42,000 barangays. We only have 21,000 barangay health stations. That's why he also invested. So in my total presentation, we needed 228 billion. And the president said, oh, that's very easy. But sir, that's only capital outlay money. No, you need people. You need human resource. Medicine. Operating expenses. But he says, if we have a house and so the other things will come in. So let's build the house first. Correct. So I told him, sir, if you will continue on giving the Department of Health what we have been receiving in terms of capital outlay, then we will finish this in 11 years time. Because we're receiving only about 20 billion a year. You know that's what people don't understand it. That's what I learned. Money, you cannot just throw it and solve a problem. Because there is a certain level. The money needs to build health centers. The health centers need to be equipped with medicines and people before they are able to provide actual services to the people and before health outcome changes. There's another interesting thing we need to talk about. The president sent you to Cuba. Yes, he did. He asked you to look at the health system there. And that's a universal health coverage model of a socialist model. Can you tell us more about that trip? Yeah, you know the president is a wide reader. I think he read somewhere or he read the book. But when he was interviewing me in Davao, he asked me to go to Davao to be interviewed as health secretary. And even before he says, oh, you're my health secretary already. He just, out of the blues, tell me, doctora, you go to Cuba. Then I told him, what am I going to do there, sir? You've never been to Cuba. No. But you've read about the successes of their health outcomes. Actually, it's very superficial, Ted. But I didn't know the deep process. The reports of WHO that their health outcomes are very good with little expenditure. In fact, yes. So I didn't really know. But out of the blues, they said, go to Cuba. What will I do there, sir? I don't know. Anybody, you go to Cuba. You observe what they are doing. Because I think that's the health system that will work for the Philippines. Especially for rural areas. So after that interview, I was named health secretary. So the first thing I did when I was in office was to arrange that trip to Cuba. So we went there in August. I came in in July. So you followed the marching orders of the president to look at the model, the health system model in Cuba. So they have no private health care. No, no private. Only government provides the health care. And I think it was really an eye-opener that their health system was really well-organized. They observed the doctor to population ratio, the health hospital bed to population ratio, and all that. And then all their vaccines, all their medicines are free. No wonder they rated very high by WHO, because they follow the parameter that were measured. It's a quality. They're even better. Yes, yes. They have one doctor for every 1,000 population. Their ratio, doctor to population ratio, is even better than the United States. The United States, correct. But their cost is so much less. They spend about $460 per capita. The US, that's why you mentioned they're most expensive. They're $8,600. The Philippines, at that time I went there. What is the per capita? $135. So my mission then was to increase the budget, the investment in health, to about $300. And we were able to achieve that in 2017. That's wonderful. So that's really part of financing it. Now there are many projects in the Department of Health that we also run and you get into some problems or did not succeed very well. Are there programs in the past, in your experience, in your career, in the government, or in a public health program, didn't do so well? And what lessons were learned from it? Yes. I think one of the most important lessons is getting the money is just half solving, half the problem. It's spending the money. Yes, and government spending is not that easy. The underutilization and all that because I think what happened to us in the DOH was that we had budgetary support but we did not have technical support on how to actually make our systems more efficient so that we will be able to utilize the funds that were given to us. Like for example, Secretary Duque was saying, oh, you get three times the budget but you have three times less people because of re-engineering. We were downsizing for so many years during Secretary Ona, during my time and yet the budget was increasing, the number of people doing the job was decreasing. So the obstacles were really the framework of human resource, matching with the program and the funding increase. Very difficult. It's like many gears in a box where you control the gears. You increase the financing but you lessen the people. The outcome is also no good. So it's very tricky. That's why one of the lessons I learned in the health sector was really, Ted, to make sure that you have a very good plan, like the Kalusugan Pang Kalatan. So that what happens in the next administration is actually sustained or followed through. But you know Kalusugan Pang Kalatan was not our plan. It was your plan. I'm from outside the DOH. It was a plan that you guys devised out of what had been happening. And we just implemented it because you said this is the way to go. We just steered and piloted the programs. Actually that's one of the things that the DOH is really, I believe more mature in, in terms of the other agencies of government. We develop strategic plans. 10 years, even 20 years down the road. In fact, I like your continuation of KP. Your Kalusugan Pang, you continued with the SDNs. So you used what was done for financing and you tried to develop the SDN. And that's where the story of the more rural health centers and more primary care, which is also what you saw in Cuba. Because in Cuba, because they have more doctors, there was more primary care and there was less need of tertiary, expensive tertiary care. But you know the bottom line, I think of Cuban model, aside from the health facilities and human resource, is really the target of government is to have all Cubanos have annual checkup. Interesting. Because it can be a health status check. No, but it doesn't have to be a sophisticated or high tech checkup. It's just making sure that every citizen of the country is seen by a health professional. And I remember a former president who used that as a campaign slogan. We're in the half of the Filipinos that die. Didn't even see a doctor. Yes. So that's an important model that the physicians must see the people and that assessment in itself will identify the problems and solve that one. Very interesting. So what are your suggestions to how now we have this universal healthcare law that's about to be signed by our president? And it's a very comprehensive law. I look at it, it's something that's very hard to do, very complex. The people that crafted it want to do everything all at one go. And what is your advice to the people sitting in government? Do you know that law was started during my time? Yeah, you were crafting it, yeah. Yeah, but the original version which Congressman Harry Roque submitted to me was actually not so acceptable. That's why we reformed it. And we put in all the problems. That's why Manchit was saying that the law for newborn screening was actually trying to solve the existing problems at that point in time. Chancellor Padilla of Lupimanila has a program on newborn screening that was passed into law. But at that time, they were competing with other health issues because of the low health budget at that time. But I think that's why when you look at the universal healthcare law, it's so much input on various issues like regulations, the human resource, the financing and all that. Because we looked at the health system or the health issues at this point in time and we tried to address all the health issues through the law. And hopefully. Of the Philippines. Yes. So you made it appropriate from a, I know when I saw the draft bill of Congressman Roque at that time, it was a copy paste from some other Thailand. We know, because we understand where it came from. But Thailand had a different background and setting of where they are. And they're a multi-payer system. We have a single-payer system, which is one of the few in the world. I think we have only about nine countries with a single payer. And it's actually an advantage for us. So I'll ask with a few remaining minutes and with all the experience you have shared with me in this episode, I'd like to ask you now, all the things you've learned about universal healthcare implementation and the big role of good leadership, strong leadership and good governance. I think people forget that. They think it's a framework of a law. I believe it's very important. The plane will not fly on its own. Yes. It needs a pilot. It needs a good pilot and a good navigator. The two of them have to work together. So explain to me how important this pillar of good governance and good leadership is. Yes, I think that's why we really need to have a multi-sectoral, multi-stakeholder approach to health. It's not just one person or one agency doing it, like the Department of Health. It has to be all the stakeholders working together. And what's very important is the leadership role has to have that ascendancy or values that is espoused by all the stakeholders so that you can actually lead them. Because if your values are not aligned with your stakeholders, then you will not have teamwork. So you're telling me health systems strengthening and health systems reform is a team sport. Yes. You need a team captain. You need a coach. And everybody must know what their role is. Are they the goalie? Are they the forward? Are they the... Yes. So everybody must perform their role. That's right. More like a conductor in a symphony creating harmony. Orchestrating the music. And that's why our basic institutions like the academe like UP and all the medical schools must actually work with government so that we produce the leaders, the health workers that actually espouse the values that we want to happen in this country. And if you're a leader, you must also know the system. Yes. You must know how... We have to be aligned. Aligned. If you're running an airplane, you must know what the engine can do, what the knobs are that you will turn. That's why the academe is important. And then I think NGOs are also important because they actually look at the entire picture and they fill in the gaps in the health system. Because the government cannot provide everything. Yes, that's true. So sometimes because you're busy addressing several issues, there are gaps left behind. And the private sector is allowed to actually fill in those gaps. But the basic framework or backbone related is a health reform agenda or a strategic plan so that all your stakeholders will have one vision, one goal, one framework, one direction to move into. That's why the leadership role of the Department of Health is very important. And it's critical. And critical. Well, with that note, I'd like to ask you to give your final words maybe to our leadership and the future leadership who are having elections. And then in another three years, we'll change again government. There's talk about federal form of government. Again, with all these distractions, we need to give advice to the government. And both of us now are outside that health system. But we can continue to give advice. So I'm giving you the YouTube, the internet for people to understand and share your experience and expertise. Yes, I think as a country, we have to really work together so that we elect the kinds of leader that espouse the values that we have. Values of good governance, values of transparency, accountability, and well, no to corruption, no to graph, and really helping our people, especially the poor and the marginalized. So let us elect the leaders that will move this country towards a better health system for us all. And if we elect the right leaders, they make the right laws, they allocate the right budget, because everybody says their priority is health, but they actually don't put the money in the health sector or they don't support the health sector. But they always say when they campaign, their priority is health. So I think we have to be critical as a people to really elect political leaders that will support our values and our agenda, health agenda, which is universal health coverage. Thank you very much, Pao. Well, that's our final message for today. With this episode, we saw many things that our experienced guest was able to share with us. Talked about the importance of good governance and good health leadership to implement reforms in the health system, to strengthen our health system. She talked about making the health system similar to a team sport, where the leader will be conducting and creating all the necessary efforts. And all stakeholders will be involved in taking care of attaining better health outcomes for the people. Well, Pao, thank you very much. And to all our viewers, thank you very much for covering this episode, a healthy session to all of you. And watch out for more episodes in health issues. Thank you.