Unintended consequences

In life, there is such a thing as “the law of unintended consequences.”

Sometimes, a law is enacted or a policy is crafted to address a particular problem. But in the implementation, the measure gives rise to consequences entirely unforeseen, unanticipated or unexpected that may, in the end, result in even bigger and more serious problems.

Take the law on devolution. As envisioned by its crafters, devolution addresses the issue of extreme centralization in government. In previous years, the national or central government had almost total control over policies and budget disbursements, so much so that provincial or city and municipal authorities had to petition “imperial Manila” for every expense, purchase or initiative.

Devolution was supposed to address this problem—unclogging sticky budgetary processes, empowering local governments and local government executives, leading to more efficient and effective governance.

But devolution has led to other problems.

Under devolution, the provision of basic services has fallen on local governments, who supposedly best know the basic needs of their constituents. One of these services is health—with the national Department of Health now relegated to crafting overall policy, running a handful of “DOH hospitals,” and overseeing local health delivery services through regional or provincial bodies, among other functions.

The policy has placed local hospitals and public health centers under the authority of local officials, who hire health personnel and are responsible for setting up and running these facilities. There has also been a drive for provincial and municipal or city governments to consult with stakeholders in the crafting of long-term health policies and programs, hopefully to put these beyond the reach of the election cycle, subject to the whims and favors of every new set of officials.

But in a situation where funding for a local government is deficient, if not nonexistent, local officials may be tempted to be more “creative” in their approaches, resulting in unforeseen consequences.

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Health Undersecretary Janette Garin, during an assessment cum celebration of the Responsible Parenthood and Reproductive Health Law, shared a story about the DOH’s findings when it set out to find the causes of an alarming rise in measles cases in the last few years, which was traced to the decline in the rates of childhood immunization against the disease.

What the DOH discovered, said Garin, was that an increasing number of parents were hesitant or resistant to bring their children to health centers for vaccination.

She traced the development to two factors. One was that, in an effort to broaden the coverage of measles immunization, health authorities began implementing a “door-to-door” campaign, with health workers visiting poor communities to offer free vaccinations to children below five years. “This was effective in the early years of the program,” said Garin, “but later on, parents began taking the vaccinations for granted. They became too dependent on the program and stopped going to health centers.”

The other reason, Garin said, was the policy adopted by local governments, authorized in some cases by ordinances, requiring health center personnel to ask for “donations” from people seeking health services, including immunization. (This was supposedly to “encourage” the health center personnel to be independent and no longer dependent on budget allocations.)

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Though the “donations” were supposed to be voluntary and the amount up to the discretion of the client, in time the practice became policy. Some personnel, said Garin, began charging as much as P250-300 per vaccination. The “donations” became such an onerous obligation that parents stopped bringing their children to be vaccinated altogether.

There is, however, a silver lining in this dismaying development. In recent months, the DOH began an information campaign targeting the public and also health personnel to inform them that basic health services, such as vaccination, should be and are free, and to encourage parents to bring their young children to health centers for immunization.

The campaign has had a measure of success: Subsequent immunization rates have risen to 80 percent, meaning more children saved from illness or even death.

The same problem applies to the delivery of basic services to pregnant women—prenatal visits, delivery, newborn and infant care, and postdelivery contraception for the mother—with women reluctant to visit health centers because they fear being charged fees they cannot afford.

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This should not be the case. Health Assistant Secretary Paulyn Ubial, at the “A Promise Renewed” conference, stressed that pre- and postnatal services are free at government health facilities.

“All pregnant women are covered by PhilHealth,” Ubial stressed, referring to the government health insurance program. “We are implementing no-balance billing in all healthcare facilities, with rebates paid [to hospitals, health centers or delivery clinics] for prenatal services and delivery.”

The DOH, Ubial added, has also met with local governments to “call on them not to ask for donations for their health services,” because these services will be reimbursed anyway by PhilHealth.

However, Dr. Benjamin Lane of WHO observes that “public finance is not easy.” He says lowly-paid health center staff may find it hard to resist asking for “donations” when these amounts are intended to augment their salaries. What all stakeholders need to do, he says, is to “strengthen the capacities of local leaders while improving the training and pay of health personnel.”