Commencement Speech for UP College of Medicine class of 2013

by Eduardo P. Banzon (Notes) on Wednesday, May 22, 2013 at 8:39pm

Dear Graduates and Parents, Chancellor Agulto, Dean Mejia, Director Gonzales, faculty members, particularly from my old colleagues from the Department of Clinical Epidemiology and the Department of Family and Community Medicine, and dear friends good afternoon. Una sa lahat, nagpapasalamat po ako sa 152 na miyembro ng UP Med 2013, at 104 na PGH postgraduate interns sa imbitasyong ito isang itong karangalan. Ako ay lumagi ng limang taon sa UP College of Medicine at Philippine General Hospital kung saan ako ay gumawa ng mabuti at hindi masyadong mabuting mga bagay mapalad lang siguro ako na walang tainga at bibig ang med stones, tennis court club house, at dingding ng PGH! Magsisinungaling ako kung sasabihin ko na di ko pinangarap noon na maging tagapagsalita sa isang UP Med graduation. Dahil sa inyo, tanggal na ang isang nakalista sa aking bucket list. Bago po ako magpatuloy, nais kong batiin ulit ang mga minamahal na magulang nandito tayo ngayon dahil sa inyong hirap at sakripisyo. Dalawamput isang taon ang nakakalipas nang nagtapos ang aking klase. Ipinagmamalaki ko na akoy bahagi ng Class 1992. Bagamat hindi kami nanalo sa Tao Rin Pala tulad ninyo - laging third place at na-disqualify pa kami, tambak naman sa amin sa basketball ang mga ibang klase kahit interns na kami. Marami kami naging faculty at sa mga nanalagi paring faculty JJ at Tech Cruz, Ants Cordero, Tony Perez, Jubert Benedicto, Ces Lim, Anna Ong, Eric Domingo, Paul Pasco, Cecille Maramba, Natzie Yang, Marlo Nievera at iba pa sana naturuan niyo silang maging kasing galing natin. Kami ay masayang nakaupo noon sa Meralco theatre, pero hindi ko rin maiwasang malungkot. Alam ko na meron kaming mga kaklase at kaibigan na malamang hindi na makikita pagkatapos ng araw na yun. Mamaya, bago kayo maghiwa-hiwalay, yakapin niyo ng mahigpit ang isat isa. Hug each other tightly for the years you shared with each other and the memories that will be there forever. 21 years and so many kilos after starting a career one that was so much less travelled people would ask me. So Doc, what is your specialty? And to this I would answer. I practice health systems with a sub-specialization in health economics and financing. This will get me a raised eyebrow, a funny face, and sometimes a smirk that tells all. I understand those responses, but allow me to share with you the work that has kept me happy and fulfilled the past 21 years. Right after the medical board exams- na sigurado ako lahat kayo ay papasa tulad ng class 92 I joined the Philippine Rural Reconstruction Movement as a community physician and organizer. This was the first of the NGOs I joined in the next four years that followed, where I provided health care services in rural barangays and urban poor areas and organized communities to take care of their health needs. My parents always wanted to but kindly never asked why. Bakit nga? It was partly paninindigan for the rallies I marched and the slogans I sh outed while in UP. It was partly living up to Alay sa Sambayanan the commitment of my fraternity, the UP Alpha

Sigma. It was in part staying true to my answers when I was interviewed for medical school admission.

Seryoso po ako nang sumagot ako noon na pagsisilbihan ko ang bayan. It may also have been the eternal dreamer in me who believes that we can, and should, all make a difference. In the end, those four years confirmed what I have painfully learned and lived with every day in PGH - that we have not succeeded in providing health care for our people. How can we say we have cured our patients if the treatment we prescribe will drive them to financial hardship, making the poor even poorer? How can we say that we have served our people well when the inherent inefficiencies in our hospital compel us to serve a few hundred less patients a day a few hundred who travelled far and away to seek the best medical care in the country? Those four years made me realize that kwento ni Rosario discussed during Family and Community Medicine will always be a inevitable tragedy, and that health for all an illusion, an impossible dream IF we fail to believe, and fail to act. Moreover, health, wellness and productivity cannot be restored by clinicians alone. The daily-wage earner missing a days work, lining up in the cold morning along Padre Faura and grateful for a 2 minute consult and a panel of laboratory tests requests; the sacadas in the haciendas of Negros whose health spending was always catastrophic; two hydrocephalic twin babies needing VP shunts because their mother failed to take preventive folic acid; the young primigravid who prepared for a safe delivery in a rural health facility but died of complications due to poor referral on the day she delivered; or the dire statistic that 60% of our countryment die without being attended by a physician, in the background of 2000 new medical graduates annually. Clearly, resolving the clinical dilemma through quality health service provision is only one part of the system-wide solution that is a combination of good governance, existence of financial safety nets, timely feedback, and access to affordable medicines and technologies. All these, in varying levels contribute to the restoration of health, wellness and productivity, and to better health outcomes for Filipinos. I begin to see health systems work as a platform to enable and incentivize clinicians to do more, to engage the private sector in public health and to scale up ideas and innovations. And so I started to think, talk and work with a systems perspective, able to connect the dots however far apart they may seem. There is no residency training program for my specialty but the years I spent in the field, at the university, with the World Bank and other multilateral organizations, with PhilHealth and other government agencies, coupled with a masters degree in policy and financing and guidance from generous mentors such as Secretaries Alran Bengzon and Jimmy Galvez-Tan have moulded me to be the health systems and health financing specialist that I am now.

But even after I answer with a long explanation what is my field of specialization, some would still ask, so sino po ang inyong mga pasyente? Bata? Matanda? Buntis? mahirap sagutin but let me try. One patient if we call it a patient was the persistently high prices of medicines. Bringing down the prices of medicines cannot be done by simply enacting a generics law. We strengthened and simplified the regulation of medicines in order to ensure that government procured drugs are not poor quality drugs sold by fly by night drug traders while opening up real competition in the private drug retail market. We had to convince fellow doctors to trust the regulatory process while getting PhilHealth to leverage its benefits to promote generic competition. It is continuing work but progress has been phenomenal. Generic drugs now have a fan base if I may say so. Prices of off-patent medicines have drastically gone down. Treatment compliance for chronic diseases has generally increased. Next was a group of dying pregnant women. A key system solution for pregnancy-related deaths was to get expectant mothers deliver in health facilities. This needed a combination of the DOH explicitly declaring through an AO that it wants mothers to deliver in health facilities, PhilHealth paying what was traditionally considered a non-insurable admission, government health center physicians re-learning how to deliver babies, midwives given more authority to inject oxytocin, local government units and politicians upgrading their health facilities and private sector health professionals investing in lying-in clinics and birthing homes. The last few years have seen dramatic increases in maternity care providers complemented by leaps in facility based delivery rates. This makes certain that all babies receive Unang Yakap, undergo newborn screening and get registred and have birth certificates. Mothers on the other hand survive the most wonderful emergency in life! A favourite patient was PhilHealth. Conducting a health system history and physical examination would show that for 17 years of its existence, PhilHealth was disoriented confused as to its role as a social health insurer, and had poor muscle mass - unable to exercise its being a strategic purchaser. Indeed, the business of PhilHealth was quite simple. The general tax and earmarked sin taxes are used to pay for premium of the poor. This, together with premium we the employed - are paying is pooled into one fund. PhilHealth then pools the risks and makes all types of cross-subsidization, in the spirit of social solidarity or bayanihan to purchase health services on behalf of its members and beneficiaries. Just like any astute purchaser, should leverage its purchasing muscle to make suppliers of health care services provide the maximum health services for the least cost. Value for money. Now, a reoriented PhilHealth is slowly building its biceps. It has finally accepted that as a social health insurer, it will always be biased for the poor. The catastrophic and primary care benefits were expected to make available to the poor health services which are not usually available to them. Deploying patient navigators called PhilHealth CARES nurses in hospitals ensures members do not get shortchanged in the services they get. The shift to contracting from accreditation cemented PhilHealths role as a purchaser in the strictest sense, not simply a funnel for health care funds. Buddies are found in many a local government from Misamis Oriental to Albay to Nueva Vizcaya to Leyte; they are showing how strategic purchasing is making a difference in the lives of Filipinos. Case rates with no co-payments are finally happening not only in public but private hosptials as well.

In 2011, PhilHealth paid 34 billion in benefits. In 2012, after reoriented and stronger PhilHealth has paid out nearly 50 billion pesos! There is still a lot of work that needs to be done with PhilHealth but my own part ended early this year. It was admittedly short but it was one heck of a ride. One other patient I would be happy to have would be PGH. But I understand that JoeGon, Marge Lat, JJ Cruz, BJ Sablan and the rest of the management team have begun to inject systems treatment to make PGH healthier. Now that would be a very interesting case for Guazon Hall. Health system treatment work takes years and will be frustrating as times but I have never been disillusioned even with slow patient response to the treatment. As long as we keep on moving the mileposts or there is progressive partial response to the treatment, I will always celebrate and move ahead. And yet even with all the explanations, may nagtatanong pa Eh, saan po kayo nagpapractice? Sige na nga. I practice all over the country and some parts of Asia. But with the call for Universal Health Coverage or UHC embraced by countries after countries, I may just find myself practicing in parts of Africa soon! Universal Health Coverage. Universal Health Care. UHC. Ano po ba yun? UHC is more than just poor people getting a minimum set of basic health services. It is about guaranteeing that all people you and me get the necessary preventive, curative, rehabilitative and palliative care without the risk of financial hardship. It is about mobilizing money to reduce inequality - prioritizing those at the bottom of the pyramid or those below the poverty line. It is about innovation and better regulation by the DOH. It is about efficient use of resources primarily through strategic purchasing by PhilHealth. UHC marks the end of medical missions, charity beds and debt of gratitude or utang na loob sa duktor; and ushers the era of practicing everyones- even the poors right to health. The statistic of nearly 60% of Filipinos dying without an attending physician which had been mis-interpreted as 60% dying without seeing a doctor will be a thing of the past. We will see sustained decreases in the share of household out of pocket payments to total health spending. And hopefully, nobody will die unnecessarily because necessary services will be accessible. With UHC, everyone can and will demand for quality health care services because it has been paid for. I now invite you members of class 2013 and the PGIs to be health system practitioners and take on the challenge of UHC. Now is the perfect opportunity to join the quest for universal health coverage. You will not be alone as the journey I started years ago is no longer the road less travelled. People who think and work health systems are now found among clinicians, academics, health managers, and a lot of young UP medical doctors. The sin tax battle showed how many clinicians like cardiologist Tony Dans fully understood that it really takes a system to make our people healthy. Surgeon Mulong Busuego is showing how a government hospital should treat its patients with dignity. And 2009 graduate Lopao Medina is proving how a systems approach can expand quality health services in an island off the coast of Quezon. And fear not that you are not ready for five years of UP Med and PGH internship had prepared you well. Dissecting the human body in our first year taught us perseverance and patience. Such

guided me when Sec. Quasi Romualdez brought me to PhilHealth in 2000 to help change its traditional approaches. Staying for 6 years was not enough; it needed me to return after five years in the World Bank to finally help pull off the reforms. And lots of patience allows me to run after my three energetic children, Dodi, Juancho and Yanni. The never-ending exams in second year toughened us up and definitely pushed us to be creative. We had to be creative enough to have a life outside of exams after all. We had to learn to keep on fighting regardless of outcomes, exam after exams. And in your case, module after module. Yet we also learned to prioritize and let go - weighing what topics to study more, or which inuman to attend. Valuable lessons for my current work advising Bangladesh and Nepal on creatively moving forward with health system reforms. As the lowest in the pecking order, the ICC year inculcated in us humility to accept our limitations and ask for help and respect for others irrespective of position, knowledge or social standing. As a teacher in UP, AIM, and the Ateneo, I am always humbled by the brilliant minds who patiently sit through my 3 hour lectures. It is indeed ironic and inspiring to have your classmates, former residents and med school professors call you sir! Always recall the passion that drives a medical clerk to stay hours after shift and spend for patients for whom he is SIC or student-in-charge in whatever field you plan to get yourself into. Remember this passion this libog as we call it in Illonggo turns off blinders, erases doubts and makes everything, or almost everything possible. Such was re-ignited when I was called back from the World Bank to lead PhilHealth in late 2011, and such was the fire spread through the entire corporation to make PhilHealth relevant again. Come internship, we were confident and courageous and it was not because of the red ID plate on May 1. But it was because all knew that interns run PGH at night. Management skills are especially put to test in the two-week JAPOD-ship in Internal Medicine, or in high risk Fridays in the OBAS. My wife Jo, who is the Ateneo Graduate School of Business Health Unit quality assurance manager, administers the MBA-Health program for which Im also a faculty member. We both believe that good management leads to good governance, which is crucial in making health systems work efficiently. Through all those years, I learned the value of team work from transcription to covering up for each other during monitoring shifts. It was never about me. And that seems to be the storyline in all the years that I practiced health system and health financing. I had worked with many an alumnus from UP Med and PGH. Trelle Gonzaga guided me in the International Institute of Rural Reconstruction. Tessa Tan Torres, now in WHO head office in Geneva, was my mentor in DCE. Meme Guerrero and I worked on moving the sale of medicines from tingi to treatment packs and she continues the fight to make more medicines cheaper, more rationally used and more accessible. And in PhilHealth, I had Eloy Marcelo, Bev Ho, Raoul Bermejo, Pura Wee, Ron Paguirigan, Percy Balderia and my classmate Poch Soria join me to boldly go where no one has gone before. Pinanganak at lumaki po ako sa Bacolod City and nagtapos na valedictorian sa Hua Ming, isang Chinese Catholic school. Marunong akong mag-enjoy dahil laking Bacolod. Pero nang matanggap sa BS Biology sa Diliman, well-behaved na ako at seryosong gustong makapasok sa

UP Med. Dalawang buwan makalipas, nabaril si Ninoy at tuluyan nang naiba ang panahon, at ang buhay ko na rin. Times changed and I took on the challenge of the changing times. Akoy sumama sa pakikibaka at sa laban ng lansangan, naging isang Alpha Sigman at tumakbo at natalo bilang kandidato ng SAMASA. At nang makapasok sa UP Med, tinuloy ko pa rin ang pakikibaka. Dito sa UP Manila, kasama ako nagsimula ng grupong Alyansa ng mga Iskolar ng Bayan na bumuhay ng aktibismo ng mga health students. Pero hindi ko kinalimutan ang pagaaral, pag-toma at pusoy-dos, at pag-aalaga nang aking mga pasyente. Patuloy ko rin pinagtibay ang pagkakaibigan sa aking mga blockmates sa Bio 4, mga dormmates sa Molave, mga brods at sis, mga taga-Manggahan, mga kasama sa UPZS at PMHS, at higit sa lahat, sa mga kasama nagsilbi sa mga pasyente ng PGH mga kaklase ko sa Class 92 at mga magagaling na kasama naming externs. We are the product of our times. Our lives are shaped by how we respond to challenges and how we take advantage of opportunities. Our alma mater has prepared us well to face these challenges and to seize these opportunities. Great strides have been made in the quest for health for all. Our country may be winning the war on UHC, but many battles have to be fought within institutions and localities. We can only succeed when you whether you become a clinician, a researcher, an academic, a policymaker or health manager live the systems perspective and passionately take to heart the lessons of patience, humility, creativity, collaboration and courage. The story of how the Philippines achieve universal health coverage is still being written. It is a story of success and wins yet also story full of missed opportunities, unmet challenges and broken hearts. As we move forward, the story must have should have will have a great happy ending Health For All Filipinos. UP Med Class 2013 the PGH PGIs of 2013 - Do join and be the co-authors to the happy ending. Good luck to all of you. Maraming salamat.