Former Health Secretary Paulyn Rosell-Ubial, MD (Public Health Advocate)

According to the Department of Health website, former Secretary of Health Paulyn Rosell-Ubial “is the daughter of former UP Professor Neon C. Rosell, and she finished her primary and secondary schooling in UPIS. She he took up BS Zoology in UP Diliman, and Medicine in the University of the East- Ramon Magsaysay Memorial Medical Center. Subsequently, she continued her studies, fulfilling her postgraduate internship in the UP-PGH and her Masters Degree in the UP College of Public Health.” Academic qualifications hardly give us an idea as to the scope and depth of experience of former Secretary Ubial in the bureaucracy and in solving the country’s health concerns. We usually only remember the importance of the Secretary of Health when a health crisis erupts. Ebola, AIDS, measles, name it, when it hits the headlines, we remember who is our current Secretary of Health. We got an interview with our immediate former Secretary of Health, a long-serving civil servant, largely wanting to talk only of evidence-based decisions of policies and nothing else. That creates problems, in a country highly political and highly politicized, which may explain her non-confirmation at the Commission on Appointments, but for sure, we have concluded, the country needs more policy wonks and bureaucrats with their heart like Secretary Ubial.

How long was your service in government Secretary Ubial?

My anniversary of entry was October 30, so it was a total of 29 years.

You are effectively out of government now?

Yes, because when I was rejected by the Commission on Appointments, I was effectively separated from the government.

Does this mean your are enjoying your GSIS already?

I can only get my GSIS at 60, so I have five years to go and I have to find something to do while I wait, and I am seeing academe and advocacy as avenues for productivity in the next five years. Government can rehire me as undersecretary, and there are offers of consultancies, but with all the controversies due to the Dengvaxia case, my husband and I came to the conclusion that it is best not to go back to government. I am working with the Philippine Council for Population Development, an NGO working on the population issue, and I hope to work with the UP College of Public Health. I am done as a permanent or regular employee of government.

You have worn a lot of hats in government, but which would you think is the hat that adequately describes who you are, you are most comfortable with?

I would like to believe I am public health advocate, meaning I advocate interventions that will prevent illnesses and premature death. Unlike clinicians who help people one at a time, public health advocates, when successful, can affect millions of lives at one go. I advocate vaccination, seatbelt use, cessation of smoking, road safety, suicide prevention. Bringing down firecracker injuries is always a challenge for secretaries of health, and during my stint in the department I am gratified to have been able to help bring this down by 70 percent the injuries for 2018, the first dramatic drop in 10 years, so from a stable rate of 1000 injuries per year, it went down to 300. Zero unmet needs for family planning facilities. Anti-smoking advocacy. The list goes on as to what the department is doing, and what I have been involved in.

Which one of your advocacies are you proudest of?

I was the head of the polio eradication unit when we staged one of the most successful national health programs: the Oplan Alis Disease. We were declared polio free year 2000 and Secretary Romualdez received the award in Japan. I am very proud of being part of that.

You mention Secretary Romualdez, considered one of the best secretaries of health of the nation for the germ of the idea of universal health care, which became Philhealth.

Definitely Secretary Romualdez is remembered to be one of the greats. The backbone of Philhealth and the idea of universal health care in the Philippines was indeed due to Secretary Romualdez. It evolved with Secretary Dayrit, another great Secretary of Health.

Another great perspective of Secretary Romualdez is we cannot reinvent the system, but we have to work with the existing system, so he had the vision of improving our health care that assumes that 50 percent is private and 50 percent is public, and he gave the vision to unify it with a national health program, so even if an indigent can walk in the private hospital. And if you are a private sector person, you can walk in a public hospital and get equal quality services. It is happening slowly now.

But it is also in the records that Senator Juan Flavier was a great public health advocate, and for me the greatest Secretary of Health of all time because his humour, jolly nature, his style really motivated the health workers to be productive. He was not a seasoned policy person, but his infectious personality, he was able to mobilize the program managers. I was with the immunization of polio during his time as secretary, and I consider that some of the best times I had in the department. He brought out the best in the people of the bureaucracy.

These are the top three I have in my list: Flavier, Romualdez, Dayrit.

The bureaucracy of the government we must value, we must hold dear, but it must be given the correct moral compass, and its leaders will determine that, as we have seen, with Flavier, the DoH people shined, values of efficiency and integrity really came out, proving once again that the people will only be as good as their leaders.

Your only child, a son, is now studying to be a doctor. Would you encourage him to enter government service?

It is very productive to be in government. I was with Gina Lopez and Judy Taguiwalo recently for lunch in Gina’s place, we realized we have done a lot in spite of our short stint in government as secretaries of our respective departments. You have the resources, Judy was saying, to really make an impact. It really has an impact on the marginalized to do things at the national level. Gina Lopez and Judy Taguiwalo were never part of the national government, so they saw the scope and reach of the national government. Before DSWD, for an indigent to get funds, a person must go through a patron or a local politician, now that is not needed anymore in DSWD or even in DoH. You just have to prove you are an indigent patient and you will be helped. The PDAF issue was an eye opener and a jolt to the system to move to a higher level. So there are many good things happening still in government.

The salary now is also competitive with the private sector. We benchmarked with government-owned corporations. With this, I encourage doctors to apply in government not just for training, but for a long-term career.

Government is still okay, so the short answer is yes, I do tell my son about government service, but it is his choice, it his prerogative as it is after all his life. His choice of a career in medicine is not because of us. It’s his life, we tell him that. He almost went into law, since he was a part of the debating team when he was studying BS psychology for his pre-med, and he was practicing on his father and mother at home for his debating skills (laughs).

Politics is intense in government?

Yes, but politicians and legislators are realizing they should not be in health, and that patronage politics should stay away from it. The recent controversies hounding our health initiatives and hampering our health initiatives are a reminder that the department is best left to professionals, bureaucrats, technocrats, policy people.

Maybe not just politicians but the Church?

In the issue of the Catholic Church in reproductive health, they have their dogmas and tradition. They have their role to play in all of these.

The Department of Health however must base its policies and decisions on science and evidence. Religion and science need not clash over policy. There is actually no conflict, or there should be no conflict. We are advocating birth spacing as a department. Birth spacing is a response to health issues, not just economic or demographic issues. Of course when you have the numbers you want, you should have the option to spacing and limiting birth. The Dpeartment does not try to control birth.

In our HIV AIDS programs, we work with the parish churches to promote abstinence, healthy lifestyles, and when all else fails, go to the health centers (laughs).

South America, Columbia and Brazil have successful population policies and they are largely Catholic countries.

The earth can hold around 15 billion. We are half that already. We really need to think of the population issue, because in 20 years it is an issue we will be forced to confront if we do not tackle this now. 2.1 is replacement growth for the Philippines, and we started with 6 in the 60s, now it is around 2.6 already, so by 2022 we want to achieve replacement level growth of 2.1.

The Health Department has a very strong anti-tobacco company stance. Its code of conduct simply makes it impossible for both sides to work together even for worthy projects. The pharmaceutical industry that has produced great discoveries and inventions are more the challenge. What should be done?

I agree, with pharmaceutical industries, it is more challenging. We have a code of conduct, but in the Dengvaxia case, you see the code of conduct would have worked, if followed, followed strictly, and there were obvious lapses the hearings and investigations are now showing. We need these investigations in order to correct the flaw and lapses. The FEC (Formulary Executive Council) and FDA (Food and Drug Administration) were compromised and we have to study this and learn lessons from that. The safety barriers and safety nets are enough if followed, as the guidelines and laws are in place.

One very important realization for the bureacracy, that since we have the money, we have the people: we must conduct our own clinical trials and studies to validate what is out there. We must form an independent research culture that is sustained and supported solely by the government. That is the big realization for me as Secretary of Health, and that is what the Duterte administration has shown us: that the government has the money. The country has the resources to do grand and ambitious projects and undertakings. We are proposing we do our own studies with RITM, UP, San Lazaro.

Other countries just increase sin taxes, but we allocated all our sin taxes to health, and not all countries do that. During the time of Secretary Ona the guidelines of the DoH was that 2 percent of our budget should be given to research and we have started to implement this during the time of Secretary Ona. Sin tax has given us the elbow room to outsource to academe. The need for research that the government totally control and is funded well is now considered not only important, but urgent.

You sound optimistic about what the Duterte government is doing in health, but what problems are we facing in actuality. I could imagine it must be still gigantic, considering the problems we are hearing about like the Dengvaxia controversy.

30 percent of our people are still not covered by Philhealth, that is 30 million: so we have some way to go to reach those in the hinterlands for example, those in disadvantaged areas, prisons, informal settlers, we still have a way to go. In my stint as DoH Secretary we call that the last mile we have to reach. But you are right that I am optimistic: our focus is the population that has no money for not just the hospital, but catastrophic we cover 80 percent of the medical expenses after the 20 percent of Philhealth. The president even added 2 billion for this. It is the collateral expenses, like transportation, that is also a problem. The DoH is trying to figure that out as well.

We have a president in President Duterte that is focused on health and education. We rose from 122 billion pesos including philhealth to 142 billion pesos in budget, and now it is 164 billion. It is the biggest increase in the budget of DoH. We were able to implement a lot of the programs, and more are in the pipeline that Secretary Duque will implement and have the vision and skill to execute. Immunization the previous budget was 3.2 billion pesos for vaccines, now 7.2 billion pesos is for that.

Our policies should just be guided by evidence. Secretary Duque will be reintroducing metrics and score cards, which he started during his first term as Secretary of Health, but that effort was waylaid by so many initiatives like the ISO to improve systems and documentation. Of course that gave us guidelines, and that is also good for quality, but metrics and scorecards give accountability and Secretary Duque will do well in that.

Before the national insurance circa 1995, quality as a concept was not institutionalized, so metrics and quality systems were needed to go beyond just the idea of service, but quality is a word needed there too. It cannot just be service without quality.

Yet we must see the statistics: There is a gap of 42,000 beds. We have one bed for 2000 Filipinos and the ideal is one bed for 800 Filipinos. Only in Metro Manila is it one for 591. I think that is a little off because I don’t think they factored in the high migration into Metro Manila in the mornings from workers and students coming in from the surrounding areas.

Any models outside the Philippines we can learn from?

We need a cadre of health workers, and since we can afford free university education, then we can hire health workers with a good salary. We deploy them. So for every 1000 Filipinos, like the Cuban model, there has to be a doctor monitoring them. We can have a nurse instead of a doctor and it will still work well.

The outcomes in Cuba in infant or maternity mortality are better than the US or any developed country, so 460 dollars per capita is invested in health in Cuba and in the US is 8000 dollars per capita, but it is the ratio of health workers taking care of a population at the preventive level that is the key. The system can prevent illnesses, and the Cuban model has a very strong primary care line of defense, so if you don’t come to the health facility, the doctor will go to your house. You have no choice but to get healthy. We see people in the streets in the Philippines with tumours in their face as big as a basketball, and that is because no one is getting them to a doctor, and this can easily be detected when the tumour was still the size of a marble.

Any teacher inspired or helped you in a big way when you were a student?

Joven Cuanang. Many teachers helped and influenced me, but he is the most memorable, and a brilliant artist as we saw when he drew the brain, as we did not have power point or transparencies then, so Dr. Cuanang would draw the brain in front of us when he was my teacher in anatomy. He is retired now and we still see each other occasionally.

How about books? Any you want to bring to the attention of our readers?

I like reading autobiographies, life stories, and it reflects my being a government personnel for so long that I have read the autobiographies of our presidents, especially from Marcos to the present, I have read them.

If I have to single out an author, I enjoyed and learned a lot from the books of Senator Juan Flavier. This again reflects my great admiration for him as a man, and for what he has done to our Department, and his contribution to our country.

Is there anything you want to say about the Dengvaxia experience of our country?

On my thoughts on the dengue vaccine, this was what I told DOH program managers when I learned about the pilot implementation happening just before the 2016 elections and the targeting of one million grade 4 school children: “Even if it were a good vaccine, no long-term safety issues, the fact that it is introduced before the elections, it will already be tainted, its rationale and purpose will always be doubted.” It was doomed to fail even before it started and the low uptake of only 67% of the target population is proof enough that the social preparation was not adequate and people had doubts as to the vaccine program’s real intention. It was problematic from the start, even before Sanofi made their announcement of a label change on Nov 29, 2017, which just confirmed the people’s doubts, because that vaccination campaign was rushed, even introducing it before completion of the phase three of the clinical trials. I was caught in a damage control situation, damned if I continued it, damned if I stopped it because 2.5 billion pesos worth of vaccines were already in our vaccine storage facility in RITM, and at that point the ADE (antibody-dependent enhancement) risk was only theoretical. Then all the pressure from Congress came in. It was a difficult time but I did all decisions with consultation and due process, plus there were an Expert Panel recommendation, Execom Resolution and an FEC imprimatur.