Historical Events and Mandates:
The Sanitaria in the Philippines were established in support of the objectives of controlling leprosy in the archipelago, of protecting the healthy population from the dreaded menace of society during the time when it was considered a highly communicable disease, when stigma was so high and no medicine for cure was available. The existence of sanitaria was further strengthened and given mandate under the Segregation Law (Act 1117), promulgated in 1907, which compulsorily segregated and isolated leprosy patients in Culion Leper Colony in 1906 (Palawan), then in regional treatment centers in Cebu (Eversely Childs Sanitarium), Bicol (Bicol Sanitarium), and Central Luzon (Tala Sanitarium, now Dr. Jose N. Rodriguez Memorial Hospital).
The Sanitarium has been the second home for thousands of leprosy patients and their families, and for many, their final destination. The sanitarium has been the initial testing ground for treatment using chaulmougra oil derivatives like ethyl ester with iodine (Mercado mixture), but it is the caring, the segregation/isolation, and finding a place away from discrimination and stigma, that made the sanitarium or “leper colony” more noted and known for the Mindanao Central sanitarium (MCS), formerly Zamboanga Leprosarium, was created pursuant to E.O. 392 dated 1930. Serving as a screening, diagnostic, and treatment center for domiciliary leprosy patients with intercurrent disease and complications, MCS also served as an institution for leprosy patients requiring hospitalization and rehabilitation.
The introduction of Sulfones in the early 1950’s changed the directions of sanitaria and outlook for patients. The sulfone drugs was considered then as “the wonder drug” and a breakthrough in the chemotherapy of leprosy, as evidenced by thousands of patients declared negative. This has resulted in the promulgation of the Liberalization Law in the treatment of leprosy in 1964, wherein patients need not be admitted in the sanitarium for the treatment of leprosy per se, but only in the presence of complications or the need for rehabilitation. This has significantly reduced the number of patients admitted in the sanitaria. Those left were old, destitute, with no one to take care of them; those with severe disabilities, and those who opted to stay to escape discrimination from their own families and communities.
The initial euphoria with sulfones was short lived with the detection of secondary, then primary strains of dapsone-resistant leprosy and the high incidence of relapse. The scenario was again followed by increasing sanitarium admission, but this time, the patients were not coming from the outside, but from inside the sanitarium community, among patients’ families, and descendants themselves. The rehabilitation role of the sanitarium was amplified. Assistance was provided by the government, with support of NGO’s and religious organizations, in the fields of farming, fishing, cottage industries and other livelihood projects within the compound of the sanitarium.
In 1988, following the successful implementation of the pilot study in Cebu and Ilocos provinces, Multiple Drug Therapy (MDT) was introduced on a nationwide scale. The use of fixed dose MDT regimen among all eligible and qualified patients brought significant changes and reduction of the case load. During this period, the clearing up of the registry was also implemented and a policy on strict admission and discharging of patients (D.O. 35 s. 1994) who did not need hospitalization, and where care and treatment support of the families and communities, were implemented. Relative to this, A.O. 6-A s. 1995 provided cash incentives to negative, able-bodied former leprosy patients upon discharge to partially alleviate the economic difficulties encountered by the cured clients in their transition to normal community life. Furthermore, providing cash incentives to discharged negative (RFT- Release from Treatment), or RFC (Release from Control) will be far more economical to the hospital who will grant the cash incentives.
The unprecedented drop of the prevalence rate of leprosy from 2.4 leprosy cases per 10,000 population in 1992 to 0.57 leprosy cases per 10,000 population in 2000 paved the way to the conceptualization of the expanded role of the sanitaria. This was largely attributed to the application of MDT. The sanitarium, as an integral component of the Department of Health Systems, needed to readjust its targets and priorities with the view of maximizing the health staff available and the health care facilities and services in the respective area of jurisdiction in support of the DOH thrusts and programs. Department Order No. 72 dated February 17, 1994 called for the redirection of roles and responsibilities of all sanitaria. Since then, all sanitaria have been providing general health care services in their respective catchment areas. Even with the decreasing admission of leprosy cases, this dual role of providing both general health care services and custodial care has put a drain in its limited resources, both financial and human. Department Order No. 375-5 dated July 26, 1994, or the Sanitaria Conversion and Development, amended D.O. 72 s. 1994, expanding further the legal mandate. Because of this, the DOH underwent a series of Succession Plans (December 1994, December 1997, August 1999) and proposed the Sanitaria Conversion Plan as part of the DOH Hospital Upgrading Plan. In regions with sanitarium, the traveling expenses incurred by the Traveling Skin Clinic personnel shall be subsidized by the said sanitarium, which has the proper jurisdiction, subject to existing auditing and accounting rules and regulations. Furthermore, to improve compliance to MDT, A.O. No.2-A dated January 30, 1998 was issued to shorten the duration of treatment of eligible PB and MB leprosy cases.
The proposed Sanitaria Conversion Plan was conceptualized and the following options were made available:
Conversion to a general hospital;
Conversion to a tertiary level rehabilitation facility or health facility with research and training capabilities;
Merger with Medical Center; and
Other options as recommended by CHD Officials and other concerned hospital chiefs in the affected catchment area.
Relative to this, the DOH Central Office consulted the various CHD directors and Chief of Hospitals and Medical Centers of the affected areas. The foregoing was recommended action for Mindanao Central Sanitarium:
To be the Sanitarium for the entire Mindanao area;
To upgrade to a 50-bed capacity general hospital with secondary capabilities, and
To upgrade to a rehabilitation center for Western Mindanao.
The expanded role initially created confusion, as well as challenges, in the administration of the sanitarium. Whereas before, the sanitarium was under the Bureau of Sanitaria services, then later under the Infectious Disease services, now it has moved to the Hospital Operations of the Department of Health. This transformation has put great challenges of operating the sanitarium into income-generating and self-sustaining DOH-retained hospital, considering the number and capacity of existing staff, health infrastructure and the population of which it will serve and cover. The past years had brought also significant adjustments and success stories to some sanitaria, like Cebu, Culion, and Tala, while others have to struggle to fit-in with the new expanded role. To date, much has still to be desired and to be improved to be fully transformed to meet the standards.
While the sanitarium transformed and expanded its role, the leprosy services also continues in terms of detection, diagnosis, treatment of new cases, and management of leprosy complications like leprosy reactions and neuritis, and rehabilitation. Some sanitaria are also involved in active case detection like LEC and also in training RHU personnel in the provincial level. However, the main bulk of its activities and budget goes to custodial care of old, disabled, cured patients who were victims of segregation policy before, and those with no families or whose families are poor to look after these patients.
The national leprosy situation was also significantly improving in terms of reducing the disease burden with the elimination of leprosy as a public health problem in 1998 using the WHO indicator of a prevalence rate of less than one (1) per 10,000 population. The MDT program, since 1988, has been implemented as an integrated program into the general health system with the National Leprosy Control Program (NLCP) at the DOH Central Office providing the lead role. The Devolution Law of 1991, which placed the ownership of the leprosy program under the LGU’s, has also made significant changes in the MDT implementation, progress and sustainability. Though leprosy has been eliminated at the National level, leprosy continued to be a public health problem in several provinces, cities, municipalities, and absolute number of new cases detected has not changed significantly, where the Philippines continued to be the highest in the Western Pacific Region. The current national leprosy statistics posed a challenge to further improve and reduce leprosy burden particularly in the sub-national level and to sustain quality leprosy activities into the general health care service, to include prevention of disabilities and rehabilitation (Physical, Social and Economic). It is recognized that the role and contribution of the sanitaria in the furtherance of these goals and objectives is very essential.
Administrative Order No. 2005-0013 dated May 30, 2005, provided the Revised Roles and Responsibilities of the eight (8) sanitaria. This included the following:
Responsibilities for the training of health workers in their respective catchment areas regarding updates, trainings, retaining on Leprosy Control Program.
Integrate the Multiple Drug Therapy (MDT) services fully with the existing general health care services.
Serve as the referral center for the management of complications, patient and family counseling and community education.
Conduct community dialogues about Leprosy and the National Leprosy Control Program (NLCP)
Provide for emergency, out-patient treatment/care for the general population in its immediate catchment area. Each Sanitarium shall upgrade its emergency room, shall provide for out-patient department and convert existing buildings as wards to accommodate in-patients for general service care.
Make available initially the following five major Service Departments namely: Medical, Surgical, Obstetrics and Gynecology, Family Medicine and Pediatrics.