Universal Health Care in The Philippines: Alberto Romualdez, JR., Paul Gideon Lasco, Bryan Albert Lim
Universal Health Care in The Philippines: Alberto Romualdez, JR., Paul Gideon Lasco, Bryan Albert Lim
Universal Health Care in The Philippines: Alberto Romualdez, JR., Paul Gideon Lasco, Bryan Albert Lim
DOI: http://dx.doi.org/10.15605/jafes.027.02.08
Corresponding Author
Alberto G. Romualdez, Jr., MD
Former Secretary of Health, Republic of the Philippines
Former Dean, University of the Philippines College of Medicine
Universal Health Care Study Group
National Institutes of Health
University of the Philippines Manila
Tel. No.: +632- 5264349
Telefax No.:+63 2 525 0395
Email: [email protected]
e-ISSN 2308-118x
Printed in the Philippines
Copyright 2014 by the JAFES
Received October 15, 2012. Accepted October 29, 2012.
Abstract
The Philippines is one of the countries that aim to develop a health care system that provides access
to health for all its citizens. This paper presents the status of health reforms in the Philippines,
particularly those relating to the attainment of Universal Health Care (UHC). In describing and
analyzing the present state of health care in the Philippines, the paper refers to key documents such
as the Philippine Health System Review of the World Health Organization and the special issue on
Universal Health Care published in the Philippine medical journal, Acta Medica Philippina, in 2010.
A huge disparity of health outcomes persists between a rich minority and a poor majority in the
Philippines. The current government is committed to reducing these inequities through a universal
healthcare scheme called Kalusugan Pangkalahatan, which involves addressing problems in the six
building blocks of UHC: information systems, regulation, services delivery, human resources,
financing, and governance, though many challenges remain. Universal Health Care addresses the
problem of health inequity by improving access to services and financial protection. However, gaps in
the six building blocks of health care must be addressed if the Philippines is to truly achieve universal
healthcare.
Keywords: universal health care, health reform, health policy in the Philippines
INTRODUCTION
In September 2008, the centennial celebration of the University of the Philippines (U.P.) featured two
presentations on the assessment of the health sector and the role of the University in health. The
analyses established that science-based health services had been put in place throughout the country
partly due to the Universitys significant participation in health development.
Nevertheless, the authors noted that one central feature disfigures the state of the Philippines health:
great disparities in access to health care, resulting in significant differences in health status, between
the rich minority and the poor majority of Filipinos.
These centennial lectures, delivered at the Science Hall of the Philippine General Hospital in U.P.
Manila, concluded that a century after adopting a modern Western health system, the Philippine health
situation was unsatisfactory and that the Philippines most important health problem was health
inequity.
The health community both in and out of the University responded by holding a series of symposia,
round table discussions, and other fora to develop approaches to resolving the issue of inequity in the
country. The results of these discussions were incorporated into recommendations for government to
lead the health sector in implementing reforms to achieve universal health care in the Philippines.
During the presidential elections of 2010, proponents of the reforms exerted efforts to introduce
universal health care into the platforms of the different candidates. These efforts were rewarded when
the eventual winner adopted universal health care (Kalusugan Pangkalahatan in Filipino) as the main
objective of the new administrations health program.
This paper analyzes the various issues confronting the Philippine health system and proposes
corresponding solutions for carrying out the mandate to establish universal health care for all Filipinos.
MATERIALS AND METHODS
For purposes of this discussion and analysis, the authors used data, information and concepts found in
the references listed at the end of the paper.
The Acta Medica Philippina is a peer-reviewed publication of the University of the Philippines Manila.
The special issue on universal health care, published in the fourth quarter of 2010, is an in depth
presentation of the issues and proposals of the original Universal Health Care Study Group that
collaborated in producing the original centennial presentations and most of the materials for further
promoting the idea of advocating for Universal Health Care as the main Philippine health system policy
direction.
The World Health Organizations (WHO) Asia Pacific Health Observatory in the Western Pacific produces
the Health in Transition Series documenting health development efforts of member countries. The
Philippine Health System Review was a collaborative effort of WHO consultants and participants of the
various national fora that led to the Universal Health Care movement in the country.
Original information and data used in this paper were sourced from official statistical reports produced
by the countrys main agencies for the collection of social and economic data, the National Statistics
Office and the National Census and Statistics Board. In some instances, data presentation involved
simple extrapolation from these two sources.
The paper begins by describing elements of the evidence supporting the assertion that inequity is the
countrys main health problem. This is followed by an analysis of the defects in the different
components of the health system and some suggested general measures to address such defects. For
this purpose, the paper uses the health systems analytical framework of six building blocks as
proposed by the WHO.
It is noted that the infant mortality rate, at less than 10 per thousand live births, and the maternal
mortality ratio, at less than 15 per 100,000 live births, of the high-income quintiles are comparable to
those of industrialized countries of the world. On the other hand, the same indicators (IMR greater
than 90 and MMR around 200) for the poorest quintile are equivalent to those prevalent in some of the
least developed countries of Africa and Asia.
Even more noteworthy is the comparison of fertility rates between the two groups. The wealthiest
women have a desired fertility of two and report an average total fertility rate of two children per
woman of childbearing age indicating that this group of women achieves their reproductive goals for
childbearing. The poorest women however desire to have only three children during their reproductive
lifetime but actually bear an average of 5 to 6 children each being unable to achieve their
reproductive goals.
Looking at simple measures of access to health service delivery reveals that these differences are
linked to similar disparities. Such measures can be used to gauge access to primary, secondary, and
tertiary care interventions.
For example, as an indicator of access to primary care, immunization rates in richer provinces of the
country are 30% to 50% higher than those in poorer provinces. Less than half of children from poor
families get one vaccination during childhood while over 80% of those from rich families are fully
immunized with the seven antigens of the governments expanded program on immunization.
Caesarian section rates are sometimes used as a gauge of quality of secondary care. The
internationally accepted gold standard for this measure is 15% of all deliveries in a given population.
However, among poor Filipino women, this rate is estimated at 2% - implying that even if they needed
it, these group of pregnant women would not be operated on. On the other hand, over 30% of wealthy
Filipino women end their pregnancies with a Caesarian section meaning that, in this population,
some women are exposed to the risks of a surgical procedure unnecessarily.
Renal transplantation, a technology intensive intervention, may be used as an indicator of access to
tertiary care. In the Philippines, it is estimated that each year approximately 8000 Filipinos develop
end-stage renal disease requiring hemodialysis and kidney transplantation. Because of the huge costs
involved, almost all of the 500 or so transplants done in the country each year are from high income
groups or foreigners.
In 2010, The Lancet Commission asserted that the goal of global health systems is to assure
universal coverage of high-quality comprehensive services that are essential to advancing
opportunities for health equity within and between countries.4
For the Philippines, advocates have adopted the following definition of universal health care: the
provision to every Filipino of the highest quality of health care that is accessible, efficient, equitably
distributed, adequately funded, fairly financed, and appropriately used by an informed and empowered
public.2
Launched in 2010, Kalusugan Pangkalahan or the universal health care program of the present
government is an ambitious effort to achieve this by instituting reforms in the six basic building
blocks of the Philippine health system. Three major strategic thrusts are likewise enunciated: (1)
Health facilities enhancement; (2) Financial risk protection; and (3) Attainment of the health-related
Millennium Development Goals
What follows is a brief overview of major defects in each of six building blocks and possible
interventions to remedy these in the next few years.
1. Health information system
The first among these is the health information system, which despite attempts at modernization
dating back to the last 30 years, continues to depend on antiquated paper and pencil data collection at
the periphery. The data, highly susceptible to human error and manipulation, feeds into a system
characterized by the uncoordinated and non-standardized use of modern information and
communication technology.
Recognizing the importance of an efficient and accurate information system, the current universal
health care program includes the introduction of modern data collection and the adoption of common
technology standards to improve coordination among the various parts of the health system. This
includes the adoption of tele-medicine, which is already being piloted in some areas.
2. Health Regulation
The next building block consists of the systems for the regulation of quality and availability of health
goods and services including pharmaceuticals. The regulatory infrastructure for health in the country is
seen as supply-side dominated with conditions mainly dictated by the regulated groups
(pharmaceutical companies, doctors and other professionals, and other suppliers of goods and
services). This has resulted in an imbalance of market forces that jeopardizes the health of the poor
and the weak.
New laws are now in place designed to improve the technical competence of regulatory agencies. The
implementation of these laws requires political will to defend these technical units against the strong
lobby groups that benefit from a weak regulatory environment in health.
3. Health services delivery
Health services are severely hampered by a fragmented delivery system consisting of an underresourced public component serving the poor majority and an over-resourced private component for
the rich minority. A Local Government Code that divides responsibilities between the national,
provincial, and municipal government units further fragments government service delivery. Most
importantly, a formal referral system to move clients between each of the different levels of service is
practically non-existent.
The universal health care program of the government includes provisions to encourage referral
mechanisms, and strengthens delivery mechanisms that are seen to facilitate the achievement of the
Millennium Development Goals.
Moreover, other programs such as the conditional cash transfer (CCT) of the government, aimed at
improving the lives of the poorest of the poor, also have a health component; and essential services
such as immunizations for children and regular checkups for pregnant women are included among the
conditions for the covered families to receive cash subsidies. These features of the CCT are
complemented by the provision of innovative service delivery systems, such as the 'community health
teams' (CHTs) that focus on preventive and promotive care.
4. Health Financing
A major feature of the countrys mode of health care financing is its reliance on out of pocket
payments estimated in 2007 to have reached 57% of total health expenditures. This situation is
totally inappropriate for a country where the majority of the population is too poor to afford to pay
even partially for the costs of effective care. It is unfair as economic barriers are the major
determinants of access to life-saving interventions.
A newly invigorated National Health Insurance Program is rapidly expanding coverage among the
countrys poorest groups. The benefits packages of the program are also being broadened to include
preventive outpatient procedures. There are plans to urgently address the pressing issues of poor
utilization of benefits and public facilities by poor income groups.
5. Health Human Resources
Probably the single most important building block of a health system is its health workforce. High
income expectations and inadequate values formation has resulted in a poorly motivated workforce.
Rational deployment is prevented by the fact that health workers skills sets do not match the needs of
the communities needing service. Perhaps 'irrational deployment' is best demonstrated by the
oversupply of nurses in the country following the increased demand in the United States and other
countries. With thousands of nurses unemployed, many hospitals have resorted to accepting them as
'volunteers'; and in other cases, they are made to undergo 'on-the-job trainings' that they themselves
had to pay. To ameliorate the situation, the government in 2011 launched 'RN Heals,' a program that
deploys nurses to underserved communities as part of community health teams.
The Health Human Resource Master Plan needs to be updated to fill the needs of a future universal
health care system. Moreover, health professionals need to be compensated well if the country is to
prevent its experienced and skilled people from being 'pirated' by other countries. Finally, all policies
related to health workforce production, deployment and management must be reviewed and existing
legislation revised where needed.
6. Health Governance
Finally, in the area of health governance, there still remains a lack of consensus among stakeholders
about a common definition of equity in health and the parameters that will determine whether
universal health care is achieved. In addition, processes for policy and decision-making are still mainly
top down. This kind of policy architecture makes health governance dependent on the political
landscape, and the six-year cycle of each presidency.
There is a need to develop new mechanisms of stakeholder consultations at different levels. Such
mechanisms may be evolved from market-research techniques that are employed by private
enterprise to promote their products. Some health agencies, such as PhilHealth and the Department of
Health, are beginning to develop these capabilities.
SUMMARY AND CONCLUSION
The Philippines is committed to achieving universal health care for its people in the shortest possible
time. To this end, the current government has announced an ambitious program comprising three
major thrusts of financial risk protection for the sick, upgrading and improvement of government
facilities, and enabling communities to achieve the health targets of the Millennium Development Goal
while addressing the emerging threat of non-communicable diseases.
In order to achieve the equity goals of universal health care, the three thrusts of the government
program must be aimed at providing remedies for major defects in six building blocks of the health
system. True universal health care providing equal access to services for all Filipinos may be achieved
if the following conditions are met:
1. The existence of a modern information system optimally;
2. Strengthened mechanisms to regulate quality and availability of health goods and services;
3. Integrated delivery of promotive, preventive, curative, and rehabilitative health services at all
levels;
4. A restructured health financing system that emphasizes government and shared risk sourcing of
funds and minimizes reliance on out of pocket payments at the point of service;
5. Improving stakeholder inputs in the system for health governance;
6. A well motivated, appropriately trained health workforce deployed to areas of need.
References
1. Acta Medica Philippina Special Issue on Universal Health Care for Filipinos: A Proposal, Vol. 44 No.
4, October-December 2010.
2. Acuin Cecilia S., Lim, Bryan Albert., Lasco, Paul Gideon. Universal Health Care in the Philippines:
An Introduction. In Acta Medica Philippina Special Issue on Universal Health Care for Filipinos: A
Proposal, Vol. 44 No. 4, October-December 2010.
3. The Philippines Health System Review. Health Systems in Transition, Vol. 1 No. 2, Asia Pacific Health
Observatory, WHO Western Pacific Regional Office, 2011.
4. The Lancet Report, Education of Health Professionals for the 21st Century, A Global Independent
Commission. Health Professions for a New Century: Transforming Health Systems in an
Interdependent World. 2012 The Lancet, Dec 4, 2010, (vol 376; pp 192358) was published initially
in The Lancet in November, 2010. It is being reproduced in expanded book form by the Commission in
full recognition of the copyright of The Lancet. Distributed by Harvard University Press, Cambridge MA
ISBN 978-0-674-06148-4
5. World Health Organization, Health systems topics, www.who.int/topics/en
6. National Statistics Office, Philippine National Demographic and Health Survey, 2008
7. National Statistics Office, Philippine Family Health Survey, 2011
8. National Census and Statistics Board, Philippines, National Health Accounts, 2008.
Looking back at the past 50 years, how do we assess the status of women in
this country, particularly in light of recent debates on the reproductive health
(RH) bill? While women make up over half of the population and their
contribution to society has clearly been incalculable, a disparity remains
between the fulfillment of their needs, on the one hand, and the services and
protections afforded to them by the state, on the other.
Without a doubt, the institutional empowerment of women can be traced as far
back as the Marcos era, with the establishment of the National Commission
on the Role of Filipino Women (now the Philippine Commission on Women) in
1975, which served -- and continues to serve -- as the national machinery for
integrating women into the economic and socio-cultural fabric of the country.
Later administrations followed suit in acknowledging women as a priority,
with President Corazon Aquinos (Cory) Philippine Development Plan for
Women; President Fidel V. Ramos (FVR) Gender and Development Budget
and his administrations grant of full representation of women in the Social
Service Commission; President Estradas (Erap) Philippine Agenda for
Women Empowerment; and President Gloria MacapagalArroyos (GMA) Framework Plan for Women and Magna Carta for Women.
A fresh analysis: education, employment, violence against women and
health
At the outset, it bears mentioning that a significant problem in this country has
often been not only the paucity of data but comparing data across time. In this
case, each administration has tended to emphasize different indicators over
others, and part of the challenge in assessing the changing status of women
has been to find a common set of measurable indicators that remain
meaningful in a comparative sense.
Despite these limitations, what follows here is a brief examination of each
presidential administrations attempts to improve the welfare of women with
More recently, the passage of the Anti-Trafficking in Persons Act in 2003 has
had a significant effect in curbing illegal recruitment schemes. Seeking to halt
the abuse and sexual exploitation of women, children and even men, this law
has sought to abolish trafficking and sexual slavery. The graph above
demonstrates the Department of Justices growing efforts to apprehend and
convict persons guilty of trafficking offenses since 2004.
Health
The focus on women's reproductive health has varied from one administration
to another, particularly with respect to the issue of fertility reduction. Under
Marcos, Presidential Decree 79 established the National Family Planning
Program that sought to respect the religious beliefs of individuals. However,
the Cory administration was heavily influenced by the doctrines of the Catholic
Church, which opposed artificial birth control. Cory thus tended to focus
primarily on maternal and child health issues at the expense of fertility
reduction.
http://www.gmanetwork.com/news/story/276661/news/specialreports/the-status-of-women-in-thephilippines-a-50-year-retrospective