Change will come.
This was what then-Senator Benigno Aquino III pledged during his presidential campaign. He made a lot of promises: Distribute Hacienda Luisita, pass the FOI bill, prosecute Gloria Macapagal-Arroyo, no more wangwang, daang matuwid. And one particularly ambitious promise centered on the issue of health: Achieve universal health care for the country.
During his inaugural speech, the new President was even more explicit: Health care for all Filipinos by 2013.
Where are the doctors?
Three years later, Dr. Paolo Medina is the only government doctor for a population of 17, 700 in Alabat Island, Quezon Province. The nearest hospital is a one-hour ride away. For worst-case scenarios, this means patients must travel to the mainland by boat.
“Given that the last passenger boat off the island for the mainland leaves at 1:00 PM, that the Philippines is a typhoon-prone country, that Alabat Island is in the Pacific Ocean and that I am practically on-call 24 hours a day—the things that I am compelled to do in the line of duty, I leave to the imagination,” says Medina.
Medina is fortunate; as an administrative officer of the local government, he enjoys job security, respectable income and other benefits mandated by law, such as social insurance. Other health workers are not as lucky.
Take for instance the current batch of Doctors to the Barrios (DTTBs). Because they are contractual employees, Medina says that they have “no employee-employer relationship with the DOH (Department of Health) and as such, they are not entitled to benefits such as hazard pays, leaves and so on.”
Originally meant to expose physicians to countryside concerns, the 1993 DTTB program soon became a cost-cutting measure for the DOH.
“[The DTTBs] work like the usual government health workers, they look like government health workers, they have responsibilities like government health workers, demands from them are what are demanded from government health workers, but they are not paid as high nor do they receive the benefits due them,” explains Dr. Christian Gomez, an independent consultant to the World Health Organization.
To have enough teachers for the government’s K-12 program, the Department of Education resorted to volunteers and contractual workers. In a race to meet Aquino’s 2013 health care deadline, it seems the DOH has done the same. “Be it DTTBs, rural health midwives or rural health nurses—they are victims of contractualization,” Gomez said.
Fewer beds, rooms for the indigent
Sean Velchez, a nurse, is not a contractual worker. He joins the 700-strong union of health professionals at the Philippine Orthopedic Center (POC) that presently enjoys the benefits and protection mandated by RA 7305—the Magna Carta of Public Health Workers. What gives Velchez cause to worry, however, is the fate of POC’s patients.
By Velchez’s estimates, a typical day at the POC involves looking after 600 patients at the out-patient department and another 700 in the wards. This does not include the 300 people that go to the orthopedic center for consultations and emergency cases every day. As of now, however, it seems that the POC is quite capable of coping with the heavy traffic.
“Despite the lack of budget na binibigay ng gobyerno, nakakapag-uwi kami ng libre even without [coverage from] PhilHealth (Despite the lack of budget from the government, we are able to send home patients for free, even without coverage from PhilHealth),” Velchez explains. Indigent patients at POC have free confinement, free check-ups and, often, free operations.
However, Velchez and his co-workers are concerned that these free services may come to an end once the “modernization program” of the government sets in. Under the proposed public-private partnership (PPP), the management and operations at POC will be temporarily transferred to the private sector. Thus, for 25 years, a private business will take over the hospital and introduce upgrades in facilities and equipment. Once the contract expires, it may be renewed again for another 25 years.
“The government will give the corporation authority to raise fees and [conduct a] due diligence market study on how much the raise will be,” Velchez said. “They can also add extra beds—not for the indigent but for the paying patients.”
At present, six out of seven beds at the POC are for poor patients. Velchez claims that if the PPP is implemented, only 70 of POC’s 700-plus beds will be allocated for the poor; the rest will be reserved for those who can pay.
PhilHealth coverage: Far from universal
“In the end, the health inequities remain so that the poorest of the poor really have no access to any forms of support in terms of health care,” Dr. Henrietta Dela Cruz, director of the Loyola Schools Office of Health Services, explains. She points to privatization and policies of “devolution” of hospitals—from national government control to local government supervision—as culprits.
“As you know, in this country, health care is primarily out-of-pocket, unlike in other countries where health care expenses are part of the budget of the country,” Dela Cruz says. “And how can we afford that, with a population that can’t pay for food?”
PhilHealth, the national health insurance program, was specifically created to address these concerns. Under Aquino’s Universal Health Care Law, enrollment of all Filipinos in PhilHealth is now compulsory. Yet, even if the program has been in existence for two decades, there are still sectors of society that are not covered by it.
Dr. Jaime Galvez Tan, a former DOH secretary, identifies the indigenous people, who constitute 7% of the population, as one such group. “I’ve been to Surigao, Zamboanga, Palawan, Ifugao—namely the far places—and I have yet to see indigenous people enroll in PhilHealth or [any] health insurance,” he says. He also lists the disabled, as well as the “rural and urban poor,” as those not yet covered by PhilHealth.
Success, triumphs
Not everything in P-Noy’s health policy will earn a failing mark, however.
“[The] Food and Drug Administration Law and the Philippine Disaster Risk Reduction and Management Law have been adequately addressed by the current administration,” Dr. Gomez says. He also considers the Reproductive Health Law and Sin Tax Law political and health victories for the Philippines.
Gomez adds that the Philippine National Health Research System Law and Basic Immunization Law have also managed to see the light of day. Moreover, around 3.5% (P51.1 billion) of the 2013 national budget is allotted to health—a huge advance from the mere 1% allotment of the previous administration. Specifically, Rappler reported a P34 billion target revenue from sin tax, which is earmarked for the Aquino health agenda.
“Never has health in the Philippines enjoyed a truly enormous finance,” observes Galvez Tan. He estimates that at least P15 billion has already been collected and that P12 billion more will be needed to enroll all Filipinos in PhilHealth.
Despite the success in the financial aspects, Galvez Tan worries that budget misallocation can present a problem. He says that most funds are allocated not to rural areas or rural barangay stations but to DOH hospitals. He deems this problematic because “the poorest of the poor live in barangays. They do not live in the cities or in the towns, but in those barangays, far-flung, rural and deep ghettos.”
Spaces for change
Amidst all the woes of public health, Galvez Tan still hopes that awareness of the situation will push the public to be more involved in health issues. “I hope that it will help spur, motivate, mobilize, put to action the Ignatian community—the larger Atenean community—to also be proactive because it also requires civil society, the academics, to also act accordingly,” he adds.
“I am a real optimist in nature,” says Galvez Tan excitedly. “[The money] is here. There is no reason why we should not have universal health care. Now, we can dream.”
“The Ateneo will always provide opportunities for you to find a niche where you can make a change,” says Dela Cruz. “I’m very optimistic that we do make it a purposive effort to guide the students not to be blinded into the practice of medicine in the traditional way of educating physicians to become clinicians.”
Three years after he first left for Alabat, Medina is still working on the frontlines. He is organizing health plans and immersions. This is his war and he is sure there are still others who will fight with him.
“I am actually very hopeful for the future of Philippine health care,” Medina says. “If I were not, I would have left my job long ago.”
