I. Introduction
These disparities are the result of the following deficiencies in our health system:
- Basic health services as well as tertiary care for the majority of Filipinos are inadequate, fragmented, inefficient, and incomplete. At least in part due to this, for lowest income groups these services are largely inaccessible and unaffordable.
- The Philippines' health sector is dominated by commercial interests of a segment of the system that is not really about health outcomes but is primarily about bottom-line profits.
- Human resources for health are insufficiently educated, inappropriately trained, and poorly motivated to address the health care concerns of most Filipinos in the setting in which they live. As a result, poorly compensated government health workers are unable to influence behaviors of their high earning private sector counterparts within the change-resistant environments of their respective professional organizations.
- Much of this commercial dominance of our health care system is the result of a failure, so gross as to constitute a default, of public financing for health. The combined weight of the uncoordinated spending for health by the national government, local governments and our national social health insurance program has been so low and so weak that it has driven our health system into a debilitating dependence on out-of-pocket payments by patients.
II. Health system reform strategies
Public spending on health is so low that it has resulted in an over-dependence on out-of-pocket expenses. This has penalized the poorer majority of the population. Although total health care spending in the country amounted to close to P 200 B in 2005, more than half of this is accounted for by out-of-pocket spending which is highly regressive for the poor, who do not have pockets to begin with. When compared across income groups, the richest groups are spending more (average of P 23,815) compared to the poorest (average of P 1,915).
In real terms, over-all government spending in health has been decreasing, owing largely to reductions in national government spending with minimal growth in local government spending. In addition, the share of social health insurance spending remains at a dismal 11% of total health expenditure more than 14 years after the establishment of PhilHealth.
While reforms must take place in all six building blocks of an effective and efficient health system, the key building block is that of health care financing because improvements in all the others are dependent on adequate financing.
1. Financing the health system reforms can be done through multiple funding sources with the goal of significantly reducing out-of-pocket spending especially by those in the poorest income deciles within the next three years. These can be achieved by:
a. Quantum increases in tax-based government spending at both national and local levels to a combined level approximately equal to 5% of total government expenditures (at least 75 billion pesos per annum).
i. National government spending to be financed through borrowing (including re-financing of existing debts), additional tax sources, and reallocation from non-social service sectors; and
ii. for local government units, mandatory increases in the proportion of IRA to be spent for health.
b. Significant increases in the PhilHealth support value for identified services in the basic package. This can be financed from the present PhilHealth reserves and increasing premiums collection through:
i. mandatory membership to PhilHealth for residents of the Philippines;
ii. the development of an initial package of basic health services to be made available to every Filipino given the present resources available to the health system. This basic package which should address the most critical health needs of the population in terms of disease burden, especially among the poor, will be expanded to include increasingly sophisticated services as further resources for health are identified and allocated over time.
2. Implementing this spending and financing plan shall be divided into two phases: securing buy-in the first three years of the new government in 2010 and implementing financing strategies in the latter half of the six-year term. Increased benefits of the system should be in place first while measures to increase revenues are being worked out.
In the Philippines, a country that produces some of the world's best doctors, nurses and other health workers, 60% of Filipinos who die do so without the benefit of health professional attention. The Philippines' health human resource problems are the result of its dysfunctional health workforce structure. The output of a workforce production system that is de-linked from the actual needs of the Philippine system are health providers for whom service is a lower priority than personal professional advancement. At the policy level, there is no evident effort to coordinate workforce production with real health needs. As a result, a commercial market philosophy pervades all programs of teaching and training institutions - including the best of government-supported agencies such as the University of the Philippines Manila.
1. Integrate and strengthen health workforce regulatory functions under one body (i.e. commission) attached to the Department of Health (initially by executive mandates but eventually through legislation) to unify standards and regulations of the production, practice, and deployment of the various health professions.
a. Mandate government health workforce teaching and training institutions to tailor production for service to underserved communities either as government (national or local) or civil society professionals
2. Update and rationalize practice laws of the different health professions premised on health care being a team effort. It should define and update the practice of each health profession, allowing for greater flexibility and cooperation to include continuing education and trainings for these professions. Rationalize the system for health workforce remuneration across the professions to take into account the principles of primary health care.
Health services at all levels for the majority of Filipinos are inadequate, fragmented, inefficient, and incomplete. For many in the lowest income groups these services are also inaccessible and unaffordable. Moreover, fragmentation is a main feature of the Philippine health care delivery system from several perspectives: public/private segregation, over-specialization, discontinuities between levels of care, as well as geographic disparities in quality and quantity of services. This fragmented system has to contend with a population that has doubled since the 1980s while total resources allocated for health have not kept pace with this rapid population growth.
1. A revisiting of the Local Government Code and its implementation with the view of enabling government facilities to be more integrated, efficient and effective.
2. The integration and organization of government facilities in accordance with the principles of primary health care based on an updated version of the Alma Ata Declaration. They should provide integrated health services either directly or through a unified and formalized referral system. The Department of Health should have the responsibility for developing and negotiating terms and conditions for installing such a system with the local government units.
The system for health regulations has been chronically weak, ineffective and has not been used as an effective policy instrument. It suffers from regulatory capture being primarily driven by the interests of the enterprises trading in health care goods. Pricing and marketing of pharmaceuticals and other health care products have distorted national expenditures on these items in such a way that essential, life-saving goods are either too expensive or absent from the market while items of dubious value dominate trade and commerce.
As a result, the investment climate for developing the industrial production of health products and supplies is uncertain. For example, there is no local pharmaceutical industry that can address the need for affordable medicines for the Filipinos.
1. Full implementation of the BFAD Strengthening Law based on the principle that health concerns take precedence over business interests. Registration and other regulatory requirements for health goods should be re-designed to ensure not only safety and effectiveness of health products but also affordability especially for government agencies.
2. Strict regulation of marketing and other promotional activities for health products including advertising prohibitions for certain goods.
3. Further strengthening of other regulatory functions of DOH, other government agencies and local governments to promote compliance with the equity and other objectives of health sector reform, including creating an efficiency coordinating mechanism in drug and technology regulation.
The structure of DOH remains the same as it was in the pre-devolution period. The functions of Centers for Health Development and the role of DOH in local health service development remains unclear and unfocused. In addition, DOH continues to exercise direct supervision and control of nationalized hospitals whose roles and relationships within the health system are not yet clearly defined.
Communities tend to be passive recipients of health services rather than active participants in its determination. Although the Local Government Code provides for the establishment of Local Health Boards, there are no explicit provisions for community participation. In fact, only a few Local Health Boards actually function as a governing body.
1. The DOH is envisioned as the national institution tasked to ensure the implementation of the reforms leading to universal health care. Its envisioned mandate is centered on regulation, policy-making, standards setting and supervision of PhilHealth.
2. Local health service delivery should be coordinated at the provincial level to ensure more coordinated and responsive local health care system.
3. Autonomous and authoritative hospital authority or hospital boards should be established, including the cross-integration between government and private hospital systems to enable sharing of resources, rational acquisition and better utilization of technology, especially in areas with limited access to public hospital facilities, and guarantee better regulation of hospitals and other health facilities
4. Community participation at all levels of the management cycle should be strengthened: situational analysis, planning, implementation and monitoring and evaluation of health programs.
Health information management in the Philippines is at best rudimentary and ministerial, but poses greatest strategic value in reforming the health system. The country suffers from lack of leadership and organization. Most of the existing information programs are not guided by a strategic framework creating disintegrated silos of data. Despite a relatively mature communications network, it is not optimally used as a resource. Capability-building on basic health information management is direly needed at all levels of the hierarchy.
1. Create a national council to provide leadership on the design and implementation of eHealth strategies in the country. The council will be mandated to craft a national eHealth masterplan anchored on the principles of primary health care and designed to maximize the use of information technology for health service delivery. This initiative should be led and facilitated by the DOH with the PhilHealth Information Network as its backbone. This council should also include the private sector.
2. Create a national health data dictionary available for use by stakeholders.
3. Identify, collect and analyze major health data necessary for implementation of Universal Health Care, including burden of disease, actual costs of health services, historical utilization and budget for health services: national, regional, provincial and municipal. This includes requiring health providers and facilities to submit mandated health reports electronically using standard formats as well as developing the capacity to analyze routine data [from mandated reports] for decision making [local/program]
4. Transparency should be the norm for all institutions involved in health care. All information concerning the operations of any component of the health system should be available to all stakeholders.
5. Empower citizens as data generators and as information users.
6. Strengthen health research through the establishment of the Philippine National Health Research System (PNHRS). Stronger research should inform all stakeholders, including the community.
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Reference:
World Health Organization. Everybody's Business : Strengthening Health Systems to Improve Health Outcomes : WHO's Framework. Geneva: WHO Press, 2007.