Universal healthcare and how to get there
When I first met President Aquino before I became health secretary, his first question was: “What can we do with this information that more than 30 percent of Filipinos die without seeing a doctor?”
Of course, the question encompassed the gamut of what we have done during the four-and-a-half years that I was in his Cabinet, on our program of universal healthcare or “Kalusugan Pangkalahatan” (KP). Universal healthcare is a global movement where countries commit to provide their peoples with needed health services, and the latter receive these without financial difficulty. KP is, therefore, a healthcare system that provides a continuum of promotion, prevention, treatment, rehabilitation and palliation. It must be readily available, easily accessible, affordable and of reasonable quality. It is critical to understand these interlinked components because implementation will require a combination of prioritization, availability of financial support, and transformational change.
Since the Alma Ata Declaration in 1978, the World Health Organization has proposed that especially poor countries pay more attention to primary healthcare by expanding immunization services, providing safe water and sanitation facilities, and encouraging breast feeding and hand washing. But as a developing middle-income country, the Philippines faces the “double burden” of diseases. While many of our poor still suffer from the scourge of “poor man” diseases such as TB, malaria and malnutrition, we now also suffer from the ailments of advanced countries whose primary causes of death are noncommunicable diseases (NCDs) such as heart disease, cancer, stroke and diabetes. Added to these are the high incidence of major trauma from vehicular accidents and the ill effects of environmental degradation, global warming and climate change, as well as new and reemerging diseases.
The challenge is how to merge the two major competing needs of promotive and preventive care with the more demanding and expensive curative (hospital) and rehabilitative care. Poor Filipinos have long been suffering from this dire situation of unavailable care; many have fallen into debt just to pay for medical treatment.
Although done with good intentions, the devolution of city, provincial and district hospitals and all health centers to local government units in the 1990s has resulted in uneven levels of service to the public especially the poor, and the loss of the defined referral system from the lower to the higher levels of healthcare. Thus, numerous provinces, cities and towns have poorly funded physical plants and dispirited staff, lacking in services and diagnostic equipment. And patients flock to regional and specialty hospitals, resulting in overcrowding and long waiting time for needed care. Poorly funded primary care services have contributed to the high demand for hospital services.
Happily, far-reaching laws in health passed during the past four years will be among the Aquino administration’s legacies that bring us nearer to our journey to KP.
Republic Act No. 10351 (or the Tobacco and Alcohol Tax), signed by President Aquino on Dec. 29, 2012, gives the government the financial capacity to cover the full subsidy of the premium coverage of 14.7 million poor Filipino families (or more than 45 million Filipinos), amounting to P37 billion for 2015 and an increase of the Department of Health budget to P103 billion (an increase never received before).
The National Health Insurance Act of 2013 mandates PhilHealth to cover practically all poor Filipinos and their families, including all senior citizens, the disabled and street children. This is similar to America’s Obamacare, recently pronounced by the US Supreme Court as constitutional—a legacy for which US President Barack Obama will be remembered just as President Aquino will similarly be honored for years to come.
Today, PhilHealth has expanded its support for primary healthcare, or its program of “Tsekap,” to cover basic blood, chemistry, and urine examinations, antibiotics for common infections, and medicines for diabetes, high blood pressure and high cholesterol. The DOH now provides full immunization coverage to all poor children against measles, Rubella (German measles), mumps, polio, hepatitis, pneumonia, rabies and selected vulnerable populations with antidiarrheal vaccine (rotavirus) and herpes virus infections.
To enhance promotive care, numerous initiatives must be launched to counteract the “silent epidemic” of NCDs, the result of an unhealthy lifestyle, a diet rich in salt, fat and starch, and lack of physical activity. Paradoxically, this is also a consequence of improved living standards, advances in healthcare and technology that have made our people live longer and overall lifestyle easier.
Modern management guru Peter Drucker said decades ago that hospitals are the most complex organizations to manage. The complexity stems from the numerous stakeholders, consisting not only of patients but also their families, the doctors and other health professionals, the pharmaceutical and hospital equipment industry, the numerous government regulating agencies, and many more. For too long, our public hospital system has been funded mainly from tax revenues, resulting in very low public service levels of the “Mona Lisa” type. As Leyte Rep. Sergio Apostol wryly described patients in government hospitals, “they just lie there, and they die there.”
This has changed, with the recent upgrade/construction of 8,175 health facilities nationwide, with a budget of more than P43 billion disbursed until the end of 2014 and more planned to be allotted until the President’s term ends in June 2016. But so much more is needed and can be done if the planned participation of the private sector can only be understood by the boisterous few who see an iniquitous design in every private hand in healthcare. Fortunately, there are now some well structured lessons for the government to safeguard the effectiveness of contracting out health services through public-private partnerships.
The challenge is to keep steady the reforms that have been initiated by continuing the expansion of the support value of PhilHealth to both primary and in-hospital care. Reforms in the entire health system, especially in health financing and hospital governance, are necessary for the initiatives to improve services to the very poor and hard-to-reach families in far-flung areas. The use of advances in information technology is almost complete, with the E-Health project with the Department of Science and Technology finalized. We cannot ignore the added resources that are needed in preparing our responses to new and emerging diseases such as MERS and Ebola, and the unpredictable but definite threats due to climate change.
Atun Rafat of the Harvard School of Public Health aptly said that to be a true mandate, universal healthcare must fulfill the dictum of “balancing health objectives through the four pillars of equity, responsiveness, effectiveness and efficiency to achieve value for money and value for many.” As I look back at the ongoing reforms we initiated at the DOH, I am reminded of a famous remark by that icon of transformational change, the strong-willed former prime minister Margaret Thatcher of Britain. When, early in her term, she was besieged with advice, she blurted out in exasperation: “Don’t tell me what. I know what. Tell me how!”
We tried how to do that in health.
Enrique T. Ona, MD, is a former health secretary.
