Where money is oxygen

“Every Filipino, regardless of status in life, should have equal access to healthcare… The law states that all cases should be treated and admitted, if necessary, by a hospital.”

Those words said by then Health Secretary Enrique Ona should be a statement of the obvious. Worldwide, hospitals have the obligation to treat emergency cases; in the Philippines, this right is enshrined in Republic Act No. 8344, which makes it unlawful “in emergency or serious cases” for hospitals to “refuse to administer medical treatment and support as dictated by good practice of medicine to prevent death or permanent disability.” It is likewise forbidden for hospitals “to request, solicit, demand or accept any deposit or any other form of advance payment” from these patients. Treatment comes first, money later.

But in many Philippine hospitals, it is the other way around. Patients and their families are confronted with a financial obstacle to emergency healthcare: the need to pay a deposit, which could run up to a big sum.

In 2014, Tutz Salarda-Chan, whose 10-year-old daughter Yanna had congenital heart disease, said they were denied treatment in a hospital in Butuan because of her family’s inability to pay the full admission deposit of P30,000. The family was forced to transfer Yanna to Davao, but unfortunately she died in transit.

The hospital denied the “deposit first” policy, but many similar stories suggest that this is the reality in many Philippine hospitals. With insufficient funds at hand, many patients are turned away, and by the time the necessary amount had been raised—or patients moved to another hospital—it is often too late to save lives. “Money is like oxygen,” one patient’s relative told me, recounting his experience when his mother had a stroke. “We didn’t have it, and so my mother died.”

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A medical emergency can paralyze people from taking the needed steps to maximize their loved one’s chance of survival. On top of the psychological impact of the emergency, the logistics can be overwhelming, and in every step, money matters. For example, an ambulance “conduction” alone can cost thousands of pesos. And when the patient does reach the hospital, there is the matter of the deposit: The more serious the case, the more money you need.

This raises the important—but overlooked —task of educating the public on the practicalities of dealing with health emergencies. Knowing that hospitals demand deposits should make families aware of the need to have accessible savings, and of the need to make sure they are insured and have PhilHealth coverage.

But the idea of health insurance remains foreign and unpalatable to many Filipinos. When you have mouths to feed, your priority is food, not insurance premiums for an emergency that may never happen. And the question of making money readily available is moot when you don’t have money in the first place. Indeed, the crux of the matter is the lack of financial risk protection that leaves many Filipinos vulnerable to “catastrophic health expenditures.”

The government understands this, and financial risk protection is one of the aims of universal health coverage, which the Aquino administration has stated as one of its goals (hence the erstwhile “Kalusugan Pangkalahatan”). But while initiatives like the “No balance billing” policy for the poorest 20 percent of the population—and increased coverage for the rest—are welcome steps, the majority remain vulnerable: Even PhilHealth coverage does not guarantee admission because it does not cover many of the expenses, and many hospitals are unwilling to admit patients simply on the basis of their PhilHealth membership.

Why don’t patients go to government hospitals instead? This brings us to another problem: the congestion and lack of personnel in public hospitals, if at all they are operational in some areas. Often, their ERs are well beyond capacity, forcing them to turn patients away. There is also the perception that private hospitals provide better care—and in emergencies, it is natural for families to bring their loved ones to a place they think will provide the best chances for survival.

Thus the resort to private hospitals, which, virtually unregulated, can get away with demanding deposits and advances, even for emergencies.

Recently, the Department of Health launched “Hospital Advisor,” a website that attempts to crowd-source feedback on hospitals nationwide. This is a good beginning, but it can truly be effective only if offenders, after due process, are actually penalized.

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There will be a tendency to blame frontliners, specially resident physicians, when stories of being turned away come up. Very recently, an OB-GYN resident at UST Hospital received flak in social media for allegedly refusing to admit a pregnant woman whose baby later died. This blaming/shaming is unhelpful: For all their best intentions, doctors and nurses in the frontlines are often overruled by the dictates of administrators, who in turn must grapple with the pragmatics of running a hospital. Who will pay for the bills that patients incur, and what means do hospitals have to go after patients who can’t? Again, the real villain here is the lack of financial protection for Filipinos.

Still, while recognizing hospitals’ concerns, emergencies are a different matter altogether, and monetary demands before treatment can compromise the health and survival of even those who have funds. After all, when your loved one suddenly collapses, you go to a hospital, not to a bank, or to relatives for financial help. Must patients be denied treatment while their kin search for money? Must they wait for banks to open, friends to wake up, money lenders to be available? In emergencies where every minute counts, treatment delayed is treatment denied.

It is time for us to strongly clamor for universal healthcare, and urge our leaders, including the presidential candidates, to take the woeful state of our health-care system seriously. It is time to ensure that emergency rooms are places of refuge and help, not of humiliation and helplessness.

It is time to change the system where money is oxygen, and those who do not have it pay with their lives.

Gideon Lasco is a physician and medical anthropologist. Visit his website on health, culture and society at www.gideonlasco.com.