‘One doctor per family’ policy

When Leni Robredo said during the vice presidential debate that she supports a “one doctor per family” policy, she was not making a naive statement. She was actually giving voice to what has been a battle cry of health reformers for a very long time: The need for strong, comprehensive and accessible primary health-care service.

Our health-care system is in dire straits. Private hospitals are too expensive for the average Filipino, and public hospitals are too overwhelmed with patients to accommodate everyone. Many cannot avail themselves of health services, and many others who can are saddled with debt. Just today, someone asked me what can be done for her friend, a patient with stage 3 breast cancer who has been detained in a hospital for over a month now after undergoing surgery, because she can’t settle her bills. Her story, while tragic in itself, is made more lamentable by the fact that it is common all over the Philippines.

The more obvious solution to this patient’s dilemma is financial: If only she had health insurance, if only she could afford her treatment, she wouldn’t have been detained by the hospital. Or legal: If our law against hospital detention (Republic Act No. 9439) had more teeth, the hospital wouldn’t have any right to detain her.

But there is also a more fundamental medical issue here: Why do so many people reach advanced stages of disease, in the first place? Surely, stage 1 cancer would have been far less costly, not to mention far less devastating in terms of health outcomes.

One reason is that it takes a really serious ailment for many Filipinos to see a doctor. An alarmingly-high blood pressure of 180/100? “Never mind, I will get even more ‘high blood’ because of the traffic just to get to the hospital.” A fracture from a motorcycle accident? “Just bring it to the hilot, we have no money.” A lump in the neck? “Malayo ’yan sa bituka”—it is far from the guts and thus can be tolerated.

Another reason is the lack of preventive health services. Dialysis is the treatment for end-stage re nal disease, but this condition could have been avoided had a diabetic patient been told, many years before, to avoid high-sugar foods. A healthy lifestyle can definitely save more lives than a heart center or an herbal supplement—but there will never be a billboard on Edsa pushing sunshine, walking 30 minutes a day, or eating vegetables.

Primary care physicians (PCPs) are key to addressing these shortcomings. Being within reach of the families assigned to them—and, ideally, having built relationships of trust with these families—PCPs are able to promptly deal with their patients’ health concerns. Only when the problem is beyond their capability will they refer a patient to a specialist, thus sparing the patient from “doctor shopping” and being made to undergo expensive (and often unnecessary) laboratory tests. With a PCP serving as “gatekeeper,” the patient in Cavite doesn’t have to travel to Manila to go to the Philippine General Hospital—and the overcrowded PGH doesn’t have to receive the patient. It’s a win-win situation for both public hospitals and patients.

PCPs are also trained and oriented to look at the patient holistically, integrating a patient’s various concerns and drawing on a long-term understanding of a patient’s medical history to come up with diagnoses and treatments. For example, knowing that a patient has a liver problem, a PCP may avoid giving medication for back pain, and be more open to nonpharmacological treatments like physical therapy.

Finally, PCPs consider the role of the whole family in both the illness and the treatment. If a child has asthma, the PCP’s intervention will be not only to prescribe medications, but also to ask the child’s father to quit smoking. If an elderly patient gets diagnosed with Alzheimer’s, the PCP may call for a “family conference” and get everyone to think about the support that is required of this condition.

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Politically, a large medical center can score more points, but what we truly need are the smaller building blocks, such as empowering “health teams” (i.e., BHWs, nurses and midwives) to do more tasks (our physician-centric laws don’t allow them to even administer certain drugs when they can easily do so); adequate primary care facilities; universal PhilHealth coverage; and—the focus of this piece—having enough PCPs.

This, of course, is much easier said than done: We don’t even have a doctor for every municipality! It requires, in the first place, enough doctors willing to focus on primary care—not an easy task in our specialist-oriented medical culture. PCPs must be given decent salaries (and incentives for their patients’ good health outcomes) that will make them consider it as a lifelong career. Importantly, we need to produce more doctors by making medical education affordable and accessible.

Most importantly, we need the political will to push for these reforms. To be fair to the Aquino administration—despite its failed promise of universal healthcare—the passage of the Sin Tax Law and the Reproductive Health Law are steps in the right direction. But we need to do more. Compared to neighboring countries like Thailand and Malaysia, we are spending less on healthcare—even as many of our children remain stunted, HIV is on the rise, and there are 290,000 new TB infections each year, to name just a few enduring and emerging health concerns.

The health-care sector—and indeed all the patients and health-care workers in our country—badly needs a champion in the coming administration. And I find it reassuring that at least one candidate understands the task at hand.

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