Dr. Enrique T. Ona, Secretary of Health, Philippines, speaks about PhilHealth, the ambitious universal healthcare system in the Phillipines, why they have not yet reached the estimated number of beneficiaries, and what needs to be done to tackle the still present problem of the lack of awareness in the poorer level of society.
President Aquino has recently stated that the Philippine Health Insurance Corporation, PhilHealth, now covers 81 percent of the population of the Philippines, as part of the government’s universal healthcare plan. So far, what has universal healthcare brought to the country?
The most important reform, or change, was the inclusion of health as a growth driver of the Philippines. Essentially, our ambition was to make sure that all Filipinos, especially the poor, were to be included in our national health insurance program.
In fact, the country already had health insurance, so-called Medicare, since 1969. This system only covered the formal sector: those employed. The poor were presumed to be taken care of through our government hospitals and had no official insurance system.
In 1995, the first Law on PhilHealth was passed. This Law stated that in 15 years, all Filipinos should be enrolled or covered through national health insurance. By 2010, however, only 54 per cent of the population was covered, essentially the formal sector.
PhilHealth mandated that every Filipino, meaning both the formal and informal sector, would be enrolled through a single insurance wherein the poor would be enrolled through a premium paid for and shared by the national and local governments. In practice, the majority of the local governments were unable to afford their share in the program. As a result, many of the poor were not enrolled.
When the new administration took over in 2010, our mantra was to include the previously overlooked poorest segment of the population. Through our Department of Social Welfare, we had identified 5.2 million households as part of the poor layer of society. Note that we spoke of households, which could include four to five family members. In terms of people, that number comes down to roughly 25 million, or a quarter of the country’s population.
If the poor are being automatically enrolled, are they also aware of their registration as well as the benefits they can enjoy through PhilHealth?
Awareness is a problem. The poor layer of society embraces the least educated and least informed of society. Apart from that, they are very mobile too, implying that they easily move around the country in search of job opportunities. We need to keep working on making sure that these people are informed, even though we have already come a long way since we started in 2010.
How are you about improving awareness levels?
Increasing awareness requires a major cooperative effort with the local governments. Our regional directors as well as our local media have an important role to play to push this information through.
Our population counts roughly 97 million people, and it is our assumption today that we have covered the poorest layer of society through PhilHealth. However, there is still a large layer, the so-called ‘near poor’, that are not yet enrolled. The projected number of families from this layer is 14.7 million, essentially 58.8 million Filipinos that should be enrolled by the end of next year.
At present, 81 percent of the population is enrolled; however, because of the uneven enrolment of the near poor, only around 70 per cent of Filipino families were really able to go to the hospitals. Now, we are cleaning up our data to ensure that the number of enrolments and number of people covered match one another.
What are your priorities in terms of investments in the healthcare infrastructure in the Philippines?
The allocated investments to improve our local government health facilities as well as our national government hospitals have significantly gone up in the last two years. We have a program called the Health Facility Enhancement Program (HFEP), which sets targets for budget allocation to improve our health care facilities through 2016.
For instance, for the improvement of our smallest political units covering three to five thousand people or 500 families on average, so-called barangays, these areas would normally have small health units with one midwife, one barangay health worker, etc., usually volunteers. Their main task is to provide local families with information on health care, as well as the basic primary care or preventive measures.
Covering a wider area than barangays, we also have around three thousand rural health units in the Philippines, servicing two to four barangays. There, the unit has a doctor, a nurse, a midwife as well as potential other healthcare workers. There may even be a dentist too. Rural health care units are the backbone of our primary health care system.
We are now ramping up the capabilities and capacity of these units. For example, we are now making sure that there are birthing facilities in the rural health units, in order to make sure that people deliver with proper medical support rather than at home. From 57.79 percent in 2010, we estimate that 70 percent of the rural health units will have birthing facilities by 2014.
Easily, 12 to 15 percent of deliveries still require a cesarean section. The first line of emergency care sits at the district hospitals, followed by the provincial and city hospitals. We also categorize our hospitals into level one, two and three. Level one hospitals typically have 50 to 75 beds. Now, our program aims to ensure that such hospitals will have a functional operating room, headed by a physician that can execute an emergency surgery.
So far, it has been very difficult to attract surgeons to level one hospitals. However, these doctors will now see their salaries increasing because of the money that is being made available through basic insurance programs. Right now, we also pursue a program wherein we recommend the provinces to have their district hospitals headed by physicians that can execute life-saving operations.
The coverage is already there, but we are also making significant amounts of funds available to ensure the placement of the right doctors in the right areas. While we have sufficient doctors in the Philippines, you will find that the majority, perhaps 70 per cent, still sits in the urban areas.
In addition to federal funds, where do you source funds from to upgrade healthcare facilities?
In addition to federal funds, we also have the local governments (LGs) as well as foreign agencies contributing to upgrade our healthcare system. We enjoy foreign assistance from the EU, USA, Australia, UK, Germany, and so forth. As a matter of fact, I meet the heads of this program on a quarterly basis to evaluate their assistance and direct it into convergence with our national strategy. The total amount of foreign assistance in 2014 is estimated at more than PHP 2.6 billion (USD 59 million). These funds are mainly used for capacity building.
The University of the Philippines has already made it a requirement for its medical school graduates to stay in the Philippines. How will this affect the quality level in the healthcare system?
Rather than a law, this university has indeed implemented the requirement for its graduates to stay in the Philippines for two years. However, they can take up a residency in any of the hospitals. Nonetheless, we foresee that a good percentage of them may volunteer to stay in our smaller hospitals during the two year program.
To deploy human health resources, we also have several programs in place. To serve the Geographically Isolated and Disadvantaged Areas (GIDA), which often have no doctors for a while, the government is paying doctors to be redeployed to these areas under the so-called ‘barrios program’. Since 2010, we have received budgetary assistance for this program. This year, more than 21,400 nurses are being deployed across the poor areas of the Philippines as part of this program.
Meanwhile, we have also been deploying community health teams, headed by a nurse or a midwife and assisted by social workers. We have also identified the 1,200 poorest localities, or communities, in the Philippines, where we are pursuing a major convergence of the social and educational services.
What are some of the main illnesses you prioritize on your agenda over the next few years?
In the next three to five years we should also be tackling the neglected tropical diseases, such as dengue and leptospirosis, which you still find in the Philippines today. We have doubled our budget to detect and treat these diseases. At present, we have 27 out of 82 malaria-free provinces in the Philippines. By definition, this implies that the province cannot have a single malaria patient in five years. By 2016, we aim to have 40 provinces malaria-free. Overall, we aim to eliminate these diseases from being a public threat. Rabies is also still a problem in our rural areas. Though we have programs to tackle diseases like rabies, the laws are not being properly implemented.
HIV, too, is an increasing problem in the Philippines. From 1983 up to 2013, the total number of HIV cases sat at around 12,000, representing less than 0.5 per cent of the population. We expect a substantial, almost geometric, increase in HIV cases in the Philippines. We have already proposed amendments to our HIV laws and are becoming more aggressive in our public education efforts for the young. Believe it or not, but 80 percent of the new cases is the result of unprotected homosexual or bisexual contact. Now, we are proposing certain amendments to the HIV law to ensure better reporting and prevention of its prevalence.
What have been some of the major successes thus far?
We have reached a number of major achievements with this government on the healthcare front. First of all, we have been able to pass a major law on the funding of health care in the Philippines, through increased taxes on alcohol and tobacco products.
Second is the passage of our reproductive health and responsible parenthood Act, which will soon make it possible for us to aggressively address the problem of maternal and infant mortality, especially for the poor and near poor.
The third achievement is the amendment to our national health insurance Act that clearly states that all civilians should be covered through our national insurance, PhilHealth, with particular emphasis on the poor and near poor. It is now mandatory, rather than a choice, to be enrolled.
What potential do you see to turn the Philippines into a medical tourism destination?
The Department of Tourism is very active in making the Philippines a priority destination, and it is a program that we too should strategically encourage. However, we leave the implementation to the private sector, as all our attention is currently required to reach universal healthcare and help the poor. We are pleased to note that we have at least half a dozen hospitals that have received international and ISO accreditations.
It is also worth noting that the Philippines has partnered with the United Nations Economic Commission for Europe (UNECE) to turn Manila, and the Philippines, into the center for public private partnerships (PPP). The modernization of our DOH hospital is for instance open to PPP investments. We are also about to start our first major PPP for the Philippine orthopedic center. In addition to that, we have around 25 other major government hospitals open to this strategy.