Enrique Ona, the former Secretary of Health in the Philippines, discusses his tenure as secretary of state, the effects of revenues from a “sin tax” on expanding universal healthcare to all Filipino citizens, as well as some of the challenges being faced in fully realizing this goal. He also discusses the current medical issues facing the country as well as the role of pharmaceutical companies in working to address them.
In 2010 you were given the task of making universal health coverage for all Filipinos a reality. What are your thoughts on the progress made towards this goal, and what challenges are currently being faced?
“As with many countries, heart disease is an issue that we need to focus on here in the Philippines, as well as strokes and hypertension. We have made progress with infectious diseases, for example we have seen a decrease in the rates of tuberculosis, but not among the poorer populations.”
This is still a work in progress; however, the question is really about how you structure the progression. There is always a debate about how to allocate funding, how much to put towards public health and immunizations, how much to use pay for premiums, and various other areas. There is still debate on exactly what constitutes “poor”, and how much funding should be used to cover premiums for that population. Poverty is difficult to define. If you look at the statistics, poverty in the Philippines is around 24 percent. However, the level of poor Filipinos that need to be subsidized is much lower than that. These are all issues that even today are hotly debated, and we need to continue to work to define who truly needs these subsidies. One of the issues that makes this difficult is that here in the Philippines, the poor population is very mobile, and many live in remote areas. Additionally, here in the Philippines we do not have a national ID, which is something else that makes clearly identifying the poorer populations challenging.
Progress in the healthcare system is a continuous process; however, having the funds to support this progress is extremely important. During my tenure we passed the “sin tax” on alcohol and tobacco, of which 85 percent of the funds generated are allocated to healthcare. The reason I mention this specifically is because this tax allowed us to have the funds to subsidize healthcare for Filipinos, and is a unique tax which has generated attention from around the globe. Through this we were able to increase the budget of the Department of Health by more than 300 percent, allowing for us to be able to pay the premiums for the “sponsored program”, which covered the poorer populations of the Philippines.
Currently, what are some of the main health issues facing the Filipino population, and what needs to be done to better address them?
As with many countries, heart disease is an issue that we need to focus on here in the Philippines, as well as strokes and hypertension. We have made progress with infectious diseases, for example we have seen a decrease in the rates of tuberculosis, but not among the poorer populations. This is also the population that is struggling the most with diarrhea, pneumonia and other infectious diseases. Speaking more generally about the country as a whole, the most serious disease, especially considering its rising rates in the country, is HIV. We need to focus on contact tracing, otherwise this will be a very difficult problem to solve. 90 percent of new cases of HIV being spread are through men having sex with men, and currently the law in the Philippines has not been amended to allow for contact tracing. Knowledge about how this disease spreads is also not as high as it needs to be.
In terms of regulation versus intervention, given your experience in the previous administration, which do you believe is the most important?
We need both strong intervention and regulation. This is why it is very important for a developing country to be aware of successful strategies that have been implemented in other countries. However, while doing this you also have to be mindful of the specifics of the Philippines and ask yourself whether each strategy could be successfully implemented here as well, and these strategies need to be looked at in a holistic context. When you focus both on regulation and intervention you are required to create priorities, and this will be a challenge moving forward, developing the needed understanding of how these various facets of health intervention and regulation should be implemented together.
What role do you see the pharmaceutical industry playing here in the Philippines, especially considering the rise in generics in the country, and how do you see this changing in the future?
The pharmaceutical sector will obviously play a very important role in the future of the Philippines. The role of generics, for example, will continue to grow in importance. Multinational pharmaceutical companies (MNCs) are able to understand that it is really important to truly care for the patients. The cost of medicines also needs to be restructured in some cases to make sure that these treatments are available and affordable for the government and the people, and that is going to be a challenge moving forward. I see now MNCs putting some of their resources into funding generics, which is one way to work towards this. Broadly speaking, the pharmaceutical companies need to be partners working to improve the health of the population. Things are changing in the country. As the country becomes more developed, and as we continue to improve healthcare, you will see rising life expectancies as well, which will have a large impact on the pharmaceutical industry.
On a larger scale, I think the problem is developing new medicines, something that of course can only be done through research. The government should work to support this research. For example, just recently in the United Kingdom and United States agreed to work together to support research for certain medications, efforts that will hopefully help to reduce the costs for some pharmaceutical companies.
What do you think about President Duterte’s plans to remove restrictive laws governing foreign direct investment?
There are changes that need to be made in our constitution concerning restrictive laws governing the entrance of multinational companies and foreign investments. We are at a crossroads currently, but I do believe that within the next 3-5 years you will see changes to our constitution. I hope there is a lot of debate over this as well, but you do see general consent for these types of amendments. As we open up as a country, it will be good for both the population as well as new companies coming to invest and do business here in the Philippines.
In general, how would you describe your tenure as Secretary for Health, and what advice would you offer to the many people working to improve healthcare here in the Philippines?
My tenure as Secretary of Health was extremely rewarding and satisfying. I have been in practice for decades, an experience that gave me the ability to identify what I thought should be the priorities. When I reflect back on my tenure, I believe that I was largely able to accomplish the goals that I had set. You can plan for everything, and have your priorities set, but at the end of the day you have to have funding to accomplish this. Due to our success in passing the “sin tax”, we had the funding. This is an area where I am still working, making sure that the money generated through this tax is utilized for healthcare spending as it should be, which sometimes can be tricky.
The economy in this country is improving, so we need to continually make sure that the budget for healthcare spending is increasing as well. We also need to make sure that the people understand our definition of universal healthcare, as in some countries that may mean that healthcare is completely free. However, in the Philippines we have a large portion of the population that is very poor and needs to be completely subsidized, meaning that more affluent members of society need to cover some of their own medical costs. This principal of solidary needs to be very well understand by the population of people paying out of their own pockets, and it should be something that they are proud to do.
Lastly, I hope that current members of the government will come to me for any advice or guidance. For example, I look forward to collaborating with Secretary Paulyn Ubial, who was an undersecretary in the DOH during my tenure as secretary. I will always be available to offer advice to current members of the government. I believe that people who are successful are so because they have stood on the shoulders of those before them.
In closing, how have you leveraged your experience as Secretary of Health to continue advancing goals you believe are important?
After I left the Department of Health (DOH) I began participating in a forum put on by the Harvard School of Public Health wherein they invite former Secretaries of Health from all over the world. One of the main focuses of this forum is to discuss the importance of universal healthcare, and I have been participating in this forum for the past 2 years. I believe I was chosen for this because they were impressed with what we had been able to do here in the Philippines in terms of passing legislation, for example the “sin tax”. Participating in this forum has been a very rewarding experience.