The Aquino Health Agenda: Universal Health Care for All Filipinos

by Department of Health (Philippines) on Wednesday, November 10, 2010 at 2:17pm (Speech of Hon. Enrique T. Ona, MD, FPCS, FACS, Secretary of Health during the Second Florentino B. Herrera, Jr. Memorial Lecture Science Hall, Philippine General Hospital, University of the Philippines Manila 27 October 2010) The State of the Nation s Health It is important to establish our current state of health. If the NSO projection for 2010 is to be believed, we are now 94 million. Likewise, population growth rate remains high at 2.04% (2000-2007 data). More than half (52.8 %) of the population is below 25 years old. Proportion of older persons is growing from 3.83% in year 2000 to 4.19 6.7% in 2007. And there are approximately 2 million live births in the country per year. Both non-communicable and communicable diseases are part of the top ten causes of death among our countrymen. Cardiovascular diseases rank as the top killer. Accidents have also climbed as the 4th leading cause of deaths. Among the causes are assaults (36%), followed by motor vehicle accidents (25%). I will be the first to admit that our data gathering leaves much to be desired. We oftentimes are operating on data that are two, three, or even five years old. Specifically in the reporting of deaths, our National Statistics Office relies on the death certificate entries, many of which need more validation. MDG Targets In 2000, the Philippines, along with 188 other countries signed the UN Millennium Declaration. This declaration seeks to decisively fight hunger, disease and poverty and foster development in the developing world. This pledge was translated into 8 Millennium Development Goals, which are specific, concrete, time-bound and quantitative targets for action by 2015. We are committed to achieving the targets. We do this not out of compliance but because we are committed in fighting poverty and improving the health of our countrymen especially the poor. These numbers are not meaningless statistics. Achieving these goals is important

because it means that we have improved the quality of life of a significant number of our countrymen. I am happy to report to you that, we are generally on track to meeting our targets. We are on track in reducing under-five mortality, with only 34 deaths per 1,000 live births as of 2008. However, catch-up efforts must be done to deliver interventions that will reduce neonatal mortality rate. Likewise, more effort is needed to attain MDG 5 (Improve maternal health), the MDG that is least likely to be met. Nonetheless, we will work harder to prevent mothers from dying. This is one of the priorities of this administration. We are also on track for MDG 6 (Combat HIV-AIDS, malaria and other diseases). In TB, we are close to our target in TB Case Detection and Cure Rates. This is due to the strong multi-sectoral collaboration in TB Control. Prevalence of HIV/AIDS has been kept below 1% although there has been a noted increase of cases in most at risk Populations such as sex workers, injecting drug users (IDUs) and men having sex with men (MSM). In malaria control, we have achieved our targets. We are continuously adding to the list of malaria free localities in the country. While, technically not included in the MDGs, Dengue has been on the upsurge this year. The number of cases this year is more than double the number of cases last year. Likewise, the threat of emerging diseases such as the multi-resistant strains of bacteria and other viral flues, etc still looms. Double Burden of Disease We are also experiencing the double burden of disease. Even with communicable diseases still accounting for a significant number of morbidities and mortalities, we are now seeing an upsurge in the cases of lifestyle diseases associated with improving economic status. Despite remaining a threat to our population s health, deaths due to infectious diseases have actually declined.

Here we see the decreasing trend of infectious and communicable disease whereas lifestyle diseases already dominate the leading causes of deaths in the country --- cardiovascular disease, Cancers, diabetes, chronic lower respiratory diseases. Disparities in Health Outcomes The general improvement in our health incomes hides the fact that many of our countrymen still have poor health outcomes. While nationally, we are on track in reducing infant and under-5 mortality, the Autonomous Region in Muslim Mindanao (ARMM), Eastern Visayas, Mindoro, Marinduque, Romblon and Palawan (MIMAROPA) and Cagayan Valley are above the national average. The incidence of infant and under-5 mortality rate is inversely related to the income level of the family. The lowest two fifths of our population have IMR and U5MR that are higher than the national average. Likewise, the high incidence of maternal mortality in Eastern Visayas, ARMM, Zamboanga, MIMAROPA and Central Visayas indicate that much more have to be done in addressing maternal mortality. These disparate health outcomes can be explained by the inequities in access and utilization of health services. Inequities in Access and Utilization of Health Services The 2008 National Health and Demographic Survey defined the average monthly income of the 5 quintiles of the population. The poorest quintile, consisting of 5.2 million families, earns, on average, a measly P 3, 460.00 a month. The second poorest quintile, consisting of 4.1 million families, has a monthly income of P 6,073.00. Almost half of all Filipino families live on roughly six thousand pesos or less. For a family of five, you can just imagine how long this will go to cover their basic needs, let alone basic health care needs. These poorest two fifths of the population often have the most dismal health outcomes due to their lack of access and utilization of health services. The National Statistical Coordination Board in 2006 has pegged the poverty threshold, or the minimum amount needed for an individual to meet the basic food and non-food requirements at P 15,057 annually. Translated to a family of 5, you need to earn a minimum of P 75, 285 a year

or P 6,273.75 a month. To be classified as poor, you must be earning below the poverty threshold. Based on 2006 statistics, 26.9% of families nationwide are poor, with 13 out of 17 regions having poverty incidences higher than the national average. In terms of actual number of people, this translates to 4.7 million poor Filipino families nationwide, with great variation in distribution. Is it mere coincidence that the President s statement saying that 30% of Filipinos die without seeing a health worker is close to the nationwide poverty incidence rate of 26.9%? Immunization Recent numbers do not provide any consolation. We have a saying that goes, Health is Wealth. The 2008 National Demographic and Health Survey seem to show the reverse, however, that Wealth is Health. The ratio of Fully Immunized Children for Women of Reproductive Age statistically confirms what we have anecdotally known for some time now: those who have more money can easily avail of health services more than those who do not. Access to Health Facilities 2003 numbers confirm once more what we have always suspected: poor families are more likely to avail of health services at public facilities. Sadly however, our government health facilities remain poorly equipped and understaffed. Access to Maternal Care Nationally, less than half of our births are delivered in health facilities, and only 6 out of ten births are delivered by skilled providers. The figures are much less when we go to certain regions. 75% of maternal deaths can be averted with combined access to family planning services and skilled birth attendant and 40% of maternal deaths can be prevented by ensuring access by mothers to skilled birth attendants and basic emergency obstetric and neonatal care in facilities. Access to skilled providers and health facilities for birth deliveries is directly proportional to family income. The percentage of births delivered in a health facility or delivered by skilled

hands for the poorest two fifths of our population is less than the national average. They are condemned to see more of their mothers die giving life unnecessarily. Financial Risk Protection A greater percentage of our women accessing healthcare have no financial risk protection through PhilHealth. The national average is not encouraging, less than 40% have PhilHealth. In ARMM, this can be as low as less than 20%. Inadequate Financial Resources for Health These inequities in health can be explained by insufficient financial resources for health. The share of the gross national product spent for health from 1993 to 2007 hovered between 2.75- 3.5%. The Global Strategy for Health for All in the Year 2000 of the World Health Organization recommends at that least 5% of GNP shall be spent for health. While health expenditure per person has apparently increased since 1993, using constant 1985 prices, the increase in expenditure for health was very minimal. From 1993 to 2007 the percentage of health expenditure sourced from private sources, including out of pocket, has increased dramatically. In the same period, there were meager increases in the contribution of government and social health insurance for health. The 1997 and 2007 Philippine National Health Accounts reveals the increasing reliance of the health sector on out of pocket expenditure. From 47% in 1997, out of pocket accounts for 54% of the total expenditure for health in 2007. Out of pocket sourcing is the worst possible way to finance health care because those who are both sick and poor face the risk of either untreated disease or impoverishment. Health Reforms in the Past The reform initiatives of the previous decade include the Health Sector Reform Agenda and the Fourmula 1 for Health. These reform agendas have been able to achieve significant progress in good governance and health regulation. However, there is recognition that much has yet to be done in terms of addressing our problems in health financing and health facilities. Inadequate Financial Risk Protection

Fifteen years after PhilHealth was established to replace Medicare, many of our people have yet to be provided significant financial risk protection from illnesses. Social Health Insurance in the Philippines As early as 1968, our government has recognized the need for social insurance in the Philippines. Thus, the Philippine Medical Care plan, also known as Medicare, was established, initially catering to the members of the GSIS and SSS. In 1995, Republic Act 7875 was passed, paving the way for the National Health Insurance Program to be administered by PhilHealth. Among others, RA 7875, as amended mandates coverage for all Filipinos by 2010. Current Status of PhilHealth We have neglected to emphasize that the PhilHealth law actually makes it compulsory for all Filipinos to enroll in PhilHealth in order to avoid adverse selection and social inequity. 15 years after the PhilHealth law was passed, we can see that the government and private sector employees have been adequately enrolled. However, there was insufficient effort to enroll individually paying members, such as those in the informal sector. The sponsored program, meanwhile, had mixed results. Oftentimes used as a tool of political patronage, the distribution of PhilHealth cards increased the awareness of the indigent sector on the need of having social health insurance. Oftentimes though, their 1 year coverage was not sustained by their local government units. Also, the sudden influx of new members having erratic coverage gave PhilHealth more problems in data gathering for coverage and entitlement. PhilHealth has about P 110 billion in reserves as of June 2010. This is good financial health for PhilHealth. However, this huge amount of reserve can be explained by how PhilHealth has been operating for the most part of its existence. It has emulated the model of private insurance and has neglected to be a genuine social health insurance whose mandate is not to primarily generate income but to afford its paying members reasonable financial risk protection. The actual coverage of PhilHealth seems to be a mystery. Conflicting figures from PhilHealth, UP School of Economics and the 2008 National Demographic and Health Survey underscore not only the need for better record keeping, but that the intention of the law for universal coverage has yet to be accomplished. The President s first State of the Nation Address reveals the inconsistency of membership figures in PhilHealth. He also declared a major policy direction he wanted to pursue: the improvement of the National Health Insurance Program.

Expectedly, more members of the lower quintiles are not members of PhilHealth. This is sad considering that it is them who need financial risk protection from illnesses the most. Also, PhilHealth membership per region is very variable, all nowhere near the 85% target that was supposedly reached by PhilHealth this year. The President is dismayed at the low benefit delivery rate of PhilHealth. The Benefit Delivert Rate (BDR) is the cumulative likelihood that any Filipino is (a) eligible to claim (registered, paid contributions); (b) aware of entitlements and is able to access and avail of health services from accredited providers; and (c) is fully reimbursed by PhilHealth as far as total health care expenditures are concerned. BDR at present is only eight (8) percent, computed by multiplying the three mentioned components which are also known as coverage rate, availment rate, and support value. Ladies and gentlemen, shortcomings in health financing have resulted in out of pocket expenses as the primary source of health expenditure. Out of pocket expenditure has been the rate limiting step of many of our countrymen in availing health services Health Facilities Neglect I always believe that the face of our public health system is the state of our health facilities. Our health facilities, as a consequence of meager financial resources and further compounded by the fragmentation as a result of devolution, has suffered neglect. After the passage of the 1991 Local Government Code, the local government units, namely the provinces, cities and municipalities were given direct control over their health systems, including health facilities. The implementation of devolution has resulted in the fragmentation of a monolithic health system into several independent health systems. The upkeep of health facilities, and of the health system as well, became dependent on the resources and priorities of the specific local governent unit. Results of devolution were mixed, as there were excellent as well as backward health facilities in the regions, provicnes, districts, or cities. Universal Health Care When I was being interviewed by the President for the position which I currently hold, he asked me what the government can do with the fact that over 30% of our countrymen die without ever seeing a doctor.

The answer to this situation is Universal Health Care. Universal Health care builds on gains on the reform initiatives of the last decade. Universal Health Care is a vision and a strategy: A Vision of how things ought to be, meaning 1) Filipinos are healthy, free from disease and infirmity; 2) Filipinos have access to quality health services. As a strategy, it is how the DOH will strive to achieve better health outcomes, make the health system more responsive, and reduce the inequities in health created by the widening gap between the rich and the poor. Simply put, universal health care prioritizes the needs of millions and millions of poor Filipino families which comprise majority of our population. We intend to focus our energies on the poorest two fifths or lowest two quintiles of our population. Universal Health care builds on gains on the reform initiatives of the last decade. Health Sector Reform Agenda (HSRA) of Dr. Alberto Romualdez focused on public health, hospital, health care financing, governance, and regulations. Fourmula One for Health under Dr. Francisco T. Duque foused on financing, service delivery, regulation, governance Universal Health Care is being implemented to improve, streamline, and scale up reforms interventions espoused in the HSRA and implemented under F1. The priority health policy directions of the Aquino Administration are as follows: 1. Focus on refocusing the implementation of the National Health Insurance Program 2. Particular attention to the construction, rehabilitation and support of health facilities: LGU/regional hospitals, rural health units, barangay health stations to enhance their capacity in providing basic health services. 3. Attainment of Millennium Development Goals 4, 5, and 6: Reduction of maternal, neonatal, and infant mortality and Support to contain/eliminate age old pubic health diseases (malaria, dengue, TB) We also intend to do the following:
 

Attain efficiency by using information technology (IT) in all aspects of health care Increase attention to trauma, the 4th leading cause of death

    

More aggressive promotion of healthy lifestyle to prevent non communicable diseases: heart disease, stroke, diabetes, obesity Attention to emerging diseases (Superbug, nosocomial diseases, A(H1N1), diseases brought about by climate change) Improve the access to quality affordable medicines Continue efforts in improving governance and regulation to eliminate graft and corruption in all areas of health care Improve the plight of health workers through interventions in health education, placement, compensation, among others Redirecting PhilHealth In redirecting PhilHealth, we want a paradigm shift in the implementation of the National Health Insurance Program. Where it must be geared towards being a genuine social health insurance for all Filipinos. To achieve this, we will emphasize the need for making PhilHealth membership a must for every Filipino. We want each and everyone of us to value PhilHealth the way we value our cellphone. The poorest of the poor as identified by the Department of Social Welfare and Development shall be automatically enrolled using national government funds. All members of the informal sector, should be required to enroll as well. We seek to improve PhilHealth membership services to increase the wareness of the public as regards its benefits and entitlements. And for the identified indigents, we shall impose no balance billing in all government hospitals. This means that they will not shell out a single peso for health services accessed at any government hospital. For us to provide financial risk protection, we endeavor to institute reforms in every link in the PhilHealth value chain: enrollment, accreditation, claims availment and processing, and insurance payments. Reforms in PhilHealth Enrollment Again, let us emphasize that PhilHealth law mandates compulsory PhilHealth membership for all Filipinos.

Towards this end, we will automatically enroll the identified indigents belonging to the poorest quintile, identified by the National Household Targeting System of the DSWD using national government funds for payment of their premiums. The members of the informal sector, especially those who can afford to pay the premium, shall be compelled to enroll. We shall explore national government-local government sharing for the second poorest quintile. We shall work with other government agencies to enforce mandatory PhilHealth membership for all Filipinos. Mechanisms to this effect will include making PhilHealth membership a requirement for school enrolment (for the protection of the student-dependent), licensing of business, renewal of driver s license and other government transactions. We are now working with the private sector to facilitate more convenient innovative schemes for members to pay for their premiums, such as through text messaging. Reforms in PhilHealth Accreditation As regards accreditation, we shall emphasize the need to ensure access to health services for PhilHealth members. In the past, the lack of accredited facilities has hampered PhilHealth members from fully enjoying their entitlements. In this regard, we shall unify licensing and accreditation of health facilities. Meaning, that once the facility has been licensed by the Department of Health, it is automatically accredited. All government health facilities shall be given provisional accreditation even as we capacitate these facilities for them to be able to comply with the requirements for accreditation. Reforms in PhilHealth Claims Availment and Processing The solution to the recurring problems of delayed payment by PhilHealth to its accredited providers is to modernize data keeping of PhilHealth. Veering away from the old pen and paper recording that is prone to a lot of errors, we shall have an IT system ultimately connected to the health facilities system. Reforms in PhilHealth Insurance Payments The support value of PhilHealth shall be increased, from an average of 20% to 70%. This will drastically cut down the out of pocket expenditure of our patients. The support value for catastrophic illnesses, such as heart attacks, strokes, kidney failure, and cancers shall also be increased significantly.

We are veering away from the present fee-for-service to other cost effective means of insurance payments. We shall designate one general practitioner as primary caregiver of a determined number of indigents, to be paid through capitation. Case payment, wherein a standard fee shall be paid for every case, shall be introduced over time. Also, national standard treatment guidelines shall be promulgated to guide our service providers in giving appropriate and cost effective care. Cognizant of the need for cooperation and support of our doctors, I met with representatives of the various medical specialties and asked their assistance in determine the realistic cost of care and medical services. Guided by fairness and equity for all stakeholders and assisted by financial, communication, and legal experts, we intend that PhilHealth be guided by these costs of care for various health services rendered. We will do away with waiting periods for availing benefits for new PhilHealth members . Once you register, you automatically become entitled to PhilHealth benefits. We shall in the coming months expand and roll-out outpatient benefit packages. Other steps We recognize that PhilHealth will have its limits in providing financial risk protection. Accordingly, we shall work with private health maintenance organizations and private health insurance companies to compliment the benefits of PhilHealth and ascertain their role in achieving universal health care. Health Facilities Enhancement Increased financial resources shall allow us to upgrade our health facilities: rural health units, district hospitals, provincial hospitals, DOH Retained hospital Through health facilities improvement, we want to Improve facility preparedness for trauma (4th leading cause of death, improve capacity of clinical/hospital care for the most common causes of mortality and morbidity, and improve access to quality affordable medicines. Public Private Partnership: given limited resources, the government needs to tap into the wealth of experience and the available resource from the private sector. While this will be a major strategy for this administration, the DOH will primarily employ this strategy in its thrust of improving health facilities.

Regional Clustering of Health Facilities is actually a health governance intervention directed at improving the capacities of health facilities across the region and beyond. Fiscal autonomy and income retention will provide the health facilities the ability to finance improvements and maintenance costs for better delivery of health services. Streamlining of licensing and regulation will be important as we want our health facilities to be able to tap into PhilHealth. Public-Private Partnerships Public-private partnerships will be our thrust in augmenting the meager resources of the government. We have already submitted to the PPP office of the Department of Finance several proposals wherein we can tie up with the private sector. The projects include:
      

IT system for DOH and PhilHealth Philippine Orthopedic Center as Center for Bone Diseases and Trauma Air ambulance project Research Institute for Tropical Medicine for commercial production of vaccines San Lazaro Hospital as Center for Infectious Diseases Commercial utilization of vacant hospital land assets Establishment of Multi-Specialty Centers in selected regions (3) in Northern Luzon, Visayas, and Mindanao Regional Clustering Our response to the fragmentation of health services and the uneven quality of services of our facilities is regional clustering. Regional Clustering of Health Facilities is actually a health governance intervention directed at improving the capacities of health facilities across the region and beyond. Regional clusters shall be composed of regional, hospitals and district hospitals as well as rural health units and health centers. Clustered Health Boards composed of the Secretary of Health or his representative, local chief executives, private partners, and civil society/NGOs shall govern clustered health facilities. This is the composition of the advisory board of clustered health facilities. The composition shall ensure adequate representation and buy-in among all sectors of in the region.

Attaining the MDGs Ensuring that the poorest families are reached by priority public health programs shall be our main strategy in attaining the MDGs. We shall be deploying Community Health Teams which are dedicated health workers assigned to an area which actively assists families in assessing and acting on health needs. The life cycle approach shall be our guide in providing needed services. This will include Family Planning services, Four ante-natal care services and delivery in health facilities (Emergency Obstetric and Neonatal Care) Other services include Essential newborn care and immediate post partum care and Garantisadong Pambata. Garantisadong Pambata is a package of interventions for 0-14 years age that includes Infant and Young Child Feeding (IYCF), Expanded Program on Immunization (EPI), Micronutrient Supplementation, Integrated Management of Childhood Illness (IMCI), Deworming, Handwashing, Water and Sanitation Strategies for Public Health In response to the increasing incidence of non communicable diseases, we shall aggressively push for healthy lifestyle. We shall encourage exercise, food labeling, avoidance of tobacco and moderation in alcohol. We shall also address the non communicable diseases threat by ensuring adequate services are present for its prevention and control. We are always on the look-out for emerging diseases such as the superbug, nosocomial diseases, A(H1N1) and illnesses brought about by climate change. The sudden upsurge in dengue cases this year highlights the need for inter-agency and intersectoral approach for addressing public health concerns. The most interesting advice I got for dengue control was from Vice President Binay, who said that the DILG should be in the forefront in mobilizing the LGUs to ensure cleanliness and prevent the proliferation of vector mosquitoes. Also, the Department of Education is essential in dengue prevention and control, as many schoolchildren can be victims of this disease.

In the next two weeks, we shall convene an inter agency task force composed of representatives of DILG, DepED, DENR, UP-NIH, the Research Institute for Tropical Medicines and specialty societies. This task force will explore all possible means to eradicate dengue, from vector control to early diagnosis, possible cures, and vaccinations. ICT Tools for Health Availability of accurate, reliable, and timely information is the key element in achieving Universal Health Care. Decision-making at all levels is dependent on quality information. It is thus imperative that we focus on harnessing critical ICT technologies in making data and information available. Significant investments must be allocated for this. ICT can be used to improve access to health services through technological investments such as telehealth etc. Human Health Resources Only with reasonable compensation, adequate facilities and opportunities for career growth shall our health workers be encouraged to stay. Our health financing and health facilities reform will redound to better pay and better work environment for them. We seek to complement our existing human health resources in the Department of Health and the LGUs with our counterparts in the Department of Education and the Armed Forces of the Philippines. The former, for better health outcomes of our school children, and the latter, for reaching the geographically isolated areas, hopefully with air ambulance or helicopter service. Research and Medical Tourism Even as we seek to reach our MDGs, Philippine Health Care must find a niche for itself in the increasingly global economy. Through research, we can find areas of interest where we can tap out molecular biologists and biotechniologists. Biomedicine is but one of the pioneering fields where our local doctors and researchers can excel. With our excellent health human resources and world famous kalinga, we can be world renowned in medical tourism. We must however assure our public that medical tourism can be a source of financing for our poor patients depending on how we cascade medical tourism s outcomes to benefit our local health facilities.