By ANNE MARXZE D. UMIL and BENJIE OLIVEROS
MANILA –When the Aquino administration took over the reins of government, the public health system was festering and the poor’s access to essential health services has been getting worse.
Ibon Foundation’s data showed that only two out of 10 among the poor have access to free health care, 74 percent have to find the means to pay for their health care. Only three out of 10 among the poor are covered by social health insurance. Eight out of 10 never had a check-up or physical exam, three out of 10 never experienced consulting a doctor, and three out of 10 self-medicated.
Due to poverty, six out of 10 people die without being able to see a doctor.
Propelled to power on the campaign promise of change, the Aquino government embarked on two major programs supposedly to rescue the ailing public health system and the poor majority from the throes of death: corporatization and public-private partnerships, and universal PhilHealth coverage.
To pave the way for public-private-partnerships, Congress tried to fast track House Bill 6069  , which mandates the corporatization of potentially viable government hospitals. House Bill 6069 or An Act Creating National Government Hospitals Corporations was approved at the committee level. A similar legislative measure is also pending at the Senate.
This was met with stiff opposition from concerned health workers and professionals, patients, poor communities and different cause-oriented groups who bonded together under the Network Opposed to Privatization (NOP). The group conducted lunch break pickets and nationally coordinated protest actions. The corporatization of hospitals, they said, would result in the privatization of government health services.
In defense of the bill, Health Secretary Enrique Ona said government hospitals would not be privatized but corporatized. In a news report, deputy presidential spokesperson Abigail Valte said that while there are moves to turn government hospitals into corporations, this does not mean that these hospitals would be privatized.
Mothers mourn for the death of health services in the Philippines. In a protest action in November last year, these mothers and the makeshift coffin depicts privatization of public hospitals as death for poor families. (Photo by Anne Marxze D. Umil/ bulatlat.com)
Valte was quoted saying in the report that, “There are proposals to incorporate government hospitals, not to privatize them. That will allow the hospitals to be run more efficiently.”
Secretary Ona has been trying to explain to the public that government hospitals would not be privatized. In an article , Ona said the DOH “is bringing certain private practices to improve efficiency and availability of public services that otherwise will take a long time or, maybe, we will not have that kind of resources at all.”
Under the corporatization scheme, the budget for government hospitals have been slashed and the respective Board of Directors of these hospitals would be given the leeway to implement measures to raise the funds for their operations, such as charging higher fees, and generate the resources for the hospital’s modernization through entering into partnerships with private corporations.
Already the budget for operations of the hospitals targeted for corporatization and public-private partnerships, such as the Philippine Orthopedic Center (POC) and the Research Institute for Tropical Medicine (RITM),have been slashed and no allocations for capital outlay have been given.
Forced to make do with the limited budget, in the meantime, and to demonstrate its financial viability to potential private investors, these hospitals have progressively increased its service or user fees.
According to data gathered by Ibon Foundation, the Philippine Orthopedic Center (POC) has already implemented a 212.2 percent increase in its laboratory fees since March of 2011. A standard chest x-ray now costs P250 ($6.09) from P120 ($2.92), x-ray for the skull APL now costs P350 ($8.52) from P135 ($3.29), kidney, uterus and bladder x-ray costs P375 ($9.14) from P120 ($2.92), complete blood count from P145 ($3.53) to 150 ($3.65) and blood cross matching from 120 ($2.92) to 195 ($4.75).
The Research Institute for Tropical Medicine (RITM) also increased its fees. A new patient before had to pay P20 ($.48) for the patient card. Now they have to pay P50 ($1.21). A patient would also have to pay P50 for the succeeding consultations as professional fee; this used to be free. Laboratory fees also went up when a new set of rates was implemented last March 15, 2012. Complete blood count with platelet count costs P350 ($8.53), blood typing costs P280 ($6.82), urinalysis costs P140 ($3.41).
These increases are just immediate measures to keep these hospitals afloat, given the reduction in government subsidies. Once private investors come in, fees would considerably increase further to ensure that they would profit from their investments.
A public-private partnership project is already in the pipeline for the RITM. According to Ibon Foundation, the RITM is about to enter into partnerships with private corporations for the local production of Pentavalent vaccine for diphtheria, pertusis, tetanus, hepatitis B and Haemophilus influenza B. The P453-million ($10.8 million) project will involve the partial localization of vaccine production from bulk preparation to the finished vaccine. Ibon said the project aims to reduce the overall vaccine procurement costs and ensure vaccine self-sufficiency. But when this is finally completed, these vaccines would surely be sold at a profit to enable the private investors to gain from its investment.
The POC , on the other hand, is up for bidding. The National Economic and Development Authority (NEDA) has approved the P5.6 billion ($135 million) rehabilitation project of the Orthopedic Center. According to the PPP Projects website , the project involves the construction of a 700-bed capacity “super-specialty tertiary orthopedic hospital” to be located within the National Kidney and Transplant Institute (NKTI) compound located along East Ave. in Quezon City. The government aims to transform the Orthopedic Center into the “country’s primary center for bone and joints diseases that is at par with global standards.” The PPP website further said, “With the project, the government would be able to provide better health care services to the public and provide access to more modern medical facilities and efficient hospital operations.” Once this is completed, the current increased fees would surely be a mere fraction of the fees that the envisioned modern Orthopedic Center would be charging.
The RITM and POC are among the eight PPP projects that the government targets to roll out in the near future. According to the PPP website, the RITM is in the process of securing government approval as of Dec. 12, 2012 while an invitation to bid was issued for the POC last Nov. 18, 2012.
Added to this, these envisioned corporatized, modern hospitals would also be involved in research and development. “The government has never invested in research and development, now it is even at the forefront of advocating that the private sector takes over this very crucial function,” said the NOP. What is wrong with this? The NOP believes that knowledge that is supposed to be generated for the good of society, such as technological breakthroughs in disease prevention and cure, would be “owned” and used for generating profits by private corporations, especially with the strict international patent laws.
Universal PhilHealth coverage
The Aquino administration’s program for universal PhilHealth coverage is actually patterned after US President Barack Obama’s health care program . An important aspect of Obama and Aquino’s health care program is universal health insurance coverage through compulsory coverage and government-subsidized coverage for a segment, not the whole, of the poor.
According to the Department of Health, it is implementing a Universal Health Care (UHC) program that aims to provide “highest possible quality of health care that is accessible, efficient, equitably distributed, adequately funded, fairly financed, and appropriately used by an informed and empowered public.” The most significant reform include in the program is the expansion of PhilHealth coverage to include enrollment of the poorest of the poor and mandatory inclusion of the informal sector who can afford to pay the premium, improvement of the membership services to increase awareness of the benefits and entitlements, access to inpatient and outpatient services and zero co-payment for the poorest in government hospitals.
The National Household Targeting System for Poverty Reduction (NHTS-PR), which was implemented by the Department of Social Welfare and Development (DSWD) to identify the beneficiaries to its Conditional Cash Transfer program, will also be the basis for identifying who will be enrolled under PhilHealth’s sponsored program.
Many of the residents of Isla Puting Bato in Tondo, Manila, are not members of Philhealth. Some list their names but were not able to get their cards, some took a year to claim their card. (Photo by Anne Marxze D. Umil / bulatlat.com)
Another new policy was implemented by PhilHealth called the No Balance Billing (NBB). According to the PhilHealth website, the No Balance Billing policy means that no other fees shall be charged or paid for by government-subsidized PhilHealth patients beyond the identified case rates .The policy covers sponsored members and their dependents.
There are 25 identified medical and surgical cases covered by this policy . These cases have corresponding case rate payments . For example, a patient with Dengue I case could avail of a P8,000 ($195) subsidy from PhilHealth. If the patient’s bill exceeds thealloted subsidy, a sponsored member would not be shouldering the excess amount.But individually paying members and employed members of PhilHealth would have to shoulder the exceeded cost during hospitalization. Sponsored members could also reimburse payments for necessary items and services during confinement. PhilHealth requires health facilities to attach the official receipt/s detailing the purchases in the claim application for the said confinement.
PhilHealth benefits under the sponsored program covers subsidy for room and board, drugs and medicines, laboratories, operating room and professional fees for confinement of no less than 24 hours.The same is also applicable to individually paying members and employed members. According to PhilHealth, premiums of members under the sponsored program are jointly shouldered by the national government and local government units or by private individuals and companies, as well as members of Congress through their Priority Development Assistance Fund (PDAF) and other philanthropists.
The government even allotted P12.6 billion ($30 million) in the 2013 budget for PhilHealth. According to the Network Opposed to Privatization (NOP), the budget allocation is in line with the 2011-2015 Philippine Development Plan, with its target to enroll 5.2 million poorest families by the year 2015.
As of January of this year, individually paying members, including overseas Filipino workers, will have to pay P150 ($3.65) per month, an increase from the previous premium of P100 ($2.43) per month. The premium payments of those employed, on the other hand, will depend on one’s salary bracket : an employed PhilHealth member earning P7,000 ($170.73) and below per month will have to pay P175 ($4.26), shared in half by the employer and the employee.
Virginia Cagadas, 53, widow a and mother of three has a stub to claim her Philhealth card but she arrived late during the distribution. (Photo by Anne Marxze D. Umil / bulatlat.com)
Contradictions in implementation
However, the government’s declaration that it aims to provide “better and quality health care” for Filipino people is fraught with contradictions.
The DOH said PhilHealth aims to “reduce out-of-pocket expenditures to prevent poor patients from being burdened by debts, especially in times of illness.”
But according to Dr. Gene Nisperos, vice president of the Health Alliance for Democracy (Head), “The government’s share in the total health expenditure has decreased from 40 percent in 2000 to 24 percent in 2008. The PhilHealth’s share had not increased beyond 10 percent and even decreased to 7.2 percent also in 2008. Therefore, the patients’ out-of-pocket expense has reached to 57.9 percent (in 2008) from 40 percent (in 2000).”
The condition of government hospitals also has to be taken into consideration. While the PhilHealth has a promising NBB policy, many government hospitals, on the other hand,are not well equipped to provide services for the cases listed under the said policy. “PhilHealth coverage is useless if the public healthcare system remains neglected,” said Dr. Julie Caguiat, convenor of NOP.
Caguiat explained, the NBB only benefits sponsored members who are confined in accredited state-run hospitals, suffering from select 25 medical & surgical conditions. These cases are the following:
Maternity care package
NSD package in level I hospitals
NSD package in levels 2 to 4 hospitals
Dilatation and curettage
Dengue I (Dengue fever, DHF grades I and II)
Dengue II (DHF grades III and IV)
Pneumonia I (moderate risk)
Pneumonia II (high risk)
Cerebral Infraction (CVA-I)
Cerebral Hemorrhage (CVA II)
Acute Gastroenteritis (AGE)
Newborn care package in hospitals and lying in clinics
However, many provincial and district hospitals are not even equipped to provide services for these cases. And this scenario would even get worse for as long as the government continues its non-allocation of appropriate funds for direct health services to government hospitals.
“In a public hospital, it is important that there are enough supplies for the needs of the patients. Emergency rooms, for example, should have complete supplies, from cotton to dextrose and medicines, because we are saving lives in the ER. But this is not happening. Now ERs of public hospitals have very limited supplies. Worse, ER fees are being exacted in public hospitals to augment their limited budget,” Jossel Ebesate told Bulatlat.com. Ebesate is a registered nurse who has been serving in the Philippine General Hospital for 25 years and is the national president of the Alliance of Health Workers.
“Hospitals in far flung areas in the provinces do not only lack equipment but also medicines and even personnel,”Dr. EleonorJara, executive director of Council for Health and Development and convener of the NOP, added.
Also, many patients are going to tertiary hospitals rather than in primary or secondary hospitals because of lack of health infrastructure.
(Photo by Anne Marxze D. Umil / bulatlat.com)
Because of this, Nisperos said, private hospitals are the biggest recipients of PhilHealth claims. According to Nisperos, the top 10 hospitals in terms of PhilHealth claims (as of 2006) are all private hospitals. “Only one out of 10 hospitals, which avail of PhilHealth claims, is a government hospital,” said Nisperos, referring to the Davao Medical Center. This is also because utilization rates are highest among employed members, while it remained low among sponsored members.
There are also questions regarding PhilHealth’s coverage. Ibon said the ultimate drawback in advancing this policy is that the measurement of the level of poverty in the country, which the government uses as reference for its indigent program, does not capture the true state of impoverishment and inability to pay for a basic service such as health.The 2008 National Demographic and Health Survey shows that 79 percent of the poorest 20 percent have no health insurance while 35 percent of the top 20 percentile also have no health insurance. Meanwhile, only one of the five respondents belonging to the poorest 20 percent is a member of PhilHealth while six out of 10 in the richest 20 percent are PhilHealth members. The 2008 survey also noted that 2.6 percent of the richest 20 percent are under the PhilHealth’s indigent program.
The identification of beneficiaries of the sponsored program and the distribution of PhilHealth cards are far from systematic.
According to residents of Isla Puting Bato in Tondo, Manila, some government employees arrived in their community telling them to list their names for PhilHealth membership.Beverly Seda, 25, mother of four,said PhilHealth cards were distributed in their area last Dec. 15, 2012 but she did not receive one.
Virginia Cagadas, 53, widow a and mother of three has a stub to claim her PhilHealth card but she arrived late during the distribution. Laura Batica, 52, mother of three, has a PhilHealth card that she got one year after her enlistment last 2011. But Batica never used her card because no one got sick in her family. If ever they got ill, she said, they went to the health center for check up and free medicines if the health center has supplies and, if there is none, they manage to borrow money to spend for their medicines.
Cagadas is also one of the poor Filipinos who received the PhilHealth card, which was distributed by the previous Arroyo administration, but she did not benefit from it because she too did not get ill. This is also one of the criticisms of progressive health groups against PhilHealth.
“The solution that PhilHealth coverage provides is curative instead of preventing diseases,” said Caguiat. Since the benefit coverage of PhilHealth is for hospitalization, it does not cover outpatients seeking consultation.
The PhilHealth card also expires after one year.For Batica, Cagadas and Seda, the PhilHealth premium is already costly at P150 per month.
Citing the preliminary results of the 2009 Family Income and Expenditure Survey, Ibon said, 70 percent of the population or 64.6 million Filipinos are struggling to survive on P104 ($2.53) or less per day, or as little as P22 ($.53), P45 ($1.09), P55 ($1.34) or P67 ($1.63) for the poorest 50 percent of the population. “For the majority, paying for health services is disastrous to families who are barely able to survive.”
Cagadas who works for almost 24 hours, sees PhilHealth as a measure to reduce expenses if ever she or any member of her family gets sick. However, her P600 ($14) a day income from a small food stallis not enough to cover for her expenses as she too is paying for her debts. She said that as much as she wanted to, she could not afford to pay for the premium. Meanwhile Batica finds it useless to have a PhilHealth card if there is no one in her family who gets sick and confined in the hospital.
To avail of PhilHealth benefits, a member should have paid the premium for at least nine consecutive months. If the payment of the premium is discontinued, the member could not avail of PhilHealth benefits no matter how many months the member had already paid. For example, if the individually paying member has been paying his premium for three years and then stopped due to financial constraints, he can no longer use his PhilHealth card, if needed. Once discontinued, say for a month or so, he should apply for another PhilHealth card and the previous PhilHealth card will be void. This policy is being questioned by cause-oriented groups.
“Where did PhilHealth Corporation spend the people’s money? It is absurd that the people paid for their insurance and yet they cannot use it?” Caguiat said.
Philhealth also enhances inequity as utilization rates are highest among employed members and remain very low among the sponsored members. Batica, whose 24-year-old son is suffering from epilepsy, said, she could not bring him to the hospital because of lack of money. Batica does not have a regular job and is only earning P90 ($2.19) or P60 ($1.46) from the lottery. “We can barely have food on the table. We’re lucky if we get to eat three times a day but most often we only eat once a day,” Batica told Bulatlat.com.
Continuation of neoliberal policies
To sum up, this is the Aquino government’s health agenda: lower and eventually eliminate government spending on health, require PhilHealth coverage, and allow private investments in erstwhile government hospitals.
That is why in the past year, the DOH has been encouraging people to enroll as PhilHealth members. The government launched the PhilHealth Sabado (Saturday) where booths of PhilHealth are set up in public places so that people could register. According to the NOP, the DOH intends to realize compulsory membership by working with other government agencies to enforce mandatory PhilHealth membership for all Filipinos. “Mechanisms to this effect include making PhilHealth membership a requirement for school enrolment, licensing of business, renewal of drivers’ license and other government transactions.”
Clearly, Aquino’s health agenda is a continuation of neoliberal policies that were implemented by the previous administrations. It only changed in name but is essentially the same policy, according to Ibon,Aquino has adopted and continued the Formula One for health of the Arroyo administration and the Health Sector Agenda of the Estrada administration. Both policies have advanced the neoliberal agenda in health such as hospital corporatization, medical tourism, and opening up erstwhile government hospitals to allow local and foreign corporations to profit from health care provision.
Caguiat said that by 2014, the budget for Maintenance and Other Operating Expenses of government hospitalswill be totally cut-off. By 2020 the government will no longer allocate budget for personnel services to government hospitals. The goal of the government is for DOH-retained hospitals to be fully corporatized and autonomous and will not receive any subsidy by 2020. “Health services will be through a health insurance system which is a private enterprise, specifically PhilHealth. Aquino’s health plan is paving the way for private businesses to gradually take full control of the country’s health care delivery. Consequently, this will deprive even more the poor of their right to health,” Jara said.
US President Obama’s health care reform was his centerpiece program when he campaigned for the presidency. He nearly lost his reelection bid because it did not even make a dent in providing access to health care services to majority of Americans. And now, the Aquino government is trying to do the same: putting up health care services up for sale.