Bu-lat-lat (boo-lat-lat) verb: to search, probe, investigate, inquire; to unearth facts

Issue No. 27                        August 19-25,  2001                    Quezon City, Philippines

A major barometer of how a government takes care of its constituency is the premium it gives to people’s health. One need not go to the hospital or the city health office to find out whether this mission has had some results, however: Every time a high government official becomes ill, he goes to the United States. And nobody knows for sure whether public funds are used for his treatment. The tragic state of the country’s health system is not so tragic, however, if seen from the fact that a growing number of medical practitioners are now joining the ranks of public health workers in clamoring for reform in the sector. They are giving a ray of hope to millions of sick Filipinos who continue to despair in the way they are criminally neglected by health officials and, because of this, choose to die at home than have their families die too because of indebtedness.

By sandra nicolas
Bulatlat.com

Twenty-three year old Fernando San migrated alone to Manila from Davao province. He worked hauling fish at the Trabaho Market in Galas, Quezon City for P150 (US$2.94) a day. Early last July, he died in the indigent ward of the Quezon Institute (QI)--an erstwhile public but now private "fee for service" hospital--leaving behind an unpaid bill of P2,890 ($56) for laboratory fees and, in all likelihood, an unfilled-out prescription for anti-tuberculosis (TB) medicines.

Sometime in May before he died, concerned about his weight loss and bloodstained system, Fernando went to the out-patient department of QI. He was diagnosed as having pulmonary tuberculosis (PTB) and asked to return daily for his anti-TB medication. Living on his meagre earnings by the day, Fernando continued to work at the market despite his ailment.

Last July 1, he was brought by a fellow fish-hauler to QI's emergency room because he had difficulty breathing. He was confined for his "community acquired pneumonia stage IV, severe active PTB stage III and byphoscoliosis (deformity of the lumbar spine)." But the hospital couldn't nurse him back to health.

Fernando's bedside table had just a drinking glass, a bottle of water and a donated bottle of nebulizing solution that he couldn't use anyway because he couldn't afford the required nebulizing mash. Nor did he have any antibiotics.

The QI provides the doctor, room and board for free to indigent patients but medicines and lab fees need to be paid for. Fernando, bereft of even a change of clothing, was at a loss about how to pay for his hospital expenses. At one point he even told his nurse that he could work his bill off as a janitor or helper as soon as he was able to. It didn't come to this though and run-down QI, probably the country's cheapest private hospital for TB patients already, was tragically not cheap enough.

In the world underclass

Government health officials blame the lack of resources for the tragic state of the country's health care system. Neglected the sector certainly is, a fact starkly seen when comparing its performance with other countries'.

The World Health Organization's (WHO) Health Development Report (HDR) 2000 assessed health systems in 191 countries and the Philippines did badly by measures of government support for health. For one, it placed 131st with its 1997 public health expenditure per capita of just US$48, a dollar less than Albania's and only US$2 more than Kyrgyzstan's.

Also highlighting the low priority given by the government to health is the mere 7.2 percent share of health in total public expenditures, less than half of the United States' 18.5 percent, which ranks the country at 127th.

The country was also at 131st place with its 48.5 percent share of public spending to total health expenditure, barely half of the United Kingdom's 96.9 percent. The balance of spending is paid for privately. The undue burden placed on already poor Filipinos is also reflected in how the WHO had the Philippines tied for 128th place with Uganda and Thailand in terms of "fairness of financial contribution to health systems."

The country's total health expenditure as a percentage of gross domestic product (GDP) of 3.4 percent ranks it at 161st place astride the African countries of Swaziland and Eritrea; this is far below the United Nations-recommended figure of 5.0 percent.

In terms of total health expenditure per capita, combining public and private sources, the country ranked 124th behind Congo and Lesotho. These truly dismal figures are, finally, also reflected in how the HDR 2000 ranked the Philippines at 126th place in terms of "level of health" trailing the pacific islands of Fiji and Palau.

Worse to come

Health sector activists retort that the government itself is to blame. Not only for the low budget given to health but for a health sector orientation that is "highly commercialized, Western-oriented or colonial, urban-centered, curative and hospital-based health care system," according to Dr. Mary Christine R. Castro of the Community Medicine Development Foundation (COMMED). These result in health services that are "not accessible or affordable to those belonging to the lower social strata," she says.

On at least the last point, the government concurs. Former health secretary Dr. Alberto Romualdez said in a Department of Health (DOH) report last year, "People have unequal access to health services... Even where facilities are present, people are unable to receive appropriate care because services are unaffordable." Yet while government and activists would agree on the dismal state of the Philippines' health care system, their proposals on what needs to be done could not be more opposed.

The government has responded with the Health Sector Reform Agenda (HSRA), conceived in 1998. In very important respects, the HSRA applies the philosophy of the free market and the supposed virtues of competitive efficiency to health care. Two of its major strategies are to "provide fiscal autonomy to government hospitals" and to "expand the coverage of the National Health Insurance."

These have been interpreted as a subtle way of making health care ever more the preserve only of those who can pay for it, where a public good is more and more provided according to private sector norms. Says Dr. Rey Lesaca, chairperson of the Health Alliance for Democracy (HEAD), "For us it is simple. Even the few health services within reach of the people are being taken away from them. They are being passed on to the private sector which we know is only about profit, profit, profit."

Certainly private insurance schemes, for instance, have downsides which are even aggravated in the Philippine context. Private insurers price on the basis of risk. In the Philippines, with the majority poor and a correspondingly high degree of sickness, profit-seeking insurance providers have an interest in charging high premiums and restricting coverage in the drive for profitability. The likely result is that relatively few members will be covered--mainly those who can afford the high premiums--and the services or treatment allowed will be limited.

The HSRA is also criticized for being out of touch with Philippine realities. "The HSRA projects increasing incomes and uses this to justify the decrease in government spending on health,” says Emma Manuel, President of the Alliance of Health Workers (AHW) and a Radiologic Technologist at the Tondo Medical Center. “But can the people really afford it? As it is now, many would rather take the chance that they will get better before going to the hospital to try and avoid the certain expenses involved. And when they are finally forced to go their condition is already critical.”

Manuel is sharp in her criticism of government policy-makers: "How can they sympathize with the bad health care conditions of the poor majority? First, they're healthy because they're well-off. And then if they do get sick they just fly off to the United States for treatment." She adds, "But I suppose they know how bad our hospitals are here. That's why they go abroad."

Protesting privatization

But health sector activists are not taking the government's moves to leave health care to the market sitting down. Just last Wednesday, August 15, they filed a petition to the Supreme Court to have Executive Order (EO) 102 and the HSRA declared null and void.

According to the petitioners, "The HSRA and EO 102 violate the pro-people provisions of the Philippine Constitution and the constitutional duty of the State to protect life and promote the general welfare of the people." EO 102 redefined the mandate, roles, power and functions of the DOH and provided for the abolition of public health programs and the streamlining of health workers in the DOH-measures consistent with the overall thrust of the HSRA.

In the petition, the group, however, asserts that these reduce the government's role to "being a monitor and regulator, no longer the sole provider of health services." As a result of this reorientation, real government spending per capita on health has already fallen to P46.06 in 2001 from P67.85 in 1997. Primary health care programs, health services to indigent patients, and health worker salaries and benefits have all suffered.

The petitioners include employees' unions of different public hospitals and institutions such as the Tondo Medical Center, Research Institute of Tropical Medicine, Philippine Orthopedic Center, Jose Reyes Memorial Hospital, San Lazaro Hospital; health organizations such as the AHW, HEAD, COMMED, Council for Health and Development, Network Opposed to Privatization, Philippine Society of Sanitary Engineers; people's organizations such as Kilusang Mayo Uno, Gabriela, Kilusang Magbubukid ng Pilipinas, Kalipunan ng Damayan ng mga Maralita and several individuals from the academe and the DOH.

The respondents identified were Executive Secretary Alberto Romulo, Health Secretary Manuel Dayrit, and Budget Secretary Emilia Boncodin.

Struggles to come  

The challenge is great, especially for the health sector activists who could only make a few photocopies of their petition for lack of funds.

The first campaigns against health privatization started in 1996 during the term of former president Fidel Ramos, specifically against the sale of Tala Leprosarium and the National Center for Mental Health. Yet, seemingly inexorably, the turning over of health to the market has proceeded--sometimes with the not-so-subtle prodding of World Bank officials pushing for "cost-recovery" schemes.

Unfortunately many among the country's poor are meanwhile forced to resign themselves to the worsening state of the health care system. Like Mang Rodolfo Sarenas, a 48-year-old junk dealer who has little hope of raising the over P100,000 needed for an anti-TB operation, they may be driven to despair: "Better to die at home than have my family buried in debt."

Yet activists continue to hold out that progress can be made. Manuel sounds realistic enough to say it is important not to pin too much hope on the petition before the Supreme Court.

We want to know what you think of this article.