Nurturing growth: Mapping out the challenge of expanding health care coverage to all Filipinos

The Philippines continues to experience a sharp disparity in the quality of health care provision in urban and rural areas. This affects coverage for the poorest and most vulnerable sections of the population. Though underinvestment by the government remains an issue, regulations have been framed to address the issues surrounding equity, access and cost. Government initiatives have, however, been met with mixed results, with the sector still going through a transition phase.

RECLASSIFICATION: The government has been pursuing initiatives to upgrade hospital facilities with the aim to provide a wide range of quality health services to all citizens. In keeping with the overarching objective of universalising health coverage, the Department of Health (DoH) introduced a new classification system for hospitals and other health facilities in 2012. This system laid out particular guidelines for the scope of services and standards of operations in specific health institutions. Under the new classification system, Level-1 hospitals should have a surgery room, surgery and maternity facilities, first level X-Ray facilities, blood station, pharmacy, dental clinics, isolation and secondary clinical laboratories. Level-2 hospitals must provide additional services including a respiratory unit, high-risk pregnancy unit and second-level X-Ray facilities. Level-3 hospitals are mandatorily required to provide facilities such as a blood bank, and ambulatory surgical and dialysis services. The new classification system has attracted censure from private hospitals, a number of which say that the system will affect health care provision for the public and may even lead to some hospitals curtailing operations. Further, there is concern that non-compliance with the new system could lead to reclassification of certain hospitals to infirmaries. This, in turn, may affect their operational viability and capacity to provide benefits via the Philippine Health Insurance Corporation – known as PhilHealth – to clients, as they would lose their PhilHealth accreditation.

PhilHealth has, however, clarified that a suitable benefits system would be devised for infirmaries. This would help any hospital that is reclassified to an infirmary due to non-compliance with classification norms remain accredited and its clients can access the appropriate PhilHealth benefits package.

The DoH has also sought to help existing private hospitals by extending the time period to comply with new classification norms by three years. The new classification system would be applicable to new hospitals while existing hospitals, especially those that do not have operating rooms, would be allowed to enhance their infrastructure within three years.

BREASTFEEDING: The Philippines took a major step towards ensuring healthy infants when the government legislated the Expanded Breastfeeding Promotion Act in 2009. The Act mandates the setting up of milk banks and lactation stations in corporate establishments and health institutions such as hospitals, infirmaries, health centres and lying-in clinics. The law also grants employees who are breastfeeding the option to take regular breaks to facilitate proper feeding.

Since its enactment, the legislation has had a positive impact on breastfeeding rates. “The breastfeeding law is part of the push to provide better health services to the people. With the implementation of the law, there has been an increase in breastfeeding rate from 36% to 47% over the period 2008 to 2011 for infants in the age range of zero to six months,” Alejandro Castro III, executive director of the Infant and Paediatric Nutrition Association of the Philippines, told OBG.

A related issue in the Philippines is the role of baby milk manufacturers in the complementary feeding stage for the age group of six months to three years. There has been general opposition in the country to the baby milk industry, which is often viewed as unreliable and lacking nutrition as compared to breast milk. This has ultimately put restrictions in the way baby milk producers operate and the products that they can deliver to the people, even though a number of products currently adhere to the rigorous manufacturing standards and can provide additional nutrients to a growing child.

WORKER SHORTAGE: Rural areas of the country currently face shortages of trained health professionals, even though the need for expertise is greatest in these regions. The growth in the number of private hospitals in urban centres and expansion of the health care business process outsourcing industry has generated opportunities for doctors and nurses. The mitigating factors are the low salaries in public health facilities, especially in rural areas, and the strenuous work conditions.

Over the years, the government has taken initiatives to encourage doctors and nurses to serve in rural parts of the nation. Programmes such as Doctors to the Barrios and Registered Nurses for Health Enhancement and Local Service (RN Heals) have been notable health drives in this regard. With the nation’s education system producing a significant number of qualified health professionals, these programmes were expected to create productive employment opportunities. However, low pay and poor work conditions continue to pose challenges to proper implementation of these schemes. For instance, nurses working in rural locations have often received delayed payment under the RN Heals scheme, an issue raised by Congress in late 2012. Meanwhile, doctors in local government hospitals earn a monthly salary of P26,878 ($648), with physicians conferred by the DoH receive P39,493 ($952). Due to the low salaries, a large number of doctors and nurses continue to move abroad. A bill was introduced by Congress in 2013 to address this problem. The legislation proposes to increase the minimum monthly salary of a doctor to P62,670 ($1510). A yearly loyalty pay of P50,000 ($1205) for doctors with at least three years of continuous service has also been proposed. The legislation will also provide an educational grant of a maximum P200,000 ($4820) to those physicians who have served for at least five years continuously.

RESEARCH: Health research spending is 0.03% of total health expenditure, which is well below the 2% figure advocated by the World Health Organisation. According to figures from the World Bank, the country spends just 0.1% of GDP on research and development (R&D), including in health. A lack of adequate public funding has resulted in the absence of an adequate research infrastructure and health informatics service. As a result, this has inhibited the formation of a robust health research system that can deliver innovative treatments. The government acknowledges that the development of the health sector is dependent on enhancing research support in areas such disease prevention and cure, development of innovative treatments and growth of the indigenous pharmaceutical industry. To this effect, partnerships with the private sector have been encouraged to enhance research output.

The Philippine National Health Research System (PNHRS) Act has also been legislated to guide the nation’s health research projects. The law will mandate policies, approve long-term programmes, and monitor and give approvals to the overall agenda for national health research. Development of an efficient and transparent health research management system is one of the foremost priorities of the new law. The government is seeking to drive R&D by forming strong partnerships with other countries and research institutions, and suitable provisions have been made in the PNHRS. The agenda will also need to include better training for researchers to provide incentives for skilled professionals to return to the country to pursue research.

AFFORDABILITY: Filipino patients, especially those in the lowest income bracket, continue to pay high medicine costs. The government has attracted criticism for having failed to fully implement the Cheaper Medicines Act of 2008, which would have allowed parallel imports of branded drugs from countries such as India, – where the cost of pharmaceutical drugs is 50% to 70% lower than in the Philippines – and sought to boost indigenous manufacturing of generic medicines.

At the same time, high quality, branded – but low cost medicines – were set to reach the most impoverished of the population via government hospitals. The uptake of generics and imported, low cost drugs, however, continues to remain low in the country and the market remains dominated by expensive branded medicines. For instance, generics constitute 20% of the total drugs sold in the country. Awareness about the reliability and quality of generic medicines remain low with many believing that branded drugs provide better outcomes.

“The retail landscape for pharmaceuticals has changed substantially over the past 10 years,” Teodoro L Ferrer, president of Generika Drugstore, told OBG. “In the past the market was very dominated by branded and originator products. This is not the case anymore as generics have made serious inroads,” he added.