In my last column I wrote that PhilHealth was far from ready to administer the universal health care program. Today, I say that the country’s health care delivery system is far from ready for universal health care (UHC).
UHC is firmly based on the World Health Organization constitution of 1948 declaring health a fundamental human right. Achieving UHC is one of the targets members of the United Nations set in 2015. On Sept. 25 that year, the resolution on “Transforming Our World: the 2030 Agenda for Sustainable Development” adopted the target of universal health coverage by 2030, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.
UHC means that all people can use the preventive, curative, rehabilitative, and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services will not ruin him financially.
This definition of UHC embodies three related objectives:
1. Equity in access to health services — everyone who needs services should get them, regardless of his ability to pay;
2. The quality of health services should be good enough to improve the health of those receiving services; and,
3. People should be protected from being pushed into poverty because unexpected illness requires them to use up their life savings, sell assets, or borrow — destroying their futures and often those of their children.
The advantages of UHC are:
• Lowers overall health care costs
• Lowers administrative costs
• Standardizes service
• Creates a healthier workforce
• Prevents future social costs
The disadvantages are:
• Healthy people pay for the sickest
• People have less financial incentive to stay healthy
• Long wait times
• Doctors may cut care to lower costs
• Health care costs overwhelm government budgets
• The government may limit services that have a low probability of success
UHC, however, does not mean free coverage for all possible health interventions, regardless of the cost, as no country can provide all services free of charge on a sustainable basis. UHC is not only about individual treatment services, but also includes population-based services such as public health campaigns, adding fluoride to water, controlling mosquito breeding grounds, and so on.
Countries that achieve UHC will progress towards other goals. Good health allows children to learn and adults to earn, helping people escape from poverty and advance towards economic growth.
For universal health care to achieve its goal, several factors must be in place. They are:
1. A strong, efficient, well-run health system that meets priority health needs by:
• informing and encouraging people to stay healthy and prevent illness;
• detecting health conditions early;
• having the capacity to treat disease; and,
• helping patients with rehabilitation.
2. Affordability — a system for financing health services to prevent people from falling into bankruptcy.
3. Access to essential medicines and technologies to diagnose and treat medical problems.
4. A sufficient capacity of well-trained, motivated health workers to provide the services to meet patients’ needs based on the best available evidence.
Primary health care is the most efficient and cost effective way to achieve universal health coverage. Primary health care is an approach to health and wellbeing centered on the needs and circumstances of individuals, families and communities. It addresses comprehensive and interrelated physical, mental and social health and wellbeing.
It is about providing whole-person care for health needs throughout life, not just treating a set of specific diseases. Primary health care ensures people receive comprehensive care, ranging from promotion and prevention to treatment, rehabilitation, and palliative care as close as feasible to people’s everyday environment. This is the concept on which the Health Maintenance Organizations in the US are based.
Quality health care makes UHC a large expense for governments. It is usually funded by general income taxes and/or payroll taxes. There are three UHC models: single payer, social health or mandatory insurance, and national health insurance.
In a single-payer model, the government provides free health care paid for with revenue from income taxes. Services are government-owned and service providers are government employees. Every citizen gets the same quality of healthcare. The United Kingdom developed the single-payer system. Cuba has the same system.
Countries that use a social health insurance model requires everyone to buy insurance, usually through employers. The government has a strong influence on insurance premiums, and prices of service providers. Private doctors and hospitals provide the services. The insurance firms pay the doctors and hospitals. Germany, France, the Netherlands, and Switzerland use this system.
The national health insurance model uses public insurance to pay for private-practice care. Every citizen pays into the national insurance plan. Canada, Taiwan, and South Korea use this model. The US Medicare and Medicaid systems use this model.
In observance of the World Health Organization (WHO) declaration of healthcare for everyone, many countries launched universal health care programs. President Rodrigo Duterte signed on Feb. 20, 2019, the Universal Health Care Bill into law, Republic Act No. 11223, An Act Instituting Universal Health Care for All Filipinos. When implemented effectively, the law will mean all Filipinos get the health care they need, when they need it, without suffering financial hardship as a result.
RA 11223 enrolled all Filipino citizens in the National Health Insurance Program. That is 109 million Filipinos spread all over the archipelago — from Batanes in the north to Jolo in the South, from Samar in the East to Palawan in the West.
According to the Department Health (DoH), as of 2009 around 40% of hospitals are public. Out of 721 public hospitals, 70 are managed by the DoH while the remaining hospitals are managed by LGUs and other national government agencies.
Both public and private hospitals can also be classified by the service capability. Level-1 hospitals account for almost 56% of the total number of hospitals. They have very limited capacity, comparable only to infirmaries.
Private hospitals outnumbered the government hospitals in all categories. The disparity is more pronounced in tertiary hospitals where the number of private hospitals is four times that of the government hospitals.
Levels 1 and 2 hospitals are relatively well-distributed across the country. However, hospitals with higher service capabilities are highly concentrated in Region 3 and National Capital Region (NCR).
The number of hospital beds is also a good indicator of health service availability. Per WHO recommendation, there should be 20 hospital beds per 10,000 population. Almost all regions have insufficient beds relative to the population except for the NCR, Northern Mindanao, Southern Mindanao, and the CAR. Among the 17 regions, the Autonomous Region for Muslim Mindanao (ARMM) has the lowest bed to population ratio (0.17 beds per 1,000 population), far lower than the national average.
Based on the data I had when I was with a private health insurance company, 6% of those insured are going to get sick during a one-year period. The average stay in the hospital is four days for a patient. That means six hospital beds would be occupied for four days during the one-year period.
Ninety percent of the insured were working people, the rest were their dependents, excluding those above the age of 60. Excluded also were maternity cases. RA 11223 enrolled every citizen in PhilHealth. With a population of 109,000,000, this means 6,540,000 people are expected to need hospitalization during a one-year period.
But that 6% is based on a population of relatively healthier people. RA 11223 insured even centenarians and included maternity. The rate of hospitalization would be much higher than 6%. Let us say it is 8%. That is 8,720,000 people falling sick. Spread over 365 days, that is 23,890 bed-days occupied at any time. But as each patient on an average occupies the bed for four days, 95,560 bed-days are needed. That is beyond the capacity of Philippine hospitals.
According to PhilHealth, 38 million enrollees are indigents. The moral hazard becomes a bigger factor. The jobless poor will seek hospitalization even if he is not sick. Hospitalization means three free meals a day and a real bed instead of a cart or the sidewalk. The doctor would agree to ordering confinement as it means revenue for him (PhilHealth pays his professional fee). The hospital also gets paid by PhilHealth for virtual services. This is actually happening as the various investigations of PhilHealth irregularities and anomalies have shown.
The private doctors with dismal practices and the lowly paid government physicians are prone to resort to fake hospitalizations. According to the DoH, the country has a huge human reservoir for health. However, they are unevenly distributed in the country. Most are concentrated in urban areas such as Metro Manila and other cities.
WHO’s target was for universal health care in developing economies by 2030. It looked like some of our legislators rushed the enactment of the universal health care bill into law so that it could be presented as their gift to the Filipino people in the elections of 2019. Among the authors were Senators JV Ejercito, Sonny Angara, Nancy Binay, and Cynthia Villar who were running for re-election to the Senate that year.
However, the country’s health care system is far from being able to provide the services the law mandates. But the politicians must have said, “Bahala na si Batman.”
Oscar Lagman was at one time or another country manager for a multinational health insurance company, adjunct lecturer in the Master in Hospital Administration program of a university, and head of Healthcare Consulting at a large consulting firm. He was also a member of the USAID-sponsored team that set up the universal healthcare program of the Province of Bukidnon.