Home > Vol 27, No 2 (2012) > Romualdez, Jr.

DOI: http://dx.doi.org/10.15605/jafes.027.02.08

Universal Health Care in the Philippines

Alberto Romualdez, Jr., Paul Gideon Lasco, Bryan Albert Lim
Universal Health Care Study Group, National Institutes of Health, University of the Philippines Manila

Corresponding Author
Alberto G. Romualdez, Jr., MD
Former Secretary of Health, Republic of the Philippines
Former Dean, University of the Philippines College of Medicine
Universal Health Care Study Group
National Institutes of Health
University of the Philippines Manila
Tel. No.: +632- 5264349
Telefax No.:+63 2 525 0395
Email: alberto.romualdez@gmail.com
e-ISSN 2308-118x
Printed in the Philippines
Copyright 2014 by the JAFES
Received October 15, 2012. Accepted October 29, 2012.

Abstract
The Philippines is one of the countries that aim to develop a health care system that provides access
to health for all its citizens. This paper presents the status of health reforms in the Philippines,
particularly those relating to the attainment of Universal Health Care (UHC). In describing and
analyzing the present state of health care in the Philippines, the paper refers to key documents such
as the Philippine Health System Review of the World Health Organization and the special issue on
Universal Health Care published in the Philippine medical journal, Acta Medica Philippina, in 2010.
A huge disparity of health outcomes persists between a rich minority and a poor majority in the
Philippines. The current government is committed to reducing these inequities through a universal
healthcare scheme called Kalusugan Pangkalahatan, which involves addressing problems in the six
building blocks of UHC: information systems, regulation, services delivery, human resources,
financing, and governance, though many challenges remain. Universal Health Care addresses the
problem of health inequity by improving access to services and financial protection. However, gaps in
the six building blocks of health care must be addressed if the Philippines is to truly achieve universal
healthcare.
Keywords: universal health care, health reform, health policy in the Philippines

INTRODUCTION

In September 2008, the centennial celebration of the University of the Philippines (U.P.) featured two
presentations on the assessment of the health sector and the role of the University in health. The
analyses established that science-based health services had been put in place throughout the country
partly due to the Universitys significant participation in health development.
Nevertheless, the authors noted that one central feature disfigures the state of the Philippines health:
great disparities in access to health care, resulting in significant differences in health status, between
the rich minority and the poor majority of Filipinos.
These centennial lectures, delivered at the Science Hall of the Philippine General Hospital in U.P.
Manila, concluded that a century after adopting a modern Western health system, the Philippine health
situation was unsatisfactory and that the Philippines most important health problem was health
inequity.
The health community both in and out of the University responded by holding a series of symposia,
round table discussions, and other fora to develop approaches to resolving the issue of inequity in the
country. The results of these discussions were incorporated into recommendations for government to
lead the health sector in implementing reforms to achieve universal health care in the Philippines.
During the presidential elections of 2010, proponents of the reforms exerted efforts to introduce
universal health care into the platforms of the different candidates. These efforts were rewarded when
the eventual winner adopted universal health care (Kalusugan Pangkalahatan in Filipino) as the main
objective of the new administrations health program.
This paper analyzes the various issues confronting the Philippine health system and proposes
corresponding solutions for carrying out the mandate to establish universal health care for all Filipinos.
MATERIALS AND METHODS
For purposes of this discussion and analysis, the authors used data, information and concepts found in
the references listed at the end of the paper.
The Acta Medica Philippina is a peer-reviewed publication of the University of the Philippines Manila.
The special issue on universal health care, published in the fourth quarter of 2010, is an in depth
presentation of the issues and proposals of the original Universal Health Care Study Group that
collaborated in producing the original centennial presentations and most of the materials for further
promoting the idea of advocating for Universal Health Care as the main Philippine health system policy
direction.
The World Health Organizations (WHO) Asia Pacific Health Observatory in the Western Pacific produces
the Health in Transition Series documenting health development efforts of member countries. The
Philippine Health System Review was a collaborative effort of WHO consultants and participants of the
various national fora that led to the Universal Health Care movement in the country.
Original information and data used in this paper were sourced from official statistical reports produced
by the countrys main agencies for the collection of social and economic data, the National Statistics
Office and the National Census and Statistics Board. In some instances, data presentation involved
simple extrapolation from these two sources.
The paper begins by describing elements of the evidence supporting the assertion that inequity is the
countrys main health problem. This is followed by an analysis of the defects in the different
components of the health system and some suggested general measures to address such defects. For
this purpose, the paper uses the health systems analytical framework of six building blocks as
proposed by the WHO.

ANALYSIS AND DISCUSSION

Table 1 is entitled Indicators of Inequitable Outcomes. It is a comparison of three key indicators of
maternal and child health of the highest income quintiles with those of the lowest income group
showing the disparity of health status between the richest and poorest population groups of the
Philippines.
Click here to download Table 1
Table 1. Indicators of inequitable outcomes (Maternal and child H indicators)

It is noted that the infant mortality rate, at less than 10 per thousand live births, and the maternal
mortality ratio, at less than 15 per 100,000 live births, of the high-income quintiles are comparable to
those of industrialized countries of the world. On the other hand, the same indicators (IMR greater
than 90 and MMR around 200) for the poorest quintile are equivalent to those prevalent in some of the
least developed countries of Africa and Asia.
Even more noteworthy is the comparison of fertility rates between the two groups. The wealthiest
women have a desired fertility of two and report an average total fertility rate of two children per
woman of childbearing age indicating that this group of women achieves their reproductive goals for
childbearing. The poorest women however desire to have only three children during their reproductive
lifetime but actually bear an average of 5 to 6 children each being unable to achieve their
reproductive goals.
Looking at simple measures of access to health service delivery reveals that these differences are
linked to similar disparities. Such measures can be used to gauge access to primary, secondary, and
tertiary care interventions.
For example, as an indicator of access to primary care, immunization rates in richer provinces of the
country are 30% to 50% higher than those in poorer provinces. Less than half of children from poor
families get one vaccination during childhood while over 80% of those from rich families are fully
immunized with the seven antigens of the governments expanded program on immunization.
Caesarian section rates are sometimes used as a gauge of quality of secondary care. The
internationally accepted gold standard for this measure is 15% of all deliveries in a given population.
However, among poor Filipino women, this rate is estimated at 2% - implying that even if they needed
it, these group of pregnant women would not be operated on. On the other hand, over 30% of wealthy
Filipino women end their pregnancies with a Caesarian section meaning that, in this population,
some women are exposed to the risks of a surgical procedure unnecessarily.
Renal transplantation, a technology intensive intervention, may be used as an indicator of access to
tertiary care. In the Philippines, it is estimated that each year approximately 8000 Filipinos develop
end-stage renal disease requiring hemodialysis and kidney transplantation. Because of the huge costs
involved, almost all of the 500 or so transplants done in the country each year are from high income
groups or foreigners.

In 2010, The Lancet Commission asserted that the goal of global health systems is to assure
universal coverage of high-quality comprehensive services that are essential to advancing
opportunities for health equity within and between countries.4
For the Philippines, advocates have adopted the following definition of universal health care: the
provision to every Filipino of the highest quality of health care that is accessible, efficient, equitably
distributed, adequately funded, fairly financed, and appropriately used by an informed and empowered
public.2
Launched in 2010, Kalusugan Pangkalahan or the universal health care program of the present
government is an ambitious effort to achieve this by instituting reforms in the six basic building
blocks of the Philippine health system. Three major strategic thrusts are likewise enunciated: (1)
Health facilities enhancement; (2) Financial risk protection; and (3) Attainment of the health-related
Millennium Development Goals
What follows is a brief overview of major defects in each of six building blocks and possible
interventions to remedy these in the next few years.
1. Health information system
The first among these is the health information system, which despite attempts at modernization
dating back to the last 30 years, continues to depend on antiquated paper and pencil data collection at
the periphery. The data, highly susceptible to human error and manipulation, feeds into a system
characterized by the uncoordinated and non-standardized use of modern information and
communication technology.
Recognizing the importance of an efficient and accurate information system, the current universal
health care program includes the introduction of modern data collection and the adoption of common
technology standards to improve coordination among the various parts of the health system. This
includes the adoption of tele-medicine, which is already being piloted in some areas.
2. Health Regulation
The next building block consists of the systems for the regulation of quality and availability of health
goods and services including pharmaceuticals. The regulatory infrastructure for health in the country is
seen as supply-side dominated with conditions mainly dictated by the regulated groups
(pharmaceutical companies, doctors and other professionals, and other suppliers of goods and
services). This has resulted in an imbalance of market forces that jeopardizes the health of the poor
and the weak.
New laws are now in place designed to improve the technical competence of regulatory agencies. The
implementation of these laws requires political will to defend these technical units against the strong
lobby groups that benefit from a weak regulatory environment in health.
3. Health services delivery
Health services are severely hampered by a fragmented delivery system consisting of an underresourced public component serving the poor majority and an over-resourced private component for
the rich minority. A Local Government Code that divides responsibilities between the national,
provincial, and municipal government units further fragments government service delivery. Most
importantly, a formal referral system to move clients between each of the different levels of service is
practically non-existent.
The universal health care program of the government includes provisions to encourage referral
mechanisms, and strengthens delivery mechanisms that are seen to facilitate the achievement of the
Millennium Development Goals.
Moreover, other programs such as the conditional cash transfer (CCT) of the government, aimed at
improving the lives of the poorest of the poor, also have a health component; and essential services

such as immunizations for children and regular checkups for pregnant women are included among the
conditions for the covered families to receive cash subsidies. These features of the CCT are
complemented by the provision of innovative service delivery systems, such as the 'community health
teams' (CHTs) that focus on preventive and promotive care.
4. Health Financing
A major feature of the countrys mode of health care financing is its reliance on out of pocket
payments estimated in 2007 to have reached 57% of total health expenditures. This situation is
totally inappropriate for a country where the majority of the population is too poor to afford to pay
even partially for the costs of effective care. It is unfair as economic barriers are the major
determinants of access to life-saving interventions.
A newly invigorated National Health Insurance Program is rapidly expanding coverage among the
countrys poorest groups. The benefits packages of the program are also being broadened to include
preventive outpatient procedures. There are plans to urgently address the pressing issues of poor
utilization of benefits and public facilities by poor income groups.
5. Health Human Resources
Probably the single most important building block of a health system is its health workforce. High
income expectations and inadequate values formation has resulted in a poorly motivated workforce.
Rational deployment is prevented by the fact that health workers skills sets do not match the needs of
the communities needing service. Perhaps 'irrational deployment' is best demonstrated by the
oversupply of nurses in the country following the increased demand in the United States and other
countries. With thousands of nurses unemployed, many hospitals have resorted to accepting them as
'volunteers'; and in other cases, they are made to undergo 'on-the-job trainings' that they themselves
had to pay. To ameliorate the situation, the government in 2011 launched 'RN Heals,' a program that
deploys nurses to underserved communities as part of community health teams.
The Health Human Resource Master Plan needs to be updated to fill the needs of a future universal
health care system. Moreover, health professionals need to be compensated well if the country is to
prevent its experienced and skilled people from being 'pirated' by other countries. Finally, all policies
related to health workforce production, deployment and management must be reviewed and existing
legislation revised where needed.
6. Health Governance
Finally, in the area of health governance, there still remains a lack of consensus among stakeholders
about a common definition of equity in health and the parameters that will determine whether
universal health care is achieved. In addition, processes for policy and decision-making are still mainly
top down. This kind of policy architecture makes health governance dependent on the political
landscape, and the six-year cycle of each presidency.
There is a need to develop new mechanisms of stakeholder consultations at different levels. Such
mechanisms may be evolved from market-research techniques that are employed by private
enterprise to promote their products. Some health agencies, such as PhilHealth and the Department of
Health, are beginning to develop these capabilities.
SUMMARY AND CONCLUSION
The Philippines is committed to achieving universal health care for its people in the shortest possible
time. To this end, the current government has announced an ambitious program comprising three
major thrusts of financial risk protection for the sick, upgrading and improvement of government
facilities, and enabling communities to achieve the health targets of the Millennium Development Goal
while addressing the emerging threat of non-communicable diseases.

In order to achieve the equity goals of universal health care, the three thrusts of the government
program must be aimed at providing remedies for major defects in six building blocks of the health
system. True universal health care providing equal access to services for all Filipinos may be achieved
if the following conditions are met:
1. The existence of a modern information system optimally;
2. Strengthened mechanisms to regulate quality and availability of health goods and services;
3. Integrated delivery of promotive, preventive, curative, and rehabilitative health services at all
levels;
4. A restructured health financing system that emphasizes government and shared risk sourcing of
funds and minimizes reliance on out of pocket payments at the point of service;
5. Improving stakeholder inputs in the system for health governance;
6. A well motivated, appropriately trained health workforce deployed to areas of need.
References
1. Acta Medica Philippina Special Issue on Universal Health Care for Filipinos: A Proposal, Vol. 44 No.
4, October-December 2010.
2. Acuin Cecilia S., Lim, Bryan Albert., Lasco, Paul Gideon. Universal Health Care in the Philippines:
An Introduction. In Acta Medica Philippina Special Issue on Universal Health Care for Filipinos: A
Proposal, Vol. 44 No. 4, October-December 2010.
3. The Philippines Health System Review. Health Systems in Transition, Vol. 1 No. 2, Asia Pacific Health
Observatory, WHO Western Pacific Regional Office, 2011.
4. The Lancet Report, Education of Health Professionals for the 21st Century, A Global Independent
Commission. Health Professions for a New Century: Transforming Health Systems in an
Interdependent World. 2012 The Lancet, Dec 4, 2010, (vol 376; pp 192358) was published initially
in The Lancet in November, 2010. It is being reproduced in expanded book form by the Commission in
full recognition of the copyright of The Lancet. Distributed by Harvard University Press, Cambridge MA
ISBN 978-0-674-06148-4
5. World Health Organization, Health systems topics, www.who.int/topics/en
6. National Statistics Office, Philippine National Demographic and Health Survey, 2008
7. National Statistics Office, Philippine Family Health Survey, 2011
8. National Census and Statistics Board, Philippines, National Health Accounts, 2008.

The status of women in the

Philippines: a 50-year
retrospective
October 3, 2012 4:03pm

Tags: lilaramosshahani, women

By LILA RAMOS SHAHANI

Looking back at the past 50 years, how do we assess the status of women in
this country, particularly in light of recent debates on the reproductive health
(RH) bill? While women make up over half of the population and their
contribution to society has clearly been incalculable, a disparity remains
between the fulfillment of their needs, on the one hand, and the services and
protections afforded to them by the state, on the other.
Without a doubt, the institutional empowerment of women can be traced as far
back as the Marcos era, with the establishment of the National Commission
on the Role of Filipino Women (now the Philippine Commission on Women) in
1975, which served -- and continues to serve -- as the national machinery for
integrating women into the economic and socio-cultural fabric of the country.
Later administrations followed suit in acknowledging women as a priority,
with President Corazon Aquinos (Cory) Philippine Development Plan for
Women; President Fidel V. Ramos (FVR) Gender and Development Budget
and his administrations grant of full representation of women in the Social
Service Commission; President Estradas (Erap) Philippine Agenda for
Women Empowerment; and President Gloria MacapagalArroyos (GMA) Framework Plan for Women and Magna Carta for Women.
A fresh analysis: education, employment, violence against women and
health
At the outset, it bears mentioning that a significant problem in this country has
often been not only the paucity of data but comparing data across time. In this
case, each administration has tended to emphasize different indicators over
others, and part of the challenge in assessing the changing status of women
has been to find a common set of measurable indicators that remain
meaningful in a comparative sense.
Despite these limitations, what follows here is a brief examination of each
presidential administrations attempts to improve the welfare of women with

respect to specific indicators of critical importance: education, employment,

violence against women, and health all of which demonstrate, in deeply
fundamental ways, the integral part that gender has played in the
developmental strategies crafted by each administration.
Education

Following the definitions set by the National Statistical Coordination Board,

Simple Literacy Rate (SLR) indicates a persons ability to read and write while
understanding a simple message in any language or dialect, while Functional
Literacy Rate (FLR) assumes a higher level of literacy, including a grasp of
numeracy, encompassing the overall ability of a person to use written
communication in carrying out important activities in his/her life.

In the charts above, a striking pattern emerges, that of women's ability to

outperform men in the acquisition of both simple and functional literacy. This
has often been attributed to women's greater diligence in the primary and
secondary years, and the tendency of boys to be involved in games, truancy,
gangs, and other forms of social violence. However, additional data
demonstrates that, in tertiary education, the gender disparity narrows because
these also happen to be child-bearing years for many young women.
Employment

In the chart above, we observe a startling reversal. Women's consistent edge

in literacy over men is subverted in the area of employment. Over time,
women tend to lag behind men in the work force. How do we explain this
persistent gap between the genders in employment rates through
each administration? In addition to gender discrimination in many institutions,
particularly in higher paying jobs, there are often inadequate facilities that
would enable women to combine work and family responsibilities. Mismatches
between education and the job market; forms of work-place inequities that
keep women in and from certain kinds of jobs; high maternal and neonatal
mortality rates; and cultural and economic pressures that compel educated
women to stay at home and care for the family are among some of the oftcited reasons.
Under the Cory administration, a significant piece of legislation to address this
gender imbalance came from former Senator Leticia Ramos Shahanis
amendments to the labor code. These were intended to strengthen the
prohibition on discrimination against women with respect to terms and
conditions of employment, which meant that a woman should not be
discriminated against in terms of pay, training opportunities, and
promotion. Under FVR, the Technical Education and Skills Development
Authority (TESDA)s Womens Center was established to train and strengthen
women's proficiency in fields usually dominated by men. TESDA also sought
to expand opportunities for community-based employment for girls who had
only completed primary and secondary education. During the Estrada
administration, the Philippine Agenda for Women Empowerment was
inaugurated with a grant of PHP 3 billion to encourage women entrepreneurs.
In line with this, President Arroyo duly highlighted the need to fight sexual
discrimination in the workplace with the Magna Carta for Women, in addition
to establishing a partnership with the Departments of Labor and Employment
and Social Welfare and Development to deliver necessary services for female
migrant workers. Still, despite all these measures, the gender gap in
employment rates unfortunately persists as of this writing, presenting a
continuing challenge to current and future administrations.

Violence against women

Without doubt, the most vexing area of study has to do with actual violence,
which women have to contend with on a daily basis. The Martial Law era was
particularly notorious for many unrecorded cases of political imprisonment,
torture, rape and killings that included countless women that remained
nameless and faceless to this day. Violence against women included arrest
without warrant, confinement, deprivation of basic needs, sexual harassment
and abuse.
In the wake of Marcos years, the Cory administration released political
detainees, restored the writ of habeas corpus and created the Commission on
Human Rights. During the Ramos administration, the groundbreaking AntiRape Law (R.A. 8353) was finally passed (after eleven long years), with
former Senator Leticia Ramos Shahani as its principal author. Prior to this law,
rape had been defined as a crime against chastity, presenting daunting
obstacles for women who hoped to press charges against their attackers. The
new Anti-Rape Law reclassified rape as a crime of violence against persons,
making it possible for anyone male or female, gay or straight, virgin or not -to lodge criminal complaints against their attackers. Under Arroyo, a new law
(R.A .9262) further strengthened the law by adding children to the list of
victims, and increasing the penalties for rape.

More recently, the passage of the Anti-Trafficking in Persons Act in 2003 has
had a significant effect in curbing illegal recruitment schemes. Seeking to halt
the abuse and sexual exploitation of women, children and even men, this law
has sought to abolish trafficking and sexual slavery. The graph above
demonstrates the Department of Justices growing efforts to apprehend and
convict persons guilty of trafficking offenses since 2004.
Health

The focus on women's reproductive health has varied from one administration
to another, particularly with respect to the issue of fertility reduction. Under
Marcos, Presidential Decree 79 established the National Family Planning
Program that sought to respect the religious beliefs of individuals. However,
the Cory administration was heavily influenced by the doctrines of the Catholic
Church, which opposed artificial birth control. Cory thus tended to focus
primarily on maternal and child health issues at the expense of fertility
reduction.

During Ramos tenure, the Medium-Term Philippine Development Plan was

launched, directly addressing the issue of population growth, as well as the
improvement of maternal and child health. In addition, the Department of
Health released Administrative Order No. 1-A, detailing a comprehensive 10element Reproductive Health Program.
Under Estrada, family planning had originally taken a back seat. Erap was
quoted in the newspapers as having said that he was against family
planning, extolling the advantages of having a large family. Certainly, the
Medium-Term Development Plan of 1999-2004 did not include strong policies
to moderate population growth, nor did the implementation of a family
planning program address fertility reduction. To address this, National
Economic Development Authority Director-General and Commission on
Population (PopCom) Chair Dr. Felipe Medalla and Department of Health
Secretary Alberto G. Romualdez, Jr. took the initiative to reshape the
Philippine Population Management Program for 2001-2004 to include a more
robust family planning policy. But Estradas term was short-lived, as were,
regrettably, the terms of the PopCom board members.
More ambiguous were President Arroyos policies on family planning as a
means to curb population growth. Although she acknowledged the problems
of uncontrolled population growth, her administrations family planning
program focused less on fertility reduction and more on neo-natal and
children's health care, as well as natural family planning methods.
What remains to be done?
Clearly, although significant progress has been made in the status and welfare
of women over the last fifty years, many challenges remain.
Gender equity in education continues to improve, with records from the
Commission on Higher Education noting a comparison of 57.44% female
graduates (269,748) versus 42.56% male graduates (199,906) in the

Academic Year 2009-2010. However, women still lag behind men in

employment despite a rise in the percentage of professionally licensed
women in 2010 at 63.7% over mens 36.3%, mens employment in 2012 is still
significantly higher at 78.4% over womens 50.4%. The socio-cultural
explanations for this astonishing reversal have already been discussed above.
But what this trend clearly underscores is the fact that our educated women
remain seriously under-tapped in this growing economy.
An even more pressing concern is the continued violence against women
throughout the country. A laudable achievement, however, is that the
Philippines is now at Tier 2 Status in the Global Trafficking in Persons Report,
no longer in the notorious Tier 2 Watch List Status, which means our
international partners now recognize the vigorous efforts both government and
civil society have made to combat human trafficking at home and abroad.
Another positive development has been the passing of the Kasambahay Bill
(H.B. 6144) in the House, which protects the rights of the 1.9 million domestic
workers in this country.
But a recent law decriminalizing vagrancy (R.A. 10158, or the revision of
Article 202 of the Revised Penal Code), sponsored by Senator Chiz
Escudero and Representative Victorino Socrates has had unintended
consequences on women. Regrettably, female prostitutes (unlike male
prostitutes and vagrants) continue to be criminalized, while men who
participate in their exploitation are not held liable for prosecution. This lack of
protection afforded to female prostitutes is in conflict with the Magna Carta for
Women and the Anti-Trafficking in Persons Act, which mandates the protection
of women from abuse and violence. A more nuanced Anti-Prostitution Bill
that targets the demand side by criminalizing those who exploit and engage in
prostitution and human trafficking would have a far-reaching impact in the
protection of women from violence. As of this time, there are pending versions
of this bill in the House and Senate, which greatly needs public support.
In terms of health, our maternal mortality ratio remains high at an alarming
221 per 100,000 live births, while HIV rates have been increasing with a 37%

rise of documented cases in the past two years.

And, last but not least, the Reproductive Health (RH) bill has become
absolutely critical for this nation. Passing the RH bill would empower women,
especially those in the poorest sectors with the highest fertility rates, allowing
them to make all-important choices for themselves and for their families.
Indeed, the Aquino administration has been unwavering in its support of
reproductive health and responsible parenthood, regarding these as crucial
elements in the pursuit of national development.
In the final analysis, reproductive health empowers a woman
in deeply significant ways since the proper interventions could
determine whether she will finish tertiary education or not, can get better jobs
in the job market, can combine home and work, will ever break the glass
ceiling if she is genuinely gifted, will survive childbirth, and can live a life free
from violence. Which means that reproductive health is not only a health
measure, in the end, but an anti-poverty strategy that ultimately hopes
to empower women and set them free.

Assistant Secretary Lila Ramos Shahani is Head of Communications of the

Human Development and Poverty Reduction Cabinet Cluster, which covers
26 government agencies dealing with poverty and development.
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