Five Thoughts About the Philippine Health Care System
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Makati Medical Center (Source: Wikipedia)
• It is expensive to get sick in the Philippines and to be hospitalized; too expensive for many Filipinos of lower middle income and below.
• Doctors have their own specializations, and coordination among multiple doctors with one patient is often not seamless, even fragmented.
• Nurses and nursing assistants are underpaid.
• Nurses are well trained, but nursing assistants could receive better training.
• The pricing of medicines based on the hospital room used is wrong.
Confinement in hospital can add up in cost very quickly, especially if lab work, procedures, and operations are involved. It can put many Filipino families in a huge financial bind.
Membership in HMOs (Health Maintenance Organizations) is advised in order to help manage the extraordinary cost that goes with hospitalization, but this stops after 65 years of age, a time when seniors will need more health care, not less. PhilHealth is useful but limited. The senior discount was helpful in my case. Yet, after all the deductions, the out-of-pocket cost was still substantial. Personal debt, especially if done through informal sources, could carry high, if not exorbitant, rates of interest. Many hospitals offer a deferred payment plan, but this can affect a hospital’s cash flow position, which could have an impact on its medical service.
In the last year, two individuals from working class families known to me have seen family members pass away from disease that crept up on them (non-COVID-19), which had required hospital care but they had kept ignoring or postponing because of the cost, until it was too late. No health insurance, no savings in their cases, and despite help from friends, it was too late. This is a story oft-repeated among those with lesser means in life.
In my confinement for over a month with COVID-19 in 2021, a number of doctor-specialists were assigned to me upon my check-in in the emergency unit – a cardiologist, a pulmonologist, an infectious disease specialist, aside from my nephrologist, endocrinologist, and neurologist; the last three from my previous history of diabetes, renal failure, and a stroke. I got the sense that they were not coordinating on my treatment given the conflicting instructions given to nurses on medications and procedures. I found myself having to call doctors to clarify things.
Health care workers were on the front line during the COVID-19 pandemic (Photo by © ILO/Minette Rimando).
In a recent two-week confinement (non-COVID-19), the experience had thankfully improved for me. The seven doctors – four from my COVID-19 confinement previously – were speaking to each other and sharing updates. A lead doctor – in this case the infectious disease specialist – set up a Viber group so that the seven of them could share notes on a daily basis. This helped the nurses explain medications and procedures more clearly. The only issue was the process of getting clearance from each of them when it became clear that my blood infection had been arrested. Chasing all seven doctors to get their clearances for my discharge took numerous follow up calls by my wife (mostly) and myself until it was finally done. The longer wait, however, added an additional day in hospital, including a long wait for accounting to itemize the final bill. The additional waiting time comes with concomitant costs.
From my conversations with nurses and nursing assistants (caregivers), I found out that they are grossly underpaid. Nurses in the private hospital were paid a monthly salary of P22,000 ($1,170). They told me that nurses in government hospitals had a higher monthly salary of P36,000 ($1,907). When asked why they did not transfer, the answer was generally one of two: Government hospital working conditions were more difficult (more patients to look after per shift, little time to rest, poorer facilities), or the private hospital was JCI-accredited, and this meant that nurses there had a better chance of working abroad (US, Canada, UK, Australia) when applying for overseas placement. A number of nurses had worked previously in Saudi Arabia and had experienced better pay and working conditions but were now looking for an immigration opportunity for a more permanent move.
Nursing assistants (caregivers) in this private hospital were in an even more precarious position. Their monthly salary was P12,000 ($638) and they were on six-month contracts with no security of tenure.
In another private hospital, a dialysis nurse there who had a monthly salary of P14,000 ($742) said she chose to return after a two-year stint in Saudi Arabia to be with an eight-year-old daughter. She earns from a second job to help her husband and family.
I also observed a pattern that I hope is not the normal thinking. In my hospital stay, I met two nurses who had been community nurses but shifted to hospitals because of the better pay. Then, I met nurses in that private hospital looking to migrate in search of better opportunities.
This is an often-heard refrain: Nurses looking or actually migrating to greener pastures. In my dialysis center, four dialysis nurses have migrated to Canada, the US, and Germany in the last two years. These are highly trained medical professionals that we lose to other countries. And there are more are in the pipeline.
Nurses are well trained, but nursing assistants could receive better training. This is the difference between a four-year degree and a short certificate course. Caregivers take a short course TESDA training with certification but perhaps could benefit from more hands-on medical training.
Newly-graduated nurses taking their oath (Source: EPA-EFE/Straits Times)
The pricing of drugs based on the hospital room used is wrong. In my first hospital stay, all the medicines were given by the hospital. I was not allowed to use my available supply of maintenance medication including insulin. The price differential between the drugs I purchased myself versus the hospital-administered medication was higher by a factor of 2-4, adding significantly to my hospital bill.
A business school colleague now managing a hospital consulting group revealed that private hospitals follow differential pricing on services and supplies charged based on the room contracted. In the case of medicines retailed in publicly accessible drug stores, this pricing differential is akin to price-gouging.
What to Do?
A lot that needs to be done about our health care system. As a senior citizen, I increasingly have to use it more frequently, so I can see certain inefficiencies in the system that can lead to high health care and hospitalization costs.
The Universal Health Care Act (2019) was enacted “to realize universal coverage through a systematic approach and clear delineation of roles of key stakeholders towards better performance of key agencies and stakeholders in the health care system.
Alvln Manalansan wrote: “Like any other health care system, the vision of the UHC Act is remarkably outstanding; however, the main challenge is in its implementation. If the UHC Law is fully implemented, it will provide equitable access to quality and affordable health care services while protecting against financial risk for every Filipino. However, as frequently mentioned by the DOH, the law cannot be implemented instantly, but only progressively, mainly due to its high resource requirements at all levels.” (Alvin Manalansan, Non-Resident Fellow, Stratbase CADR Institute and Convenor, CitizenWatch Philippines, March 2021, “Urgency to transform fragmented health system.”)
What to do to bring more efficiency into the health care system?
We could start by appointing a secretary of health who is well-respected by the medical and health care establishments, with knowledge ranging from community health care to hospital care, from pre-natal and maternal health care to gerontology care for the elderly), and everything in between. The secretary need not be expert in all areas; he or she just needs to know the leading players in each field and can assemble a first-rate team to look after and manage the system’s different parts.
Business consultant Peter Wallace wrote: “In 2020, the country’s total health expenditure reached PhP1 trillion, 5.6 percent of GDP in that year. So, it should be the most important department in government, with the most competent, most highly experienced leader that can be found. From what we’ve heard, there are such leaders. The President only has to choose which one. Now.” (Peter Wallace, “Like it is”, PDI)
Let’s assemble the finest group of health economists, business managers, and public policy analysts to sit with the Department of Health’s leadership team and key medical practitioners to take apart the Universal Health Care Act to see how the entire system can be more integrated, more seamless, more efficient, and less costly to all Filipinos. Studying how certain countries have set up their national health programs (i.e. Canada, countries in Europe) would be instructive. Congress has created an Education Commission II to overhaul the basic education system to improve system performance; a similar Health Commission should be considered.
A consolidation of small private hospitals with larger hospital groups would bring needed investment into this sub-sector, help modernize it, and generate the economies of scale that could drive costs down.
Health insurance should be made available to all, with substantial benefits, and a variant for senior citizens should be designed and implemented, including home care for the elderly and even hospice care for those nearing death. Incentives and tax breaks should be available to private health insurers providing health insurance and HMO coverage to seniors above age 65.
Most important, investment by Government in community health and preventive medicine should be increased. As in many cases in other fields, investing in prevention minimizes future risk and is less costly than clinical care.
Lastly, let’s pay our nurses and non-doctor medical personnel better wages. We need to provide better economic benefits to encourage them to stay in the country.
Juan Miguel Luz was former Dean and Head of the School of Development Management at the Asian Institute of Management, and former Undersecretary, Department of Education.
