Inequities in Philippine’s healthcare system push patients into debt trap

When 17-year-old Cyrus Lescano was infected with Leptospirosis, a zoonotic disease endemic in the Philippines, his family was forced to travel to a Metro Manila hospital, as public hospitals in their province told them they could not handle the complications that arose from his disease.

Cyrus later on spent months at the hospital, leaving his family deep in debt.

The state health insurance, PhilHealth, covered only 2 per cent of the US$22,000 hospital bill, as that was the subsidy rate for his diagnosis.

His father, Claro Lescano, works as a house painter to pay off the loan. The land title for his sister-in-law’s home was used as collateral for the loan.

“I calculated my daily salary and the loan I need to pay the hospital bill,” said Lescano. “My salary for one week covers only one day of hospital room fees.”

Battling inequities in healthcare system
This is a common challenge faced by many Filipinos, as the Philippines continues to fight inequities in its healthcare system.

Medical bills in the country are impoverishing even for the working class.

Healthcare specialists said a lower-middle income country like the Philippines can only afford to cover healthcare expenses of the poorest of the poor.

“It cannot be equal for everybody in terms of financial return or assistance that you give to the patient,” explained former Philippine Health Secretary, Dr Enrique Ona.

PhilHealth’s coverage per patient is based on so-called case rates, with coverage varying per disease. In general, coverage is higher the more catastrophic a disease is.

Dr Michael Caampued, president of the Philippine Society of Public Health Physicians, said: “Let’s fund more primary care facilities because it’s cheaper. It provides more preventive and primary care interventions, and then everybody has a chance to be covered.”

As of 2022, only 21 per cent of Philippine provinces had adequate primary care facilities, according to the Department of Health (DOH).

The plan is to build 28 primary and urgent care multi-specialty centres, dubbed BUCAS, by 2028. They are designed for the 28 million poorest Filipinos.

The first such facility opened in early March this year.

Doctors told CNA that such facilities close the gap between village-based health centres and tertiary hospitals. They offer services not typically done in rural health sectors, such as minor surgeries for patients not needing hospital admission.

Health financing
However, these reforms require funding.

In the Philippines, public healthcare is financed through the DOH’s annual national allocation, a locality’s budget for health, other social welfare programmes, and a patient’s out of pocket spending.

Over half of hospitals in the Philippines are privately run.

Some government medical facilities are run by a locality, and others by the DOH. There are also others that are independent revenue-generating state hospitals.

Revenue from betting centres managed by a state-run firm, Philippine Charity Sweepstakes Office, are also used to help pay hospital bills of needy patients. Other forms of assistance are available through government agencies.

The process of securing funding, however, can be long and arduous, as in the case of Lescano, whose family had to line up at different offices for financial assistance.

Cyrus, was admitted at a private hospital. But some public hospitals already have so-called Malasakit Centres (Care Centres), where these different agencies extending social assistance are represented for ease in processing applications.

In 2012, the Philippine government imposed so-called sin taxes on products such as cigarettes and alcohol. The taxes help fund the health department and PhilHealth.

Advocates are hoping that electronic cigarettes or vapes can be included in the future.

PhilHealth, however, has drawn flak for delayed payments of its obligations to private hospitals.

Dr Ona, the former health secretary, said digitisation would be helpful to streamline the processing of the claims.

Dr Campued, the public health specialist, however, said electronic medical records are still not uniform across hospitals, making the processing more difficult.

As part of a pilot programme, PhilHealth is testing advance payments to healthcare providers for its coverage of out-patient services under its outpatient benefit package dubbed Konsulta.

Turning to supplements, instead of medicine
Amelita Depra, a mother of four, was diagnosed with goiter, an enlarged thyroid gland, two months ago.

Like many Filipinos, she could barely save up for the future, much less buy all of her prescribed medication.

Depra works at a salon in Metro Manila as a freelance manicurist, where she earns under US$4 dollars a day. She had hoped to work overseas as a domestic worker in the Middle East.

“I hope to work abroad as we are poor. I want my children to finish college,” she said. “Then this happened. I have high blood sugar. My agency says it can’t send me overseas to work.”

Unable to afford medications for her condition, she has turned to supplements that are cheaper but not prescribed by her doctor.

Many Filipino patients are foregoing life-saving cures as they cannot afford them. Instead, they are choosing non-medicinal food supplements that are unlikely to treat their medical conditions.

Essential medicines in the Philippines cost at least three times more than international prices, according to the DOH.

Supplements not registered with the local Food and Drug Administration are openly sold to Filipinos, and they are marketed as cures to various ailments.

According to the World Health Organization (WHO), substandard and falsified medical products may cause harm to patients and fail to treat diseases.

Advocates said the government should create a national pool of medicine through bulk procurements to lower costs, instead of having each locality and medical facility buying medicines separately at different volumes and various price points.

But the pharmaceutical sector in the Philippines argues that cheap does not always mean good, urging the government to evaluate previous medicine suppliers to state-run medical facilities.

Dr Diana Edralin, president of the Pharmaceutical and Healthcare Association of the Philippines, said the health and safety of the patients should be the main priority.

Meanwhile, some big pharmaceutical companies have started selling drugs at a lower cost in some countries to make access to medicine more equitable.

“We group our countries into different tiers, and these tiers are determined with regards to the economical dynamics of a country, so the GDP (gross domestic product), the healthcare infrastructure framework of a country, the out-of-pocket segment, as well as the policies enabling access to specific therapeutic areas,” said Ms Michelle Erwee, global head of access to medicines at pharmaceutical company Takeda.

“So pricing is determined by these economical factors and the dynamics of these countries.”

Prices for medicine in the Philippines affect both the rich and the poor.

About 75 per cent of out-of-pocket health spending for the poorest Filipinos, and 58 per cent for the richest, goes to medicine, said the WHO.

Observers said the country’s geography, with over 7,000 islands, also makes it tough to store and distribute medicine.

“I think a lot of issues in the Health Department stems from expired medicines because of logistics and management issues,” said former Philippine Secretary of Health Paulyn Ubial.

“We really have a huge problem if we buy a huge amount of drugs and then there’s just a blanket distribution.”

The government’s long-term plan is to promote local drug manufacturing by creating economic zones for pharmaceutical firms.

“We have to promote competition. There has to be many more brands, many more companies coming in,” said Philippine Assistant Secretary of Health Albert Domingo.

“So not only do we allow products from the outside but if we can actually manufacture those products locally, then why not?”

More healthcare workers leaving the country
Rene Capito, lead convener of the United Private Hospital Unions of the Philippines (UPHUP), said the government still owes its members an average of over US$2,400 each in allowances promised to them for service rendered during the Covid-19 pandemic.

The UPHUP is the country’s largest union of healthcare workers employed in private hospitals.

“I wanted to use the allowance to buy my wife’s medicine. She was diagnosed with chronic kidney disease last August,” said Capito, saying that there is little care for healthcare workers.

“She has been going for dialysis. As a husband and health worker, the allowance would greatly help (to pay) for her medicine.”

The DOH said the allocated budget for payment of these allowances is over 50 per cent short of what is needed to pay off all the filed claims. At least US$480 million more is needed to pay pending allowance claims.

Beyond delayed allowances, low salary and job insecurity are also driving many Filipino healthcare workers to look for jobs abroad.

More than 350,000 doctors, nurses, and midwives have left the country to work overseas between 1990 and 2017.

Health workers’ rights activist Robert Mendoza, who is the president of the Alliance of Health Workers, cited a host of factors that are driving low morale among healthcare workers, adding that the government “has no genuine care for health workers”.

“One, we’ve always called for a living wage. Health workers in the Philippines have the lowest pay in Southeast Asia,” he said.

“Second, the work is inhumane. The ideal one-is-to-12 nurse-to-patient ratio is not met.’”

Dr Caampued said healthcare workers deployed to rural areas and places with high crime rates face the risks linked to those communities.

These workers are also blamed by patients and their families for the inadequately-equipped health facilities, he added.

“They wouldn’t care if you’re the nicest doctor, if their life or their son’s life is on the line. They really will really demand something that might not be there, because that’s part of the grief they’re trying to find someone to blame.”

On Talim Island in Binangonan town, a two-hour boat ride from the mainland, for instance, there is only one two-bed capacity birthing facility for the 17 villages there. About 30,000 Binangonan residents live on the island in the middle of the Philippines’ largest lake.

“I saw that nurses were not willing to stay here,” said Talim Island nurse Rose Dela Cruz.

“As a village nurse, even if the work is 8am to 5pm, many patients still come to my home (to seek medical help). Work is 24/7.”

Despite the long and tough work conditions, she finds moments of joy whenever she is able to safely deliver a baby at the birthing facility.

“When you hear a baby cry after birth, it feels great. It’s not a material thing. It is a life you hold in your hand,” she said.

The local government is constructing an infirmary hospital to expand the services offered to patients for free. This includes plans for an emergency area and some laboratory services.

Healthcare workers on Talim Island also face dangers related to transport woes.

Last year, midwife Fe Marie Ocampo, who was deployed to the island, died as the boat she was on capsized.

The midwife, who was living in another town, was working towards securing her nursing licence. She had to stay at least three days a week on the island to avoid the long daily travel.

Her daughter, Garie Dizon, told CNA: “I am inspired by my mother. She helped a lot of people. She was a hero.

“I also want to be a nurse, and follow her dream and help many people. I will fulfil her dream.” CNA