The Ailing Public Health

Cover Story - The Ailing Public Health

By Bob Acebedo

In one precisely stunning instant, the maverick Ligaya Acosta, former top- ranking official of the Department of Health’s Eastern Visayas Regional Office, can never be more unregretful when she bolted and made a 360-degree turn from her 28-year career with the government’s principal health agency early last year. After reportedly claiming to have stumbled on a “Pandora’s box” or hidden agenda about the government’s family planning program erstwhile as DOH’s Program manager for Natural Family Planning, Acosta huddled to expose what she claimed as a “deadly deception” about the DOH’s “Ligtas Buntis” Program, purportedly the government’s maternal and child health care campaign which was launched sometime in January of last year. “I was very sad. We are supposed to be a Department of Health, we should be more concerned of the health and welfare of our people…but they were only concerned of the targets. In fact, as an incentive to ensure that targets were met, health workers were to be paid an honorarium of P200.00 per day from the one hundred million peso budget of the program, which I learned later, was increased to two hundred million. Indeed everything about the program is plain deception—the worst corruption ever, as it is not only corrupting money, but also corrupting human lives,” Acosta told Impact.

“When the very deplorable ‘Ligtas Buntis’ was launched in 2005, I decided I could no longer keep quiet. Thus, on February 14, 2005, I decided to give up my job and risk my life and my family to expose the deadly deception,” Acosta added.

Ostensibly, as the government’s principal health agency, the Department of Health flaunts, in broad terms, its touted mission of “providing equitable, sustainable and quality (underscoring mine) health for all Filipinos, especially the poor.”

But Acosta can only be more skeptical if indeed the DOH has lived up to deliver its flaunted mission. “How can we ever say ‘quality, equitable, and sustainable health’ when, for example, we massively promote contraceptives and sterilization services, because voluminous documents prove that it ‘kills’ and cause a lot of horrible side effects.”

State of Public Ill-health

 

DOH

No. Not only contraceptives and population control program have rendered skew and inutile the government’s delivery of supposedly “equitable, sustainable, and quality” health services, particularly for the impoverished—but, as health experts and informed observers contend, the glaring indicators of the current ailing state of the country’s health situation have become even more appalling as before. More so, with the pervading issues of geographical inequity (where people who live in rural and isolated communities receive less and lower, if substandard, quality health services) and socio-economic inequity (where the poor do not receive health services due to inaccessibility and unaffordability) prevailing throughout the country, observers believe that the touted mission of delivering “equitable, sustainable, and quality” frontline health services to Filipinos is conspicuously yet far from real.

Already, the perennially wrenching economic slump has, according to the 2003 National Demographic Survey, pushed more Filipino households to opt or visit public health facilities than private hospitals and clinics. Barangay health stations, which are supervised by the Rural Health Units (RHUs) and urban health centers, have registered the most clients, followed by the RHUs and urban health centers themselves. Similarly, a survey done by the social Weather Stations for the World Bank in 2001 also shows the country’s poorest 30 percent, or one-third of the national population, seeking help mostly from the local health units for their aches and pains.

This national state of ill-health is worsened even more by the equally disturbing trend of mass migration of doctors and nurses from both the public and private health sectors to inarguably hefty-paying jobs abroad, thus making rural areas—which comprise 60% of the population—even more vulnerable to human resources deficiencies. The U.P.-Philippine General Hospital alone, the World Health Organization-Regional Office for the Western Pacific reports, loses 300 to 500 of their nurse workforce every year. Midwives who are in the front-line in providing health services, the same report revealed, are seeking jobs as caregivers in other countries. It is important to note that, according to the Department of Health’s 2002 Demographic Report, midwives registered the highest attendance in infant deliveries in the country with 39.3%, surpassing other health workers—doctors, 26.9%; trained “hilot,” 26.0%; untrained “hilot,” 3.4%; and nurses, 1.2%.

Sadly enough, then, it is not far-fetched to infer that the ever growing number of impoverished Filipinos who are helplessly impelled to seek help from local government-funded health care centers are yet likely to find nothing more—neither the doctor nor the medicine or cure—as even local health centers, long devolved since 1993 to the local government units (LGUs), are equally infested with the ailing problems of corruption and local politics, let alone the minuscule budget allotted to health, resulting to a teeming host of profligate practices as, among others, bribery or kickbacks and overpricing in the purchase of medicines, short and ghost deliveries (of medicines) or purchase of substandard drugs, rigged biddings, absence of procedural procurement plan, and what-not.

Then and even worse as now, the national state of ill-health, particularly in the public health arena, has even more accommodated dismal consequences—prevalence of supposedly preventable diseases as main causes of morbidity or mortality, high occurrence of locally endemic diseases, high infant mortality rate as compared with those of neighboring countries, nutritional problems and parasitism being common among children, and others more.

The Manila-based Regional Office for the Western Pacific of the World Health Organization reports some facts about the current health situation in the country: “In rural areas, people’s health is affected by difficult access to health services and by the presence of locally endemic diseases like malaria, filariasis and schistosomiasis. The four leading causes of morbidity are communicable diseases, the fifth being hypertension. The prevalence of communicable diseases is still very high, while that of noncommunicable diseases is increasing and will continue to do so…Nutritional problems and parasitism are common among children…From 2000 to 2004, outbreaks of malaria, dengue, measles, cholera, typhoid, hepatitis A and diarrhea were investigated.”

The Department of Health’s 2002 Demographic Report revealed the top ten causes of morbidity in the country, namely: (1) Pneumonia, (2) Diarrhea, (3) Bronchitis, (4) Influenza, (5) Hypertension, (6) Tuberculosis/Respiratory, (7) Diseases of the Heart, (8) Malaria, (9) Chicken Pox, and (10) Measles.

Perceptibly, it may be gleaned that most of the ten causes of morbidity are supposedly ‘preventable’ as deigned according to the capability and sophistication of modern medical science. But apparently, with the same diseases yet plaguing high in the country, the Philippines likely fails so to possess neither the capability nor the sophistication to prevent these diseases.

 

PGH

Inadequate health care financing is one perennial concern. Health experts and informed observers are quick to blame the meager budget allocated to the health sector as the primary reason for the country’s inability to combat the supposedly preventable top-killer diseases. The World Health Organization (WHO) cites “poor health care financing” as the number one (1) factor contributing to the Philippines’ limited or inadequate health care system. Other factors cited by WHO include: (2) inappropriate health service delivery system; (3) brain drain of health professionals; (4) excessively high price of medicines; (5) inadequate enforcement of regulatory mechanisms; and (6) insufficient effort expended on prevention and control of new diseases.

Statistics from the WHO’s Health Databank show that the country’s per capita health expenditure decreased from Php 1,484 (US$ 26.69) in 2001 to Php 1,435 (US$ 25.80) in 2002. As of 2001, the government’s allocation for health only contributed a minuscule 0.41% of the total government expenditure. This is undeniable far below than Thailand (11.6 percent), Malaysia (6.5 percent), Vietnam (6.1 percent), Indonesia (3.0 percent), Cambodia (16 percent), and even Bangladesh (8.7 percent), which is believed to be Asia’s most economically distressed.

Moreover, WHO statistics revealed, while 77% of health expenditure was used on personal health care in 2002, only a meager 11% was used for public health; and in 2002, only 33% of the Department of Health’s budget was allocated to public health, while 57% went to hospital services.

Currently, the Philippine Congress has earmarked P10.6 billion for the Department of Health for year 2006. This is much lower than those of other government agencies or departments like—the Department of Education (P119.1 B), Department of Public Works and Highways (P62.3 B), Department of National Defense (P46.6 B), Department of Interior and Local Government (P45.6 B), Department of Agriculture (P15.7 B), and the Department of Transportation and Communication (P14.3 B). Clearly, also, the 2006 P10.6 billion budget, even lower from 2002 (P 11.4 billion), of the health department constitutes barely 1 percent of the P1.053 trillion 2006 total national budget and certainly not enough to cover the health needs of more than 80 million Filipinos, let alone the salaries and benefits of more than 200,000 public health workers assigned to the more than 2,000 rural health units (RHUs) and urban health centers.

Amid the debilitating problems and challenges that have wracked the health sector no end, not even the implementation of DOH’s Health Sector Reform Agenda (HSRA) of 1999, which sought to improve the financing and delivery of health services, as well as the passage of the 1992 Republic Act 7305, dubbed as the Magna Carta for Public Health Workers, have provided relief to the ailing plight of public health in the country.

The implementation of both the Magna Carta for Public Health Workers (R.A. 7305) and the Health Sector Reform Agenda (HSRA), Ligaya Acosta says, has equally been found wanting and, worse, has even contrived some unseemly consequences. “The implementation of the Magna Carta for Public Health Workers has been found wanting. Since there were no additional funds that went with it, not all provisions could be implemented, or it is not the same in all sectors, thus causing demoralization. Some LGUs implemented the financial provisions, while others did not, reportedly because of lack of funds. Even the Department of Health has not been able to implement the Magna Carta for the same reason. And, although it is specifically provided in the Magna Carta that health workers cannot be transferred without their consent, this was not followed when DOH had a reorganization, and many health workers were displaced.”

Acosta further explained, “The Health Sector Reform Agenda has both its advantages and disadvantages. While the concept maybe laudable as it is meant to ultimately make the health facilities self-reliant by having it run like a private corporation, it still has much to be desired. Worse, the public health insurance (PhilHealth) which was supposed to go with it has been politicized, and prominently figured in a scandal in the last (2004) presidential elections.”

Wrong Priorities and Donor-driven

 

Emergency

On cursory blush, however, the pervading problem plaguing public health in the Philippines is not only scarce resources or inadequate health care financing as misprioritizing health programs and activities. Health experts and critics decry that current priorities are skewed to focus more on health programs, like population control, that are largely or completely donor-driven or funded by powerful transnational agencies, and thus leaving very little resources for strengthening other essential health activities and programs—including, among others, health regulation and standards setting, health information gathering and surveillance, preventive health care services, such as immunization. “While the DOH or the government as a whole is admittedly trying to do its best to achieve its objectives, it is focusing on the wrong priorities, which is dictated by international funding agencies, which we now know for certain have their own ‘hidden’ agenda,” Acosta told Impact.

That the government’s health agenda is influenced, if beholden, to transnational funding agencies—like the USAID, UNFPA, WHO, UNICEF—is a known fact, according to informed sources and critics. In the case of population control, for instance, Acosta revealed how these foreign agencies’ fund flow into some government agencies, and even NGOs or other local groups. “These international agencies not only fund the Department of Health but other government and non-government organizations as well—the Department of Education, among them. Thus, they also could influence the contents of the textbooks being used in schools. They also fund the Philippine Legislators Committee on Population and Development (PLCPD), an NGO based in Congress. These agencies give huge funds for training programs and services which are tailored according to their objectives. They also fund numerous Information-Education and Communication (IEC) materials to brainwash everyone to believe what they are preaching. These funds are either directly offered, or the agencies like the DOH make project proposals and submit them to the funding agencies.”

Acosta further argues that while the top ten leading causes of illnesses and death in the country are deigned preventable if given the funding priority they deserve, the bulk of funds is placed on population control. “The program, like population control, which has the most funds get the most aggressive promotion and services, and while the others are relegated to the background. We have, for example, flooded for almost 40 years our rural health units with pills, condoms, and depo-provera, but we lack medicines for Pneumonia, Diarrhea, Bronchitis, Influenza, and Hypertension which represent the top five leading causes of death in the country. As health programs and services should be based on a thorough analysis of actual health problems and conditions, so also that public health should focus on the preventive aspect, especially on the top ten leading causes of illnesses and death in the country, which is not being given the funding priority it deserves.”

Devolution Woes

 

Patients waiting.

Since its implementation in 1993, the country’s health department is still reeling from the effects of devolution. The Local Government Code split the health department into three. Big hospitals remained under the control of the health secretary. Regional hospitals as provincial health workers went to the provincial governments while district hospitals and municipal health workers are controlled by mayors.

But while the devolution of public health facilities and services would have been expected to enhance or strengthen the capabilities of local governments to formulate and implement their own health programs, it has more likely aggravated the already ailing condition of public health in the country as to even more pave for new forms of corruption, health politics, and health workers’ demoralization in the local government fronts.

According to Avigail Olarte and Yvonne Chua of the Philippine Center for Investigative Journalism, in their investigative report “Up to 70% of Local Health Funds Lost to Corruption” dated May 2-4, 2005, kickbacks from the purchase of drugs—also known as standard operating procedures (SOPs), rebates, internal arrangements and ‘love gifts’—given to mayors, governors and other local officials range from 10 to 70 percent of the contract price.

“Decentralization was expected to reduce corruption, especially in drug procurement. Yet for the most part, such practices as overpricing, rigged biddings, short and ghost deliveries, and the purchase of substandard drugs remain pervasive,” Olarte and Chua reported.

Devolution, says Juan A. Perez III, a former DOH official, seems to have resulted only in “democratizing corruption.”

Similarly, Ligaya Acosta shares the same view. “The devolution of public health services has generally worsened the health condition in the country. While it could have been an excellent opportunity for the local government executives to improve health, as they see the actual conditions in their locality, this has been found wanting due to different priorities by LGUs, local officials and politicians who are rather bent on using local funds to construct roads, waiting sheds and basketball courts than on health, and also due to the entry of politics into the picture.”

Acosta even ventures to recount an instance where medicines are purchased not as needed by the local health unit but according to the amount of “SOP” or kickback given by the supplier. “I am not saying all local government units are corrupt, but there are those who purchase medicines not according to the needs of the locality based on data, but based on how much ‘SOP’ is given by the drug company. Thus, a lot of drugs just expire because they are not really the ones needed by patients. I recall one instance when the Municipal Health Officer of one locality came to us at the Regional Health Office for help, because she was being forced to sign documents for the purchase of drugs, which she knew deep in her heart were not needed in her locality.”

Symptoms of Social, Moral Ills

 

DOH

Inarguably hence, on the whole, the current national state of ill-health lamentably unveil or bemoan more problems, if “illnesses,” than one that continue to plague the plight of public health in the Philippines: inaccessibility and unaffordability of quality, equitable and sustainable health care services due to geographical and socio-economic inequities; burgeoning demand for public health services which have remained inadequate; brain drain of health professionals; unabated prevalence of the same top leading causes of morbidity which are otherwise deemed preventable; poor health care financing; inappropriate health care delivery system, where there is excessive reliance on use of high-end hospital services rather than primary care, including an ineffective mechanism for providing public health programs; excessively high price of medicines; inadequate enforcement of regulatory mechanisms; insufficient effort expended on prevention and control of new diseases; demoralization among public health workers; misplaced of wrong prioritizing of health programs and services that favor population control and other donor-driven programs than other essential health services; and the health department’s devolutions woes and ills as health politics, corruption skewed LGU’s priorities, short and ghost deliveries of medicines, rigged biddings, purchase of substandard drugs, kickbacks and overpricing of medicines, etc. etc.

As it were, this litany of public health’s debilitating ills and woes would have since long rendered the health sector, if not the entire country itself, seriously bed-ridden and easily slip down to a comatose state, if not outrightly pass out to its demise.

But, curiously so—and on the face of it—may it be reckoned that perhaps these crippling ills and problems hounding public health are, far from being endemic to the country’s health sector, veritable symptoms of bigger or greater social ills that abound in Philippine society?

Likely so, observers believe, as such indicators of an ailing public health condition cannot eschew its social underpinnings from the wider human society, both locally and internationally. For instance, the glaring disparity in terms of accessibility between public and private health systems, where a shrinking number of people can afford high-end personal health care services as compared to the burgeoning number of impoverished populace opting for public health care facilities and services, is clearly symptomatic of the bigger socio-economic inequities—due to, among others, social injustice—in a country already stuck in a wrenching economic muck. Or, the health department’s devolution woes of corruption and patronage politics that have inflicted health care in many local governments may just be indicative of a bigger culture of waste, corruption and patronage that immanently pervade both in low and high places of Philippine society. Or still, the battering incursion of transnational funding agencies dictating the country’s health programs and agenda is but cadged from transnational forces’ and nations’ profligate whims or greed for global hegemonic control or dominion.

In sum, wherefore, the many debilitating ills plaguing the public health system, reflecting as it were the greater societal ills, may just as well be symptomatic of the country’s ailing moral health. And, verily, that requires saying, over and over again.

Meanwhile, the maverick Ligaya Acosta proudly claims she has never even attempted any bit to rue about her leaving the Department of Health after 28 years. “I should have done it earlier and save more souls. I cry everyday of my life now, not because I worry of my family’s provisions, but in amazement of what the Lord has done and is doing in my life. When I gave up my job at DOH, I thought I would be missing my constant travels, but God gave me more by expanding my territory. My work now may not be as financially rewarding, but the joy and peace that I and my family feel can never be quantified. Besides, I now know my permanent address—HEAVEN, and thus I should concentrate my efforts towards reaching that final destination.”