Universal Health Care
Cecilia S. Acuin, M.D.
Julian M. Cañero, M.D.
Ernesto O. Domingo, M.D.
Kenneth Hartigan-Go, M.D.
Chrysanthus E. Herrera, M.D.
Paul Gideon D. Lasco, M.D.
Bryan Albert T. Lim, M.D.
Alvin B. Marcelo, M.D.
Junice D. Melgar, M.D.
Ramon P. Paterno, M.D., MPH
Alberto G. Romualdez, M.D.
Table of Contents
Acknowledgment ............................................................................................................. ii
Executive Summary ....................................................................................................... iii
Draft Executive Order ..................................................................................................... xi
Introduction ..................................................................................................................... 1
Governance .................................................................................................................. 19
Health Information Systems .......................................................................................... 27
Regulatory Reforms ...................................................................................................... 41
Organizing Health Services Towards Universal Health Care ......................................... 60
Reforms in Health Human Resources in the Context of Universal Health Care ............. 78
Health Financing ......................................................................................................... 123
The authors acknowledge the contributions made by Ms. Ana Go of the Asian Institute of
Management Dr. Stephen Zuellig Center for Asian Business Transformation.
This paper was supported by grants from the University of the Philippines System and
the National Academy of Science and Technology.
The 1987 Philippine Constitution affirms the right to health of ALL Filipinos and
directs the State to protect this right. Despite the efforts of both the government and
private sector to apply the advances of scientific medicine and modern public health
methods, health status indicators have been slow in improvement and have lagged
behind our ASEAN neighbors. Within the country, there are glaring disparities in health
status among regions and income groups. This disparity in health status results from the
inequities in society in general and, within the health system, from the inequity in access
to health services. This inequity in access results from a health system characterized by:
inappropriate governance within the health system, an antiquated and inadequate health
information system, ineffective regulation of health goods and services, fragmentation of
health service delivery, a dysfunctional health workforce, and unfair, unjust and
inadequate health care financing.
The Philippines must implement Universal Health Care to address the inequities
in the health system. Universal Health Care is defined as the provision to every Filipino
of the highest possible quality of health care that is accessible, efficient, equitably
distributed, adequately funded, fairly financed and appropriately used by an informed
and empowered public. Universal Health Care will ensure health as a right to ALL
Filipinos regardless of ability to pay.
To implement Universal Health Care, radical reforms are needed in the six
building blocks of the health system, namely: focused and directed governance based
on a policy of equity, a dynamic health information system useable for health policy
formulation, regulation of health care, integrated and rational health service delivery, an
adequate production of well motivated human health resources, and an adequate and
equitable health financing.
The Department of Health serves as the government’s overall policy formulation
and implementation agency in health. The DOH must assert its leading role within the
health sector and develop the cooperation of other sectors of society to implement
Universal Health Care.
The most glaring governance problem to achieve Universal Health Care is the
lack of an encompassing policy of health service provision that explicitly addresses the
issues of health inequity and its social implications. The firmly entrenched top-down
approach stifles attempts at introducing participatory processes in health decision-
making and policy formulation through the Primary Health Care Approach.
The DOH in consultation with the other sectors of society must articulate a clear
and explicit national policy of health service provision that directly addresses the issue of
inequity. An executive order addressed to all government agencies that defines health
equity as equal and just access to health care will provide the basis for the
implementation of Universal Health Care.
Participatory processes must be effectively implemented for decision-making and
policy formulation along the lines of the Primary Health Care approach. Existing
mechanisms must be strengthened and new ones installed for the effective and
meaningful participation of families, communities, professional groups and other relevant
groups in the management and operation of health programs, facilities and activities.
Health Information Systems
Information systems are crucial for decision-making and policy formulation.
However, the health information systems in the Philippines are rudimentary and
ministerial – the data are gathered and recorded as a matter of duty, and not for their
usefulness to the health care system.
Higher offices are deprived of timely information which could be crucial to
effective and dynamic national policies. The lack of effective leadership and direction for
the implementation of health information standards has caused stagnation in the
improvement of the data gathering system.
To address this burgeoning problem, the Department of Health must take the
lead in the creation of a framework of health information system, taking its cue from the
rapidly expanding field of e-Health. This is defined by the World Health Organization as
a cost-effective and secure use of information and communication technologies in
support of health and health attendance fields, including health care services, health
surveillance, health literature, health education, knowledge and research.
The Health Information System of the Philippines must reflect a multi-user and
multi-perspective design. It should be able to provide support for the decision-making
process by deconstructing what decisions need to be made, the knowledge that is
required to support these decisions, and the information and data components. Services
should be documented at the point of care – relevant patient information will eventually
form the building blocks of the national health information database.
Regulation of health stems from the government’s responsibility to ensure that
the people, especially the underprivileged, have adequate and equitable access to
health products, facilities and services. A regulatory system aims to provide a set of
methods to influence behavior of both providers, specially the private sector, and protect
the buyers from their own inability to judge quality. Regulation must improve access,
advance moral principles and counteract monopoly.
The Philippine health regulatory authority struggles with the problems of scarce
resources, inadequate staff and capability, inefficient use of available technology, and
lack of progressive technological development. Health policies and regulations are
inadequately enforced, because of the lack of manpower, technical capacity, funding,
organization, as well as the problem of legal constraints. As a result, health facilities are
not only substandard and dilapidated, but uncoordinated and fragmented, if not absent.
Initiatives must be taken to address these problems. An integrative framework for
the harmonization of the different regulations of the health care system is necessary.
Coordination and capacity-building must be at the forefront of these reforms. The various
stakeholders, such as the LGUs and the private sector, must also be directly involved as
well. Education and other participatory processes will be central in engaging the different
stakeholders of health.
Health services can be characterized by the dichotomy of public and private
hospitals and the fragmentation at the local level. The former traces its roots back to the
American colonial model, whereas the latter stems from the enactment of the Local
Government Code of 1991. Primary care is devolved to municipalities and barangays,
and there is a palpable absence of a unified, cohesive and logically organized referral
system. These problems are further compounded by the lack of quality assurance of
these health institutions.
Health services can be improved through the implementation of the following reforms:
1. Strengthening Primary Care – through the development of the “Essential Health
Package” (EHP) that center on problems identified in the community. The EHP
should not limit services and goals, but instead serve as starting points of a
comprehensive primary health care program. Pilot EHPs can be implemented in
several disadvantaged provinces.
2. A multidisciplinary primary care team approach that is linked to a referral system.
The primary care team will serve as the gatekeeper between the patients and the
3. Reinstituting the District Health System through political and financial support –
the subcontracting of a capitation based Global Health Budget to provide
essential health services can be used to reinvigorate the district health system.
4. Integrating all referral hospital services, whether public or private to align with the
visions of Universal Health Care.
The DOH must take the lead in removing the structural barriers to the integration
of our national health systems.
Health Human Resources
The health care system of the country suffers from the paradox of lacking health
care professionals, especially in economically depressed regions, while at the same time
enjoying an oversupply of the said professionals. Most doctors and nurses are
concentrated in the private sector, while the supply of midwives, who provide the basic
health care needs for the poor, is inadequate to meet the demands of the rural and
barangay health centers.
These problems can be traced back to three factors: unregulated market forces,
quotas determined by capacity rather than sustainability, and absence of emphasis on
public service and common good. These factors combine to produce the phenomenon of
migration to other countries and overcrowding in a highly competitive job market.
Reforms in HHR production must be anchored on fundamental changes in the
recruitment, education, training and deployment of health care professionals. These
must be guided by the overall objective of providing competent, well-motivated,
transformative and committed professionals in a system of universal health care. These
must be based on a country’s demands of health care instead of market forces.
These reforms will be anchored on regulations. A commission headed by the
DOH and including members from the CHED, PRC, PHIC, LGUs, DOLE, DEC, etc, can
spearhead the efforts in promulgating policies regarding the standards and regulations in
the production, practice and deployment of health professionals.
The Philippines faces the same health financing issues of the region: chronic
underfunding, inequitable sourcing of funding (low public spending leading to high out-of-
pocket spending), efficiency issues in terms of allocation of limited financial resources
and payment mechanisms leading to higher health care costs. Added issues are the
fragmentation and overlap of the health financing institutions and by the lack of an
articulated national health policy based on equity and health as a right as basis for
health financing policy formulation.
To rectify the situation, the stakeholders in Universal Health Care must craft a
unified Health Financing Policy based on equity and health as a human and
Total Health expenditure (THE) must be increased to the WHO recommended
level of 5% of GDP. Government and Philhealth share must be increased such that Out
of Pocket payments are eventually reduced to 20% of THE.
Funding for health care must be allocated to the more cost effective public health
interventions and primary care services, while maintaining the quality of tertiary level
health services. Philhealth’s move towards Case Mix payments, true capitation and
global budgeting should be further developed for financing both primary and tertiary care
Achieving the goal of UHC also demands that government address the social
determinants of health beyond the health system. Increasing poverty should be
addressed by a comprehensive national socio-economic development that includes
asset reforms, agricultural modernization and national industrialization. Universal Health
Care will address issues of inequity of access. National socio-economic development will
create the living conditions for a healthy population. Only with a clear program for
national socio-economic development, will Universal Health Care succeed in making our
Purpose of this paper
This paper will serve as the basis for the proposed executive order which follows.
Draft Executive Order
BY THE PRESIDENT OF THE PHILIPPINES
EXECUTIVE ORDER NO.____
Directing all government agencies to cooperate, coordinate, facilitate, and otherwise
contribute to the implementation of Universal Health Care for all Filipinos.
WHEREAS the 1987 Philippine Constitution affirms the right to health of all Filipinos and
directs the State to protect this right;
WHEREAS scientific medicine and modern public health, introduced in the Philippines
more than one hundred years ago, have contributed to the improvement of overall health
status of Filipinos;
WHEREAS despite continued efforts of government and private sector in the application
of scientific medicine and modern public health methods in the health care of Filipinos,
current health status indicators show that the Philippines still lags behind its neighbor
countries in health development;
WHEREAS the health status of individuals, families, and communities in the Philippines
varies widely in accordance to socio-economic status and geographic area;
WHEREAS this wide variation in health status between and among population groups
results from social inequities and, within the Philippine Health system, from inequity in
access to health services;
WHERAS this inequity in access to health services results from the following
characteristics of the Philippine health system:
Inappropriate governance within the health system
Antiquated and inadequate health information systems
Ineffective regulation of health goods and services
Fragmentation of health service delivery
Dysfunctional health workforce;
Unfair, unjust and inadequate health care financing
Draft Executive Order
WHEREAS health development programs in the country at all levels have not sufficiently
taken into account the major social determinants of health;
WHEREAS Universal Health Care, defined as the provision to every Filipino of the
highest possible quality of health care that is accessible, efficient, equitably distributed,
adequately funded, fairly financed and appropriately used by an informed and
empowered public, will address the inequities of the Philippine health system;
NOW THEREFORE I, Benigno Simeon C. Aquino III, President of the Republic of the
Philippines by virtue of the powers vested in me by law, do hereby order the following:
SECTION 1. Mandate: In accordance with the provisions of the Constitution and in a
manner consistent with the Administrative Code of 1987, the Local Government Code
(RA 7160) as well as all health provisions of other legislative and administrative
issuances, the Department of Health (DOH) is hereby mandated to be the lead national
agency in the formulation of policies, development of programs, issuance of guidelines
and provision of technical support that will lead to the establishment of Universal Health
Care as the vehicle for health development;
SECTION 2. Tasks: to accomplish this mandate, the DOH is instructed to:
a. Undertake a review of the structure and functions of its organic as well as
attached agencies with the end in view of recommending changes (including
necessary administrative issuances and where needed legislative proposals)
oriented along the lines of Universal Health Care;
b. Organize tasks forces, committees, or any type of bodies deemed necessary to
secure the participation of all relevant national government agencies and
instrumentalities, local governments, civil society, and communities in the
development of a national Universal Health Care program;
c. Within a month from the issuance of this Executive Order, to present to the
President and the cabinet a two year plan to comprehensively address the health
problems of disadvantaged population groups particularly the poor, women,
children and the elderly;
d. With the cooperation of the other social development agencies (Education,
CHED including state institutions of higher learning, Labor, Social Services) as
Draft Executive Order
well as the economic agencies (Budget, Finance, NEDA), develop a budget
proposal for 2011 directed along the lines of Universal Health Care.
SECTION 3. In support of the DOH’S tasks in relation to Universal Health Care, the
following agencies are directed to extend all cooperation:
a. DILG – to ensure full cooperation of local government units in the implementation
of Universal Health Care
b. Education, CHED and government academic and service institutions: ensure the
participation of the education sector in the development of the UHC program.
c. NEDA and other economic and financial agencies – to identify and mobilize
resources in support of UHC
d. DSWD – to identify priority segments of the population for UHC implementation.
SECTION 4. Areas of Concern: the above tasks should address issues, challenges, and
obstacles to the attainment of Universal Health Care in the following areas:
a. Health Governance – establish equity as the overall philosophy of the Philippine
health system and strengthen existing mechanisms and where necessary install
new ones for the effective and meaningful participation of families, communities,
professional groups, and other relevant groups in the management and operation
of health programs, facilities, and activities.
b. Health Information – utilize all available resources to establish a National Health
Information System which will set standards in the collection, collation, analysis
and utilization of information in support of Universal Health Care.
c. Regulatory Functions – ensure implementation of regulatory laws, edicts,
decrees, and other issuances in support of a Universal Health Care policy and
giving priority to health concerns (especially of the disadvantaged population
groups) over commercial interests of private groups or individuals;
d. Health Services Delivery – actions, such as the development of gatekeeping
mechanisms, should be taken to promote the vertical and horizontal integration
of health services within government at all levels and between public and private
Draft Executive Order
e. Human Resources for Health – lead the various health workforce regulatory
agencies (including CHED, PRC, DOLE, DFA) in the development of an
integrated plan for health workforce recruitment, production, deployment, and
management (including compensation schemes) to support Universal Health
f. Health Care Financing – increase combined government spending at national
and local levels as well as through the National Health Insurance Program to
levels needed to significantly reduce the out of pocket component of total health
expenditures to 20% or less by 2015;
SECTION 5. Effectivity: This Order shall take effect immediately.
DONE in the year of Our Lord 2010 this __day of December
FOR the President
By Executive Secretary.
Cecilia S. Acuin, M.D.
Bryan Albert T. Lim, M.D.
Paul Gideon D. Lasco, M.D.
University of the Philippines Manila National Institutes of Health
Being poor and sick is a deadly combination no Filipino should have to
suffer. The downward spiral of poverty and illness must be halted by
timely, accessible and adequate health care.
The Philippine Situation
Health is a basic human right guaranteed by the Philippine constitution. The
great disparity in access to and use of health care has resulted in unacceptable
differences in health status between the rich minority and the poor majority of Filipinos
constituting a grave violation of this right for most of our countrymen.
60 low est
NMR PostNMR IMR ChildMR U5MR Perinatal
Figure 1. Under 5 Mortality rates, NDHS 2008
Conventional health status indicators of life expectancy at birth (LEB), infant and
child mortality (IMR), and maternal mortality ratio (MMR) show considerable variation
when disaggregated according to income groups and geographic location. Rich urban
communities like those in Metro Manila, Cebu, and Davao, with access to modern
facilities, have outcomes comparable to those of developed countries – i.e., LEB over 80
years, IMR less than 10, MM less than 15. In contrast, poor rural communities, such as
those in Bicol, the Samar provinces and ARMM, have results that approach those of
least developed countries – i.e., LEB under 60 years, IMR over 90, MM over 150. 1
Infants (period from birth to 1 year of age) from the poorest quintile die at twice
the rate of the richest during the neonatal period (birth to first 28 days of life), and at four
times the rate during the post neonatal (after 28 days to 1st year) and under 5 periods.
(see figure 1) The Child (1 to 4 years of life) mortality rate of the poorest is almost 10
times that of the richest.
I III NCR IV B VI V III X XII A RMM
Philippines II CA R IV A V V II IX XI CA RA GA
Figure 2. Prevalence of wasting in children <5 yrs by
region, NNS 2008, data from FNRI
Nutritional status is among the strongest predictors of childhood mortality. 2 The
same patterns of disparities can be observed from results of the 2008 National Nutrition
Survey (NNS) of the Food and Nutrition Research Institute (FNRI).
The prevalence of childhood thinness or wasting, an indicator of severe acute
undernutrition, in ARMM is the highest in the country based on the 2008 National
Nutrition Survey. It is double that of neighboring Davao (Region XI) and more than twice
that of Cebu (Region VII) which has the lowest prevalence among the regions. (see
Underweight prevalence, one of the hunger-related Millennium Development
Goals (MDG), increased from 24% in 2003 to 26% (2008) nation-wide, and the key to its
reduction will be to address hunger, illness and poverty in Regions like Zamboanga
(Region IX), Bicol (Region V), and MIMAROPA (Region IVB) where 1 in 3 children are
underweight. (see figure 3)
I III NCR IV B VI V III X XII A RMM
Philippines II CA R IV A V V II IX XI CA RA GA
Figure 3. Underweight Prevalence in children <5 years by
region, NNS 2008, data from FNRI
These disparities are the result of the following deficiencies in our health system:
Basic health services as well as tertiary care for the majority of Filipinos are
inadequate, fragmented, inefficient, and incomplete. At least in part due to
this, for lowest income groups these services are largely inaccessible and
The Philippines’ health sector is dominated by commercial interests of a
segment of the system that is less driven by health outcomes but is primarily
about bottom-line profits.
Health personnel are insufficiently educated, inappropriately trained, and
poorly motivated to address the health care concerns of most Filipinos in the
setting in which they live. As a result, poorly compensated government
health workers are unable to influence behaviors of their high earning private
sector counterparts within the change-resistant environments of their
respective professional organizations.
Much of this commercial dominance of our health care system is the result of
a failure, so gross as to constitute a default, of public financing for health. The
combined weight of the uncoordinated spending for health by the national
government, local governments and our national social health insurance
program has been so low and so weak that it has driven our health system
into a debilitating dependence on out-of-pocket payments by patients.
A comparison with neighboring countries
The Philippines has lagged so far behind its neighbors in ASEAN in terms of rate
of mortality reduction that it may miss reaching its MDG 4 goal of reducing the under five
mortality rate by 2/3 from 1990 levels by 2015. Our rate of reduction has slowed
alarmingly particularly over the last 8 years (from 59 to 38 in the period 1990 - 2000;
from 38 to 34 between 2000-2008). Our country is already expected to miss its MDG 5
goal of reducing MMR to 1/4 the 1990 rate - a goal that Malaysia, Thailand and Vietnam
have already met - as well as the goal to reduce poverty, which is actually increasing. 3
Figure 4. U5MR of ASEAN countries (ranked by GNP per capita) 1990- 2008, UNICEF 2010
Figure 5. MMR of ASEAN countries 1990- 2008, WHO 2010
The disparities are apparent in public health program coverage as well. (see
figures 6 to 9) Equity in coverage is a problem particularly for technology dependent
care. For example, ORT includes home fluids which can be given at home without
considerable external resources (unless restricted to ORS), but SBA & vaccines have
distribution issues in addition to allocation ones; antenatal care can be provided closer to
home so the equity gap is narrower than birth attendance. The provision of SBA is
particularly relevant to reducing MMR and neonatal MR, but needs to be coupled with
other facility interventions, as Thailand's experience shows.4
Among our ASEAN neighbors, Thailand has the narrowest gaps and the highest
coverage levels. Yet even Vietnam appears to have surpassed us in terms of coverage
though not necessarily in narrowing equity gaps. Myanmar's immunization gap is
narrower than ours, while Indonesia is closing in on us at this time.5,6
Comparison of ORT use for childhood diarrhea
90 by lowest & highest income quintiles
Cambodia Indonesia Philippines Thailand
Figure 6. Comparison of ORT use for childhood diarrhea by lowest & highest income
Skilled Birth Attendance coverage
by lowest and highest income quintiles
Indonesia Philippines Vietnam
Cambodia Laos Thailand
Figure 7. Skilled birth attendance coverage by lowest & highest income quintiles
Antenatal care (at least 1 visit)
by lowest & highest income quintiles
Indonesia Philippines Vietnam
Cambodia Lao PDR Thailand
Figure 8. Antenatal care (at least 1 visit) by lowest & highest income quintiles
Immunization coverage by lowest
& highest income quintiles
Cambodia Indonesia Lao PDR Myanmar Philippine Vietnam Thailand
Figure 9. Immunization coverage by lowest & highest income quintiles
Why universal health care?
To address these deficiencies, radical reforms in all components of the Philippine
health system are required. Such reforms must be aimed at achieving UNIVERSAL
HEALTH CARE in the country over a reasonable period of time (10-15 years). This
means that every Filipino should have access to high quality health care that is efficient,
accessible, equitably distributed, adequately funded, fairly financed, and directed in
conjunction with an informed and empowered public. The overarching philosophy is that
access to social services is based on need and not on the capability to pay. This,
ultimately, places people at the center of socio-economic development.1
Universal health care is the government's mandate to ensure every Filipino's
right to health. It is a health system imperative because it improves the efficiency of the
nation's human resources. And it is a society's moral responsibility - that the rich, the
able and the powerful, in solidarity, support the poor, weak and marginalized.
Hence, UHC goes beyond just providing universal insurance coverage, which
only reduces the financial barriers (affordability) to health. A more comprehensive
approach involving the health and societal systems need to be mobilized to reduce
physical (availability), cultural (accessibility) and other barriers to care.
This paper proposes a UHC model for the Philippines adapting the 6 building
blocks of a health system: 1) health financing, 2) health human resources, 3) regulation
of drugs and other health products, 5) health service delivery, and 6) governance in
health.7 Each of these building blocks will be described in the succeeding chapters. Each
chapter includes proposals for their reform in order to achieve UHC.
A brief history of the Philippine health care system
The Philippine health care system can be described as pluralistic, having evolved
from indigenous healing practices through several centuries of exposure to varying
colonial health systems. Remnants of these different influences can be appreciated in
the values and practices of Filipinos regarding health. Health care is provided by a
mixture of public and private sources, with utilization mainly decided by capacity to pay.
The system is fragmented in several ways: 1) there is fragmentation within the public
system as the Department of Health has no direct link with local government service
providers, 2) among the local governments, the provincial health system has no direct
link with the city and municipal health systems that are within its geographic area, 3)
government links with the private sector are limited to licensure by the DOH and
accreditation by Philhealth, 4) the referral system operates largely on a personal level,
depending on who one knows at the next level of the health system hierarchy.
The inequities in health care delivery can be traced historically to the Spanish
colonial era, when health care provided to the Spaniards and the native elite differed
from that available to the rest of the populace. (see appendix 1) Attempts at public health
intervention have even been interpreted as efforts to contain the spread of epidemics
(primarily cholera in the 1800s) from the poor to the well-off.8 While efforts to increase
access to health care were made during the American and early Republic periods, these
continue to be challenges up to the present.
There are many laudable initiatives in the history of the Philippine health care
system, and many firsts in Asia or the developing world achieved (for example having a
government entity solely focused on Nutrition policy - the NNC) but the reach of these
efforts have fallen short of expectations. The vision of Universal Health Care comes on
the heels of multiple attempts at health system reform.9,10,11 By this time it is hoped, we
have learned from our past and are ready ensure equity in health.
A brief overview of UHC in other countries
Appendix 2 provides an overview of the different health systems of countries
considered to have achieved UHC. There are essentially three sources of financing:
taxes, health insurance and out-of-pocket (OOP). Countries with UHC have striven to
reduce OOP in order to increase access to health care and to make it more equitable.
The degree to which taxes or health insurance are used to meet health expenditures
reflects the values and philosophies of the different countries. On one end of the
spectrum is Cuba, where government foots the bill for all its citizens and for (almost) all
their health expenses,12,13 and the other extreme, possibly represented by the Thai
model, has health insurance paying for most, if not all, expenses. However, Thailand's
government pays the premium for majority of its population and owns and runs majority
of the hospitals and health facilities - so in essence, government still provides the bulk of
total health expenditure.14,15
The organization and management of the health systems varies, with Cuba,
again on one end, where all facilities are government run. 12,13 South Korea may be at the
other end, where health facilities are mostly in private hands. 16 However, a common
feature is the degree to which the health system is regulated in order to meet socially
determined goals of equity and access. Among countries where government owns and
runs the facilities, the concern is usually about quality of care (for example, waiting time,
distribution of manpower and services). For those where the facilities are predominantly
private, the main issue appears to be cost-containment for the system as a whole.
Governments employ means tests and other methods (for example, age, nature
of employment, risk status like pregnancy) to determine who needs services for free or
to be subsidized and by how much. Different systems vary in the services covered,
although catastrophic care appears to be universally covered. The extent to which
governments themselves provide care also varies; health providers may not necessarily
be government employed, while pharmaceuticals and other health products/devices,
often in private hands, are covered through various schemes.
1. Blueprint for Universal Health Care 2010-2015 and Beyond. University of the
Philippines Forum. http://www.up.edu.ph/upforum.php?i=289. Accessed December
2. Pelletier DL, Frongillo EA Jr, Habict JP. Epidemiologic Evidence for a Potentiating
Effect of Malnutrition on Child Mortality. American Journal of Public Health. 1993
3. The Millennium Development Goals Report 2010. United Nations, 2010.
4. Acuin CS, Khor GL, Liabsuetrakul T, Achadi EL, Htay TT, Firestone R, Bhutta ZA.
Maternal, neonatal, and child health in Southeast Asia: towards greater regional
collaboration. Lancet. Article in press.
5. Gwatkin DR, Rutstein S, Johnson K, Suliman E, Wagstaff A, and Amouzou, A.
Socio-Economic Differences in Health, Nutrition, and Population in Cambodia. The
World Bank, September 2007.
6. Countdown 2008 Equity Analysis Group, Boerma JT, Bryce J, Kinfu Y, Axelson
H, Victora CG. Mind the gap: equity and trends in coverage of maternal, newborn
and child health services in 54 Countdown countries. Lancet. 2008 Apr
7. Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes.
World Health Organization, 2007.
8. De Bevoise, Ken. 1995. Agents of apocalypse: epidemic disease in the colonial
Philippines. Princeton University Press, Princeton, New Jersey
9. National Objectives for Health, 2005 – 2010. DOH Manila, 2005
10. Health Sector Reform Agenda Philippines, 1999-2004. HSRA monograph series no.2
Department of Health, Manila, Dec. 1999.
11. Fourmula One (F1) for Health. Department of Health, 2006.
12. Ochoa, FR and Visbal LA. Civil society and health system in Cuba. A case study
commissioned by the Health Systems Knowledge Network, World Health Organiztion
Commission on the Social Determinants of Health, 2007
13. Health in the Americas. Pan American Health Organization, 1998
14. Wibulpolprasert S. Thailand Health profile 2005-2007. Bureau of Policy and Strategy,
Ministry of Public Health. Thailand, 2007.
15. Sakunphanit T. Universal Health Care Coverage Through Pluralistic Approaches:
Experience from Thailand. Health Care Reform Project, National Health Security
Office, Thailand, 2006.
16. Soonman K. Thirty years of national health insurance in South Korea: lessons for
achieving universal health care coverage Health Policy Plan. 2009;24(1): 63-71 first
published online November 12, 2008
17. Hassenteufel P and Palier B. Towards Neo-Bismarckian Health Care States?
Comparing Health Insurance Reforms in Bismarckian Welfare Systems, in Reforming
the Bismarckian Welfare Systems (eds B. Palier and C. Martin). Blackwell Publishing
Ltd. Oxford, UK, 2009.
18. Brown LD. Comparing health systems in four countries: lessons for the United
States. Am J Public Health. 2003 Jan;93(1):52-6.
Appendix 1: A History of the Philippine Health System
HEALTH FINANCING HEALTH HUMAN INFORMATION GOVERNANCE & SERVICE DELIVERY
RESOURCES SYSTEMS REGULATION
PRE- Fee-for service. “Fee” was Each village had its own Oral traditions Healers had concurrent Done by healers. Very local in
COLONIAL anything of value agreed upon healer; there were also committed to functions as village elders scope.
“No health by the healer and patient itinerant healers. memory & passed or priests
care system; on via
as ” apprenticeship
SPANISH Religious hospitals sourced Health care provided by Pen and paper. Largely by religious orders, Hospitals ran by religious orders
“Feudal health their budget from revenue native healers, Data not until the 19th c when the catered to the elite, soldiers and
care system” which included donations, etc. paraprofessionals standardized & beginnings of public health the indios.
Spanish government provided (vaccinators, mediquillos, unreliable system seen through local
some support to medicos etc) & religious orders health boards, sanitary Private practice begun in the late
titulares assigned to the until the mid 1860s when inspections, & quarantine 19 century
provinces the University of Santo measures were set up
Tomas opened its
medical school to native
AMERICAN Largely fee for service, except 1905 – UP College of Data kept per 1898 – Military Board of 1907– Philippine General
“Health care for government facilities that Medicine and Surgery hospital/ facility Health to care for the Hospital was established and
system served the poor for free was established, with the Centralization still a injured American soldiers opens in 1910.
established in Johns Hopkins as problem
1930; blueprint. Nurses 1902 – worst cholera 1933 – Community Health and
produced in Philippine epidemic hit the country. Social Centers established.
Normal School. Led to the establishment of These were the precursors of
Civilian Bureau of Health Rural Health Units/ Centers
Several graduates of UP and Bureau of During the Commonwealth,
Medicine were sent governmental laboratories. Bureau of Health had 11
abroad for further Sewage system and water community and social health
training. Several supply improved centers, 38 hospitals, 215
milestones in medicine puericulture centers, 374 sanitary
happened in this era. Health System centralized; divisions, 1,535 dispensaries &
policies such as Food & 72 laboratories.
Medical associations Drugs Act (1914) enacted
began to flourish; PMA
started in 1903
Japanese Some hospitals continued to Health professional Many health Dissolved the National Many services could not be
Occupation operate under the Japanese - training was disrupted records & facilities Government and replaced it continued during the war &
backed government with during this period were destroyed. with the Central Japanese Occupation.
services given for free Administrative Organization
of the Japanese Army.
Health was relegated to the
Department of Education,
Health and Public Welfare.
HEALTH FINANCING HEALTH HUMAN INFORMATION GOVERNANCE & SERVICE DELIVERY
RESOURCES SYSTEMS REGULATION
EARLY Health services in government The Philippine Medical Disease In 1947 the DOH was In 1954 the RHU Act (RA 1082)
REPUBLIC facilities provided free to all; Act of 1959 (RA 2382), Intelligence Center created,as well as a institutionalized the Rural health
private care paid for out-of- followed by the 1st established in 1960 Bureau of Hospitals and a Units, tasked to provide the ffing
pocket on a fee-for-service Philippine Midwifery Act "to assess the Bureau of Quarantine . In basic services: Maternal & Child
basis. (RA 2644) in 1960 & state of the nation's 1948 the Institute of Health, Environmental Health,
GSIS created other laws governing & health, to supervise Nutrition (now FNRI); & in Communicable Disease Control,
regulating the practice of activities and 1963, a Food & Drug Vital Statistics, Medical Care,
different health training in Administration (later known Health Education & Public
professions. MDs epidemiology and as BFAD) were established. Health Nursing.
continue to train in US, health statistics 1958 – EO 288, partial
with some choosing to and to give advise decentralization of DOH
migrate. to the health with creation of 8 Regional
secretary". Offices and Directors
MARTIAL LAW Medical Care Act of 1969 Migration of MDs to US An integrated Focus on Health Nutrition & child health
implemented; health takes up increases health information Maintenance. Specialty emphasized with the establish-
2.8% of GNP system was hospitals were built (Heart, ment in 1974 of NNC & in 1976
attempted but not Lung, Kidney, PCMC, of EPI. Primary health care
continued RITM) started in 1979. Integrated Health
Care Delivery System mandated
DECENTRALIZ National Health Insurance Act Continued diaspora of FHSIS developed Generics Act passed in Inter-local health zones started in
ATION of 1995. Philhealth created. health workers, now by 1990 & modified 1988; with the LGU code of 1999
PhilHealth assumed the involving nurses & other in 1996. 1992, health care was 2003- TB DOTS implemented.
responsibility of administering health professionals with National Telehealth devolved.
the former Medicare program migration not just to the Center of UP-NIH Health Sector Reform
for government and private US but to other countries established started in 1999
sector employees from the as well
Insurance System in October
1997, from the Social Security
System in April 1998, and from
the Overseas Workers Welfare
Administration in March 2005.
Appendix 2: Characteristics of Countries with Universal Health Care
Country Health service organization Governance & Regulatory How is health financed? Who benefits & what are paid
(references) context for?
Cuba Integrated, organized, led and Cuba is a socialist state. Oriented The National health system All Cubans are covered with full
(12, 13) funded under the direction of towards primary & preventive provides services for free to all. medical and dental services,
the State, with operations care, community participation is Government covers almost 90% including hospitalization and
decentralized into provinces & central to its health organization & of health expenditures in the prescription drugs
municipalities mobilization efforts. country, the rest come from out-
S Korea Providers (MDs & hospitals) are There is no gatekeeping system. Regulated fee for service pays Although policy for mandatory
(16) mostly private, paid for by Although there is now a single- services administered through a health insurance was enacted
insurance-regulated fees for payor natl health insurance national health insurance since 1976, universal coverage
services; services not covered system, the mostly private system as single payor, with was achieved only in 1989 with
are charged at market rates. providers prefer unregulated govt subsidizing insurance for inclusion of the self-employed.
services. the informally employed, small Curative services, biannual
business employees (partial checkups and vaccination are
support) and the poor (full covered. Co-payments are
support) . Govt' accounts for just discounted for the poor, >65 yrs,
53% of THE. OOP is high and for chronic & catastrophic
relative to other OECD conditions. Co-pay for out-patient
countries. services are higher for hospital
than for clinics.
Thailand The Thai health system is a mix The central government sets Government pays insurance for All Thais are covered. Under the
(14, 15) of public & private- the govt policies & regulates the health 3/4 of pop’n not covered by Universal Coverage Scheme &
provides majority of hospital and system, with health offices in- employment schemes; SSS, reimbursement for curative &
most community level care charge of operations at provincial, Employees, employers & capitation arrangements for
while private sector provides district & subdistrict levels. Private government share in the preventive care are made with
about 1/3 of hospital care & hospitals are mostly in urban insurance of those employed contracted health providers.
urban specialist areas. Private bed, special nurse &
eyeglasses are not covered by
UK, Nordic Primary care trusts link Government owns and regulates General revenues (taxes) pay All citizens are covered for
countries community, specialty and health care providers for 86% of health expenditures hospital & ambulatory care, as
(17, 18) hospital care, with GPs (under well as drugs, but dental care and
govt capitation contracts) acting glasses are not well covered
as gatekeepers - all are state
employed. QOC is a big issue
Country Health service organization Governance & Regulatory How is health financed? Who benefits & what are paid
(references) context for?
Germany, Germany has regulated private Health insurance is based on the Highly regulated, universal, In France, about half of
France health providers; France has principles of social solidarity and multi-payer health insurance ambulatory care, dental & eye
(17, 18) networks of a mix of private & risk pooling. Government tightly systems pay for ~80% of health care are covered by
public providers and services - regulates the rules by which expenditure, rest is paid through supplementary insurance. Only
patients are free to choose their providers negotiate fees with private insurance and out of the richest 25% of Germans have
provider and level of care within insurers or sickness funds. pocket. Taxes pay for those not supplementary insurance, as
the terms of their insurance Doctors' unions negotiate fees & covered by employment mandated by law.
benefits or pay OOP if beyond regulatory conditions on behalf of insurance.
these terms. Cost containment MDs
is a big issue
Canada National policies protect Most physicians are private Publicly administered, single- Canadians are covered for "all
(18) solidarity & community interests, practitioners who are paid by payer (govt from taxes) national medically necessary services",
while provinces are responsible Medicare at fee-for-service rates. health insurance systems pays including some prescription drugs.
for operations. These rates are negotiated for services. Govt accounts for Private insurance pays for dental
Community care access centers through provincial medical about 70% of health service, rehabilitation care, private
are the hub of service provision associations. Most hospitals are expenditures, rest from private care nursing, rest of prescription
non-profit, paid with provincial or insurers and out of pocket. drugs
regional budgets through
Alberto G. Romualdez, M.D.
University of the Philippines Manila National Institutes of Health
Overall governance of the Philippine health system is vested in the national
government through its Department of Health (DOH). The DOH is headed by a cabinet-
rank Secretary of Health appointed by the President of the Republic of the Philippines
and concurred in by the Commission on Appointments of the Philippine Congress
(Legislature). It exercises technical supervision over all agencies, institutions, groups,
and individuals who provide health services or are otherwise considered as stakeholders
of the health system through national health policies, standard setting, and rules and
regulations covering the provision of health care. These include entities of the national
government, local government health services, as well as private sector health providers
including civil society or non-governmental organizations.
DOH is the government’s overall policy formulation and implementation agency
in health. To support this function, DOH oversees a number of attached agencies
responsible for areas of special concern in the health sector in which the Secretary of
Health is chair or co-chair of the respective governing bodies. Among these are Phil
Health for health care financing, the National Nutrition Council for nutrition policy, and
the Population Commission for population issues and reproductive health.
DOH also directly administers and controls a network of national hospitals that
provide tertiary medical care. In addition it also has technical authority over other
national government agencies that maintain facilities that provide health services to
particular groups or populations (e.g., Defence and Education Departments and the
Governance of local government health facilities and services is exercised by
DOH through its programs for technical assistance and support as well as by virtue of its
regulatory powers and the accreditation process of the Philippine Health Insurance
Corporation (Phil Health). In addition, DOH serves as a key link with multilateral and
bilateral international donors with interests in the health sector.
A major share of the national expenditures on health (about 60%) goes to a large
private sector that also employs over 70% of all health professionals in the country. This
dominant private sector is also technically supervised through the regulatory agencies of
the DOH. The National Health Insurance Program through Philhealth and its benefits
programs also has a significant role in the financing of the private hospital system.
As well, DOH has some influence on a largely unseen “informal” health system of
alternative health care through the Philippine Institute of Traditional, Alternative and
Complementary Health Care (PITAHC).
Key issues and concerns
The lack of a clearly articulated overarching philosophy of health service
provision that explicitly addresses the issue of health equity and its social implications is
a major deficiency of the Philippine health system and its governance structures. Such a
deficit results from a firmly entrenched top-down approach to policy formulation, planning
and management of a health care delivery system that is dominantly supply-side driven
and provider oriented.
As a consequence, the attempt to introduce participatory processes in health
decision-making and policy-formulation with the adoption of the PHC approach in the
early eighties faded out with the emergence of “selective primary health care” and the
resurgence of technology-dominated vertical approaches. The present governance
infrastructure, even as decentralized through devolution, does not allow for effective
community participation which was an important element of the Primary Health Care
Governance Functions within the Health System
The concern for equity and the provisions for community participation should be
built into the mechanisms for discharging the core governance responsibilities in health
at all levels –from highest central level to the most peripheral units of implementation. In
the present Philippine situation, core governance responsibilities (or functions) are
currently exercised as follows:
Policy formulation and strategy development at all levels -
o Within the executive branch of government there are a number of
mechanisms by which DOH can exercise its health policy and
coordination functions. Cabinet meetings provide opportunities for direct
interaction with the President and the heads of the other government
departments that carry out health or health related activities including
other social services such as education, welfare, economic development,
and security. Membership of these agencies in other coordinating bodies
and attached agencies of DOH provide other venues for policy
formulation and coordination of strategies.
o DOH cooperates and provides technical support to key committees of the
two chambers of the Philippines Congress. Through such committees, the
health sector provides inputs to legislation on health whenever the two
branches of government agree on the need for such.
o There are presently no formal mechanisms for providing technical health
information and communication support for the judicial branch of
Planning of health programs and mechanisms for health service delivery –
o At the national level, DOH develops plans for supporting priority public
health programs such as TB DOTS, Immunization, and Maternal
Neonatal and Child Health and Nutrition. It has also formulated the
National Objectives for Health that provides inputs to program planning at
different levels. The DOH also plans the development of capabilities of
national service outlets such as retained hospitals
o At the local level the DOH has developed technology for the formulation
of local investment plans for health. Provincial investment plans for health
(PIPH) initiated in some provinces have recently been rolled out to all
provinces. City and municipal level planning processes are also
programmed within the year.
o In the private sector, the DOH together with local governments can
influence planning of facilities and services through regulations on the
distribution and location of such facilities and through standard setting
and licensing functions.
Managing the health sector –
o The DOH hospital system is presently managed through direct interaction
between the Secretary of Health and the hospital chiefs. The hospitals
also communicate directly with the Budget Department as well as
individual congressmen who provide them with additional funds. A policy
of fiscal autonomy and income retention has led to unprecedented
dependence on user fees for financing resulting in exclusion of non-
paying population groups.
o Management of public health programs (including those of national
concern such as communicable disease control) is discontinuous with
local governments responsible for implementation at grass-roots level as
mandated by the Local Government Code of 1992. As well, direct
management of hospital services up to secondary and tertiary levels has
been devolve to provincial governments. Although local health boards
have been set up at both levels, these have been largely non-functional in
practice and even those that do exist lack powers and authority to provide
effective consumer and community inputs to governance and
Public accountability and transparency
o Because of the extremely confused reporting lines, satisfactory public
accountability and transparency for health outcomes and key result areas
of health programs are nearly impossible. Administrative and financial
accountability mechanisms are better developed but still remain out of
public reach (at community level).
Generating and interpreting intelligence and information
o The present system for data gathering as well as analysis and use of
information is antiquated. Information technology is inadequate and
inappropriate at all levels but especially at the barangay and community
Coalition building within and outside health sector
o DOH and a number of local government health offices maintain close
links to established civil society organizations but these are generally at
program level. There are however no existing mechanisms to seek out
and develop such linkages at policy levels. Peoples’ and grassroots
organizations have only sporadic opportunities to participate in
governance functions at any level.
Coordination of International Assistance
o DOH through its Bureau of International Health and Cooperation has
overall responsibility for coordinating externally funded health activities
particularly those undertaken by official multi and bilateral development
organizations. DOH is also the official contact of the World Health
Organization which participates in international health coordination on the
official donor side.
Recommendations for Improving Governance
1. A clear articulation of an overall philosophy of health service provision that explicitly
addresses the issue of equity:
An executive order addressed to all government agencies concerned with health
should be issued. The EO will define health equity as equal and just access to
health services for all Filipinos regardless of income. It will also direct the
mechanisms to reform the health system to achieve equity in all the six building
2. Installation of an effective participatory process in decision-making and policy-
formulation in health along the lines of the Primary Health Care approach:
The system of PHC committees at community, LGU, regional, and national levels
in place in the 80s should be revived. These bodies should have real power over
health policy formulation, decision-making, and management of health programs
Additionally, regularly monitoring of public perceptions and opinions on health
matters should be a standard component of implementing mechanisms for
policies, programs and projects.
3. Development of Indicators of Good Governance in Health
The concept of good governance in health is a recent development and there few
established indicators for its measurement. In general, the indices thus far
developed are derived from management systems and as such tend to reflect
It is recommended that policy issuances, program performance, and other
functions of leadership and management be analyzed and evaluated from the
perspectives of the various people-centred domains of health stakeholders.
Indicators of equity and people participation should be emphasized.
Assessments should take into account the social determinants of health as
factors affecting health equity.
Health Information Systems
Alvin B. Marcelo, M.D.
Julian M. Cañero, M.D.
University of the Philippines Manila National Telehealth Center
Information has been identified by the World Health Organization as one of the
pillars/building blocks for strengthening health systems. 1 This is in recognition of the
crucial role of information systems in supporting decision-making at many levels of the
health sector. Indeed, valid and reliable information is requisite for the delivery of more
effective, efficient and equitable health care. 2 This makes health information
management one of the cornerstones of universal health care. If properly designed to
address health inequities, health information systems can assure that every Filipino will
have access to quality healthcare and to an effective, efficient, and sustainable health
History of the Philippine Health Information System
As early as the 1960s, the Department of Health (DOH) already operated a
national health information system. This was revised slightly in 1984 to reflect the shift in
strategy for towards Primary Health Care, a policy adopted by member states of the
World Health Organization, including the Philippines. 2
In 1989, the Field Health Services Information System (FHSIS) was first
implemented to replace the old system. It mandated field personnel working in the local
Barangay Health Stations (BHS) or Rural Health Units (RHU) to collect data for the
different national health programs. At the time, data collectors were burdened with
submitting as many as forty different forms yearly. With the devolution of health services
to the Local Government Units (LGU) in 1992, there was deterioration of the quality of
management and services, poor staff morale, deteriorating infrastructure and lack of
financing of operational costs and services. 3 This led to the design and implementation
of the Modified Field Health Services Information System (MFHSIS) in 1996 which
reduced the number of forms submitted from 40 to only 7 per year. In 2001, the system
further evolved into the Distributed Field Health Services Information System (DFHSIS)
and was piloted in 6 different sites. However, there were multiple problems encountered
with the system and was thus, not scaled nationwide. 2
In 2007, the Philippine Integrated Disease Surveillance and Response (PIDSR)
Project was created to provide a framework and to propose a comprehensive approach
to health information systems development. This was followed by a DOH-led Philippine
Health Information Network (PHIN) in 2008 which designs and implements the Philippine
Health Information System (PHIS). In terms of the implementation, the specifics and
operational aspects of these programs at the field level are not yet clearly documented.
Specific Problems of the Philippine Health Information System
The management of health information in the Philippines is at best rudimentary
and ministerial because data collectors perform their work as a matter of compliance
without regard for the information's usefulness for decision-making at all levels. Several
factors were found to have caused this.
Paper Based and Manual Reporting Systems
Health information systems in developing countries in general are paper-based
and manually driven. This is best represented by the tally sheets of cases filled up by
health workers in health centers weekly and monthly. Each vertical DOH program (e.g.,
maternal care, expanded program on immunization, etc.) is represented by its own
separate tally sheet and corresponding logbook. This results in health care workers at
the grassroots level being overburdened with manually recording and computing
statistics for all of these programs. In turn, delays ensue because health care workers
give it low priority compared to patient care. By the time the tally sheets find their way to
higher offices, several weeks or months may have already passed. 4
As a matter of convenience, a health statistic report is considered complete only
when all of its component data are accounted for. This means that unless all barangays
(villages) submit their tally sheets, the municipal report cannot be labeled complete. The
provincial report in turn cannot be completed without data from all the municipalities.
Under this all-or-none scheme, the delay of a single barangay can potentially hinder the
release of the much needed national health report. This phenomenon occurs all around
the country which results in national statistics being delayed for more than a year. 4 In
fact, the latest national health report still dates back to 2008, as of this writing.
Health data is first observed and compiled at the barangay level then submitted
to the Municipal Health Officer before it is compiled yet again and submitted to the
Provincial Health Officer. This system was meant to allow local health officers to detect
local anomalies and trigger them to take immediate action. This system however,
deprives higher health offices the timely data they need in order to effect national health
policy changes. Furthermore, as data passes through each level, it becomes susceptible
to consolidation errors as well as deliberate mishandling of data. This results in higher
level data becoming poorer in quality. 4
Health care workers at the grassroots level are generally aware of targets of
national health programs and are expected to meet them. For example, a national target
for a program may set an arbitrary 80% coverage for the current year. Some indifferent
health care workers may report immunization coverage statistics that match their target
even if their actual data is lower. Setting targets for data reports is both counter-
productive and manipulative. It explicitly suggests to health workers what numbers are
expected while the paper-based reporting implicitly provides them with the freedom to
edit their results without accountability. This results in poor quality data which are used
for decision-making like procure medical supplies. These also become basis for national
policy decisions.4 In some cases, poor quality data has resulted in over-procurement of
vaccines that were essentially wasted because the drugs exceeded the number of
children to immunize.
Mixing Good with Bad Data
While some health care workers at the grassroots level (such as those described
earlier) are indifferent about data quality, others are diligent. But when these two sources
(good and bad quality data) are combined, the consolidated result becomes
questionable and even useless. Furthermore, health workers who are meticulous about
their work become demoralized when they learn that their hard work has been rendered
practically useless by colleagues who are known to fabricate their reports. 4
Disintegrated and Paradoxical Vertical Programs
The Department of Health delivers various vertical programs such as maternal
care, child care, family planning, TB, malaria, leprosy, and many others. Each of these
programs has its own reportorial requirements, own sets of forms and logbooks for the
use by the health care workers. A patient may be recorded in more than one logbook if
he presents with several conditions (e.g., a pregnant woman under treatment for TB).
This can result in bloating the number of patients in the center's census if the number of
records in the logbook is used to count the number of patients served.
Some programs contradict each other's objectives. In the maternal care program,
an increase in the number of pregnant women is expected (given the rise in population
growth). On the other hand, the family planning program also expects an increase in the
number of women using contraceptives. However, we know for a fact that an increase in
the use of contraception should result in a decrease in the number of pregnancies.
When these targets are not met, some health care workers are compelled to just invent
numbers to fit the program’s expectations. 4
At present, a typical health center is like a data cemetery, that is, it has piles of
logbooks and paper records gathering dust over the years. These logbooks once
archived are forgotten and not used for planning or for analysis. Without easy access to
their census, health care workers in the health center are not aware of the incidence and
prevalence of diseases in their communites. 4
Lack of Computerized Health Information Standards
While the DOH and Philhealth maintain their respective computerized health
information systems, they are not standards-based and cannot easily exchange data
with each other. There is also lack of a roadmap and leadership as to who should build
and manage the national health information system.
What is e-Health?
E-health is a relatively new term for an emerging field in the intersection of
medical informatics, public health and business, referring to health services and
information delivered or enhanced through the Internet and related technologies. 5 The
World Health Organization defines it as a cost-effective and secure use of information
and communications technologies in support of health and health-related fields,
including health-care services, health surveillance, health literature, and health
education, knowledge and research. It currently encompasses several fields:
● Electronic Medical Record – a computerized legal medical record used within a
● Electronic Health Record – a collection of electronic medical records which refer
to a single patient
● Patient Health Records – a patient controlled electronic medical record (i.e.
● Telemedicine – the delivery of health care to a remote site through the use of
● Telehealth – the delivery of health services (not limited to clinical care) through
the use of telecommunications technologies
● Health Informatics – resources, devices and methods required to optimize the
collection, storage, retrieval and use of health information
● Consumer Health Informatics – analysis, study and implementation of methods
for making health information accessible to consumers / patients 6
● E-learning – provision of educational materials and virtual classroom interaction
through telecommunications technologies
Due to the rapid development of the field, these are only a few examples of the
sub-domains which comprise the general term e-Health.
e-Health as part of the 6 building blocks of the WHO framework for improving
The WHO proposed framework for improving health systems consists of 6
building blocks: service delivery; health workforce; information; medical products,
vaccines and technologies; financing and leadership and governance. Furthermore, it
characterizes a well-functioning health information system as one that ensures the
production, analysis, dissemination and use of reliable and timely information on health
determinants, health system performance and health status. 1
Figure 1. Interactions of the 6 building blocks for improving health systems
e-Health as part of the solution to the problems of the Philippine Health
A health information system (HIS) is an integrated set of components that work
together to provide support for decision making in healthcare. Because of the multi-user,
multi-level perspectives of HIS, designing and implementing them are challenging.
Literature is rich with documented failed HIS implementations. 7
In general, most failed HIS reveal unfilled gaps in the knowledge and skills of all
stakeholders of the health system. A poorly designed HIS will be unable to provide
support for the decision making of public health managers, clinicians, and patients
whereas an effective one clearly creates value for all of these stakeholders. An effective
HIS is built through a process that starts with understanding what decisions need to be
made by these various players and be able to deconstruct them into the data elements
for collection. For purposes of Universal Health Care therefore, a deep understanding of
decisions that pertain to guaranteeing the comprehensiveness of healthcare must be
defined clearly at the outset so that appropriate health information systems can be built
that can deliver this promise. Figure 2 shows how responsive health information systems
should be designed: starting from knowing what decisions or actions are to be made and
deconstructing these sequentially into knowledge and further into its information and
data components. Following this deconstruct paradigm, the resulting health information
systems are more able to address the needs of decision makers at different levels of the
Data Information Knowledge Decision
Figure 2. The Construct-Deconstruct Paradigm
Deconstructing Healthcare: Information at the Point-of-Care
The collection of health information begins with an encounter at the point of care.
Although these encounters come in many forms (in clinical settings or in household
surveys), those that have most impact to the universality of healthcare are those that
document services at the point-of-care. For example, a health care worker will interview
patients about their symptoms, perform a physical exam as well as request for some
necessary laboratory tests. Every data collected from the patient contributes to his
health record and helps the health worker take appropriate actions or make decisions
about the level of care to provide. The health record becomes the fiduciary tool to
document the services (and their quality) delivered to a person. The concept of universal
health care is hinged on documentation of quality services received by patients from
their providers as depicted in their health records.
Constructing the Public Health Information System from Point-of-Care Data
Health information systems do not end at the point-of-care. When several patient
records are combined and analyzed in a facility, they can provide information on the
performance of the institution. While the collection process may have ended for the
clinician and the patient, focus then shifts to the public health professional who will
consolidate these individual data to find patterns that may be emerging from a
population. The public health information system is then built from point-of-care data.
Although designed and collected separately, individual level data in the clinics and
facilities become the building blocks that form the larger public health information
system. It is this multi-purpose, multi-stakeholder nature of health information (individual
at one level yet public at another) that makes health information systems complex and
difficult. The varying needs and agendas of clinical and public health stakeholders, if not
properly addressed, can result into disintegration and information silos in different parts
of the health system.
Telemedicine: Providing Access to Health Services
The World Medical Association defines “telemedicine” as: “the practice of
medicine over a distance, in which interventions, diagnostic and treatment decisions and
recommendations are based on data, documents and other information transmitted
through telecommunication systems.”8 It is a thoroughly studied discipline that dates
back to the initiatives of the National Aeronautics and Space Administration (NASA) to
monitor vital signs of astronauts in space. It has since evolved into a myriad of
applications ranging from telemetry to telesurgery. Evidence shows substantial benefits
from telemedicine for patients in remote hard to reach areas. 9
If universal health care means being able to connect every citizen to the health
system, then access becomes a fundamental principle that is needed to guarantee that
A Reference Information Model for Healthcare
The complexity of modeling health information challenges designers and
architects of health information systems. While most transactions will be done by local
health workers, more sophisticated analysis will be made by higher level experts. A
standard dataset is necessary to guide both field workers and central epidemiologists in
the way they manage their information.
The minimum data set to document service provided (which we may call the
“service data atom”) are the following:
3. Service provided
These five data elements, having been found to be fundamental to documenting
health care and universal access, should then advise government of the health
informatics standards that are needed to create interoperable information systems, to
1. Client registry: a master list of all patients and their identifiers
2. Provider registry: a master list of all providers and their identifiers
3. Terminology registry: a list of all attributes relevant to documenting healthcare.
This terminology registry will contain the canonical codes and names for the main
services rendered by providers to patients (e.g. antenatal care, BCG vaccination,
4. Standard date and time formats
5. Standard geographic codes down to the barangay level; and if available, to the
latitude and longitude using a standard base map
The current national health information system leaves much to be desired.
Despite substantial internal and external investments, health information systems are
still disintegrated and non-interoperable. Lacking access to a blueprint or enterprise
architecture, implementers are left to their own designs and build systems that will not be
able to communicate with each other. The Department of Health must prioritize the
creation of the enterprise architecture to enable the participation of a larger group of
implementers in both the public and private sector.
With this blueprint, the Department of Health then needs to define the health
informatics standards that will meet the requirements of the enterprise architecture. With
these standards, implementers will be constrained to operate within a clear set of rules
which, if fully complied, will guarantee inter-operability with similarly compliant systems.
These standards must be promulgated at the soonest possible time by DOH even if it
would mean letting go of their current implementations that do not meet these new
Lacking the enterprise architecture and standards, implementers are best
advised to store the minimum dataset, the service atom, which contains the five data
elements: patient identifier, provider identifier, service identifier, location identifier and
1. Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes.
World Health Organization
2. Marcelo, AB, Ramos, BT, dela Rosa J et al. Evaluation of Decentralized Field Health
Service Information System in Selected Infectious Disease Surveillance and Control
Project Sites in the Philippines. Department of Health.
3. Grundy, J, Healy, V, Gorgolon L, Sandig E. Overview of Devolution of Health
Services in the Philippines. Rural Remote Health. 2003 Jul-Sep;3(2):220. Epub 2003
4. Marcelo, AB & Marcelo PF. “Report of Pregnancy by Short Messaging System
(SMS): A Strategic Data Point in the Philippine National Health Information System”.
University of the Philippines Manila
5. Eysenbach G (2001). "What is e-Health?" J Med Internet Res 2001;3(2):e20
6. Eysenbach G (2000). “Consumer Health Informatics” BMJ 2000; 320; 1713
7. Littlejohns P, Wyatt JC, Garvican L. Evaluating computerised health information
systems: hard lessons still to be learnt. BMJ 2003 Apr 19;326(7394):860-3.
8. WMA Statement on the Ethics of Telemedicine.
http://www.wma.net/en/30publications/10policies/t3/index.html Accessed December
9. Wade VA, Karnon J, Elshaug AG, Hiller JE. A systematic review of economic
analyses of telehealth services using real time video communication. BMC Health
Serv Res. 2010 Aug 10;10:233.
Kenneth Hartigan-Go, M.D.
Asian Institute of Management – Dr. Stephen Zuellig Center for Asian Business
Predicaments of the Philippine Regulatory System
Regulation plays a vital role in the success of the Universal healthcare by
ensuring that the people, especially the poor will have access to quality and accessible
health products, devices, facilities and services. Health care regulatory system is an
important imperative of the government to ensure access to quality and accessible
health products, devices, facilities and services, especially those commonly used by the
poor through the set of standards and enforcements. With the adoption of Universal
Health Care, the government should be able to assert its regulatory authority to ensure
accessibility of quality healthcare services. Its regulatory bodies should have adequate
resources. However, this has been a serious challenge for the government. The
mechanisms for regulation of health goods, services and facilities remain inadequate,
weak and unresponsive.
Regulatory system aims to provide a set of methods to influence behavior. This
particular reform agenda is part of the six building blocks for building stronger health
systems1 and contributes to the overall understanding, application and adoption of a true
Philippine Universal Health Care.
The roles of regulation are fairly established,2 these are:
Establishing Rules Governing the Private Sector
Protecting Buyers from Their Own Inability to Judge Quality
Counteracting “Supplier Induced Demand”
Advancing Specific Moral Principles
Health regulatory authority, in general, grapples with scarce resources,
inadequate staff and capability, inefficient use of available technology, and lack of
progressive technological development. “There are no funds for technical and operations
researches, which are necessary to provide the basis for standards development. There
are not enough training facilities, testing laboratories and experts to handle the
qualification requirements for regulation of manpower, certification/conformity testing and
monitoring of regulated products.”3
Another identified factor includes the lack of quasi-judicial power amongst
regulatory authorities as they are currently “limited to standards development,
inspection, licensing and accreditation, assessment, monitoring and imposition of fees.”3
Regulation of health facilities
The Bureau of Health Facilities and Services (BHFS) of the DOH is in charge of
the regulation and licensure of health facilities and services such as hospitals, clinics,
laboratories and other health service establishments. In support of the BHFS is
Philhealth accreditation which provides incentive for compliance in the quality guidelines.
However, the criteria used in BHFS licensure and DOH accreditation are mostly
based on inputs like number of beds and the presence or absence of certain medical
equipments and medical professionals. Outputs and performance indicators like in-
patient and out-patient visits, and the health condition of the discharged patient are not
given enough weight.”4
Despite the presence of various laws and guidelines on quality assurance and
efficient investment, health facility remains substandard and fragmented. These laws
and guidelines includes: Administrative Order 21 s. 2007 Harmonization and
Streamlining of Licensure System for Hospitals; Guidelines for the issuance of certificate
of need to establish a new hospital (AO 29 and its amendments AO-4, AO-4A and AO-
4B); the Rationalization Plan of health facilities; RA 4226 (An Act Requiring the
Licensure of all hospitals in the Philippines and Authorizing the Bureau of Medical
Services to Serve as the Licensing Agency); and other guidelines concerning birthing
facilities, private clinics, blood banks, dialysis center, etc.
The problem lies in the enforcement of the laws and authority. In 1999, the
Department of Health identified that the lack of manpower, technical, organizational and
legal constraints hamper the enforcements of the policies and regulations. 5 They cited
that the competency and skills of regulatory officers are inadequate. Sotto (2006) also
“Until recently, there was not even an introductory training course
for regulatory officers of the DOH. In the past, regulatory officers attended
a two-week training course conducted by the UP College of Public Health.
A few were sent abroad to gain exposure in standards setting and
enforcement practices of other countries. Except for the Bureau of Health
Devices and Technology, which requires its regulatory officers to take a
Master of Science in Applied Physics, Major in Medical Physics, an
advanced degree is not compulsory for the regulatory officers below
division chief level.”6
The lack of technical capacity has been compounded by the inadequate number
of staff. “With more than 1,700 registered hospitals in the Philippines alone, a total
manpower complement of approximately one hundred staff from the BHFS and CHD is
generally unsatisfactory to provide regular and quality assessment and monitoring of
these hospitals and health facilities.”6
As a result, some of the health facilities, particularly those maintained by local
government units such as rural health centers and barangay health stations, are
substandard and dilapidated, if not, none existent. Health facilities are uncoordinated
and fragmented. In many cases, primary and secondary hospitals are situated next to
rural health units, but were largely performing the same basic outpatient health center
functions.7 Contrary, there are localities without healthcare providers particularly in the
far-flung areas. Close to 60% of all accredited hospitals are located in Luzon while over
70% of free standing dialysis clinics are found in the National Capital region alone.
Moreover, there are hospitals that have deteriorated thus can no longer perform the
services according to their level. More often than not, such cases were neglected for
lack of adequate resources to respond to the resource needs.
The health referral system lost cohesion post-devolution. Logistics, transport,
patient referral protocol, distinctions (complementarities) between levels of service were
all affected adversely by lack of clarity regarding local government co-operation and
under-financing of the operational costs of the district hospital.7
Regulation of health professionals
The Professional Regulations Commission administers, implements and enforces
the regulatory policies for the practice of health-related professions. It administers
licensure exams, enhancement and enforcement of professional, occupational, ethical
and technical standards.
In support of the PRC are the Specialty Societies that practice self-regulation in
their respective field of professions. These societies monitor the practice and hold
continuing education programs for their members and compel members to participate in
conferences, symposia and other society activities. Societies also police unethical
behavior and those found guilty of unethical conduct are expelled from its roster and
subjected to further disciplinary actions by the Philippine Medical Association which is
the umbrella organization of all medical societies.
Philhealth also contribute to the enforcement of standard for healthcare providers
through accreditation. Accredited providers may participate in the National Health
Insurance Program which ensures quality of service. Accreditation may be revoked or
suspended when acts are committed resulting in adverse patient outcomes or when
there is evidence of fraudulent claims.
Despite various regulatory mechanisms, gaps has been identified which affects
access to quality health service amongst providers. The Philippine Health Human
Resource (HRH) Master Plan identified the lack of integrated HRH system or an
overarching framework that will ensure efficient production, deployment, regulation, entry
Other issues identified include the standard workforce to population ratio,
workforce to bed ratio; and the maldistribution of health professionals concentrating
primarily in the urban areas.
Based on the HRH Master Plan, the workforce to population and bed ratio,
stipulated in the DOH A.O. 147 s. 2004, is insufficient to respond to meet the patients’
needs. Moreover, there were necessary positions that were not included in the minimum
standard. For the case of the Rural Health Units, DOH A.O. 100 s. 2000 stipulates the
standard workforce to population ratio; however, it is also limited to doctors, nurses,
midwives and rural sanitary inspectors and fails to take into account medical
technologists, dentists and other health professionals which counter the Sentrong Sigla
The low standard is compounded by maldistribution of health workforce between
rural and urban areas. It has been reported that 50 to 70 percent of all medical
practitioners are concentrated in the cities (Department of Health, 1994). Moreover, it
was recorded in 2005 that 36 percent of the 7,671 government doctors are in the
National Capital Region while the other regions average 300 doctors. However, the
ARMM and the CARAGA, two of the poorest rural regions only have 89 and 76,
respectively.8 In the case of Philhealth accreditation, 35% of its accredited doctors are
based in NCR. This is about eight times more than the average number of Philhealth
accredited doctors in regions outside NCR.
Regulation of health devices
The Bureau of Health Devices and Technology (BHDT), created by P.D. 480 and
P.D. 1372, responsible for formulating and implementing standards for radiation facilities
and devices used in medicine, dentistry, veterinary medicine, industry, education,
research, anti-crime, military and consumer applications. It also conducts health
technology assessment, studies and researches on radiation devices and technology
and provides technical assistance and consultative services to stakeholders.
However, due to meager resources and limited technological capacity, BHDT
lags behind the industry. It has not been able to cope with the technological progress as
the industry invest heavily in research and development to produce more products to be
imported to the country.
Technical and operations training remains a challenge as there are very few
experts to handle the regulation of quality standards for healthcare,
certification/conformity testing and monitoring of regulated products. There are
difficulties in dealing with industry as health regulators may not possess the skills to
substantially manage resources or industry people.
Maldistribution is also a problem for medical devices. Of the 3,860 basic X-ray
facilities, 1,200 can be found in the National Capital Region. Of the total of 5,141
facilities are found in the country, across the regions. Regions with least categories are
CAR, ARMMM and CARAGA. General Radiography facilities found in CAR, ARMM and
CARAGA are 67, 23 and 46 respectively.9
Regulation of medicines
RA 9711 reorganized and expanded the existing setup of the Bureau of Food
And Drugs (BFAD) into Food and Drugs Administration (FDA) with four specialty areas
that include: (1) Center for Drug Regulation and Research (to include veterinary
medicine, vaccines and biologicals); (2) Center for Food Regulation and Research; (3)
Center for Cosmetics Regulation and Research (to include household hazardous/urban
substances); (4) Center for Device Regulation, Radiation Health, and Research, formerly
the Bureau of Health Devices and Technology become fully integrated with the FDA.
Prior to the law, BFAD had to operate with meager resources, inadequate staff,
lack of technological development in carrying out its responsibility of regulating drug
industry and their products, devices, vaccines, food, cosmetics, nutriceuticals and
hazardous household chemicals and toys.
BFAD, aware of such shortcomings, have conducted studies that show that there
is a grave lack of manpower where regulated establishments and products overwhelm
inspectors such in the tables shown below. The ratio of the number of Food and Drug
Regulation Officers (FDROs) with the number of establishments is 1:202; while the ratio
of the number of evaluators for the PSD with the number of products is 1:1,513. These
data somewhat give an overview of how BFAD is in urgent need for reorganization and
Figure 1. Establishments vs. CHD Manpower Complement per CHD (2006)
Figure 2. Breakdown of BFAD Regulated Establishments (2006)
Figure 3. BFAD Registered Products vs. number of evaluators (2006)
In addition to overseeing the safety of food and cosmetics, the agency also faces
a formidable load of nearly 20,000 registered drug products. The equipment for
chemistry, manufacturing and controls for registration approval need to be upgraded to
cope with an increasing number of applications for product registration numbering to
approximately 150 to 200 applications monthly.10
Aside from the regulatory mechanisms, accepted standards in manufacturing
such as the Good Manufacturing Practice (cGMP) have not been satisfactorily and fully
implemented. As of October 4, 2010, there are only 57 establishments with cGMP. The
implementation of full compliance to GMP has been repeatedly postponed. The
prevailing argument of most drug companies is that they need to continue operating in
order to have profits to plough back into investments for their plant’s GMP. cGMP
certification must also be applied to the source of finished medicine products imported
by local importers.10
There are also issues in poor regulation of generic drugs in terms of the capacity
to comply with bioequivalence requirement for establishing product interchangeability as
stipulated by the Generics Law of 1998 and further by the Universally Accessible
Cheaper and Quality Medicines Act of 2008.
Another significant omission of the agency as a truly effective regulatory agency
is the absence of a functional adverse drug reactions (ADR) monitoring and
Pharmacovigilance system. In 1995, the Philippines became a full member of the World
Health Organization Adverse Drug Reaction Surveillance System based in Uppsala,
Sweden (now the WHO-Uppsala Monitoring System) through the establishment and
early accomplishments of the National Adverse Drug Reaction Committee (NADRAC).
However, over time, the Philippines became almost a non-functional status in the WHO
program. Currently, FDA has embarked on an effort to revive ADR monitoring
spearheaded by its new ADR Unit which organizes training seminars all over the country
for key DOH-retained and LGU-operated hospitals and pharmacies, but not the private
health sector yet.
FDA also failed to regulate unethical intensive marketing practices which led to
“asymmetry of information” where the consumers know very little about the nature of the
product and the variety of choices and options, while the drug manufacturers and
intermediaries particularly the physicians and pharmacists know much more. The
asymmetry of information led to brand loyalty amongst consumers and physician
resulting to some sort of monopoly which allows firms to set prices above the
competitive level. This has also resulted to irrational drug use.
FDA failure in regulating marketing practices of drug industry has led to some
form of industry group self-policing their members to undertake ethical marketing,
advertising and promotions through a code. This industry code, while not perfect, defines
the limits of permissible interaction and relationship between prescribers and drug
industry. But since this code covers only the research and development based industry,
it does not cover local drug companies or non-members of the Pharmaceutical Health
Care Association of the Philippines (PHAP).
The poor compliance to regulatory bodies and accepted standards undermines
the quality, safety and efficacy of the pharmaceutical product. Moreover, the market
imperfections and inability of the government to address the issues through competitive
market mechanisms perpetuates the proliferation of high cost of medicines. The
pharmaceutical market remains afflicted by substandard, counterfeit drugs that threaten
the life of the consumers.
Regulation of Health Financing
In 1994, the DOH issued the Rules and Regulations on the Supervision of Health
Maintenance Organizations (AO No. 34 s. 1994), which gave the Office for Health
Facilities Standards and Regulations (OHFSR) authority to exercise regulatory functions
for HMOs, whether investor-based, community-based or cooperative-based.11 The
OHFSR issues licenses and permits, including the Clearance to Operate, to HMOs, and
provides medical and employer organizations with a list of HMOs whose clearance has
been issued, suspended, cancelled or revoked.
Despite the mandate, HMO operation in the country has been generally regarded
as highly unregulated. The framework for regulation remains to be the Presidential
Decree No. 612 (Insurance Code) issued in 1974 and amended by Presidential Decree
No. 1460 (also known as the Insurance Code of 1978).
Based on the DOH A.O., the minimum facilities for an investor-based HMO
acting as a stock corporation are the management of one tertiary hospital or affiliation
with five tertiary hospitals, and an outpatient clinic with basic diagnostic facilities for
resting ECG, chest and extremity X-rays and CBC, urinalysis and fecalysis. Meanwhile,
community-based or cooperative HMOs operating as non-stock or non-profit are
required to be affiliated with one general hospital and one outpatient clinic. As of
December 31, 2005, there are seventeen (17) DOH-licensed HMOs in the country.
Despite the mandate from the DOH and Insurance Commission, there remains
some regulatory ambiguity. “Pre-need and health care plans that are considered as
“insurance” products fall outside the jurisdiction of the Insurance Commission. This has
resulted in differing rules and regulations applied to various insurance products, and
thereby created confusion in the market.”12
“Due to the lack of rules to enforce the provision of the Cooperative Code,
cooperatives were driven to provide various in-house insurance schemes to meet the
needs of their members. However, these insurance schemes are unregulated, did not
undergo any actuarial studies and may therefore be considered as unsafe and unsound.
It exposes their members to further risks. More than 65% of total cooperatives registered
with the CDA are no longer operating due to mismanagement, governance issues and
more importantly, the lack of rules and regulations. Since most of these cooperatives
have, in one way or another, informal insurance schemes, the need to come up with the
necessary regulations becomes more apparent to protect their members’ interests.”
Aside from the HMOs, Philhealth can also utilize its leverage as the national
health insurance provider to negotiate for quality, access, cost benefit and cost
containment imperatives. By, leveraging Philhealth’s purchasing power, it can strengthen
its influence over service provider behavior, drug cost, quality of services, etc. At
present, Philhealth fails to consider this aspect of regulation and acts more like a
As a result of the inefficiencies of the regulatory authorities, health products,
devices, facilities and services remain inaccessible to the majority of the Filipinos,
particularly the poor. The upper class A and B can avail first class services, branded
medicines, hi-tech laboratory tests from world class private tertiary hospitals in the urban
centers. While the poor, particularly those in the far-flung rural areas resorts to
substandard, poor quality, fly-by-night health facilities, medicines, and services. There
are even those unreached Filipinos who have not seen any health facilities, health
professionals, medicines, and devices- even those as basic as sphygmomanometer.
Current Initiative to Address the Problem
Given these concerns, the Department of Health is pushing for various reforms to
strengthen the health regulatory authorities through stronger mandates, management
and governance, augmentation of resources, capability and technological development.
Acknowledging the need for reforms, a new Food and Drugs Administration Law
(RA 9711) was passed in June 2009 to strengthen the administrative, technical capacity,
and resources of the drug regulatory authority. The law also indicated fiscal reforms
within the FDA to encourage growth and development in technical capacities through
increase in user’s fee and a business plan for investment.
With the introduction of the new law more funds can be utilized by the agency to
gear up its capability to address the various issues. It now faces and evolves towards a
more effective regulatory agency in compliance with ASEAN Harmonization standards.
The challenge so far, is the delay in crafting the implementing rules and
regulations which remains in the draft stage. Moreover, at the moment, FDA is headed
by an interim director general but only as the Officer-In-Charge designate. Because of
this situation, more in-depth and substantive reforms might not be undertaken unless the
political mandate is clear and the position and title is officially made.
The other recent piece of legislation is RA 9502 passed in June 2008. The
government imposed a mandatory and voluntary drug price reduction. Moreover, it
complements the Generics Act of 1998, for it also requires and ensures the production of
an adequate supply, distribution, use and acceptance of drugs and medicines identified
by their generic name.
However, the law remains inadequate. The law requires greater collaboration
amongst the regulatory and other concerned agencies particularly Philhealth. Philhealth
needs to take advantage of its leverage and the provisions of the law to reinforce greater
compliance amongst the providers and the industry.
Conclusion: Alternative Interventions for Regulatory Reforms (Universal
The analysis of the predicaments of the health regulatory system depicts
complex and systemic problems which entail dynamic and systemic approach for the
Integrative framework and harmonization of regulatory mechanisms
There is a need to address the fragmentation of the regulatory system and the
health system itself. An overarching and integrative framework of Universal Healthcare
should be reinforced amongst health regulators both at the national and local level.
Regulatory authorities should be working hand-in-hand to ensure provision of
comprehensive and quality health care. A good facility alone will not deliver good health
services. It should be complemented by adequate and competent health care providers,
with equipment, medicines at affordable cost particularly for the poor. Ensure
coordination amongst regulatory tools of each agency. For example, exploring areas for
Philhealth’s roles both as the main purchaser of health goods and services. It can
leverage its position to lower costs and ensure quality, thus assuming quasi-regulatory
Strengthen the Regulatory Authorities and harmonize mechanisms
Strengthen the mandate, system, regulatory tools, systems and resources of the
regulatory agencies. Give the regulatory agencies quasi-judicial powers to ensure
compliance of the private sector. However, it must also be ensured that accountability
and transparency should also improve. Put information technology systems and
performance management systems in place to enhance efficiency and transparency in
Deputizing the LGUs
Intensive efforts are needed to educate devolved local government health
systems to understand their role in health regulation. Health regulation should not be the
sole responsibility of national agencies. LGUs have an important stake in protecting the
health of their constituents. Short of analytical testing, there are many ways that LGUs
can ensure quality, such as supplier prequalification, physical inspection, supplier
performance monitoring, good storage practices, and rational drug use. This also
recognizes the fact that drug quality is more than analytical testing.
Involve the private sector and educate the consumers
The private health care system (clinicians and hospitals) have to be informed and
made to appreciate that the selection of essential medicines has to be tightly regulated
and cost and price are part of a clinical decision tree. They have to accept other
payment mechanisms such as case payment instead of fee for service. DOH-retained
hospitals must be reminded of AO 137: Waiver of Excess Fees and Charges for
Philhealth Indigent Patients in All DOH-retained hospitals. Failure to justify the non-use
of formulary (essential drug list) means disincentives from the NHIP in paying
professional fees.13 On the part of the consumers, they should be given the proper
information with regards to their options. For example, intensify campaign for use of
1. Everybody’s business: Strengthening health systems to improve health outcomes.
World Health Organization, 2007.
2. Roberts MJ, Hsiao W, Berman P, Reich M. Regulations. Chapter 11, in Getting
Health Reform Right. Oxford University Press, 2004.
3. National Objectives for Health. Philippines 2005-2010. Department of Health,
4. Capuno, J. A case study of the decentralization of health and education services in
the Philippines. HDN Discussion Paper Series. PDHR Issue 2008/2009 No. 3.
5. Villaverde M, Solon O, Ramirez M. Health Sector Reform Agenda Philippines 1999-
2004. Department of Health, 1999.
6. Sotto, A. The Challenge of Health Regulation in the Philippines: Towards
Acceptability and Efficiency. University of Queensland, 2006
7. Grundy J, Healy V, Gorgolon L, Sandig E. Overview of devolution of health services
in the Philippines. Rural and Remote Health 3 (online), 2003: 220.
8. De Guzman, JPS. Flight of the caregiver. Medical Observer, 14(1), pp. 12-13. 2005
9. Number of X-ray Facilities by Category and By Region as of August 24, 2007.
Bureau of Health Facilities and Services. Manila, 2009.
10. Food and Drug Administration Philippines. http://www.bfad.gov.ph Accessed
December 3, 2010.
11. Rules and Regulations on the Supervision of Health Maintenance Organizations.
Administrative Order No. 34 series of 1994. Department of Health, 1994.
12. Lanto GM, Almario J, Geron MP. Microinsurance: does traditional regulation apply?
Philippine Institute for Development Studies Policy Notes, October 2008.
13. Waiver of Excess Fees and Charges for Philhealth Indigent Patients in All DOH-
retained hospitals. Administrative Order 137 series of 2002. Department of Health,
Organizing Health Services
Towards Universal Health Care
Junice D. Melgar, M.D.
University of the Philippines Manila National Institutes of Health
The delivery of health services is fragmented into over over 3,000 discrete units,
2,600 facilities at primary, provincial, regional and national levels and over 1,000 private
facilities of which only the hospitals have been counted. (see figure 1) The public-private
dichotomy seems to have evolved naturally from the Americal colonial model while the
fracturing of the public health system is of recent origin, the enactment of the Local
Government Code of 1991. This Code conferred the power and authority for health care
services, including primary care and hospital services to specific LGUs, barangays,
muncipalities and cities and provinces. The result is the absence of a unified, cohesive
and logically organized health system, but instead “several autonomous organizational
structures with the common thread being their concern with the provision of health goods
Primary health care is provided at 3 levels: over 15,000 Barangay Health
Stations (BHS), close to 19,000 Rural Health Units (RHUs) or Urban Health Centers
(HC), and over 300 Primary or District Hospitals. (DOH BHFS, Distribution…). BHS and
RHU services revolve mainly around the following: diarrheal disease, ARI, dental health,
environmental health (specifically water and toilet), immunization, family planning,
nutrition, prenatal and postnatal care, and TB control.2 This health care provision has
been described as “selective PHC,” “vertical,” i.e. aligned along programs, disease and
interventions, not on people, doctor-centered, and “rationed” by availability of doctor,
medicines and laboratory services.3
The “district health office” was specified as such in 1987. The office exercised
jurisdiction over district hospitals, municipal hospitals, rural health units, barangay health
stations and all other Ministry units in the health district.4
With devolution mandated in 1991, health districts were transferred to the
jurisdiction of provincial governments where many did not thrive owing to the lack of
funds and the departure of personnel.5 Health districts were revived and rehabilitated as
Interlocal Health Zones (ILHZ), i.e. a “clustering of a group of contiguous municipalities
that have a core referral hospital and a number of primary level facilities such as RHUs
and BHS.”5 According to the administrative order, ILHZs were designed to be venues for
harmonizing preventive and curative care through integrated governance, management,
financing, resource-sharing and provision of health services.
Referral hospital system. There are 4 hospital levels reflecting “graduated
resource capacities and care capability”: 41% are primary, 36% are secondary, 9% are
tertiary, and 6% are quaternary.1 In general, there are slightly more government beds for
all levels, except for tertiary hospitals where private beds are the majority. The number
of hospitals appears to be directly related to the size of the regional population.
However, there are significantly less government hospitals in the more impoverished
regions belying the notion that “government hospitals are mechanisms for tempering
LEVEL 1-4: LEVEL 1-4:
721 HOSPITALS (100%)
1,074 HOSPITALS (100%)
48,349 BEDS (100%)
47,642 BEDS (100%)
LEVEL 4: LEVEL 4:
LEVEL 4 50 HOSPITALS (7%) 69 HOSPITALS (6%)
21,034 BEDS (44%) 14,976 BEDS (31%)
LEVEL 3: LEVEL 3:
LEVEL 3 38 HOSPITALS (5%) 183 HOSPITALS (17%)
5,212 BEDS (11%) 15,428 BEDS (32%)
LEVEL 2: LEVEL 2:
L-2 271 HOSPITALS (38%) 405 HOSPITALS (38%)
14,890 BEDS (31%) 11,582 BEDS (24%)
LEVEL 1: LEVEL 1:
362 HOSPITALS (50%) 417 HOSPITALS (39%)
L-1 L-1 L-1 7,213 BEDS (15%) 5,616 BEDS (12%)
RURAL & URBAN
Figure 1. Levels of Health Care Delivery (Source: DOH Bureau of Health Facilities and
General performance of health delivery organizations
Primary care: With primary care facilities widely dispersed and administered
disparately, it is very difficult to get a picture of their functionality and viability. In 2003,
Sentrong Sigla (SS) announced the percentage of facilities that met SS standards: 53%
of health centers, 15% of district and provincial hospitals, and 3% of barangay health
stations.7 The SS Quality Assurance Program inquired into the delivery of basic services
- EPI, Disease surveillance, Control of ARI, Control of Diarrheal Diseases, Micronutrient
Supplementation/Nutrition, FP, TB control, STDs and HIV-AIDS, Environmental Health
and Sanitation and Cancer control – as well as compliance with facility standards and
regulation. However, we have no information whether any general assessment of
Primary care provision is being done, whether or not via the SS QAP.
Inter Local Health Zones (ILHZ). 23 years after the concept of the district was
laid down, the effort to “model” ILHZ consumes a lot of DOH and donor resources and
effort. DOH targeted the modeling of about 152 ILHZ (calculated from NSCB) in 65
convergence sites. As of 2006-2007, 83 of these ILHZ are reported to be functional.8
Yet, despite some very promising practices in 5 provinces, enormous challenges persist,
including the perennial insufficiency of human and physical resources, unstable political
leadership of the Health Boards, misunderstandings about the role of the DOH, and
insufficient management resources and capacity, including of information. 5 These
structural difficulties prompted the evaluator above to ask a basic question: Do devolved
health services have strategic advantage over other options of delivering health care
services, in terms of providing equity and efficiency?
Patient responses and outcomes. According to the National Demographic and
Health Survey (NDHS) 2008, 8% of Filipinos visited a health facility or sought
consultation in a month, 3.9% in public facilities and 3.1% in private facilities. In terms of
specific facilities, 34% went to RHU/BHS, 20% to private hospitals and 19% to private
clinics. Reasons for consultation were illness/injury, 68%; and check up, 28%.
4% were confined in one year, 51% in public facilities, 48% in private. In terms of
specific facilities, private hospitals accounted for 44% of inpatients, provincial and
regional hospitals for 17% per level, and district hospitals, for 12%.
It is apparent that patients, even the poor are more inclined to seek care in
private facilities and the only barrier seems to be cost. The cost of consulting in a private
facility is 3 times that in public facility (PhP 2,864. vs. 1,051.; while the cost of inpatient
care in private hospitals is also 3 times that in public hospitals (PhP 2,4278. vs. 9,849.)9
For a middle income country, the fact that the Philippines is not meeting some of
the health indicators associated with public health, such as immunization against
measles in one-year olds and death rates associated with TB, indicates something
amiss with the health system. This fact is emphasized in maternal mortality, the
reduction of which is associated with a strong referral system at the district level.10 Poor
health outcomes are a function of the way health care services are organized and made
To address the problems wrought by the inherently disorganized health care delivery
system, the following steps are being proposed:
I. Strengthen Primary Care to ensure responsiveness and sustainability
Devolution has caused the provision of primary care to be non-uniform, focused
on a few vertical programs, and substandard in many cases. A strategic step towards
strengthening is to reconfigure and implement a package of “Essential Services”.
Develop and provide an organic Essential Health Package (EHP)
Primary care or Essential care was originally defined in the Alma Ata declaration
as “Essential health care based on practical, scientifically sound and socially acceptable
methods and technologies made universally accessible to individuals and families in the
community through their full participation and at a cost that the community and country
can afford to maintain at every stage of their development in the spirit of self-reliance
and self-determination11 EHP of varying sizes and composition have been proposed for
countries, including those reconstructing from war and conflict, without much success. 12
This failure has been attributed to the failure to recognize that EHPs are inherently
“value” laden and that where values conflict they could distort the package, prolong its
implementation and eventually affect its viability. Another lesson is that the enabling
conditions for the realization of the package are vital: “good technical and management
training for the eventual providers of essential services, adequate resource levels,
consistent allocative decisions, sound professional tools made available across services
(information, relevant guidelines for action, realistic targets, functioning monitoring
mechanisms), and effective incentives.”12 Chile’s EHP and the way it was processed is a
notable precedent in this regard: There was no preset package but an organic one that
assimilated people’s demands and needs; packages were developed for both primary
and secondary levels; citizens and public officials were involved in discussions on the
benefits and costs of the package; and the package is periodically subject to evidence-
In response to the most pressing health problems affecting most Filipinos,
including those in the Millennium Development Goals (MDGs), an Essential Health
Package has been proposed to the WHO that consists of services around 8 areas:
Maternal and Newborn Care, Reproductive Health, Child Health and Nutrition,
Communicable Diseases, Noncommunicable Diseases, Mental Health, Acute Care and
Oral Health.14 The package is based on studies in rural and urban communities. It
specifies services at 3 levels – BHS, RHU/HC, and District hospitals – and specifies the
required personnel, essential medicines and diagnostic examinations per level. The
package describes facilitating factors as well as obstructing factors, and was projected to
cost PhP 1,379.00 per capita.3
The EHP is not conceived to limit services but to serve as starting points for
patient-centered care. The Primary Health Care principle of putting people “in the center”
implies going beyond simple health care provision to address peoples’ needs, foster
enduring relationships between providers and patients, and relate to people not as
objects of care but as partners in managing their health and community.13 Person-
centered care, which is equity taken to the individual level, has been shown to increase
patients’ trust and compliance, improve treatment effects, strengthen integration of
preventive and promotive care, and promote better quality of life.13
Our proposal is to pilot the EHP and EHP process in 6 or so provinces prior to
cascading it. The first step is to build consensus and support for the EHP nationally and
in the pilot provinces. It is necessary to get the buy-in of critical stakeholders - patients,
providers, and policymakers across LGUs, DOH, Philhealth and other funders. The next
step is to put in the necessary human and logistical requirements and assure continuing
funding. The last step is to implement and assess.
Enable primary care teams to develop primary care network and select patients
for referral to the primary care hub, the district hospital
The complex and social nature of many health problems requires solutions
coming from other health workers as well as from nonhealth sectors. This requires a
multidisciplinary primary care team that is closely linked with other community resources
and able to tap into these resources as often as necessary. Health-related human
resources include laboratories, pharmacies, health specialists, shelters, transport
drivers, drug rehabilitation centers, etc. Nonhealth human resources include parents,
teachers, social welfare agencies, credit facilities, lawyers, law enforcement, employers,
etc. Broad linkages are necessary for the comprehensive management of social health
problems but also serve to engender intersectoral support for health.
Simultaneously with building bridges to the community, the primary care team
acts as gatekeeper identifying those patients requiring more technical diagnosis and
care and channeling them to the hospital system, via the district hospital. Based on the
roles and capacities delimited by the EHP, the primary care team will manage patients
and refer them to the upper levels accordingly.
Our recommendation is to include these “broadening” and “filtering” functions of
the primary care team when they are selected and trained.
Figure 2. Primary Care as a hub of coordination: networking with the community served
and other partners
II. Expedite the establishment and/or functioning of the district system or
Interlocal Health Zones (ILHZ) as the key link between the Primary System and
the Hospital system
The gatekeeping and filtering functions of several primary care teams will
converge on the District facility and system. Though the district facility was originally
conceived to deconcentrate from a centralized system,11 the same is being used
inversely to integrate the primary care and hospital systems. The district health system
has been proven to be essential and effective in localities where multiple stakeholders,
but particularly different configurations of local chief exectutives, endeavored to rise
above LGU political boundaries and jointly managed what are incipient forms of district
systems under devolution.5 Though the formation process is arduous and the new
district systems continue to be buffeted by all sorts of political, financial and
administrative challenges, the pivotal role of district systems need to be asserted and
institutionalized for the long term integrity and viability of the health system. This is
important for municipalities and cities where barangays are decisive.
Reinstitutionalize the District Health system through political and financial
support through the province
The original concept of the district health system flowed from an emphasis on
autonomy through decentralization (not devolution):
“A district health system based on primary health care is a more or less self-
contained segment of the national health system. It comprises first and foremost a
welldefined population, living with a clearly delineated administrative and geographic
area, whether urban or rural. It includes all institutions and individuals providing health
care in the district whether governmental, private or traditional. A district health system,
therefore, consists of a large variety of interrelated elements that contribute to health in
homes, schools, work places and communities, through the health and other sectors. It
includes self-care and all health workers and facilities, up to and including the hospital at
first referral level and appropriate laboratory, other diagnostic and logistic support
services. Its component elements need to be well-coordinated by an officer assigned to
this function in order to draw together all these elements and institutions into a fully
comprehensive range of promotive, preventive, curative and rehabilitative health
Anchored on the principles of Primary Health Care, district health systems are
expected to incorporate the guiding principles of equity, accessibility, emphasis on
promotion and preventions, intersectoral action, community development,
decentralization, integration of health programs, and coordination of separate health
services.11 Under the present conditions of unfettered LGU autonomy, the integration
role of district health system becomes imperative, where integration is defined as “the
process of bringing together common functions within and between organizations to
solve common problems, develop a commitment to a shared vision and goals, and,
using common technologies and resources, achieve health goals for the community.”11
Three elements of integration are particularly vital: integration of service tasks, eg
providing primary preventive and outreach services from hospitals; integration of
management and support functions, eg planning, budget, communication, training,
transport, quality assurance and research; and integration of organizational components,
eg putting in place a coordinating mechanism like a council that ensures that discrcete
parts of the system -human, physical and financial- are harmonized.11
Our propoposal is to support the provincial governments’ assertion of their power
and authority to revitalize and strengthen the district health system in both rural and
urban settings. DOH must mobilize human, technical, political, and funding resources to
reestablish the place of district system in the whole delivery system.
Facilitate and support the establishment of well functioning District Hospital
The district hospital is defined as a hospital at the first referral level that is
responsible for a defined geographical area with a defined population and governed by a
politico-administrative organization. District hospitals generally serve communities of
50,000-500,000. In some countries, an intermediate facility between the primary care
center and district hospitals exists serving populations of 10,000 to 50,000. The physical
scale of the hospital is established on the basis of a determination of the number of beds
required and a suggestion for the minimal hospital area per bed. 11
District hospitals perform a wide array of functions, in addition to the provision of
First Referral Level Care, including public health functions and training and research.
The essential services provided at this level are: Medicine, Surgery, Pediatrics,
Obstetrics and Gynecology and Dentistry; which are supportyed by: Anesthesia,
Radiology, and Clinical laboratory11
District hospitals play a critical role in providing timely medical care, including
surgery for the conditions that typically account for a large share of the population’s
disease burden, such as surgery for complications of childbirth. Surgery for these and
other conditions is most effective when provided at the district level, particularly in the
poorest countries. Proper performance of their functions actually increase the over-all
cost eefectiveness of health care. Yet district hositals are typically underfunded and
suffer deficiencies in quality.15
Our proposal is to integrate the rehabilitation and strengthening of district
hospitals as part of the entire district system. Such strengthening can be piggybacked on
current efforts to improve health care and hospital facilities under the Province-wide
Investment Planning for Health (PIPH). However, beyond the physical infrastructure,
continued human, political and funding support must be assured.
III. Integrate all referral hospital services – public and private – and align with the
principles of Universal Health Care
Hospitals, especially large hospitals, are often perceived by the public to be the
epitome of the health care system, associated with dramatic interventions in life-and-
death conditions, imposing buildings, high technology gadgets, and the availability of,
purportedly, the best specialist doctors. Financially they account for about 50% of over-
all health care expenditure…. and organizationally dominate the rest of the health care
system.16 Yet, the roles of hospitals are changing dramatically with changes in
emergency and patient care, workforce configurations, patient expectations of quality
care, etc.17 Hospitals need to “work with each other, …integrate with communities they
serve by moving from a typical technocratic planning model to a more sophisticated
discussion with the public and other stakeholders,…and respond much more
dramatically to changes in public expectation and in the practice of medicine.”17 Referral
hospitals (secondary and tertiary) can be seen as the “capstone” of the referral pyramid,
neither too heavy nor too light or the levels below them will lose cohesion. A
restructuring of referral hospitals is necessary to improve appropriate referral and
utilization, especially by remote and rural populations; to transform the inappropriate use
of referral hospitals as primary health care providers; to improve efficiency; and to
provide much better outreach and support to lower levels of care.” 18
With the involvement of all stakeholders, develop a unified policy framework
A unified policy framework that would clarify the goals and roles of government
and private hospitals is necessary to prevent further fragmentation of the hospital system
and to align them with national goals and policies on equity. 1,19
Although both public and private facilities are generally described as belonging to
general categories (primary, secondary, tertiary and quaternary) based on the degree of
departmentalization and specialization, the delineations are not always distinct and
tertiary hospitals are known to provide primary care. Meanwhile, other hospital varieties,
such as ambulatory and 5-bed hospitals, require a reworking of the concept.1 Defining
the content of hospital packages – such as what they did in South Africa 18 – rationalizes
the system while informing all stakeholders.
Our proposal is for the DOH to develop a unified concept and framework of the
hospital system and its different components, public-national, public-provincial and
private/nongovernment to guide the rationalizing and unifying process.
Continue efforts to integrate nationwide hospitals and hospital services
The fragmented operation of Philippine hospitals which result in ineffectuality,
inefficiency and inequity require extensive integration mechanisms, some of which are
already being done, e.g. sharing of resources between private and public hospitals, and
coordinated referral systems.19 Coordinating bodies have also been proposed, such as a
hospital development commission for regulation, and a health services and technology
assessment authority for information.1
The Secretary of Health, Sec. Ona, has mentioned the “clustering of health
facilities as a health governance intervention directed at improving the capacities of
health facilities across the region and beyond.20 This is indicative of DOH’s willingness to
assume a stronger role in health system integration.
Our proposal is for DOH to study the viability and appropriateness of the different
unifying mechanisms proposed.
IV. DOH must act decisively to address structural barriers to the rationalization
and integration of the health system.
Below is a model of the health system and its different levels:
Figure 3. Model of health system based on Primary Health Care
The recommendations raised - which include developing an Essential Health
Care Package, strengthening the District system and hospital, and integrating the
hospital system - cannot be effectively undertaken or sustained if two structural features
of the system: devolution and privatization are not strategically addressed. Patchwork
remedies, such as the establishment of additional structures to coordinate and
harmonize fragmented function will merely add to the work and complexity, and result in
further ineffectuality and inefficiency.
We propose a serious rethinking of devolution, which, is woven not just into the
Local Government Code, but into the 1987 Philippine Constitution. Decentralization is
proposed by experts as a policy mechanism to achieve a specific objective, e.g.
efficiency, effectiveness, political democracy, etc.21 But in the Philippines, devolution is
not just a means; it is an end in itself.
Sec. Ona’s concept of “regional clustering,” which falls within the framework of
both the LGC and Constitution bears serious support.
We also propose serious thinking of public-private partnership, which is
ubiquitous in all the levels of health care, but bears attention given the poor’s growing
predilection for private care in the light of poor public health. There is much scope to
support private initiatives and public-private collaboration, but the bottomline is to
prevent excessive profit making on health, further fragmentation of services, and wider
disparities in health care.
To summarize, DOH needs to properly organize and manage health care levels
in all parts of the system “so that people get the services they need when they need it, in
ways that are user friendly, achieve the desired results, and provide value for money.”22
1. Caballes AB. An Appraisal of the Policy Environment for Philippine Hospital Sector
2. Field Health Services Information System Annual Report, 2007. Department of
3. Modol X, EHP Funding and Costing Feasibility Preliminary Report. September 8,
4. Executive Order No. 119. Reorganizing the Ministry of Health, its Attached Agencies
and for Other Purposes. Republic of the Philippines. January 30, 1987.
5. Comparative Analysis of 5 Inter Local Health Zones: Current Practices, Policy and
Program Directions. http://erc.msh.org/hsr/linksites/lhs/ComparativeAnalysis.pdf.
Accessed November 30, 2010.
6. Administrative Order 174, Series of 2004. Departmenet of Health.
7. Sentrong Sigla – Home. http://www.doh.gov.ph/sentrong_sigla. Accessed December
8. Andersson B and Alcantara MO. Philippines: Health Sector Development Program
Technical Assistance Consultant’s Report. Asian Development Bank, 2007.
9. National Demographic and Health Survey. National Statistics Office, 2008.
10. Freedman LP, Waldman RJ et al. Who’s got the power? Transforming Health
Systems for Women and Girls. UN Millenium Project Task Force on Child Health and
Maternal Health, 2005.
11. District Health Facilities: Guidelines for Development and Operation. World Health
Organization Regional Publications, Western Pacific Series No. 22, 1998.
12. Pavignani E and Colombo S. Analysing Disrupted Health Sectors: A Modular
Manual. World Health Organization, 2009.
13. Lerberght WV, Evans T et al. The World Health Report 2008: Primary Health Care –
Now More Than Ever. World Health Organization, 2008
14. Development of an Essential Health Package, submitted by Health Futures
Foundation, Inc. to WHO Philippines, Sept 2010.
15. The Critical role of district hospitals in providing poor communities with timely, cost-
effective care. Disease Control Priorities Project, April, 2007.
http://www.dcp2.org/file/78/DCPP-DistrictHospitals.pdf. Accessed December 1,
16. McKee M & Healy J. The Role of the Hospital in a Changing Environment. Bulletin of
the World Health Organization 2000;78(6):803-10.
17. Edwards N. et al, Policy brief no. 5: Configuring the Hospital in the 21 st Century.
World Health Organization, 2004.
18. Hensher M, Price M and Adomakoh S. Referral Hospitals Ch. 66. Disease Control
Priorities Project, 2006.
19. National Objectives for Health, 2005 – 2010. DOH Manila. 2005
20. Ona, E. The Aquino Health Agenda: Universal Health Care for All Filipinos.
Florentino Herrera Memorial Speech, October 22, 2010.
21. Saltman RB, Bankauskaite V and Vrangbæk K eds. Decentralization in Health Care
– Strategies and Outcomes. World Health Organization, 2007.
22. Waddington C and Egger D. Integrated Health Services – What and Why? World
Health Organization Technical Brief No. 1, May 2008.
Reforms in the Health Human
Resource Sector in the Context
of Universal Health Care
Ernesto O. Domingo, M.D.
University of the Philippines Manila National Institutes of Health
An indispensible component of UHC is HHR that is adequate, of the correct mix,
optimally deployed, highly skilled, well motivated, reasonably stable, and functioning
within an integrated health care delivery system which utilizes primary health care as the
primordial service at the community level.
There are 22 categories of trained health workers in the Philippines which do not
necessarily correspond to international classification as a result of peculiar demands by
the Philippine health care system. 1 For the purpose of this paper only 6 categories will
be included divided into 2 groups designated principal and accessory. This arbitrary
classification is based on the current and future role these professionals will assume in
UHC. The principal category includes physicians, nurses and midwives. Assorted
paraprofessionals, dentists, physical therapists belong to the accessory category. Unless
qualified the term HHR refers to all six.
One of the most iniquitous features of the current health care system is the
absence or inaccessibility of professional health care to the majority of poor Filipinos. It
is estimated that 60% of Filipinos who die do so without health professional attendance. 2
A survey of government health workers per region in 2006 lifted from the WHO Health
System in Transition Document (HIT) of 2010 is shown in Table 1. Of the 17 regions
surveyed the number of doctors, nurses and midwives in three of the most affluent
regions (NCR, III, and IVA) are, by far the highest. On the other hand the lowest
numbers of these health professionals are registered in the most depressed regions
(CAR, MIMAROPA, XI, Caraga and ARMM) For comparison 40.0%, 34.9% and 26.7%
of doctors, nurses, and midwives respectively are in the three most affluent regions while
the corresponding figures for the three most depressed areas (CAR, MIMAROPA,
ARMM) are 8.2%, 8.9% and 9.4%. NCR, Region III (Central Luzon) and Calabarzon
have the largest proportions in the two highest wealth quintiles, while ARM,
SOOCSKSARGEN, and MIMAROPA have the largest proportions in the lowest wealth
quintiles. CAR is only somewhat better.
Table 1. Government health workers per region, 2006.
Region Doctors Nurses Dentistsa Midwives
No. % No. % No. % No. %
NCR 650 22.0 683 15.6 561 28.8 1,065 6.3
CAR 83 2.8 151 3.5 32 1.6 599 3.6
Ilocos (I) 154 5.2 232 5.3 110 5.7 1,019 6.0
Cagayan Valley (II) 95 3.2 176 4.0 69 3.5 816 4.8
C. Luzon (III) 284 9.6 384 8.8 171 8.8 1,630 9.7
CALABARZON (IV-A) 247 8.4 459 10.5 1,802 10.7
MIMAROPA (IV-B) 83 2.8 124 2.8 527 3.1
Bicol (V) 179 6.1 271 6.2 89 4.6 1,072 6.4
W. Visayas (VI) 263 8.9 485 11.1 111 5.7 1,689 10.0
C. Visayas (VII) 215 7.3 305 7.0 139 7.1 1,495 8.9
E. Visayas (VIII) 152 5.1 208 4.8 90 4.6 880 5.2
Zamboanga (IX) 94 3.2 167 3.8 42 2.2 541 3.2
N. Mindanao (X) 116 3.9 203 4.6 73 3.8 956 5.7
Davao (XI) 69 2.3 110 2.5 62 3.2 859 5.1
SOCCSKSARGEN (XII) 108 3.7 186 4.3 55 2.8 817 4.8
CARAGA (XIII) 85 2.9 116 2.7 57 2.9 631 3.7
ARMM 78 2.6 114 2.6 26 1.3 459 2.7
Philippines 2,955 100.0 4,374 100.0 1,946 100.0 16,857 100.0
Note: a. – 2005
Source: DOH, 2009; PSY 2008, NSCB.
We see in the Philippines the paradox of inadequate to absent health care
professionals in many economically depressed regions in the face of an overall
oversupply of such professionals nationally. For example, the total output per year, i.e.
the number of doctors, nurses and midwives passing the Professional Regulation
Commission (PRC) licensure examination covering the years 2005 to 2009 is shown in
Table 2. These numbers constitute the pool of available HHR for the health care system.
In fact in terms of density of health workers relative to the population, the Philippines is
doing well compared to its Asian neighbors (see figures 1 and 2). The density of doctors
in 2004 was 1.14 per 1000 population which was above that of Indonesia in 2006 and
Thailand in 2007. There were 4.2 nurses for every 1000 Filipinos in 2004. This density
was comparable to that of China, Malaysia, Thailand and Korea, and above that of
Indonesia. The 2008 average midwife-to-population ratio of 1.70 per 1000 population
was highest when compared to Malaysia, Indonesia, Thailand, the Republic of Korea
Table 2. Licensure examination passersa
Profession Yearly average Period covered
Medicine 2,382 1999-2008
Nursing 29,934 1999-2009
Midwifery 1,852 2010b
a. Source: Professional Regulation Commission (PRC)
b. – only year date available
Figure 1. Doctors per 1,000 population in the Philippines & selected countries, 1990-2008.
Source: WPRO-WHO, 2009
Figure 2. Nurses per 1,000 population in the Philippines & selected countries, 1990-2008.
Source: WPRO-WHO, 2009
But where are these health care professionals? When disaggregated by type of
practice, the proportion of doctors and nurses in private hospitals is well above those in
public ones. (see table 3) The reverse is true for midwives because midwives are
employed mostly in government run facilities at the barangay level doing primary care.
The number of Department of Health (DOH) registered barangay and rural health
stations number a little over 14,000 and 2,000, respectively, in the year 2001.3 Hence,
while most midwives are employed by the public sector (government) the sheer number
of facilities needing their services cannot be matched by the output of the schools for
midwifery. In the 2003 National Demographic and Health Survey (NDHS) the facilities
that were most utilized were the barangay health stations, followed by public centers and
private clinics.3 Based on the results of the 2007 HPDP-OP survey, those belonging to
the two highest income quintiles accounted for 50% of those who opted for private
(hospital) care while families belonging to the two lowest quintiles comprised 55% of
those who went to government hospitals. (see figure 3) In sum therefore more doctors
and nurses serve the private sector. Midwives who serve mainly the public sector cannot
adequately man the large numbers of barangay and rural health stations because the
production of these professionals relative to demand is comparatively much less than for
doctors and nurses. Considering that the poor Filipinos rely mainly on barangay and
rural health stations for their health service needs the shortage of midwives in these
facilities amounts to lack of access.
Table 3. Government and private health workers, Philippines, 2006.
Profession Government Private Total
No. % No. %
Doctors 2,955 38.8 4,660 61.2 7,615
Nurses 4,374 18.8 18,948 81.2 23,322
Dentistsa,b 1,946 89.8 220 10.2 2,166
Pharmacistsb 29,274 95.7 1,302
Midwivesc,d 16,857 93.3 1,218 6.7 18,075
a.- in hospitals
b. - 2005
c. - 2002
d. – private, self-employed: private employees: and private, self-employed and employees
Source: PSY 2008, NSCB
Figure 3. Hospital Utilization by hospital type and patient income quintiles
Source: 2007 HPDP-OP
In relation to the above, consider the staffing pattern in the five leading tertiary
hospitals in Manila shown in Table 4. These hospitals which also have the most
advanced health technologies in the whole Philippines have a combined capacity of
2095 beds. Their combined medical staff excluding the trainees (fellows and residents)
comes to about 6,151 physicians almost all of whom are specialists. This comes to a
rough ratio of 2.9 physicians per hospital bed. Assuming a very high bed occupancy rate
of 90%, and assuming further that 30% of these physicians have multiple hospital
affiliations, the ratio is still high at 2.2 physicians per hospital bed. These private
hospitals are not only adequately staffed but are in fact overstaffed. Each subspecialty of
medicine is served by an excess number of kindred specialists, in some reaching
ridiculously high number. Since these hospitals cater to the rich and affluent few; the
highest level of care is thus disproportionately consumed by the economically well off
and denied to the poor majority. This is a classic case of inequity. Thus, it is accurate to
say that in the Philippines 70% of physicians serve 30% of the population who can pay
while 30% serve the rest who cannot pay.
Table 4. Bed capacity and number of staff physicians in five top private tertiary hospitals
in Metro Manila
Hospital Number of Beds Physiciansa,b,c
A 600 1,900
B 300 900
C 237 1,056
D 480 1,294
E 478 1,001
Total 2,095 6,151
a - mostly specialists
b - exclude M.D. trainees
c - some affiliated to other hospitals
Root causes of the problem
To understand the problems besetting the HHR sector one has to go back to the
way they are produced. There are at least three easily identifiable causes. These are:
1. near complete dominance by free market forces, with demand favored over
need under the philosophy of what the market can bear;
2. capacity for training determining quota of students rather than sustainability of
graduates entering the workforce;
3. absence in the educational/training program of a strong emphasis on public
service and the common good over private gain.
Ever since the complete deregulation of higher education in the 1990’s any
institution which can comply with the requirements of the Department of Education
(DEC) and Commission on Higher Education (CHED) is allowed to offer courses in the
health professions. In medicine, from five medical colleges in the 1960’s, all located in
Metro Manila, the number has grown to its present 38 located in various regions of the
country. For nursing the number is even more bewildering, 465 schools and colleges all
over the country. For midwifery there may be some logic in approving the operation of
223 schools because midwives are the backbone of the barangay and rural health
stations. Still the question can be asked, by what basis have these numbers been
In fact the only basis for the proliferation of these professional schools is that
they have the capacity and the resources to offers such courses, reinforced by the
policies of the approving agencies of government (CHED and DEC) that pay little to no
attention to need and sustainability.
All schools and colleges offering degrees in medicine, nursing and midwifery are
given quotas on the number of students they can accept into their classes. The quota is
based on the institution’s capacity to provide “standard” quality of instruction which in
turn is based on number and competence of faculty, classrooms, equipment and
patients available as material for instruction. Without going into the merits of the
“standard” as well as the quality of the others, this practice does not take into
consideration the absorptive and retentive capacity of the public and private sectors
engaged in health care provision.
A perusal of the enrolment figures for the three professions is shown in Table 5.
For the year 2006 the total enrolment in nursing was 340,961. For midwifery the total
enrolment for a 4 year period, 2001-2005, came to 59,836. Without bothering with the
yearly fluctuations in enrolment, the yearly average for this course is 14,935 for the
period covered. For medicine the total enrolment for the 38 medical schools is not
available. However, a surrogate figure can be extrapolated from a number of data. For
example, the total enrolment in the first year class for the last seven years, 2003-2010,
ranges from a low of 2365 to a high of 3745 with an average of 2751. Assuming an
attrition rate of 20% from the 1 st year up to graduation the projected number of students
finishing the course is from 1892 to 2996, average 2444. These figures are close to the
number of M.D. graduates who took internship preparatory to taking the licensure
examination: range 1671-2733, average 2255 per year (2004-2009).
Table 5. Number of schools/colleges and enrolment of principal HHR1
School/college Total enrolment
Medicine 38 13,957c
Nursing 465 340,961d
Midwifery 293 59,836e
Sources: PRC, CHED, APMC; a - year 2006; b - year 2010; c - extrapolated data from 1 year
enrolment and internship; d - year 2010; e- year 2001-2005
The entry of these students into the various schools and colleges occurred
without consideration neither to where they will go after graduation nor to the capacity of
the workforce to absorb them. This results in migration to other countries or relocation to
employment unrelated to the original profession (physicians working as nurses) or
crowding into highly competitive workplace (overstaffed tertiary hospitals).
There is no accurate and timely count of active health workers in the health care
system, much less warm body counts in real time and actual location. 1 There is also no
timely accounting of loss thru attrition. Thus, even the replacement of loss vis-à-vis
replacement via new recruitment, and filling of unmet needs become shaky estimates.
This is a yawning deficiency with consequences on HHR production. Developing the
system that will provide these data should be a major objective of the reform envisioned
for the health information sector.
In order to forecast the future need for HHR the DOH in collaboration with WHO
developed in 2000 a 30-year Human Resource Master Plan (HRMP-2000-2030) for the
Philippines, a sample of which is shown in Table 6. The plan is based mostly on
estimates of population growth and the consequent need for HHR according to arbitrary
standard ratios. Notwithstanding the many questions raised by the method, the plan
nevertheless can be used as a starting point for more detailed planning.
Table 6. Projected Demand for Health Workforce, 2010-2030 (selected years),
Projected Workforce Requirements
2010 2015 2020 2025 2030
Doctors 19,402 21,158 23,080 25,851 27,491
Nurses 185,788 202,603 221,010 241,166 263,244
Medical Technologists 6,393 6,633 7,033 7,553 7,779
Physical Therapists 7,644 8,346 9,117 9,964 10,893
Occupational Therapists 5,733 6,250 6,820 7,443 8,126
Pharmacists 23,518 25,646 27,976 30,527 33,322
Midwives 18,897 20,603 22,469 24,513 26,751
Source: Lorenzo FME et al HRM Master Plan (2010-2030), 2005
Unfortunately, there is no indication whatsoever that this plan or any other plan
has ever been considered by those responsible for producing these HHR. Instead, the
supply side, that is, the demand by would be health professionals, becomes the only
imperative responded to by these “producers.” The need if ever it is considered by the
“producers,” refers only to demand from foreign employers.
The mismatch between overproduction and inadequate absorptive and retentive
capacity of both the public and private sector is at the heart of HHR migration. Table 7
shows the position of the Philippines in the top 20 countries trend in the migration of
health professionals. This and the maldistribution of those who remain in the country
driven by the imperative of economic gain can be linked to the inequity of access to
health professional care.
Table 7. Top 20 countries of medical education for IMG physicians in the United States1
Country Total Percentage
India 51,447 20.7%
Philippines 20,601 8.3%
Mexico 13,834 5.6%
Pakistan 12,111 4.9%
Dominican Republic 7,979 3.2%
Grenada 6,749 2.7%
USSR 6,450 2.6%
Dominica 5,854 2.4%
China 5,375 2.2%
Egypt 5,266 2.1%
Iran 4,940 2.0%
South Korea 4,845 2.0%
Italy 4,732 1.9%
Spain 4,343 1.8%
Germany 4,197 1.7%
Syria 3,869 1.6%
United Kingdom 3,698 1.5%
Montserrat 3,569 1.4%
Columbia 3,343 1.3%
Ireland 3,302 1.3%
Source: American Medical Association, 2009
The 77.5% of IMGs are in patient care. Note that the Philippines is the only
country in Southeast Asia in the top 20. If the only reason for physician migration were
lack of local opportunity, then there should be more immigrant physicians from our
neighboring countries. The same can be said of nurses and other health professionals.
Maybe there is more to just overproduction and lack of local opportunity. Maybe there is
something missing in the way they are educated and trained.
Public service and the common good over private gain
Nowhere in the education and training of would be health professionals, by all the
academic institutions in the country, is there a deliberate and serious effort to emphasize
public service and the common good over private gain. A perusal of the representative
curricula from three medical schools, each representing a particular vested group (see
appendices 1, 2 and 3) show the near absence of dedicated time in the curriculum for
students to be made aware that they have a responsibility in providing public service and
promoting the common good. In the medical curriculum of the National University, an
institution with the mandate and the tradition to place public service and the common
good on equal importance as academic excellence, the total time allocated for the
discussion on matters bearing on the subject is only 64 hours out of a total of 2,502
didactic hours in the first 2 years of school. And while there are at least 23 weeks out of
131 weeks in the clinical years (3 rd year to internship) that will provide this opportunity, it
is doubtful whether in fact, this time is devoted to such concern.
The grant of access to education and training in the health professions has not
been linked at all to achieving a reasonable probability that the student when he
graduates, will place himself in some context that will contribute to the improvement of
access and equity in health.4 While there have been some attempts, especially by the
National University, to incorporate this principle in their academic undergraduate and
postgraduate programs, the effort is “feeble” in the context of the national problem. The
educational process fails to modulate the dominant motivation of the majority of the
students and their families, which bankroll their education, which is to recoup their
investment with profit, in the practice of the profession.
The heavy emphasis on the science of medicine in the clinical years relegates
the discussion of the social aspects of the profession to unwelcomed distraction. For
comparison the time allotted to a course that provides the venue for discussing the
social, economic, anthropologic, and ethical dimensions of health problems in the
undergraduate years of medicine (1 st and 2nd yr) is shown in Table 8. The table
represents the national university which is secular and public, a religious and private
university with the largest enrolment, and a small institution with no pretensions to public
Table 8. Time in the curriculum providing opportunity for socio-anthropo-ethico-
behavioural (SAEB) discussion1
Curriculum Medical College
A B C
Preclinical (1 -2 yr.)
Total Time 2,502 hours 2,390 hours 2,514 hours
% biomedical 94 94 92
% SAEB 6 6 8
Clinical (3rd-4th yrs.)
Total Time 79 weeks 1,303 hours 1,282 hours
% biomedical 81 86 86
% SAEB 19 14 14
Internship (5th yr.)a
Total Time (weeks) 52 weeks
% biomedical 85
% SAEB 15
Total Time (weeks) 52 weeks
% biomedical 62-85
% SAEB 15-38
Sources: Official college brochures
a - Internship part of undergraduate in A, postgraduate for B and C
In recruitment of future HHR
The regulation of health professional education is the responsibility of the CHED
(CHED, RA 7722) in the case of medicine and nursing while the DEC (DEC, RA 2644,
revised 1992) prescribes the requirements for the midwifery course. Although CHED and
DEC are the ultimate authorities prescribing the minimum requirements for admission to
these professional schools, their corresponding education board as well as the official
organization of their respective schools and colleges, for example, the Association of
Philippine Medical Colleges (APMC) may prescribe other admission requirements.
As a result of free market forces, stiff competition for enrollees ensues since
there are not enough applicants to fill the quotas of the schools and colleges. The
bottom line requirements for enrollee applicants are thus reduced to academic
qualification and ability to pay for the education. Even academic requirement is not
uniform as some institutions are forced to accept students below the desired academic
cut-off to survive financially. Therefore the recruitment process fails to identify in the
search for the ideal student, the one who after graduation has a high probability of
contributing to access and equity in health service.
In undergraduate and graduate education and training
In 1975 medical schools were criticized for preparing students for “dimly
perceived requirements of the twenty first century, while largely forgetting or even
ignoring the health needs of today and tomorrow.”4 Unfortunately, the overwhelming
health need of the Philippines today is still basic health services for everyone, not tertiary
care with state of the art facilities.
A quick glance at the undergraduate offerings of the health professions show the
stereotypical and pigeon-hole character of the courses. The products of these programs
are graduates prepared to practice their profession on the classical model of one on one,
professional-clientele contact, in a controlled environment. Basic health services
anchored on primary health care principles need professionals whose education and
outlook prepare them to work not only with individual patients but with communities both
as care givers and transformative leaders. The undergraduate student is being prepared
to be technologically savvy but is not equipped to appreciate, much less handle the
attendant social dimensions of illness.4
In 1997 the National Health System (NHS) of Britain was reviewed in order to
improve the speed of delivery of health services. Heretofore, the average waiting time
from referral to treatment was a long 18 months. In a publication entitled High Quality
Care for all, the NHS established the mission of providing high-quality care – driven by
clinical leadership, best evidence, and innovation – as the organizing principle of the
service and has put the NHS firmly on the path toward systemic improvement in
outcomes and efficiency. The review involved 2000 clinicians from all fields of care. It
was a trailblazer because clinicians defined what an effective health care system is. It
also involved them in defining the link between funding and the care provided. Finally
they were challenged to develop a system that puts quality of care before financial gain.6
Without assuming that the foregoing will be the organizing principle of UHC
(although it is an accepted principle) it nevertheless highlights the role that clinicians and
other health professionals should additionally assume in a UHC. The present system of
undergraduate and graduate education does not give the student as much as a nodding
acquaintance, not to mention comprehensive knowledge, on how our particular health
system works. The undue emphasis on technical knowledge, proficiency in skills, literacy
in technology, and narrow specialization prepare students for practice in first world
countries rather than a developing country like ours.
The template in undergraduate and graduate education turns out graduates
distinguished only for being copies of one another, clones in other words. The
curriculum, pedagogy, and assessment tools for measuring exit qualifications ensure
that this will be the case. Products of this educational process will be greatly
handicapped once confronted by real health problems in families, communities and
In deployment and retention
Consideration of deployment should be part of the production process. An
accurate estimate of the need, based on real time high quality information, is the first
requisite of a successful deployment program. Many first world countries are able to
estimate their needs for health human resource on a continuing basis. This estimate is
the basis for regulating the production of health professionals. Measures are available to
their government which are basically incentives to stimulate production or disincentives
to downsize the output if the system is a free market. There is no comparable data in the
Philippines. There is therefore no firm basis to anchor an accurate HHR production.
There is a HHR production plan in the DOH which estimates the need for the
next 30 years based on projected population increase as shown in table 6. 7 Such a plan
does not capture the true need for HHR because it does not incorporate deployment
data among many others. In the end the deployment status for HHR will be determined
by output and the market forces. Only in a limited manner can the absorptive capacity for
the health workforce be accurately estimated unless reform in the information systems
provide the technological tools.
The DOH, based on plantilla will have figures of their absorptive capacity. The
same is true for the local government in so far as the health facilities under their control
are concerned. Various industries know their need. But in the private sector, the capacity
of the workplace to support the health care worker is difficult to establish. If the situation
in a private hospital were to be used as a rough parameter for example, the number of
practicing physicians to hospital beds, the resulting number is indicative more of supply
than need. Staffing in a private hospital is based mainly on the principle of the more
physicians the better. This is anchored on another principle: the physician is the clientele
of the hospital because he is the one who brings in patients.
In principle, the public sector need for HHR must be filled primarily by graduates
of state supported institutions. There are model programs of government that can be
replicated to fill this need like the School of Health Sciences in Leyte, Aurora and
Cotabato. However, the need is empirically estimated to be bigger than can be produced
by these institutions. Therefore, the private sector must make up for the deficiency
based on the strategies to be discussed subsequently on recruitment, education and
Once absorbed into the system, the workforce needs to be nurtured. Part of the
nurturing process is the provision of competitive working conditions very basic of which
is salary and non-monetary perks. The gap between what a health worker in government
gets compared to one privately employed is too wide to be left unattended. It is useless
to talk of effective deployment unless the playing field is leveled.
Objective underlying reforms in HHR production
The principal objective of the production of HHR should be to provide competent,
well-motivated, transformative and committed health professionals to the health system
that provides universal care. In order to achieve this objective, fundamental changes
have to be instituted in the recruitment, education, training and deployment of health
The selection process for students to be given access to a health profession
career must identify those who are expected to be assets in addressing the problem of
access and equity in health care in our country. Depending only on academic
qualification and ability to pay for their education as the main criteria for admission do
not increase this probability. In fact, as reported by Stefan Theil, achievement
differentials i.e., value added to human capital by attending college, are actually higher
at good quality schools with less selective admissions than they are at IVY league
universities. In other words, academic discrimination based on a few point differences in
academic score is less important in getting the desirable student. Criteria designed to
ferret out characteristics that have high predictive value on the career path the student
will most likely follow after graduation should be the main feature of the selection
As a start, active scouting for desired students must compliment the current
passive method of student intake. The initiative must be on the school, not on
prospective students. The mechanisms for doing this selection process are well
developed and have only to be adopted. One example is scouting for students with
excellent sports aptitude.
Innovative screening and interview techniques found successful by big business
corporations, world-class universities, religious orders, military academies, lobby groups,
cause oriented advocacy organizations and others can be adopted. Professional groups
specializing in selection methodologies can be tapped for the purpose.
The future career paths of entering students should not be left completely to
random probabilities. There should be a predetermined student mix where a proportion
of students in a given class are admitted and deliberately guided to a particular career
path, with full knowledge of the students and the faculty. Considering the size of the
entering class in medicine (see table 9) even a 10% share of students deliberately
recruited for a specific purpose will eventually result in a sizeable cadre to spearhead a
Table 9. First year enrolment in 38 medical schools 2003 to 2010 and annual number of
interns from 2004 to 2010
School Year 1st year class Interns
2004-2005 2,587 2,730
2005-2006 2,365 2,640
2006-2007 2,504 2,277
2007-2008 2,572 1,957
2008-2009 2,771 1,671
2009-2010 3,745 1,447
Source: Association of Philippine Medical Colleges (APMC)
For state supported schools admission for return service agreement or some
similar arrangement has to be policy. This is an equitable way of repaying the subsidy
extended to the student coming from tax money. A similar arrangement can be justified
in private schools for students enjoying scholarship from government. The private school
can also be persuaded to allocate slots in their classes for student who will be their
scholars, in exchange for which government will reciprocate via tax-incentives and the
An even better, in the sense of higher success rate, admission policy is to accept
students who have a “social contract” with their community of origin. In the model
adopted by the School of Health Sciences, University of the Philippines Manila, in
Tacloban Leyte, all the students were selected by the community. The continuing stay of
the students in the School depend on the continuing endorsement by the community at
the end of every service leave, which is also a feature of the program. The retention rate,
that is the number of graduates who return to their communities or equivalent places, to
practice their profession is an outstanding 95% over decades of producing such
It has been shown in the School’s experience that selecting students from within
the underserved communities, in particular those from poor families improve the
eventual retention rate. By favoring native intelligence and trainability over achievement,
many future professionals with desirable qualities, who would otherwise be lost to the
system, were given a chance to complete their education and eventually serve.
The health problems of the country need professionals whose education and
outlook prepare them to work not only with individual patients but with families,
communities and population as care givers and as transformative leaders. The global
demand for doctors, nurses and other health professionals, particularly in wealthy
countries, has shaped the design and content of the medical curriculum to turn out for
export, products whose knowledge, skills and way of thinking are suitable for health
systems foreign to the Philippine situation.
The undergraduate program must be fashioned so as to bring out in the students
not only the desire but also the ability to respond to the nation’s health problems. Both
the content and the methodology of undergraduate education need fundamental
reorientation for the singular purpose of making it relevant and responsive to the major
health problems afflicting the majority of Filipinos who are also poor.
The curriculum should be infused with more social sciences, interwoven in the
teaching of biomedico-technical subjects and further reinforced by dedicated hours of
motivating. Technical lecture should be introduced by a brief discussion of the subject’s
social dimensions. Teaching must be contextual rather than purely content oriented.
Values, especially social values must be given ample space. Ethics governing individual
patient care should be expanded to include those applicable to communities and
populations. Always, the economic implication of any intervention in relation to outcome
must be part of the discussion of any disease state as is the acquisition of state of the art
technology. It is desirable that comparison be made between the outcome of
predominantly social intervention as against purely technological.
A cursory examination of the curriculum content of the medical undergraduate
program from three medical schools as shown in table 8 and appendices 1, 2 and 3
indicate the comparative importance given to the social dimensions and determinants of
health compared to achieving professional competency in the undergraduate instruction
in medicine. This can be inferred from the time allotted to subjects and/or assignments
(rotation) where concern for relevance can be thoroughly discussed. The data in table 8
would indicate that unless every instruction period in any subject or course is considered
as opportunity for putting social dimensions to the technical subjects, the time dedicated
to such kind of discussions will be overshadowed by technical matters. Hence, the need
to be contextual rather than context oriented.
The undergraduate curriculum of the health professions is rigid and inflexible.
The assumption is all graduates will pursue the same career path: all will be taking care
of individual patients. Those who have inclinations to pursue other career paths have
been deprived of the opportunity to at least be introduced to the disciplines they will
need later, hence the last three years of their schooling, in medicine, for example, have
The curricula, at least for medicine, nursing, and midwifery should be flexible to
enable students to differentiate early and follow their chosen paths without being
required to take the standard course for the degree. The only must courses should be
those that will equip the student with the language and fundamentals of the profession.
Beyond this, the curriculum should be flexible. It should allow the student who has made
the decision on what he should be after graduation, to start acquiring the requisite
knowledge and expertise relevant to his chosen career in the undergraduate years. This
flexible curriculum is in fact, a requirement for a system where the desirable student is
recruited and guided to a specific career path. The flexible curriculum may also require
multidiscipline and multi-college offerings for a given course. It will inevitably require a
“breaking-down” of the walls that now separate colleges and departments in many
universities. The student emerging from such an educational process will find
multitasking in the workplace a less formidable challenge.
Another feature of the desirable educational process is the service leave wherein
a student leaves school for a short time for immersion either in a community or a
government run health care facility. The exposure can serve two purposes: strengthen
(reinforce) his desire to serve, or, realize early that this is not the career he wants. Either
way the result is beneficial to the system.
The locus of schooling if it is close to where the student comes from, greatly
enhances the prospect of the student settling in his native community or some similar
areas. Therefore, dispersal of health professional schools should favor areas where the
need for health services is unmet.
The undergraduate program should be able to shift to a new program with ease
and dispatch, when demanded by the health sector reform. It should also be able to
create a new type of health professional. It may well be that the backbone of the basic
health service nationally is not a physician, nor a nurse, nor a midwife but a chimera
emerging from an amalgam of health disciplines. Such a professional may, without
intending to, be ineligible to be recruited to work outside the country because, there is no
way his academic status may be evaluated according to international norms.
Training in the context of this paper refers to the postgraduate period. It pertains
to a program that endows a specialist status to the trainee. Mainly demanded by
specialty professional societies, certification as to specialist status is also by them.
In specialty training
A universal health care system will require a mix of generalists and specialists,
the right proportion of which has to be based on an accurate estimate of the need for
their services. Currently, specialty training in medicine, the type and number in
particular, is supply driven. Organized private specialty societies determine the number
of training positions in recognized institutions as well as the program. As anticipated the
output of the programs are not in accordance with needs but on capacity of the training
institution. This has given rise to a situation where there are more specialists than
generalists, a condition that has impacted on the quality and cost of medical care. (see
table 10) In this table members of the Philippine Medical Association (PMA) can be
considered the closest number to licensed physicians practicing their profession in the
country regardless of the type and place of their practice or their whereabouts. On the
other hand, members of numbers 8 and 9 societies are pure specialists with no patient
care activity. Those from numbers 2 to 7 societies are almost all patient care specialists.
Members of number 10 society most likely provide family and primary care. From these
numbers a rough estimate of generalists to specialist ratio will range from 1:3.3 to 1:3.0;
very far from the desirable ratio of less than 1:1 in favor of generalist required in a UHC
Table 10. Membership to major professional societies in medicine1
Society Number of members
1. Philippine Medical Association 64,315
2. Philippine College of Physicians 7,660
3. Philippine College of Surgeons 2,256
4. Philippine Pediatric Society 3,333
5. Philippine Obstetrical and Gynecologic Society 3,131
6. Philippine Academy of Ophthalmology 1,539
7. Philippine Society of Head and Neck Surgery 458
8. Philippine Society Pathologists 597
9. Philippine College of Radiology 1,132
10. Philippine Academy of Family Physicians ~ 6,000
Source: Individual Societies
In nursing where there is a real need for nurse specialists, the output from
training institutions is very niggardly because, in fact, there are not even a handful of
institutions that can provide specialty training. In midwifery the issue is more about
postgraduate training rather than specialty training. This is not to say that there is no
need for a midwife specialist. In the future, when UHC is fully implemented, such a
midwife specialist will surely be needed and will emerge.
In postgraduate training
Postgraduate training at present is very much a drug industry directed activity
since the fund needed are provided by them. The specialty training programs in
hospitals are heavily subsidized by the pharmaceutical companies. All the major
postgraduate activities including annual conventions and overseas attendance of
trainees are bankrolled by drug firms. Withdrawal of financial support can result in
closure of a significant number of training slots in many institutions while postgraduate
courses will effectively stop.
The biggest number of postgraduate specialty training positions is available in
the Philippine General Hospital (PGH). No other medical center in the country comes
close to PGH in this regard. Table 11 shows the specialty slots called fellowship in the
Department of Medicine in PGH, which has the most number of fellows in training
among all the departments, both clinical and basic. Of the total 74 fellows in 2008, 72 or
97% were funded by pharmaceutical companies. At the Manila Doctor’s Hospital which
has only 8 fellows in the whole institution, 7 or 88% are drug company supported. Similar
situation exists in the rest of training hospitals in the country.
Table 11. Post-residency specialty slots (fellowship), Department of Medicine UP-PGH
Medical Center, 2008
Total number Supported by Drug Supported by
of fellows Company Hospital
Allergy / Immunology 2 2 0
Cardiovascular 16 16 0
4 4 0
Endocrinology 9 8 1
Gastroenterology 6 6 0
Hematology 3 3 0
Infectious Diseases 2 2 0
Medical Oncology 10 10 0
Nephrology 8 7 1
Pulmonary Medicine 10 10 0
Rheumatology 4 4 0
Total 74 (100%) 72 (97%) 2 (3%)
Source: Director’s Office, UP-PGH
Postgraduate programs should be taken away from drug companies’ support.
Professional availing of such programs must be made to pay the cost. A structured,
mandatory and credited postgraduate education must be required for continuing
certification of all health professionals.
Specific initial reforms in the HHR sector
Philosophy of reform
Health human resource or health workforce is a decisive sector for the attainment
of UHC. The smallest functional unit of HHR is a team and its primordial function is to
provide primary health care according to the Alma Ata declaration.8 HHR production,
specifically number and mix, is based on country need. Sustainability and the
maintenance of an effective, efficient, technically competent and happy workforce are
concerns that are of equal importance as production.
The centerpiece policy is regulation. There should be regulation in the
production, education, training, licensure, deployment, retention and the workplace
Policy instrument for HHR reform
The policy instrument is the integration under one body of all regulatory functions
exercised by various stakeholders that influence the ability of HHR to optimally provide
the requirements of a UHC.
Stakeholders in the HHR sector
Students and their families
Schools, Colleges and Universities
PRC and their respective Boards
Association of Schools, Colleges and Universities based on profession.
National Professional Organizations. Examples: Philippine Medical
Association (PMA), Philippine Nurses Association (PNA), United Midwives
Association of the Philippines (UMAP)
Specialty Professional Organizations. Examples: Philippine College of
Physicians (PCP), Philippine College of Surgeons (PCS), and Philippine
Pediatric Association (PPA)
Department of Health (DOH)
Local Government Units (LGUs)
Department of Labor and Employment (DOLE)
Private Health Insurance (HMOs)
Hospitals and Clinics
Non-Governmental Organizations (NGOs)
Based just on the number of stakeholders, it is readily obvious that attempts at
rationalization, integration and regulation of HHR production, deployment, and retention
will face tremendous difficulty because, each stakeholder, has interest and turf to
protect, which interest and turf many not be exactly supportive of UHC. Consider for
example, the number of medical schools relative to the population (see table 11). Under
the present arrangement, would CHED have enough clout to close schools which stay
afloat only because of foreign students?
Table 11. Medical schools/colleges in selected ASEAN countries1
Country Number of medical Population (in Ratio of schools per
schools/colleges thousands) thousand population
Philippines 38 90,457 1:2380
Indonesia 32 238,523 1:7454
Thailand 12 60,482c 1:5540
Malaysia 8 27,863 1:3483
Source: Asean database, 2008
a. 2010 b. 2004 c. 2005 d. 2005
The commission model
An attractive model for the policy instrument is a Commission headed by the
DOH with the following as mandatory members: CHED, PRC, Philhealth, LGU, and ad
hoc representatives from DOLE, DEC, educational institutions, national professional
organizations, and people’s organizations. The membership of these institutions and
agencies in the commission reflects their important role in the configuration of the HHR
sector: DOH is ultimately responsible for the state of health of the population aside from
being the lone Department of government that has the organization, resources and
reach to implement a nationwide health care program: CHED determines the content
and standard of education for health care professionals; PRC is responsible for licensing
of health professionals as well as ensuring ethical and legal behavior in the practice of
the profession; Philhealth, when it finally succeeds in being a true social health
insurance with universal coverage could leverage the quality and quantity of health
services to its members because it will be the major source of funding; the LGU which is
now responsible for providing health services at the provincial and municipal level
provides, funds, administers, and monitors these services; DOLE regulates foreign
employment wherein health professionals constitute a significant number, aside from
having a role in remuneration and entitlement of employees; schools, colleges and
universities are the educators and trainors; professional organizations determine the
production of specialists as well as confer titles to the professional which translates into
the compensation scheme followed not only by private care facilities but also by
Philhealth; people’s organizations represent the interest of the consumers and
communities, which interest must find its way into policy and governance. The
commission may create technical committees representing the other stakeholders not
represented in its membership. The Secretary of Health will head the commission
because the DOH is the dominant agency in matters pertaining to HHR.
The commission shall be the only body empowered to craft and promulgate
policy that pertains to standards and regulations of the production, practice and
deployment of various health professionals.
It is solely responsible for the crafting of any law to be approved by the Congress
in matters within its responsibility.
It shall be given the power to impose compliance to the policy it promulgates
under pain of sanction.
DOH CHED PRC Philhealth LGU
Health Human Resource Commission (HHRC)
Chair and CEO
(Secretary of Health)
Recruitment Education Training Deployment
- Family and student - DEC - Training Hospitals - LGU
representatives - CHED - Specialty - DOH
from Universities - Universities Societies - DOLE
- PMA, PNA, UMAP - Training Hospitals - Etc. - Phil. Hospital
- LGU - Etc. Association (PHA)
- DEC - Etc.
Figure 4. A suggested organizational chart of the Commission
Specific initial reforms in HHR as currently existing
The problems in the HHR already in place have been discussed earlier in this
paper. The root causes of the problems have been analyzed. The consequences of
these problems have been linked to the current state of HHR in the country. Reforms to
address prospective HHR personnel have been proposed but a different set of remedial
measures are needed to align the current HHR to the implementation of UHC. These
measures, at some point, must merge with those instituted in the reform for prospective
HHR as to eventually be a single system.
Principles governing the reform
1. Health service (care) is a team effort. This is a radical departure from the
identification of a specific health professional, most often a physician, as the basic
provider of health care. This assumption has spawned the expectation that there
should be a doctor in every barrio. Requiring the presence of a physician even for
clusters of barangays is not only unrealistic, but also uneconomical and
unsustainable in the long run. The team concept starts with the type of services
needed and to be provided over a defined geographic area from whence a health
service team is assembled. The team is a functional organization, not a “physical”
aggregation. The location of the different members need not be in one place all the
time. What is more important is availability of expertise whenever needed, by
whatever means, including surrogate presence via modern communication. Thus,
the membership of the team is variable. A health professional may actually be
available to more than one team.
2. There is no hierarchical system. While the Health Care Team (HCT) may be
composed of different health professionals, this by no means implies an automatic
hierarchical system. Presently, whenever a health team is assembled, the members
implicitly assume and defer to a predetermined “pecking order” based on the
educational level of the professional members. Thus, if a physician, nurse, midwife,
and paraprofessional constitute the team, it is assumed that the physician is first in
the hierarchy with the paraprofessional, last. The team concept recognizes
differences in level of expertise but not in the relative importance of their role at a
3. Leadership in the team is not automatic. Leadership changes according to
circumstances. It is determined by many factors that include need, availability,
commitment, expertise, and nature of the service among others. For example, if the
service to be provided is simply giving standard vaccination, the team leader can be
a midwife or even a paraprofessional (adequately trained, of course). If the team
leader who happens to be a physician is unavailable most of the time, the
responsibility can be delegated to the nurse, and so on.
4. Functions as well as responsibility are flexible and moveable. Not only
leadership function but other functions and responsibilities as well, should be allowed
to move from professional to professional under the proper condition that includes
guaranteed safety of the health care recipient. Programs are sometimes stymied
because of very strict rules about delegating or moving functions from personnel to
personnel. This is the consequence of having individual and separate laws governing
the practice of each profession.
5. Realistic reward system. The reward system should take into account the actual
contribution to the team effort. The current payment scheme to health professionals
is discriminatory. For example, Philhealth pays for the services of some
professionals even if the bulk of the work is done by others, who are not among
those deemed by it to be compensable. In the team concept, material compensation
should reflect actual participation, quantity, and quality of work put into the service by
a member, relative to the others. It should be possible for a nurse to be paid more
than the doctor under the preceding conditions, or the midwife more than the nurse.
6. A functioning network of health services and referral system. A health team
concept with its shifting membership, function and responsibility cannot succeed
unless there is a seamless network of progressively higher level of care, available to
the health care team via a working referral system. The basic health team which is
operating at the level of the barangays should feel secure that when the need arises,
help is available from the other primary health facilities as well as from secondary
and tertiary health care centers.
Basic requirements for HCT to function optimally
The creation of HCT to provide PRIMARY HEALTH CARE in a Universal Health
Care System requires at least three enabling conditions. These are:
1. A legal basis that will operationalize the six specific principles just enumerated in the
2. Mechanism for maintaining a skilled workforce to include,
a. Continuing education and training. This should be a required activity. It
should not be an ad hoc program. An office should be created tasked with
developing, implementing, monitoring, and evaluating the program. Clear
objectives of the program should be stated, the mechanics of implementation
chosen, and outcome measures developed. Outcome status in the
professional competence of the team members should be part of the criteria
for assigning function and responsibility, as well as the corresponding reward.
b. Opportunity for members of the HCT to continually upgrade their technical
skill and proficiency skill
c. Periodic assessment of the preparedness of the team members by simulation
of a contrived situation
3. An environment that keeps the workforce happy and well-motivated.
Attrition in the workforce, especially the unplanned ones, is a constant threat to
the effectiveness of the HCT. Some of the incentives to promote contentment and keep
motivation high are:
a. Full implementation of the Magna Carta for health workers. This is a basic
provision and must be the minimal basis for compensation.
b. Compensation from Philhealth for all members of the team. This must be
implemented as soon as possible because discriminating against some
professionals who provide health care service creates demoralization which
drives them to seek work elsewhere.
c. Competitive remuneration scheme equivalent to the private sector should be
an objective. At the very least, the difference should not be substantial.
d. Opportunities for professional growth and advancement should be available
to members, and should be encouraged even if it results in attrition, as long
as the lost member proceeds to a higher level of professional status.
e. Participation or representation in policy formulation from the HCT level and
higher. Members must be given the opportunity to attend and/or participate
during policy discussions.
f. There should be adequate protection for members from legal and political
harassment. The Civil Service Commission may provide a novel basis for the
Policy instrument for current HHR reform
There is need to consolidate into one omnibus law all the individual professional
The individual laws governing the education, training and practice of a particular
profession is the greatest hindrance to evolving a HCT. As already discussed, the HCT
that will provide the primary health care at the level of the community in a UHC scheme
will have to be characterized by a high degree of flexibility and adaptability. Variations in
membership, function, leadership, compensation, professional growth and advancement
as well as measures to minimize destabilizing attrition cannot be done without an
omnibus (integrating) law. The individual professional law is really more for protecting
turf and privilege rather than access and equity in health care. The omnibus law is meant
to remove that. In its stead the law will provide the legal basis for creating an effective
health care team, that should be the basic unit at the community level, providing primary
health care under a Universal Health Care System.
The crafting of the LAW should be the priority task of the HEALTH HUMAN
In the interim the COMMISSION may provide the format for the organization of
the HCT and its immediate deployment at the commencement of the UHC system.
The attainment of UHC will require reforms in at least six sectors of health;
financing, governance, services, regulation, information and HHR. The two
recommended fundamental reforms in the HHR sector have to be harmonized with
recommendations from the five other sectors. The integrating mechanism for
harmonization, the one that will set into motion the efforts to move to UHC has to be a
policy pronouncement from the President of the Republic. It can come in the form of an
Executive Order directing all the concerned agencies and offices under the Executive
Branch of Government to provide the framework for the achievement of UHC.
1. Romualdez AG, De La Rosa JF, Flavier JDA, et al. Health Systems in Transition.
World Health Organization, Western Pacific Regional Office. Philippines 2010.
2. Villaverde MC, Bethan MM, David LC. National Objectives for Health Philippines,
2005-2010. Department of Health 2005.
3. Caballes A. An Appraisal of the Policy Environment for Philippine Hospital Sector
Development. HPDP-OP, USAID-UPECON 2010.
4. Clavel L, Tayag JG (Eds). Strategic Directions for Health Sector Reform. UP Manila
Centennial Lectures. University of the Philippines Manila 2009.
5. World Health Forum. WHO Regional Office for Europe 1984, vol. 6, 1985.
6. Darzi A. A Time for Revolutions – The Role of Clinicians in Health Care Reform. New
N Engl J Med. 2009 Aug 6;361(6):e8. Epub 2009 Jul 22.
7. Lorenzo FME et al. The Philippines HRM Master Plan (2005-2030). Department of
8. Declaration of Alma-Ata. International Conference on Primary Health Care. Alma-
Ata, USSR, 6-12 September 1978.
Appendix 1: Curriculum of Medical College A
First Year: Human Development, Structure and Function
Course Course Title Credits
HS 201 Human Health and Wellness 40 hours
OS 201 Human Cell Biology 120 hours
OS 202 Integration and Control Systems 136 hours
OS 203 Skin, Muscles and Bones 104 hours
OS 204 Head and Neck 72 hours
OS 205 Thorax 144 hours
OS 206 Abdomen and Pelvis 142 hours
HD 201 Human Ontogeny and Parturition 130 hours
HD 202 Human Physical and Psychosocial Development 120 hours
IDC 202 The Making of a Physician 64 hours
IDC 211 Introduction to the Research Process 32 hours
IDC 211.1 Laboratory Research 90 hours
Total: 1,194 hours
Second Year: Human Pathophysiology and Therapeutics
Course Course Title Credits
HS 202 Biopsychosocial Dimension of Illness 108 hours
Ther 201 Pharmacologic Basis of Therapeutics 80 hours
OS 211 Integration, Coordination and Behavior 180 hours
OS 212 Locomotion and Sensation 180 hours
OS 213 Circulation and Respiration 216 hours
OS 214 Digestion and Excretion 180 hours
OS 215 Reproduction and Hormonal Regulation 180 hours
OS 216 Hematopoiesis and the Immune Response 72 hours
IDC 203 The Patient and Illness 64 hours
IDC 212 Introduction to Clinical Epidemiology 16 hours
Elective Student directed elective 32 hours
Total: 1,308 hours
Third Year: Ambulatory Medicine
Course Course Title Credits
OS 217 Systemic Diseases 4 weeks
Ther 202 Pharmacotherapeutics 2 weeks
Anesth 250 Integrated Clinical Clerkship I in Anesthesiology 1 week
FCH 250.1 Integrated Clinical Clerkship in Family Medicine 2 weeks
FCH 250.2 Integrated Clinical Clerkship in Community Medicine 2 weeks
Integ 250 Integrated Clinical Clerkship in Dermatology 1 week
Med 250 Integrated Clinical Clerkship I in Medicine 3 weeks
Musc 250 Integrated Clinical Clerkship in the Musculoskeletal System 2 weeks
Neurosc 250 Integrated Clinical Clerkship I in Neurosciences 2 weeks
ObGyn 250 Integrated Clinical Clerkship I in Obstetrics Gynecology 4 weeks
Ophtha 250 Integrated Clinical Clerkship I in Ophthalmology 1 week
ORL 250 Integrated Clinical Clerkship I in Otorhinolaryngology 1 week
Pedia 250 Integrated Clinical Clerkship I in Pediatrics 4 weeks
Radio 250 Integrated Clinical Clerkship in Radiology and Nuclear Med 2 weeks
Surg 250 Integrated Clinical Clerkship I in Surgery 3 weeks
IDC 204 Holistic Medicine 1 week
IDC 213 Evidence Based Medicine 24 hours
IDC 221 Management in Health Care I 1 week
IDC 222 Management in Health Care II 1 week
Elective Student directed elective 2 weeks
Total: 39 weeks
Fourth Year: Hospital Based Medicine
Course Course Title Credits
Anesth 251 Integrated Clinical Clerkship II in Anesthesiology 2 weeks
EM 251 Integrated Clinical Clerkship in Emergency Medicine 2 weeks
FCH 251 Integrated Clinical Clerkship in Family and Community Med 4 weeks
Med 251 Integrated Clinical Clerkship II in Medicine 6 weeks
Neurosc 251 Integrated Clinical Clerkship II in Neurosciences 2 weeks
ObGyn 251 Integrated Clinical Clerkship II in Obstetrics Gynecology 4 weeks
Ophtha 251 Integrated Clinical Clerkship II in Ophthalmology 2 weeks
ORL 251 Integrated Clinical Clerkship II in Otorhinolaryngology 2 weeks
Ortho 251 Integrated Clinical Clerkship in Orthopoedics 2 weeks
Pedia 251 Integrated Clinical Clerkship II in Pediatrics 4 weeks
Rehab 251 Integrated Clinical Clerkship in Rehabilitation Medicine 2 weeks
Surg 250 Integrated Clinical Clerkship in Surgery 4 weeks
IDC 205 On Being a Physician (integrated in rotations)
Elective Student directed elective 4 weeks
Total: 40 weeks
Track A Internship: Comprehensive Health Care
Course Course Title Credits
Anesth 260 Internship in Anesthesiology 1 week
FCH 260.1 Internship in Family Medicine 2 weeks
FCH 260.2 Internship in Community Medicine 6 weeks
Med 260 Internship in Medicine 8 weeks
Neurosc 260 Internship in Neurology and Psychiatry 3 weeks
ObGyn 260 Internship in Obstetrics and Gynecology 8 weeks
Ophtha 260 Internship in Ophthalmology 2 weeks
ORL 260 Internship in Otorhinolaryngology 2 weeks
Ortho 260 Internship in Orthopedics 2 weeks
Pedia 260 Internship in Pediatrics 8 weeks
Rehab 260 Internship in Rehabilitation Medicine 2 weeks
Surg 260 Internship in Surgery 8 weeks
Total: 52 weeks
Track B Internship: Core Internship + Electives
Course Course Title Credits
FCH 260.1 Internship in Family Medicine 2 weeks
FCH 260.2 Internship in Community Medicine 6 weeks
Med 260 Internship in Medicine 8 weeks
ObGyn 260 Internship in Obstetrics and Gynecology 8 weeks
Pedia 260 Internship in Pediatrics 8 weeks
Surg 260 Internship in Surgery 8 weeks
Electives Student directed electives 12 weeks
Total: 52 weeks
Track C Internship: Straight Internship in a Department
Course Course Title Credits
SI 270.1 Straight Internship in Family & Community Medicine 52 weeks
SI 270.2 Straight Internship in Medicine 52 weeks
SI 270.3 Straight Internship in Otorhinolaryngology 52 weeks
SI 270.4 Straight Internship in Pediatrics 52 weeks
SI 270.5 Straight Internship in Radiology 52 weeks
SI 270.6 Straight Internship in Rehabilitation Medicine 52 weeks
SI 270.7 Straight Internshpi in Surgery 52 weeks
Appendix 2: Curriculum of Medical College B
Course Hours Weighted Score
Gross and Clinical Anatomy 340 10.0
Physiology 272 8.0
Biochemistry 272 8.0
Histology 102 3.0
Preventive and Community Medicine I 51 1.5
Clinical Epidemiology I 45 1.5
Neuroscience I 33 1.0
Medical Ethics I 34 1.0
Psychiatry I 17 0.5
Course Hours Weighted Score
Medicine I 204 6.0
Pathology 238 7.0
Pharma - Therapeutics 170 5.0
Microbiology 136 4.0
Surgery 102 3.0
Clinical Pathology 68 2.0
Obstetrics I 51 1.5
Parasitology 51 1.5
Medical Ethics II 34 1.0
Preventive and Community Medicine II 34 1.0
Neuroscience II 34 1.0
Behavioral Medicine I 34 1.0
Clinical Epidemiology II 34 1.0
Pediatrics I 17 0.5
Anesthesiology 17 0.5
Course Hours Weighted Score
Medicine II 340 10.0
Surgery II 238 7.0
Pediatrics II 170 5.0
Obstetrics II 51 1.5
Neurology 51 1.5
Behavioral Medicine II 51 1.5
Gynecology 51 1.5
Legal Medicine 51 1.5
Preventive and Community Medicine III 51 1.5
Ophthalmology 34 1.0
Medical Nutrition 34 1.0
Radiology 34 1.0
Otorhinolaryngology 34 1.0
Medical Ethics III 34 1.0
Clinical Epidemiology III 45 1.0
Dermatology 17 0.5
Rehabilitation Medicine 17 0.5
Appendix 3: Curriculum of Medical College C
Course 1st Sem 2nd Sem Total
Hours Hours Hours
Human Anatomy 256 224 480
Physiology 192 192 384
Biochemistry 128 128 256
Preventive and Community Medicine I 48 48 96
Pedagogy 16 16
Psychiatry I 32 32
Course 1 Sem 2 Sem Total
Hours Hours Hours
Medicine I / Physical Diagnosis 96 192 288
Microbiology 128 128
Parasitology 96 96
Pathology 160 160 320
Basic Pharmacology 96 96 192
Preventive and Community Medicine II 48 48 96
Radiology 16 16 32
Surgery I 32 32
Pediatrics I 32 32
Psychiatry II 32 32
Bioethics I & II 32 32
Course 1st Sem 2nd Sem Total
Hours Hours Hours
Medicine II 128 128 256
Surgery II 104 104 208
Obstetrics Gynecology 80 80 160
Pediatrics II 80 80 160
Ophthalmology 16 16 32
Advanced Pathology & CPC 32 32 64
Otorhinolaryngology 16 16 32
Preventive and Community Medicine III 80 80 160
Psychiatry III 32 32 64
Legal Medicine & Jurisprudence 32 32 64
Clinical Pharmacology 32 32
Bioethics III 32 32
Perspective in Medicine 16 16
Research Methodology 4 4
Course Total Units
Community Medicine Clerkship ½ month
Medicine Clerkship 2½ months
Obstetrics and Gynecology Clerkship 2 months
Ophthalmology Clerkship ½ month
Otorhinolaryngology Clerkship ½ month
Pediatrics Clerkship 2 months
Psychiatry Clerkship ½ month
Surgery Clerkship 2 months
Bioethics IV 12 hours
Elective ½ month
Ramon P. Paterno, M.D., MPH
Chrysanthus E. Herrera, M.D.
Institute of Health Policy and Development Studies
University of the Philippines-Manila National Institutes of Health
Review of Literature
Functions of Health Financing
There are three general functions of Health financing: 1) revenue generation, 2)
risk pooling and 3) purchasing.1 Revenues for the health system are usually generated
from taxes, social health insurance premiums and out-of-pocket expenditures. Revenues
generated from taxes or social health insurance premiums are pooled together and
provide protection against catastrophic health expenditure and impoverishment. Out-of-
pocket expenditure pools the risk at most, only at the household level and provides the
least financial protection against catastrophic health expenditure and impoverishment
aside from actually excluding those who have subsistence earnings. Catastrophic health
spending is defined as spending more than 40% of the household income after basic
subsistence needs have been met.2 The revenues generated are used to purchase
As discussed in the introduction, there are four general models of health system
1. Tax based funded - the UK National Health Service (NHS) model or the Cuban
2. Social Health insurance funded - the German Bismarckian model
3. Government subsidized National Health Insurance paying for the services provided
by private providers - the Canadian model and
4. Out of pocket system – including private insurance paid out of pocket. The US model
after which the Philippines is modeled, is a combination of the different means of
financing health care: government subsidized insurance with Medicare for the elderly
and Medicaid for the poor, a tax funded Veterans health service and private health
insurance or out of pocket payments for the rest. The US model is characterized as
having one of the highest national health expenditure 3 (16% of GDP in 2007) but with
a large number of the population uninsured (49 million) and with health outcomes
ranked only as number 37th in the world.4,5
Recent documents of the WHO have called for Universal Coverage to address
the continued health inequities among nations and within nations. The WHO Western
Pacific Region Health Financing Strategy for the Asia Pacific Region 2010 – 2015
(WPRO HFS) specifically calls for 1) Universal Coverage, 2) Renewal of Primary Health
Care and 3) Health Systems Strengthening.
Health Financing Trends in the Asia Pacific Region
Most countries in the Asia Pacific Region face the following health financing
issues: chronic underfunding, inequitable sourcing of funding (low public spending
leading to high out-of-pocket spending), efficiency issues in terms of allocation of limited
financial resources and payment mechanisms leading to higher health care costs.
Most developing countries within the Asia Pacific Region spent (in terms of Total
Health Expenditure or THE) less than 5% of GDP based on National Health Accounts for
2007. Vietnam had the highest THE at 7% of GDP. The Republic of Korea, Mongolia,
Cambodia and Nepal also spending above 5% of GDP on health. In contrast, the
Philippines spent 3.5% of GDP.6 (See figure 1. The lower bar represents government
spending, while the upper bar represents private spending as % of GDP.)
Figure 1. Government and Private health spending as Percentage of GDP in the Asia
Pacific Region NHA 2007 (Source: WHO Western Pacific Regional Office)
The WPRO HFS paper asserts that there is fiscal space among governments of
the region to increase health spending, that tax revenues of 13.2% of GDP and total
government revenues at 16.6% of GDP are the lowest of any region in the world. Health
revenues can be increased in the region “by increasing domestic tax revenues,
expanding the tax base, developing social health insurance, borrowing externally or
seeking debt repayment relief.”6
Sources of Funding
Government spending was less than 2% of GDP in almost half of these
countries. The Philippines government share was about 1.2%. 6 (see figure 1)
Government spending on health was too low to support universal coverage.
Evidence within the Asia Pacific region which covers the 37 countries of the WHO
Western Pacific Region and the 11 countries of the WHO South-East Asia region,
suggests that countries whose governments spend less than 5% of GDP on health had a
higher percentage of households with catastrophic health expenditures.6 (see appendix
The major source of health care financing in most countries of the region was
out-of pocket (OOP) payments. Regional data also suggests that countries with greater
than 30% out-of-pocket health expenditures had higher percentage of households with
catastrophic expenditure and consequent impoverishment.6 (see appendix 2)
Globally, the Asia Pacific region in 2005, had one of the higher levels of out of
pocket health expenditure, with over 40% of total health expenditures in the Western
Pacific region and over 60% in the South-East Asia region.6 In the Philippines, OOP
share was 54% in 2007.7
Another major issue of health financing is not just the underfunding and
inequitable sources of funding but the inefficient allocation of limited resources. In the
Asia Pacific region:
…80% of essential care and 70% of desirable health interventions can be
delivered at the primary level but an average of only 10% of health resources are
used for primary care in Asia… six countries in the Asia Pacific region spent less
than 20% on primary health care. The Philippines spent about 11% on public
health care. By comparison, in 11 OECD countries, outpatient care costs
Figure 2. Allocation of financial resources to primary health care (2005 estimates)
(Source: Midterm review of implementation: Regional Strategy on Health Care Financing in the
WHO Western Pacific Region 2006-2010, P. Annear, 31 August 2008)
About half of total health spending in Cambodia, China, the Lao People’s
Democratic Republic and Vietnam went to Pharmaceutical and diagnostic services. 6
The manner in which Health Care Providers are paid can significantly affect both
the cost and quality of care, and is therefore instrumental in achieving optimal use of
resources. The more common methods of payment mechanisms are: fee-for service,
salaries, case payments, capitation and global budget.
The main provider payment mechanisms in the Asia Pacific region are budget
allocations, salaries and fee-for- services. Regulations regarding fees and balance billing
tend to be weak.6
Fee for service (FFS) is a payment mechanism where the provider is paid for
every service provided, usually at the time of service. According to Liu Xingzhu, “FFS is
regarded as the worst payment method because it encourages over provision of
services and drives cost up”8 This payment mechanism is, however, usually strong in
terms of quality.
Path to Universal coverage
Carrin et al in the WHO Special Bulletin, November 2008 describes the path to
Universal coverage from an initial stage of a health system characterized by the absence
of financial protection, with a dominance of out of pocket expenditures; to an
intermediate stage of coverage characterized by a mixture of a predominantly out of
pocket payments, community based health insurance initiatives, and limited social health
insurance and tax based spending, and the stage of universal coverage characterized by
a predominance of a tax or a social health insurance funded health system or a
combination of both.9
Figure 3. Key health financing options at different stages of the evolution towards
universal coverage. (Source: WHO Special Bulletin Nov. 2008)
Tax-based versus Social Health Insurance revenue generation for financing
Universal Health Care
The main advantages of generating revenues for health through taxes, if properly
designed and collected, are that the burden of contribution is more progressive, and it
usually incurs less administrative costs. Coverage is by virtue of citizenship or residence.
A tax funded National Health Service has more direct ways of containing costs. Its major
disadvantage is that tax revenues generally go to the general appropriations and the
government health agency has to compete with the other government agencies for the
appropriate budgetary allocation for health.10 This may however be offset by an
automatic appropriation for health. If there is an automatic appropriation for debt
servicing, then there is a moral and ethical basis for automatic appropriation for health,
given that health as a human right is universally accepted.
The major advantages of financing Universal Health Care through Social Health
Insurance (SHI) are that the funds raised through SHI premiums are earmarked for
health and the SHI funds represent additional revenues for health.
On the other hand, the disadvantages of SHI are the following: higher
administrative costs, especially in countries where the employed formal sector is not fully
developed and where there is a large informal sector and indigents. Coverage is
dependent on identification, enrollment and collection of premiums. Historically, SHI
started in Germany. It took Germany 47 years to achieve 50% coverage and another 58
years to achieve 88% coverage. This was so because of the difficulty of covering the
informal sector.1 In the Philippines, the informal sector makes up at least 50% of the
workforce11 and will continue to increase if the trend towards de-industrialization is not
SHI, because of its nature as an insurance system, pays for personal care.
Public health services, which should cover the whole population, are expected to be paid
from general taxation revenues. Therefore, there would still be a need to generate
revenues from taxes to pay for population based health interventions such as health
promotions, safe water and sanitation, or services that require high or almost universal
population coverage such as immunization.
The major disadvantage is that SHI premium contributions are less progressive
than income tax payments. Formally employed workers bear the burden of financing
Universal Coverage as they are triple taxed in the form of automatically deducted
income tax, automatically deducted SHI premiums as payroll tax and indirect taxes such
as Value Added Tax.
What ever financial route a country takes to achieve Universal Coverage
(through taxes or SHI or a combination of both) the World Health Report 2010
summarizes what countries must do: raise sufficient funds, reduce the reliance on direct
payments to finance health services and improve efficiency and equity.12
The Philippines: Health financing situation
The Philippines faces the same health financing issues of the region: chronic
underfunding, inequitable sourcing of funding (low public spending leading to high out-of-
pocket spending), efficiency issues in terms of allocation of limited financial resources
and payment mechanisms leading to higher health care costs. An added issue is the
fragmentation and overlap of the health financing institutions.
Underfunding of the Health System
In 2007, the Philippines spent P235 billion or 3.5% of GDP on health. From 1995
to 2007, the Philippines total health expenditure as a nation has ranged from 3.4% -
3.7% of GDP.7 (WHO recommends 5% of GDP as public or government health
Billions of Pesos
100 5% GDP
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Figure 4. Philippines total health expenditure (THE) 1995 – 2007. (Source: NHA, 2007)
Figure 5. Trends in out of pocket spending versus Philhealth and Government share in
Total Health Expenditure. (Source: NHA, 2007)
Government share of total health expenditure (both national and local) was only
P61B or 26.6% and Philhealth share was only P20B or 8.5% resulting in 54.3% (P127B)
Out of Pocket expenditure.7 (see figure 5)
Philhealth share in National Health Expenditure has risen but at a very slow rate.
Almost half of Total Health Expenditure in 2007 or around P110B out of P235B was
spent on pharmaceuticals. Sales were 80% in drugstores, 10% in hospitals and 10% in
government institutions. Branded medicines made up 97% of sales leaving only 3% for
generics. Multinationals controlled 68.7% of the market, with Philippine companies only
As a country, we are not spending enough on public health and primary care.
We spend from 73-78% of our national health expenditure on personal care versus 11-
14% for public health.7 The Philippine Health Sector Reform Agenda had envisioned
that, as government hospitals exercised fiscal autonomy and allowed to charge user
fees and retain income, (in large part, coming from Philhealth reimbursements), they
would need less and less government subsidy and this in turn would lead to a shift of the
DOH budget from hospital subsidy to more funding for public health programs.14 As can
be seen from figure 6, this shift did not happen as the public health expenditure has
remained fairly constant at about 11-14% of total health expenditure.
% Share in Total Health Expenditure
60 Public Health
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Figure 6. Total health expenditure by use of funds 1995 – 2006
In terms of payment mechanisms, fee-for-service payment mechanism remains
the dominant form of the reimbursement mechanism of Philhealth, constituting 90% of
reimbursement for hospital claims.15,16 This has led to overprovision and higher cost of
Fragmented Health Financing System
Government health spending is fragmented among hundreds of stakeholders:
DOH, LGUs (provincial governors and municipal and city mayors) and Philhealth, with
different health financing philosophies, mandates and responsibilities. The LGUs
comprise 81 provinces, 136 cities and 1,495 municipalities. DOH finances retained
hospitals and national health programs. LGUs use their internal revenue allotments to
finance their health facilities and services. The provinces finance the provincial and
district hospitals. Municipalities are in charge mainly of public health and primary care.
Philhealth pays for services of DOH, LGUs and private health facilities. There is often
overlap with what Philhealth reimburses and what the DOH and LGUs provide. 17 The
private sector comprising more than half of service providers and hospitals have their
own largely unregulated fee schedules.
The Path to Universal Coverage: the role of Philhealth
The path of the Philippines towards universal coverage appears to be through a
health system financed by a combination of Tax-based revenues and Social Health
Insurance. All past health sector reforms have assigned a key role for Philhealth to
address our health financing problems. Philhealth or our social health insurance program
has focused on population coverage the last 9 years and has claimed to have achieved
universal or 85% coverage in 2004 and again 86% as of 2010. Coverage, however,
must be viewed in terms of breadth, depth, height and utilization by populations groups
that are most in need of financial protection. 6
Social Solidarity in reverse
The claimed 86% population coverage in 2010 is contradicted by the National
Demographic Health survey in 2008 which gave a result of only 38% of respondents
being aware of at least one household member being a Philhealth member. More
recently, the SWS Survey of Filipinos on Healthcare Services and Financing, Jan – Feb
2010, commissioned by the Pharmaceutical and Healthcare Association of the
Philippines gave similar results – only 36% of respondents had Philhealth coverage. But
a more alarming result is a disaggregation of Philhealth coverage among the ABC
versus the D and E income groups: 62% for ABC, 36% D and only 29% E. 18
Philhealth’s claimed high population coverage is not reflected among hospitalized
patients in government hospitals. Philhealth’s own Quality Improvement Demonstration
Study (QIDS) found that only about 25.5% of children under 6 yrs of age hospitalized in
11 provinces in the Visayas had Philhealth coverage during the baseline survey in
The depth of coverage comes from the comprehensiveness of Philhealth’s
benefit package which, up to now, mainly covers inpatient benefits. Philhealth’s
outpatient benefits are limited, covering TB DOTS, Maternal Care, and Malaria, and the
Out Patient Benefits for Sponsored members in accredited health centers, as examples.
It does not include outpatient drugs for common non-communicable diseases, such as
for hypertension and diabetes.20 Almost half of the Filipino’s health expenditure is on
The height of Philhealth’s coverage is the financial protection provided.
Philhealth’s benefits cover from 40-60% of hospitalization expenses. Philhealth
conducted an internal survey on support value (per cent of hospitalization costs covered
by Philhealth benefits), in government wards, based on selected hospitals’ statement of
accounts for the years 2004 – 2006. The results for 2006 gave a support value of 56%
for ordinary cases, 50% for intensive cases and 44% for catastrophic cases. 19 This
support value might even be eroded by as much as 30% by out of hospital purchases.
Philhealth’s Quality Improvement Study found that patients in the secondary hospitals in
the Visayas had outside of the hospital purchases that amounted to 30% of their total
Philhealth’s mandate, as stated in RA 7875 or the law that created it, is to
“provide ALL citizens with the mechanism to gain financial access to health services”.
RA 7875 further states: “Access to care must be a function of a person’s health needs
rather than his ability to pay.”21 A proxy indicator of Philhealth’s provision of financial
access to health services is the share of Philhealth in the total national health
expenditure which remains unacceptably low.7
We would like to add a fourth dimension for universal coverage: that the poor are
able to utilize their Philhealth benefits following the principle of Social Solidarity. Among
the different member groups of Philhealth, the Sponsored Members (the indigents) have
much lower utilization rates.15
In the end, mere population coverage by Philhealth does not automatically
translate to the poor being able to utilize their coverage, much less be provided financial
Another disturbing data is that public hospitals are not benefiting enough from
Philhealth reimbursements. In 2006, among the top ten hospitals reimbursed by
Philhealth, only one, Davao General Hospital, was a government hospital. The rest were
tertiary private hospitals mainly serving those who can afford to pay for health services.
Public money, through Philhealth premiums, is maximized by private hospitals to
improve their facilities, which serve those who can pay. In 1999, the Health Sector
Reform Agenda (HSRA) monograph already recognized the “raiding of the meager
benefits of the NHIP by private providers.”14
Slow impact of Health Sector Reforms
The health sector reforms in the Philippines, from Health Sector Reform Agenda
in 2001 to Fourmula One have approached health financing problems “incrementally and
have not dramatically improved the health financing picture.”17 In 2001, the state of
health financing was described as having: “heavy dependence on family OOP spending;
(46% in 1997) (with) inadequate benefit spending by NHIP, low program benefits and
bias towards hospital-based care, limited population coverage, weak benefit delivery and
provider payment mechanisms.14
From 2001, HSRA, the National Objectives for Health (NOH) 2005-201022 and
Fourmula One and now the DOH Health Care Financing Strategy 2010-2020 have
looked at Philhealth as having the key role in health financing reform: “health care
reforms will focus on making NHIP the major payor of health services (HSRA), the
flagship program of health financing (NOH) and “the lead implementor of health
financing reform.” (Fourmula One) “Expand coverage, increase benefit payments,
include outpatient benefits, use alternative forms of payment mechanisms, improve
marketing to increase beneficiary knowledge about PHIC benefits, and improve
information system” has been the mantra since 2001 and is now being repeated by the
Aquino Health Agenda. (See appendix 3 for Health Financing Targets of HSRA, National
Objectives for Health 2005-2010 and Fourmula One) Yet ten years later, the state of our
health financing can still be described as in the previous paragraph, but with a worsening
OOP share at 54% and Philhealth share still at 8.5% only.7 Perhaps it is time to reassess
the central role assigned to Social Health Insurance in achieving Universal Health Care
for the Philippines.
AHA: HCF strategy
Last October 22, 2010, Secretary of Health Enrique Ona unveiled the “Aquino
Health Agenda: Universal Health Care” in the 2nd Philippine Health Outlook Forum
sponsored by Zuellig Foundation. Meant to address the glaring inequities in health status
within the country, Universal health care was presented as a continuation of
comprehensive health sector reform from the health sector reform agenda (1999-2004)
and Fourmula One for Health (2004-2010). The priority health policy directions of the
Aquino Administration include a roadmap towards universal health care through a
refocused and revitalized Philhealth. Main targets are expansion of the NHIP coverage
with enrollment of the poorest of the poor and mandatory enrollment of the informal
sector; increased awareness of Philhealth benefits and entitlements, access to both
inpatient and outpatient services and zero co-payment with no balance billing for health
care costs incurred by the poorest in government hospitals. (underscoring ours)
Other areas for improvement are: health facilities enhancement, with improved
access to quality affordable medicines; attainment of the MDGs; more aggressive
strategies for Public Health; and Information and Communications Technology for
However, the budget of the DOH for 2011 remains at P33 billion. And the Aquino
Health Agenda does not specify how the revenues for Universal Health Care will be
raised and to what extent.
A chronically underfunded health system, with total government, national and
local, and Philhealth share amounting to only about 35% of Total Health expenditure
leads to a level of out of pocket spending (54%) that is much higher than the 30% OOP
level cited by the WPRO Health Care Financing Strategy paper as an upper limit,
beyond which catastrophic health expenditures and impoverishment of the population
increase. As a result, poor families forego seeking health care. 65% of Filipinos who die,
continue to die without medical attendance. 40% of the poorest households cannot buy
the medicines they need.23 Those who are able to access health care through
borrowings, are exposed to the risk of further impoverishment. Exclusion of the poor
from needed health services and/or further impoverishment lead to increasing disparities
in health status among regions, and income groups.
The major issues in health financing are:
1. Divergent Health Financing Philosophy among the major health stakeholders and
2. The chronic underfunding of the health system
3. Inequitable sourcing of funding for health: low government share leading to high out
of pocket share
4. Efficiency issues
a. Allocative: spending the limited health resources on expensive tertiary health
care versus the more cost effective primary and preventive health care
b. Payment mechanisms: the dominance of the inefficient fee-for-service
c. Fragmentation and overlap of the different financing institutions with
Philhealth seemingly acting independently of the DOH. (see Philhealth’s
performance vis-à-vis targets set in HSRA, NOH 2005 – 2010 and Fourmula
Health financing Philosophy
It is crucial to have a unified Health Financing Philosophy among the major
stakeholders in health in implementing Universal Health Care. Basic to Universal Health
care is the premise that health is both a human right (WHO constitution and UN
instrumentalities) and a constitutional right. (guaranteed by the Philippine constitution)
As a right, health and universal access to health care become primarily the
government’s responsibility. It is the government that has and can mobilize the
resources needed to fulfill the right to health. Health as a right means that ALL Filipinos
have the right to health care first as human beings and second as citizens and not
because of Philhealth’s capacity or incapacity to enroll them. A well regulated private
sector can and should be encouraged to contribute to the attainment of Universal Health
Care. Private providers should be encouraged to serve in marginalized areas, even on a
temporary rotating basis. Private companies can provide their employees benefits in
addition to that being covered by Philhealth. Health and health care services should not
be viewed merely as a cost that has to be contained. Rather they should be seen as a
necessary investment that enables people to live a productive and meaningful life that
allows them to contribute to the overall national development. Equity is the overriding
health policy goal as stated in the Health Governance module. The goal of Universal
Health Care is to abolish disparities in health status among population groups, among
income groups, among regions within the country. If all stakeholders in health agree
with the above philosophy, then there will be minimal contradictory health financing
What is Universal Health Care
Universal Health Care is defined as the provision to every Filipino of the highest
possible quality of health care that is accessible, efficient, equitably distributed,
adequately funded, fairly financed and appropriately used by an informed and
This means ALL Filipinos will be able to access needed health care, without
significant out-of-pocket payments at the time he/she needs it. But it is not charity,
because it has been pre-paid either by the taxes or the Philhealth premiums that ALL
How much will Universal Health care cost?
If government health spending is set at 5% of GDP, this should have been
P451B in 2011 with a projected GDP of P9.02Trillion. (GDP based on IMF projection
Table 1 summarizes target levels of total health expenditure (THE) as percent
share of GDP. THE for 2011 is targeted at 4% of projected GDP, THE 2013 at 4.5%,
THE 2015 at 5% GDP.
Table 1. Target Scenarios for increasing Total Health Expenditure to 5% GDP by 2015.
Year 2007 2011 2013 2015
GDP* in current price 6,647 9,018 10,549 12,341
(billions of pesos)
THE 3.5% 235
THE at 4% 361
THE at 4.5% 475
THE at 5% 617
* Projected GDP taken from IMF World Economic Outlook Database April 2010
Table 2 shows the share of government and PHIC of total health expenditure as
out of pocket share is reduced from 54% in 2007 to 20% by 2015.
Table 2. Scenarios for decreasing out of pocket share of total health expenditure. (Source:
THE by Sources of Funding: 2007 – 2015 (2007 actual, based on 2007 NHA)
Year THE in Gov't Amount PHIC Amount OOP Amount
Billions of P share share share
2007 P 235 26.6% 63 8.5% 20 54% 126.9
2011 P 361 35% 126 18% 65 47% 169.7
2013 P 406 40% 162 25% 102 35% 142
2015 P 617 45% 278 35% 216 20% 123
For 2011, Government share, national and local, targeted at 35% should be
P126B, PHIC share at 18% should be P65 B and OOP share would decrease to 47% or
P169B. Of the total government and Philhealth share of P181B, P120 B should go to
Primary Care or the essential health package described in the next section.
By 2013, government share, both national and local, should increase to 40% or
P162B, Philhealth share to 25% or P102 B and OOP reduced to 35% or P142B.
The figures for 2015 are the targets to be able to finance Universal Health Care
by 2015 and reduce OOP spending to 20%. THE at 5% of GDP equals P617B, with 45%
Government share and 35% Philhealth share. (see figure 10)
Figure 7. Distribution of health expenditure by sources of funds, 1995-2015.
To start UHC, the DOH budget for 2011 should have been at least P90B instead
of P33B, with LGU spending P36B or a total of P126B government share. (see table 2)
The needed additional P57B (in addition to the P33B DOH 2011 budget) could also be
equally divided between the DOH and the LGUs as long as there are clear
provisions/mechanisms to ensure more equitable distribution of the funds for the LGUs.
The LGU fund should primarily go to the least developed regions to enable these regions
to catch up and decrease their inequities in health and to ensure comprehensive benefits
for all Sponsored beneficiaries.
There is an alternate proposal for implementing Universal Health Care.24 This
entails the setting up of a National Health Development Fund with at least an additional
P50B to the present DOH budget. This National Health Development Fund will provide
1. P14 Billion for the PHIC premium of the poorest 60% of the population
2. P10B for health infrastructure
3. P10B for improving personnel salaries of the government Health Human
4. P15B to ensure adequate supply of 100 essential medicines
5. P1B for disaster preparedness
Implementation can begin with the poor families in the regions with the worse
health status: ARMM, MIMAROPA, Samar-Leyte, Bicol, Zamboanga peninsula, West
Visayas and Davao Peninsula and the urban poor areas of Metro Manila, Metro Cebu
and Davao. A major portion of this Health Development Fund will finance the essential
health package (infrastructure, personnel and the 100 essential medicines) to be
described in the following section.
This budget shortfall can be sourced through expanding the tax base and more
efficient tax collection, from the increment of revenues of the Documentary Stamp tax,
Excise Tax (Tobacco tax), Road Users Tax, earmarked funds from PCSO and Pagcor, a
continued strong anti-corruption drive, a portion of Philhealth P110B health fund, the
removal of Philhealth’s P30,000 monthly salary cap for premiums and Debt for Equity or
Millennium Development Goals swap.
A strong anti-corruption drive should save the national government some P280B.
(The amount lost to corruption announced during the presidential campaign.) P100B of
this can be used to finance UHC.
Philhealth uses a salary cap set in 2007 at P 30,000 per month. This means that
someone earning more than P30,000 whether P40,000 or P1,000,000 a month still pays
the same premium as someone earning P30,000 a month. Removing the salary cap will
increase Philhealth’s premium collection by at least P11B annually.25
Philhealth has a P110B fund as of June 2010. 20 P50B of this could be used to
provide comprehensive benefits for the sponsored members, without depleting the
reserve funds. Comprehensive benefits for the Sponsored members would achieve the
Zero-co-payment target in government hospitals. Later the zero-copayment in
government hospitals can be expanded to cover the rest of Philhealth’s beneficiaries.
This would then make being a member of Philhealth attractive and justify raising
premiums in the future.
Table 3 lists the possible sources of increased revenues for Universal Health
Care. HSRA in 2001 proposed the automatic appropriation of the 25% incremental
revenue of the Documentary Stamp Tax and the Excise Tax Laws which RA 7875 states
must be appropriated for Philhealth premium subsidy. (3% of the proceeds of the sale of
Fort Bonifacio was also mandated for health by the Bases Conversion Development Act
but was never collected.)14
Table 3. Potential sources of funds for universal health care.
Source Revenue Potential for UHC
Philhealth Reserve Fund P110B Initial input of P50B
Removal of PHIC salary cap P11B
Anticorruption drive P280B P100B
Road users’ Tax P10B P5B
Pagcor P30B P7B
PCSO (30% to charity) P22.6B P6.8B
Documentary Stamp tax (25%
of incremental revenue)
Sin taxes amendment
1st yr P20B P10B
2nd yr P30-40B
3 rd yr P40-P50B
4th yr P70B
Debt for Equity Swap 40% of National P100B
TOTAL P240B + P50B from PHIC fund
It is not enough to increase revenues for health; we have to make sure that it is
utilized effectively and efficiently.
Recently, a set of an “essential health package” (EHP) or basic health services to
which ALL Filipinos should be entitled, has been defined by a Filipino Technical Working
Group under the sponsorship of WHO Philippines Country office. What is significant is
that it has been costed. Costing was modeled on a working rural Inter-local Health Zone
(ILHZ) consisting of 5 municipalities (and their respective RHUs) centered around a
functional district hospital with the necessary health facilities, equipment and essential
medicines, and staffed by the health human resource needed to provide the defined
The EHP consists of 8 services with supporting diagnostic laboratory services
and an adequate supply of prioritized essential medicines. The 8 services build on the
existing RHU health services and were expanded to include community mental health
and oral health and rehabilitative services connected with non-communicable diseases.
The cost to provide ALL Filipinos with this basic health package comes out to about
P1,400 per Filipino. In 2007, with a total health expenditure of P235B, the country’s per
capita health expenditure was already P2,640. However 54% of this P235B came from
out of pocket as noted earlier.7
The costing of the EHP gives us a more scientific basis for health budget
formulation. To provide ALL Filipinos basic health services, we would need at least a
health budget of P135B (P1,400 X 94 million Filipinos in 2010). The proposed 2011 DOH
budget is only P33B, LGUs spend an approximately equivalent amount and Philhealth
reimbursements totaled about P25B in 2009. All in all, the projected 2011 government
spending, including Philhealth would be about P90B leaving a shortfall of P45B, just to
ensure provision of basic health services up to the District Hospital level. The P135B
does not include the cost of tertiary care.
Overlapping of Finance Agents
The DOH as the lead agency should convene a task force made up of
representatives of the major stakeholders in health to determine who should pay for
what services. There should be minimum overlap in the financing of services needed to
achieve Universal Health Care. The financing roles of the DOH, LGUs and Philhealth
have been defined in the DOH Health Care Financing Strategy.17
Philhealth is moving towards diagnosis related case payment system, wherein
cases are classified into groups that are clinically similar and expected to have similar
hospital resource use and therefore similar reimbursement costs. This would simplify
reimbursements and incentivize efficient management of cases. This payment
mechanism, however, would still not incentivize health promotion and prevention of
The provision of the Essential Health Package can be subcontracted to
interested ILHZs using a Global Budget based on the capitation amount of P1400.
Previously only a minority of ILHZs were functional but subcontracting might provide the
financial incentive for district hospitals and surrounding municipalities to work together.
This capitation payment/global budgeting would incentivize promotive and preventive
health services to lessen the need for the more expensive curative services and
A similar costing must be done for secondary and tertiary care services as basis
for budgeting for provincial, regional and national hospitals.
Social Determinants of Health and UHC
To achieve Universal Health Care and to decrease inequities in health,
government must spend for health care. It must spend for health care in the most
equitable, effective and efficient way to ensure ALL Filipinos access to needed health
care without significant out of pocket payment at point of service.
We must however not forget the social determinants to health (SDH) approach.
The SDH approach believes that improvements in the health sector only account for
about 20% of the improvement in health status while improvements in the social
conditions account for the larger 80 %.26,27
The country needs a clear program to address the pervasive poverty that is the
root of the inequities in health status. The Philippine Midterm Progress Report on the
MDGs states: “The government’s anti-poverty strategy must focus on agriculture and
rural development through asset reforms (agrarian reform, urban land reform and
ancestral domain reform) accompanied by reforms in the agricultural sector, such as
investments in productivity improvements and supporting infrastructure.” Agrarian
reform, together with agricultural modernization, will create the basis or the domestic
market for national industrialization.
Only with a clear program for national socio-economic development, will
Universal Health Care succeed in making our people healthy.
1. Carrin G and James C. Health Financing Policy Issue Paper: Reaching Universal
Coverage vs. Social Health Insurance: Key Design Features in the Transition Period.
World Health Organization, 2004.
2. Xu K, Evans D, et al. Household Catastrophic Health Expenditure: a Multi-country
Analysis. World Health Organization, Geneva. Lancet 2003; 362: 111-17.
3. Centers for Disease Control and Prevention: US Health Expenditures.
http://www.cdc.gov/nchs/fastats/hexpense.htm. Accessed November 26, 2010.
4. Murray C and Frenk J. Ranking 37th – Measuring the Performance of the US Health
Care System. The New England Journal of Medicine, 362;2 pp. 98-99. January 14,
5. The World Health Report 2000: Health Systems: Improving Performance, World
Health Organization, 2000.
6. Western Pacific Region Health Financing Strategy for the Asia Pacific Region 2010-
2015. World Health Organization, 2009.
7. Philippine National Health Accounts, 2007
http://www.nscb.gov.ph/stats/pnha/2007/default.asp. Accessed November 30, 2010.
8. Xingzhu, L. Policy Tool for Allocative Efficiency of Health Services. World Health
9. Carrin, G et al. Universal coverage of health services: tailoring its implementation.
Bull World Health Organ. 2008 November; 86(11): 857-863.
10. Normand, Charles and Axel Weber. Social Health Insurance, A Guidebook for
Planning. World Health Organization/ILO.
http://whqlibdoc.who.int/publications/50786.pdf Accessed on November 27, 2010
11. Soonman Kwon, Segmenting the Informal Sector with a view to Adjusting Premiums
Based on Ability to Pay in the Philippines, Final Report to GTZ, Sept. 2005
12. The World Health Report 2010: Health Systems Financing: The Path to Universal
Coverage. World Health Organization, 2010.
13. Philippine Pharmaceutical Industry Factbook 7 th Edition. Pharmaceutical &
Healthcare Association of the Philippines, 2008.
14. Health Sector Reform Agenda Philippines, 1999-2004. HSRA monograph series no.2
Department of Health, Manila, Dec. 1999.
15. Paterno RP, Margie Naval M and Valparaiso A. Validation of Philhealth Performance
using 10 Key Performance Areas for the years 2004 – 2006. University of the
Philippines Manila – National Institutes of Health, 2008. Submitted to the Committee
on Health, Philippine Senate.
16. Matthew J, Banzon E, Basa RJ. The Impact of Social Health Insurance in the
Philippines, 1972 – 2007. Presentation July 9, 2007.
17. Toward Financial Risk Protection, Health Care Financing Strategy 2010 – 2020,
HSRA monograph no. 10. DOH Philippines, 2010.
18. SWS Survey of Filipinos on Healthcare Services and Financing, Jan – Feb. 2010.
19. Quimbo SA, Kraft AD, Capuno JJ. Health, Education and the Household: Explaining
Poverty Webs. University of the Philippines School of Economics, 2008.
20. Ona, E. The Aquino Health Agenda: Universal Health Care for All Filipinos.
Florentino Herrera Memorial Speech, October 22, 2010.
21. Republic Act 7875: The National Health Insurance Act. 1995. Republic of the
22. National Objectives for Health, 2005 – 2010. DOH Manila. 2005
23. World Health Survey. World Health Organization, 2002.
24. Galvez-Tan JZ et al. Benigno S. Aquino III Transformational Health Agenda: The
First 100 Days; the First 1000 Days.
25. NSO Family Income and Expenditure Survey, 2006.
26. McKinlay J & McKinlay SM. Medical measures and the decline of mortality. In H. D.
Schwartz (Ed.), Dominant issues in medical sociology (2nd edition). New York:
Random House, 1987
27. McKeown T, Record RG, Turner RD. An interpretation of the decline in mortality in
England and Wales during the twentieth century. Population Studies. 1975
Appendix 1. Public Health Spending and % of Household catastrophic health expenditure
(Source: Xu, K, Evans DB, Kawabata K, et al. 2003. Household catastrophic health expenditure:
a multi-country analysis. The Lancet. Vol(362):111-117)
Figure 3. Out of Pocket spending and % of households with catastrophic expenditure.
(Source: Xu K, et. al. Protecting households from catastrophic health spending. Health Affairs, 26.
No. 4 (2007): 972-983)
Health Financing Targets of HSRA, National Objectives for Health 2005-2010 and
Targets HSRA 2001 NOH 2005-2010 Fourmula 1, 2004
Increase Revenues Automatic Increase investments Mobilize from extra
for Health appropriation of the from internal and budgetary resources
25% incremental external sources, User fees
revenues of improve efficiency of Fees for regulatory
Documentary Stamp resource use. services
Tax and Excise Tax Increase local govt From real property
Base spending for health assets
(3% proceeds from
sale of Fort Bonifacio)
Total Health 3-4% GDP
Govt share 50% of THE by 2010
Zero copayment for
Zero copayment for
30% of all PHIC
PHIC share Reimbursements to 15% of THE
P60B /yr in 5 years
(still P27B as of 2010)
Allocative efficiency 20% of THE to Public
PhilHealth “HC financing reforms Flagship program of Lead implementor of
will focus on making Health financing Health financing
NHIP the major payor reform;
of health services Main lever to affect
changes in each of
the 4 components of
“Refocused” or Increase benefits and Expand coverage; Expand coverage
“Revitalized” alternative payment increase benefit Benefits
schemes spending; include Provider payment
Expand coverage outpatient benefits mechanisms
Secure financing Improve marketing
Remove salary cap mechanisms
Expand accreditation Information system
infrastructure – full
blown info system