COVID-19 and the Philippine Healthcare System

March 20, 2020

by Jose Lorenzo Lim

Earlier this year amid the growing threat of the COVID-19 virus, Department of Health (DOH) Secretary Duque said that the Philippines does not have a weak healthcare system. This was in response to a World Health Organization (WHO) statement expressing its concern with how other countries with weak healthcare systems are dealing with the COVID-19.

But is the country’s health system really “not weak” and ready for this pandemic?

A “not weak” healthcare system?

Sec. Duque said that the WHO was not referring to the Philippines but “third world developing countries” with weak healthcare systems. He said that the Philippines is classified as a “middle-income” country according to World Bank standards. But a closer look at the country’s healthcare system indicates otherwise.

Looking at available health facilities, data from the DOH shows that there are 1,236 hospitals in the country as of 2017. Of these, 65% are private hospitals which are the main beneficiaries of the insurance-based healthcare system through the Universal Health Care (UHC) Act. The WHO recommends 20 beds per 10,000 population. The Philippines has never reached the recommended ratio. This indicator even worsened from 14.4 beds per 10,000 population in 1990 to only 9.9 beds per population in 2014, according to the Philippine Statistics Authority (PSA).  When it comes to community health services, only 47% of barangays had barangay health stations in 2018.

There is also a significant shortage of health personnel in the country. The PSA reported a ratio of one government physician to 33,000 Filipinos, which is far from the WHO recommended 1:1,000 doctor to population ratio. In 2016, the DOH said that the country is in need of 15,000 doctors to meet the healthcare needs of Filipinos each year.

The number of public health nurses is also dismal at a ratio of 1 to 50,000 Filipinos. Philippine Overseas Employment Administration (POEA) data show that despite the scarcity of government health workers, the country has been exporting nurses for decades, which is worsening the brain drain of the health sector.  The Philippines deployed 19,551 nurses in 2016 or 53 nurses per day. In 2013, the Department of Labor and Employment (DOLE) advised nurses to find work in business process outsourcing (BPO) as medical transcriptionists, billers, and health care secretaries since they can no longer be accommodated in government hospitals.

These shortages in medical facilities and personnel are due to government’s low prioritization of the health sector as seen in the national budget. While it seems good that the health sector budget has increased from Php177.7 billion in 2019 to Php185.5 billion in 2020, its overall share in the national budget has fallen from 4.9% to 4.5 percent. The Php7.8 billion or 4.4% increase in the health sector budget is even eaten up by inflation.  

There have also been cuts to much-needed health programs that could help the country better cope with the ongoing pandemic. For instance, the budget for the Epidemiology and Surveillance Program which monitors, investigates, and analyzes disease outbreaks was cut by more than half. It was reduced from Php262.9 million in 2019 to Php115.5 million in 2020.

The budget for Health Systems Strengthening Program was also cut by Php6 billion in 2020. The program is used for ensuring a wide range of human health resources such as doctors, nurses, midwives, community health workers, and other health care providers.

Enter COVID-19

COVID-19 is an infectious disease that causes respiratory illness such as fever, cough, and even pneumonia. This is spread through contact with an infected person by cough or sneeze or even droplets of saliva.  The disease was first seen in Wuhan, China.

As of writing, the Philippines has a total of 230 cases with another 506 persons under investigation (PUI). Nearly eight percent (7.8%) of the total cases died while only 3.5% have recovered. Most of these cases were admitted to the Research Institute for Tropical Medicine (RITM) or in private hospitals such as The Medical City and St. Luke Medical Center facilities in Quezon City and Global City.

The DOH emphasized the need for self-care like social distancing, use of face masks by the sick and health workers, proper cough etiquette, frequent handwashing, and self-quarantine.

This has been communicated, albeit through vague messaging and to limited coverage, through press conferences, media releases, and the infamous Tiktok video. However, the burden of doing groundwork in communities has fallen in the hands of scarce barangay health workers (BHW). The DOH in 2019 said that the country needs an additional 802,422 BHWs.

As the number of confirmed cases increased, the DOH called for a Code Red Sublevel 2. This means that sustained community transmission of the disease or an increasing amount of local cases whose links cannot be established has been observed in the Philippines.

The DOH initially declared Code Red Sublevel 1 on March 7 after the first case of local transmission of COVID-19 was confirmed. After five days, Code Red Sublevel 2 was raised. This eventually led to the Inter-Agency Task Force on Emerging Infectious Diseases (IAFT-EID) calling for the community quarantine or lockdown of the National Capital Region (NCR). This was then raised to an enhanced community quarantine of the entire Luzon island on March 17.

Bursting at the seams

As the number of COVID-19 cases quickly increased, the lack of and strain on health resources and personnel has revealed how weak the country’s healthcare system really is.

A group of private hospitals that have been attending to most of the COVID-19 patients appealed to the government to establish COVID-19 designated hospitals. Private hospitals stated that they are “lacking in manpower” since an “alarming number” of employees have been put on a 14-day quarantine. This left remaining hospital staff to tend to persons under investigation (PUIs). Moreover, personal protective equipment (PPEs) are running short while COVID-19 isolation areas are becoming scarce.

The government responded by designating the Lung Center of the Philippines as a COVID-19 exclusive hospital. This is not yet feasible though since it also tends to many cancer patients around the country.  Aside from the Lung Center of the Philippines, the Dr. Jose N. Rodriguez Hospital was designated a COVID-19 exclusive hospital while the University of the Philippines (UP) – Philippine General Hospital said it is also willing to exclusively handle COVID-19 cases.

However, public hospitals are also running on limited resources. The Philippine General Hospital (PGH) appealed to the public for PPEs like masks, 70% alcohol, and surgical gowns. While some public hospitals have received PPE donations and free shuttle rides for frontline responders, such as from the Office of the Vice President, other hospitals are still struggling with shortages in medical supplies and personnel.

The Kit

The lack of access to test kits may have likely contributed to the sudden surge in COVID-19 cases. The Philippines was reported to have only 2,000 kits.  To date, only 1,172 tests have been conducted. Sec. Duque has said that there are only about 200 to 250 people tested a day at the RITM for the disease. Only patients with a travel history to countries with confirmed cases of COVID-19 or have had close contact with confirmed cases are prioritized. Those that show symptoms but do not have a travel history nor had close contact are advised to self-quarantine due to the limited number of test kits.

A local COVID-19 test kit was developed by a team of scientists from the Philippine Genome Center and the UP Manila’s National Institutes of Health, led by Dr. Raul V. Destura. The local kit is cheaper than foreign test kits and can show results in hours compared to foreign ones that take 24 hours to have results. The local test kits cost around Php1,320 per test while foreign kits cost Php8,500 per test. Around 6,000 local test kits were said to be in stock.

Among the government’s supposed Php27.1 billion COVID-19 response package is up to Php3.1 billion directly for health-related efforts including purchasing more test kits. The Php3.1 billion will come from Philippine Amusement and Gaming Corporation (PAGCOR), Philippine Charity and Sweepstakes Office (PCSO), and Asian Development Bank (ADB).

However, protocols setup by the DOH for testing seem to have exceptions. For instance, politicians, such as President Duterte, and their family members who did not show symptoms of COVID-19 nor had exposure to confirmed cases were still tested. The DOH however, clarified that they used the old triage system that allowed these politicians to get tested since the decision tool was not yet revised then.

There are provinces such as Tacloban that have no access to test kits since the Luzon lockdown has stopped delivery of packages. According to the City Mayor of Tacloban, hospitals have to get test kits from the NCR and send them back to RITM to get results. But with the Luzon lockdown, this seems impossible. Provinces are saying they are fighting COVID-19 blindly since there is no mass testing being done for PUIs or Persons Under Monitoring (PUMs). RITM is the only facility for processing tests and the DOH is still working on getting five other laboratories accredited in Baguio, Manila, Quezon City, Cebu and Davao.

PhilHealth for the few

PhilHealth also rolled out an insurance package for COVID-19 cases for accredited level 2 and 3 hospitals. The package ranges from the cost of testing to Php4,000 for the referral package, Php14,000 coverage for the isolation package, and Php32,000 coverage for patients with moderate pneumonia due to COVID-19. Moreover, the No Balance Billing (NBB) policy will be applied to COVID-19 claims.

However, data from PhilHealth shows that private hospitals would mostly benefit from payment of COVID-19 insurance packages since there are more level 2 and 3 private hospitals. In 2019, there were 355 level 2 and 3 private hospitals accredited by PhilHealth while there were only 97 level 2 and 3 public hospitals accredited. Data from the DOH shows that as of March 20, 65% of confirmed COVID-19 cases were taken to private hospitals. To ensure funding for COVID-19 claims, PhilHealth is releasing Php30 billion to hospitals that apply for this financial assistance.

While private hospitals handle most of the COVID-19 cases and would get most of the PhilHealth claims, it seems that they have passed on the duty of caring for these patients since the insurance claims are too low for them. This may show that private hospitals see COVID-19 as not being profitable compared to other medical cases. The passing on of big private hospitals to government hospitals shows how profit-oriented the Philippine health care system is and how DOH willingly bows down to the demands of these big private hospitals.

Health Service for All

COVID-19 reveals how the Philippine health care system is vulnerable. Health workers are stretched with citizens having to donate PPEs to them. Additionally, testing for COVID-19 is only administered to patients who have met the narrow criteria or are relatives of government officials. While the PhilHealth insurance packages for COVID-19 are welcome, these public funds will mostly be used to pay for the claims of private hospitals.

In the short term, local government units (LGUs) should ensure that a clean water supply be made available to all communities during the lockdown to maintain cleanliness and combat the disease. Moreover, testing kits should be made available to all PUIs, PUMs and frontline health workers to avoid underreporting. Undocumented cases will only lead to continued transmission. Fighting COVID-19 could start at the barangay level by establishing more barangay health stations that are fully equipped and staffed to regularly monitor the health of community members.

In the long-term, our healthcare system should have a socially just alternative to PhilHealth as a healthcare funding, policy-shaping and regulatory system. It should have comprehensive and universal direct public funding and coverage of healthcare costs that is fully free healthcare for all. Aside from this, a public-led health system should also be equitably staffed, equipped and funded through a truly progressive tax system.