Universal Health Care: 5 years later

April 8, 2024

by Maricar Piedad

The recent declaration by several non-contiguous city governments of a pertussis or whooping cough outbreak is worrisome. As of this writing, 862 pertussis cases and 49 deaths have already been reported nationwide. What is worrisome, however, is that the national government has only remained nonchalant. The president is nowhere to be found and the health secretary seems unperturbed about the state of calamity.

The Department of Health (DOH) has assured people that pertussis is treatable and that vaccine doses are on the way. But the agency is not answering the question: what is causing the sudden surge of pertussis cases when the disease has been supposedly managed in the past years?

This brings to everyone’s mind the bigger lingering issue of decrepit healthcare in the country. Five years ago, the government promised a “new dawn of healthcare” after the passage of the Universal Health Care (UHC) Law. Health services would finally be accessible and affordable to the Filipino people, the government declared. But the fulfillment of such promise is yet to be seen.

Does UHC truly care?

The UHC Law was derived from the Universal Health Coverage model promoted by the World Health Organization (WHO) and international financial institutions such as the World Bank and the Asian Development Bank (ADB). The UHC model promotes health financing to address health system gaps. It strengthens the role of social health insurance as the major player in the system by assigning the state as a health services purchaser instead of an investor in strengthening public health facilities and the services delivery system. This model has led to the growing power of private health corporations to take over as health service providers and to take advantage of the severe incapacity of the public health system.

In short, UHC is the commodification of health services. The UHC Law has become instrumental in the commercialization of health services, resulting in greater inaccessibility and unaffordability of healthcare for ordinary people. It practically abrogates the role of the state in upholding the people’s right to health. 

PhilHealth power

The UHC Law has prioritized the social health insurance system by giving key roles to the National Health Insurance Corporation or PhilHealth. In the past years, the corporation has been given a large allocation in the national budget and the power to collect larger premium contributions from the people.

In 2019, PhilHealth received an allotment of Php67.4 billion from the national budget. It increased 48.9% in 2023 when the agency was allocated Php100.2 billion. In 2024, the agency proposed a slightly higher budget of Php101.5 billion, but this was not approved due to the clamor of the people.

In terms of premiums, from the 2.75% premium rate in 2019, the UHC Law has approved an increase to 5% in 2024 and 2025. This has resulted in an increase in the monthly premium from Php275 minimum and Php1,375 maximum in 2019 to Php500 minimum and Php5,000 maximum in 2024. The incremental increases over the years have resulted in a huge accumulation of PhilHealth premiums paid by the people. The direct contributions, or premiums paid out of pocket by employed Filipinos, reached Php77.1 billion in 2019, which grew to Php146.1 billion in 2023.

UHC geared PhilHealth to be the major source of financing for health. But the latest Philippine National Health Accounts (PNHA) shows that household out-of-pocket (OOP) expenses are still the main source of health expenditures in the country. OOP’s share in the current health expenditure (CHE) in 2022 was 44.7%, higher than its record of 41.9% in 2021. Meanwhile, the combined shares of the national government, DOH, the local government unit (LGU) and PhilHealth were only 44.2% of CHE. PhilHealth contributed a mere 13.6%, among its lowest recorded share.

The 2022 National Demographic and Health Survey (NDHS) paints the same picture. Among the respondents who have been confined to a hospital or clinic, majority of their hospital bills were still paid using their salary, loan, or sale of property. On average, total hospital bills reached Php46,640, and PhilHealth only covered Php17,507, or 37.5% of total hospital bills.  Even with the continuous increase in allocation from the government and the increase in collected premiums, PhilHealth’s support value remains low. This shows the ineffectiveness of heavy reliance on the health insurance system, while the government is not addressing the chronic issues that the health system is facing.

Neglect of primary health

The global Declaration of Alma Ata in 1978 laid out the importance of ensuring the primary health care system as a strong preventive measure to achieve the highest well-being of the people. But since UHC is focused on the financialization of health, the primary health system has been neglected.

The re-emergence of preventable diseases may be said to be the result of a deteriorating primary health care system. The surge of pertussis and measles cases is the effect of a weakening immunization program, which is among the preventive health programs that are essential to the attainment of health. The ideal immunization rate is 95% coverage of the eligible population. In 2012, the national full immunization rate of children 0 to 12 months old was recorded at 74.9%, which fell to 69.1% in 2019 and declined further to 60% in 2022.

Currently, the country is suffering from a double burden of disease, as both communicable (CD) and non-communicable (NCD) diseases are still substantial causes of death in the country. Many existing NCDs, such as cancer, some cardiovascular diseases and diabetes are manageable and treatable if detected early. However, the government has cut the budget for its NCD prevention program, the Philippine Package of Essential NCD Interventions (PhilPEN). The set target of using the PhilPEN with 70% of the eligible population was never achieved, and the latest record is only 10.6 percent.

CDs, on the other hand, are dangerous as they easily spread and affect the vulnerable. Pertussis and measles are examples of CDs that could have been prevented through a strong intervention program. Meanwhile, the constant dengue outbreaks in rural and urban areas are proof of poor CD prevention and management programs. Still, the budget for these programs is being cut.

Poor health support

Addressing the severe gap in the available health infrastructure is not a priority under the UHC, considering that the building of Health Care Provider Networks (HCPN) has fully integrated private corporations into the health service delivery system. Through HCPN, private hospitals and health facilities are being used to serve the share of the population not accommodated by the limited capacity of public health facilities. This further incentivizes the building of private hospitals in profitable urban areas.

In the latest DOH data, there are a total of 1,307 licensed government and private hospitals, of which 861, or 65.9%, are privately owned. These private hospitals are concentrated in the major economic regions of CALABARZON (174), Central Luzon (126), and National Capital Region or NCR (108), not fulfilling the role of the private sector in supporting the public system since hospitals are still scarce in the poorer regions.

Public primary health facilities remain inadequate. Currently, there are a total of 23,614 barangay health stations (BHS), meaning only half of the 42,034 barangays in the country. The health center-to-population ratio remains worrisome because the latest report shows that there is one health center per 41,477 people.

Filipino health workers remain overworked, as the healthcare worker-to-population ratio has not improved under UHC. The public health workers to population ratios are one physician per 26,014 population, one public health nurse ratio per 4,911 population, and one midwife per 5,074 population. Among the three public health professional workers, only the public health nurse-to-population ratio target was achieved.

Privatization, a bitter pill

UHC is just another name used for the commercialization, financialization and privatization of health services. The redirection of the public health system from direct service delivery and strong population-based health programs to an over-reliance on health purchasing resulted in more inaccessible and expensive healthcare. The finance-driven UHC even led to the deterioration of essential health services like preventive health.

UHC promoted a disease-based, individualized and insurance-reliant approach to health. It is far from the comprehensive approach needed to truly solve the systemic ills plaguing the country’s health system. UHC’s main promise of protecting people from health-related financial catastrophes has not been achieved either.

The promotion of social health insurance has taken much-needed resources away from the most vital health interventions that the state should have focused on. PhilHealth is taking away the money that could have been spent on building more health facilities, investing in advanced health technology, and compensating the overworked Filipino health workers. It could have been spent as well on health intervention and education programs.

The anxiety people felt after the proclamation of pertussis is understandable. People know that the country’s health system is not equipped to protect them from the disease. Vaccines against pertussis are yet to be purchased from abroad, which delays the supposed immediate response to the issue. The dismissive attitude of the government is also reminiscent of the times when COVID-19 cases were just starting in the country, and this attitude further triggers the people’s collective trauma.

Five years of unfortunate health events seem to be just that, unfortunate, but clearly show the state’s systematic letting go of its responsibility to promote the people’s right to health. As long as private profit interests in health are prioritized by the government and prescribed as the cure to health system ills, health emergencies will persist.