By Dr. Alberto RomualdezDean, Graduate School of Health

SciencesPamantasan ng Lungsod ng Maynila

Equity in health fair, just, and equal access to health care by all Filipinos.

Constitutional guarantee: Article II Section 15 – “The State shall protect and promote the right to health of the people and instil health consciousness among them.”

Overall health status – Lower than Thailand, Malaysia, Japan and Korea

The 70 years average life expectancy at birth is more than 15 years shorter than those of developed countries.

The infant mortality rate of about 35 per thousand live births translates into 80,000 Filipino babies dying of preventable causes each year

Maternal mortality ratio that has remained well above 150 per 100,000 live births – meaning more than 3,000 Filipinas dying unnecessarily every year.

Status of Health Equity in the PhilippinesIndicator High Income /

urban areasLow Income / Rural areas

Life Expectancy

at Birth>80 <60

Infant Mortality

Rate<10 >90

Maternal

Mortality Ratio<15 >150

Inequity in Health OutcomesAverage Fertility Rate by Income Quintiles

Income Group Average Fertility Rate

(Desired)

A 2.0 (1.9)B 2.4C 3.7D 4.7E 5.6 (3.1)

Factors Promoting Health InequityOrganization of Health Services

Cost of medicines and other health supplies

Distribution of human resources

Health Care Financing

Organization of Health ServicesPublic- Private Sector imbalance

Highly resourced private sector servicing 20-30 % of population

Health promotion/Disease prevention lag behind Curative Service provision

Fragmentation of ServicesOverspecialization of curative servicesDevolution of health services - national and

localWeak regulatory mechanisms

Result: Inequitable Access to Health ServicesLess than 50% of poor women get vitamin

supplements compared to 80% of high income women

2% of lowest quintile women and 20% of highest quintile have caesarean sections

Less than 50% of children from lowest quintile homes compared to 80% from highest quintile are immunized

Each year, less than 5% of the estimated 3000 new Filipino end-stage renal disease cases can have kidney transplants

Cost of medicines and other health suppliesThe prices of medicines in the

Philippines are among the highest in the world – higher than Europe and America and most of Asia and certainly too high in relation to household incomes of most Filipinos. Given the high prices, most medicines are beyond the paying capacity of most Filipinos.

Number of day’s wages needed to purchasea 30 days treatment with Ranitidine- Philippines, 30 days- Sri Lanka, 10 days- Brazil, 10 days- South Africa, 5 days

Source: WHO, World Health Survey, 2002

Average 4-week Medicine Expenditures within Household Expenditure Quintiles

$0

$10

$20

$30

$40

Ghana Coted'Ivoire

Senegal Morocco

Tunisia India

Pakistan Philippines

Med

icin

e Ex

pend

iture

s in

Las

t 4

Wee

ks b

y Qu

intil

es

Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5

$88$153

Result: Poor families cannot afford to pay for medicines

It is estimated that 70% of all health workers are employed in a private health sector that serves only the 30% of the population that can afford to pay for their health care.

Private clinical practice in lucrative urban areas is preferred by most doctors and even midwives. For nurses, teaching in nursing schools is significantly more rewarding than providing nursing care.

The fact that the market for expensive services is limited to the rich few partly explains the on-going exodus of health professionals at all levels.

Maldistribution of human resources

Dysfunctional Health Workforce StructureThe output of a workforce production system that is

de-linked from the actual needs of the Philippine system are health providers for whom service is a lower priority than personal professional advancement. They are ill-prepared for dealing with health problems in the Philippine setting.

Market orientation has influenced all the programs for health workforce production. In medicine, the number of schools, the curriculum, and even the type of faculty is determined by a philosophy of “what the market will bear”. The medical professions as well as the other health professions are self-centered and protective of professional privileges, status and opportunities.

Health Care FinancingTotal Health Expenditure (2005)

PHP 200 billion% of GNP < 3 %

% of GNP per WHO > 5 %

NHA2004: Sources of FundsGovernment (local & national) 30.3%

Social Health Insurance 9.5%

Private Shared Risk 12.5%

Out of Pocket 47.7%

Only those with money (i.e., the Only those with money (i.e., the rich) can fully pay for out of pocket rich) can fully pay for out of pocket payments and often they have payments and often they have generous health insurancegenerous health insurance

The near-poor and the lower The near-poor and the lower middle classes can become middle classes can become impoverished to meet out of impoverished to meet out of pocket payments for health care.pocket payments for health care.

The very poor don’t The very poor don’t even have pocketseven have pockets

Recommendation: Aim for Universal Health Care Increase in level and coordination of government

spending by national government (including DOH and PHIL Health as well as other sources such as PAGCOR, PCSO) and local government to reduce out of pocket spending to <30%

Restructure HRH production of government institutions to target government and other service oriented organizations and to emphasize service over self-interest

Strengthen regulation of private sector to include, where appropriate and necessary, cost containment measures and taxation of non-essential services

Restructuring HRH production and Deployment – UP ManilaReturn service requirement to be extended to

all units and all training programs – including PGH

“Consecrate one generation” of graduates to service in government and/or underserved communities or areas

Review private practice aspirations