OVERVIEW OF THE PHILIPPINE HEALTH SYSTEM

According to the World Health Organization (WHO), a health system is composed of all activities whose primary purpose is to promote, restore or maintain health. It is composed of health care institutions, supporting human resources, financing mechanisms, information systems, organizational structures that link them together and collectively culminate in the delivery of health services to patients. The Philippines has a dual health system consisting of a public sector and a private sector. The former is largely financed through taxes, allowing services to be given for free or following socialized user charges; while the latter is largely market-oriented and utilizes user fees to finance health services. Hence, the poor obtains health services from health facilities operated by the government while the rich opt for health services from private facilities. Since the devolution of health services under the Local Government Code of 1991, health services provided by the public sector became shared by the Department of Health (DOH) and the local government units (LGUs). The DOH, as the lead agency for health, became responsible for the development and implementation of national policies and plans, regulations, standards and guidelines on health, as well as the innovation of strategies in health to improve the effectiveness of health programs. It also acts as the administrator of national health facilities, and sub-national health facilities. Moreover, it provides services for emergent health concerns that require complicated new technologies deemed necessary for public welfare upon the direction of the President of the Philippines and in consultation with the LGUs concerned. On the other hand, the LGUs shall assume primary responsibility over the delivery of health services and the provision of health facilities devolved to them. The DOH shall in coordination with LGUs shall design and instill mechanisms providing for an integrated and comprehensive approach to health care delivery among LGUs, through the referral system and the networking of local health agencies. The DOH has adopted the sector-wide approach as the means to manage the implementation of FOURmula ONE for Health (F1) to be known as Sector Development Approach for Health (SDAH). The DOH and SDAH partners shall stimulate LGU participation to adopt F1 and national priorities in their respective localities such as advocacy on the economic and socio-political advantages of instituting health reforms, provision of incentives and forging performance-based agreements between the national and local governments among others.

Goals of the Philippine System

The Philippine health system has three primary goals that correspond to the goals of health systems as defined by the WHO. These goals are: better health outcomes, more responsive health system and equitable health care financing.

Better Health Outcomes

The health systems main purpose is to ensure that the health status of the people are as good as possible throughout their lifecycle by the appropriate use and adequate provision of health care. There is a need to attain the best level of health status for the general population and achieve the least possible variation in health status among individuals, groups and geographic areas in the country (World Health Report, 2000; World Health Organization, 2000).

More Responsive Health System

The health system needs to meet the expectations of the population it is serving. Responsiveness is a measure of the adequacy on how the health system is attending to the peoples expectation of how they should be treated by the health service providers. It is focused on the client centeredness of health care and encourages better performance towards it. This includes the patients and their families right for choice, respect, dignity, confidentiality and quality health care. Satisfaction with the health system on the other hand reflects the peoples evaluation of how their expectations were met by health care providers. The health system should provide patients and their families greater public satisfaction in the overall performance of the health system.

Equitable Health Care Financing

Equitable health care financing means that financial risks are distributed in a population based on an individuals capacity to pay rather than his or her risk of illness. The health system should ensure that an individual or family will not be forced into poverty due to the payment of health care or prohibited to avail of health care because of costs. Financial risk protection is provided by risk spreading strategy wherein revenues from people are pooled and utilized for the payment of those who get sick.

Health Status of the Filipinos

The health status of Filipinos is improving but the rate of improvement is not as good as the health status of other countries in South-East Asia.

Life Expectancy at Birth, Crude Birth Rate and Crude Death Rate are Improving
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Between the years 1980 to 2004, crude birth rate decreased from 30.2 to 20.5 births per 1,000 population, while crude death rate decreased from 6.2 4.8 deaths per 1,000 population (Philippine Health Statistics, 2004).

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Filipinos are living longer now with an average life expectancy at birth of around 70.5 years in 2005. This be attributed to the improving health status of the people and other socio-economic factors.

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Leading Causes of Morbidity

As in the past, most of the ten leading causes of morbidity are communicable diseases. The leading causes of morbidity from infectious causes include acute lower respiratory tract infection and pneumonia, bronchitis/bronchiolitis, acute watery diarrhea, influenza, pulmonary tuberculosis, acute febrile illness, malaria, chicken pox, measles and dengue fever from 1996 to 2006. Morbidity rates of these diseases have been observed to be declining over the last couple of years. Two of the top ten leading causes of morbidity are non-communicable diseases which are hypertension and diseases of the heart. Malaria is still the most common and persistent mosquito-borne infection in the country and drug resistant cases are on the rise.

Table 1. Ten Leading Causes of Morbidity Philippines, 1998-2007 Source: Field Health Service Information System, 1998-2007 Rank
1

1998
Diarrheas Bronchitis/ Bronchiolitis Pneumonias Influenza Hypertension TB respiratory Diseases of the heart Malaria Dengue Fever Chickenpox

2000
Diarrheas Bronchitis/ Bronchiolitis Pneumonias Influenza Hypertension TB respiratory Diseases of the heart Malaria Chickenpox Measles

2002
Pneumonias

2004
Acute lower respiratory tract infection and pneumonia Bronchitis/ Bronchiolitis Acute Watery Diarrhea Influenza Hypertension TB respiratory Chicken pox Diseases of the heart Malaria Dengue Fever

2006
Acute lower respiratory tract infection and pneumonia Acute Watery Diarrhea Bronchitis/ Bronchiolitis Hypertension Influenza TB respiratory Diseases of the heart Acute Febrile Illness Malaria Dengue Fever

2007
Acute lower respiratory tract infection and pneumonia Acute Watery Diarrhea Bronchitis/ Bronchiolitis Hypertension Influenza TB respiratory Diseases of the heart Dengue Fever Malaria Chicken Pox

2 3 4 5 6 7 8 9 10

Diarrheas Bronchitis/ Bronchiolitis Influenza Hypertension TB respiratory Diseases of the heart Malaria Chickenpox Measles

Other infectious diseases such as rabies, filariasis, schistosomiasis, leprosy and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) remain relevant public health problems even though they are not leading causes of illness and death. Rabies incidence in the Philippines is the 6 th highest in the world. Filariasis is the second leading cause of permanent disability among infectious diseases. Schistosomiasis remains endemic in the country although it has been eliminated in most South East Asian countries. And while the leprosy has been considered as eliminated based on national prevalence levels, certain areas still have prevalence rates above the elimination target. Dengue fever is known to have sudden increases in the number of outbreaks within a year. There is no vaccine or specific drug regimen to cure it. HIV/AIDS prevalence is estimated to be low in the Philippines but, high risk behaviors appear to be increasing and could lead to high incidence over time.

Leading Causes of Mortality

Despite the positive developments in the life expectancy, Filipinos are still affected by a double burden of disease, both from communicable and non-communicable Fig re 2 M lity Tre d of Com u icab D a s, M lig an u . orta ns m n le ise se a n t diseases. Non-communicable diseases are responsible for N op e lasma d D ase of th H artp r 1 0 0 Pop lation n ise s e e e 0 ,0 0 u majority of deaths in the country. The trends of the Philip ine 1 5 -2 0 p s, 9 3 0 4 Sou : Ph p eH lt St ist 2 0 rce ilip in ea h at ics, 0 4 causes of death are from disease of the heart and malignant neoplasm which comprise more than a third of the total causes of deaths. Meanwhile, deaths due to D a s of th H a ise se e e rt accidents doubled from 21.5 per 100,000 population in 1994 to 41.3 per 100,000 population in 2004 (Philippine M lig a t N op sm a n n e la Health Statistics, 2004). Deaths caused by communicable diseases have been reduced by more than half in the last Com u ica leD a s m n b ise se twenty years. This is quite evident in the decrease of pneumonia deaths from 86.4 per 100,000 population in 1984 to 38.4 per 100,000 population in 2004, a 55.5% Ye rs a reduction (Philippine Health Statistics, 2004). Deaths from all forms of tuberculosis have also decreased by 40% in the last two decades. This is the result of more aggressive disease prevention and control efforts of the government and improvements in curative care.
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Infant, Under-Five and Maternal Mortality

The infant mortality rate (IMR) and under-five mortality rate (UFMR) per 1,000 livebirths in the Philippines have been declining through the years, but the rate of decline has slowed down during the 1990s. The IMR was estimated at 30 infant deaths per 1,000 livebirths in 1993 then decreased to 24 per 1,000 live births in 1996 (National Demographic Survey, 1993 and Family Planning Survey, 2006). The three most common causes of infant deaths are pneumonia, bacterial sepsis, and disorders related to short gestation and low birth weight. On the other hand, UFMR was estimated at 64 deaths per 1,000 livebirths in 1993 then declined to 24 per 1,000 livebirths in 2006. The most common causes of under-five mortality are pneumonia, accidents, and diarrhea (refer to Figure 3). Fourteen percent of all deaths in women aged 15-49 years are maternal deaths. The countrys maternal mortality ratio (MMR) was estimated at 209 per 100,000 livebirths between 1987 and 1993 (National Demographic and Health Survey, 1993). This improved to 162 per 100,000 livebirths in 2006 (Family Planning Survey, 2006). Maternal deaths are mainly due to hypertension, postpartum hemorrhage and complications from abortions.
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There is regional variation in the attainment of health outcomes such as infant and maternal mortality rates. Some regions are performing better than the national average while the others are performing poorer than the national average. Problems in administrative reporting are also aggravating the situation (refer to Figure 5 and 6).

Figure 6 M . aternal M ortality Rates, Philippines and Regions, 20 6 0

Source: Fie H ld ealth Se rvice Inform ation System2 0 , De 0 6 partmof He e nt alth, Philippines, 2 0 06
P hilippine s N CR CAR I II III IV-A IV -B V V I VII V III IX X X I XII Caa a rg ARM M

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Disasters and Emerging/ Re-emerging Illness

The Philippines, being in the so-called Circum-Pacific belt of fire and typhoon, has always been subjected to constant disasters and calamities such as floods, typhoons, tornadoes, earthquakes, tsunamis, volcanic eruptions, drought, and flashfloods. Man-made disasters such as land, air and sea disasters, civil and armed conflict also take their toll in lives and properties. The country is also threatened by emerging and resurgent diseases. Emerging infectious diseases are newly identified or previously unknown infections, such as severe acute respiratory syndrome (SARS), while reemerging infections are secondary to the reappearance of a previously eliminated infection or an unexpected increase in the number of a previously known infectious disease, such as avian influenza, mad cow disease and meningococcemia. Both types can cause serious public health problems if not contained as close as possible to its source.

Responsiveness of the Philippine Health System

The availability of data for the overall responsiveness and satisfaction of the Philippine health system is very limited and there is a need to improve its process of collection. The level of public responsiveness and satisfaction with the health products, facilities and services are cited below:

Responsiveness of the Health System

Table 2. Percentage of People Receiving Poor Responsiveness in Hospital Inpatient Care Facilities and Ambulatory Services in Selected Domains, Philippines, 2000
Source: World Health Survey, 2000 PERCENTAGE WHO GAVED POOR RATING INDICATOR HOSPITAL INHOSPITAL PATIENT AMBULATORY CARE SERVICES 43.4 40.0 Waiting time 37.1 37.6 Privacy 41.3 41.3 Treatment information 47.4 45.5 Involvement 44.4 42.3 Talked privately 45.5 44.1 Confidentiality of records 52.3 46.9 Choice of health care provider 42.5 38.2 Cleanliness 50.3 44.7 Space 43.3 Family visit

RESPONSIVENESS DOMAINS Prompt attention Dignity Autonomy Privacy and Confidentiality of Records Choice of health care provider Basic amenities Social support

The responsiveness of the hospital inpatient and ambulatory health care services in the Philippines is generally acceptable as shown by the result of the World Health Survey in 2000. There were less than half of the clients who rated with poor responsiveness the hospital in-patient care and ambulatory health services in the domains of being provided prompt attention, respect for dignity, autonomy, privacy and confidentiality of records and availability of basic amenities and social support. However, the choice of health care provider and availability of adequate space have been rated poorly by more than half of the respondents for hospital in-patient care (refer to Table 2). There is limited or no data on the responsiveness of primary health care facilities.

Satisfaction with the Health System

Table 3. Net Satisfaction with Health Facilities with Most Used Health Facility by Area Philippines, 2000
Source: Filipino Report Card on Pro-Poor Services, World Bank, 2000 Philippines Over-all Satisfaction For profit hospital Traditional healers Non-profit hospitals RHU Government hospital BHS +87 +96 +94 +91 +82 +79 +74 Metro Manila +87 +95 +100 +100 +100 +72 +50 Luzon +88 +96 +88 +71 +90 +85 +59 Visayas +88 +100 +97 +100 +81 +70 +84 Mindanao +83 +93 +93 +100 +62 +76 +75

In 2000, the Filipino Report Card on Pro-Poor Services showed that there was a high level of overall satisfaction with health facilities. Satisfaction was significantly higher for private facilities than government facilities. For profit hospitals were rated +96, while the government hospitals were rated +79, rural health units (RHUs) were rated +82 and barangay health stations (BHS) were given a rating of +74. Although in the same survey, government hospitals got higher ratings from the rural households and those from the lower socio-economic class. In the same report, private facilities when compared to government facilities ranked superior on quality aspects, at par on convenience of location but inferior on cost aspects. In other words, cost was the only categorical advantage of government facilities over private facilities. Health services provided by public facilities were used mainly by those who could not afford the widely preferred private services.

Equity in Health Care Financing

In 2005, a total of P180.8 billion was spent on health related expenditures which is equivalent to 3.1% of the Gross National Product (GNP) in 2005. Of this, 59.1% or P106.9 billion was taken from private sources which include out-of-pocket, private insurance, health maintenance organizations, employee-based plans and private schools. Around 48.4% or P87.5 billion is primarily from out-of pocket which means that the burden of paying for health care is still predominantly shouldered by individual families instead of the government or insurance. National and local governments spent a total F u 7 ist u iono H a hEx e d u ig re .D rib t f e lt p n it re of P51.9 billion, or 28.7% of total health expenditures, b So rceo Fu d y u f ns while social health insurance paid P19.9 billion or 11%. P ilip in s, 2 0 h p e 05 S u ce P ilip in N t n l H a hAcco n s, 2 0 o r : h p e aio a e lt u t 05 Other sources accounted for 1.2% or P2.1 billion (Philippine National Health Accounts, 2005). Loca l The above sources of funds reflect different insurance mechanisms with varying degrees of ability to pool resources and spread health risk. The individual family, through direct out-of-pocket expenditure, is the least effective and most inefficient health insurance institution. A familys income and size limit the resources that can be pooled for health expenses. And since members are often exposed to similar health risks, the family has limited riskpooling capacity. Until now, there has been limited progress made in expanding social risk pools which includes government budget and social insurance funds for health. In 1994, social risk pools financed only as much as 44% of total health spending and decreased to 42% in 2005 (Philippine National Health Accounts, 2005).
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N t al a ion Govern e t mn 1 .8 % 5 4 Socia H a h l e lt Insu n ra ce 1 .0 1 %

P t Sou s riva e rce 5 .1 9 %

On the average, families spend only 1.9% of their annual family expenditures on health care, based on a survey conducted in 2000. The average health expenditure amount of a family then was roughly P2,660 and ranged from P572 to P4,430. Of this amount, 46.4% was spent on drugs and medicines, 24.1% on hospital room charges, 21.7% on medical charges including the doctors fees, 3.5% on medical goods, and 4.3% on combined expenses for dental charges, contraceptives, and other health services.

Fig re u

Challenges of the Philippine Health System

Given the scenarios presented in the previous sections, it is evident that the Philippine health system is confronted with challenges in achieving its three goals: improving the health status of the population, developing a health system that is more responsive to the health needs of the people and ensuring equity in financing health care.

Table 4. Comparative Trade Prices of Branded Medicines (in Peso) Philippines, India and Pakistan 2004
Source: MIMS 2004, Philippines; IDR 2004, India & Red Book 2004, Pakistan Medicine Preparation 300 mg tablet 10 mg tablet 400/80 mg tablet 20 mg tablet 300 mg capsule 40 mg tablet 5 mg tablet 80 mg tablet 50 mg 50 mg tab 5 mg SL tab 2 mg cap 1g vial inj. Medicine Brand Name Ponstan Buscopan Bactrim Adalat Retard Lopid Lasix Plendil ER Diamicron Ventolin Voltaren Isordil Imodium Fortum Manufactur er Pfizer Boehringer Roche Bayer Pfizer Aventis AstraZeneca Servier Glaxo Novartis Wyeth Janssen Glaxo Philippine s 20.98 9.26 14.80 37.56 34.66 8.56 35.94 11.00 315.00 17.98 10.29 10.70 980.00 Pakista n 1.46 0.60 1.09 3.85 2.89 1.28 8.25 5.00 65.88 3.92 0.23 1.94 322.75

Medicine Generic Name Mefenamic Acid tab Hyoscine-N-butylbromide Cotrimoxazole Nifedipine Gemfibrosil Furosemide Enalapril maleate Gliclazide Salbutamol Diclofenac Isosorbide dinitrate Loperamide Ceftazidime pentahydrate

India 2.80 2.45 0.75 1.50 13.17 0.53 5.95 7.57 132.38 0.92 0.26 3.27 418.72

There are also problems in the accessibility and quality of health products, facilities and services. The access to cheaper but quality drugs and medicine is poor. In 2003, the Philippine pharmaceutical market was estimated to be P65 to 70 billion and accounted for roughly 45% of health spending. Despite the large pharmaceutical market, local drug prices are 2 to 30 times higher than in Canada or neighboring Asian countries. This situation exists partly because low cost quality generic medicines comprise only 15 to 20 percent of the market while the rest are dominated by high-priced branded medicines (See Table 4). Furthermore, drug distribution is controlled by a few big distributors, mostly private drugstores; 85% of all drugs sold in the country are dispensed from these private pharmacies. The access to health facilities and health professional is also poor. In 2003, around 60% of all births were attended by a trained health professional in a health facility but the rest were delivered by hilots or unlicensed midwives and other untrained attendants (NDHS 2003). In the same year, around 34 out of 100 deaths from all causes and around 65% of deaths from certain conditions originating in the perinatal period were attended by a medical or health professional (PHS 2003). Government primary health facilities are conveniently located as 94% of households are within 15-minute walking distance to a Rural Health Unit (RHU) or Barangay Health Station (BHS). However, these facilities were frequently bypassed resulting in overcrowding of higher level facilities that are supposed to be reserved for more specialized care. On health facility utilization, the Filipino Report Card on Pro-Poor Services in 2000 showed that 77% of households surveyed used health facilities of one type or another (See Table 5). Urban households tend to use health facility services more compared to rural households. Government facilities were more frequented than private facilities due to the cheaper cost of health services being offered. Those who used the private

facilities were predominantly rich households and urban respondents, although poor respondents reported using private facilities as well.

Source: Filipino Report Card on Pro-Poor Services, World Bank, 2000 Philippine s (%) 77 39 20 10 9 (4) 30 28 2 (2) 8 M. Manila (%) 82 35 20 6 9 (2) 46 44 2 (2) 2 Luzon (%) 68 36 24 4 8 (3) 28 27 1 (4) 3 Visayas (%) 84 44 16 21 7 (5) 27 25 2 (0.2) 12 Mindanao (%) 82 42 16 14 12 (9) 24 22 2 (3) 17

Table 5. Utilization of Health Facilities by Area Philippines 2000

Visited health facility Mainly used government facility Government hospital BHS RHU No private facility Mainly Used facility For profit Non-profit No govt. facility Traditional healers

These challenges have been in the forefront of major reform initiatives in the health sector and remain as the focus of the implementation framework for health reforms that will be discussed in the next section.