What universal healthcare is not

It is so unfortunate that at a time when the public badly needs the assurance of financial protection from being possibly afflicted by the COVID-19 infection, we are faced with serious allegations and investigations on alleged corruption that bedevils PhilHealth, the cornerstone of our universal health program. President Duterte, out of exasperation, recently threatened to scuttle PhilHealth by possibly privatizing it or preferably only reorganizing its structure.

To date, unfortunately the public has been made to believe that the Philippine version of “universal healthcare” – represented by PhilHealth – is a free health care provision for all Filipinos, whether rich or poor. As a matter of fact, there is a general and overall misconception that all medical services from primary healthcare up to hospital tertiary care are expected to be free, especially in all government hospitals – from so-called level 1 up to level 3 or level 4 hospitals.

These expectations have been reinforced with the passage last year of RA 11223, “An act instituting universal healthcare for all Filipinos, prescribing reforms in the healthcare system.” This has been aggravated by the misinterpretation of the general intentions of the law and its implementing rules and regulations and coupled by the pronouncements of a good number of our political leaders.

But nothing can be farther from the truth, as universal healthcare was not meant to be free for all and for all medical services and for all citizens! The concept is so attractive – if only it is affordable.

Unfortunately, our Department of Health has been reticent in explaining to the public the spirit behind the global movement to advance the concept of universal healthcare. Instead, it has become a participant in actively promoting the national misunderstanding of what “universal healthcare” is all about.

PhilHealth is not free care for all and not for all diseases and there will be a gradual and progressive expansion of coverage as the economy of the country correspondingly expands. How government responds to these healthcare demands as it balances the health budget needs to the other public budget needs in education, defense, public works, the environment and others will continuously test the levers of our national leaders as healthcare becomes a national issue in every coming election. You can see how Medicare (Obama Care) in the US is always a principal debate issue during every presidential election. This is true in most advanced countries as well.

Although “universal healthcare” has a long history since its initial declaration in the Alma Alta conference in 1948, most developing countries initiated the concept in the 1990s as their economies improved and many others have attained a middle income level of their economy. In today’s setting, a middle-income country has a minimum per capita income of about $5500 or more and whose national health accounts is about 6 percent of GDP. In essence, financial stability and support during catastrophic health events can be achieved when a country’s per capita health expenditure is such that people are not seriously burdened or become poor by the cost of being sick and is in need of hospitalization.

That health is a human right for every one to have access to a reasonable healthcare implies that any person has a right to an (a) available, (b) accessible, (c) affordable and (d) reasonable quality of healthcare when he gets ill.

In the Philippines therefore, universal healthcare predicates that all Filipinos when they get sick should have not only a medical service that is available but there must be an accessible health facility and the care is affordable to either the government, to the patient or both and of a reasonable quality. A Filipino, for example, in Jolo who develops a brain hemorrhage and needs care from a brain surgeon should have that service made available and accessible at a reasonable time at a cost that “he can afford.” It therefore demands that both the law and the public are clear on the issue of affordability and the capacity of the country and its health system to satisfy the above demands and expectations. This interplay of the demands from health prevention through an expansive primary care while trying to fulfill the demands of the more immediate hospital care (preventive, curative, rehabilitation) is the challenge for what type of healthcare system reform we will follow.

Universal healthcare through PhilHealth must therefore be understood from the following tenets:

• The public must understand the concept and demands of a quasi-socialized nature of universal healthcare, with the well-off subsidizing part of the cost of the healthcare given to the poor. This will be a measure of the egalitarian and humanitarian attitude of our society towards our poor population. However, we must first identify the poor among us whose annual premium will have to be paid for/subsidized by the national or local government or both. This segment of our population (20-30 percent) must be well identified and accepted by those who will have to pay a higher premium (higher taxes).

• A national consensus must be forged so that those in the non-poor, formal and informal sectors pay a progressive and higher premium based on their income.

• An immediate need to make an in-depth and regular (annual) study on the cost of hospital care and fees of the health providers, especially the doctors. In this regard, there is an urgent need to initiate a similar study of the varying costs of hospital care of the myriad diseases. A regular actuarial study is necessary to determine the extent of affordability of PhilHealth, preferably on an annual basis, and to determine an acceptable co-payment scheme for both the hospital costs and the professional fees of the doctors. A realistic and regular study, preferably on an annual basis, on the true cost of health services jointly with our health providers would enable the paying public to determine the additional insurance they may have to obtain (co-pay) from other private insurers. This will also protect PhilHealth from the excessive public demands on services that it cannot afford.

• Instead of privatizing PhilHealth, it would be best to establish PhilHealth as a quasi-government institution headed by a physician-leader with proven leadership in public health, hospital care and administrative experience who fully understands the complexity of the urgent health reform we are now pursuing. Much like our central bank, the PhilHealth president must be supported by a board of varied experiences in healthcare reforms. The board members must be selected from those experienced in health financing, medical actuary and information technology but who fully understand the intricacies of human health and suffering when one is unwell with all its complex societal ramifications. Since the recent PhilHealth law has defined the board composition, an interim group/commission of experts in healthcare, finance, information technology and health insurance be created immediately to advice/recommend changes or reforms to PhilHealth. The commission can draft its recommendations and can then be dissolved upon completion and implementation of their proposals.

What is more obvious and glaring today is the recognition of how the on-going COVID-19 pandemic has exposed our vulnerability and unpreparedness despite our supposed experience with previous national catastrophic events that had occurred during this current decade. It is, however, gratifying that the present administration and Congress have finally realized the funding needs to rapidly upgrade our health facilities, including establishing future vaccine capabilities, an advanced center for new and emerging diseases and finally addressing the economic needs of our health workers, especially our nurses and many more.

If we are able to do today what appears to have moved our national leaders during the past eight months, then maybe, years from now, we can look back and say that the COVID-19 which ravaged the country in 2020 was not all for naught!

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The author served as health secretary from 2010 to 2014.