Rx for health: Not just money or dole-outs but real reforms (Second of three parts)

IN HIS MESSAGE that accompanies the proposed government budget for next year, President Benigno C. Aquino III notes that the allocation for health is 13.6% higher than 2010’s P29.3 billion (According to the 2010 General Appropriations Act though, only P28.7 billion was allocated to the Health department).

Yet if one were to compare health’s share of the budget for this year and what the corresponding figure could be in the next, the difference isn’t much.

For 2010, the health allocation is 1.8% of the P1.54-trillion national purse. For 2011, the Aquino administration is proposing P32.62 billion for health — as indicated in the proposed National Expenditure Program — which is 1.9% of the P1.64-trillion national budget. The increase in terms of share in the total budget then would amount to just a tenth of a percentage point.

But that isn’t all. When he was still on the presidential campaign trail, Mr. Aquino had promised that health would take a 5% share of the national budget. It would seem now that he is off by at least 3.1 percentage points from what he had pledged, and short by almost P50 billion in peso terms.

Mr. Aquino, however, appears to have an ally in Dr. Esperanza Cabral, who was the last secretary of the Department of Health (DoH) in the previous administration.

According to Ms. Cabral, the promised increase should not all happen in one year. “Because if you throw P80 billion to the department, but the department is not ready to spend it, sayang naman (it would just be a waste),” she says. The increase, she says, should be incremental according to the “absorptive capacity” of the DoH.

“The spending should be programmed because the accomplishments are also programmed,” Ms. Cabral says. “Hindi naman matatapos lahat ng health care problems natin sa isang taon (Our health care problems won’t be solved in just one year anyway).”

That’s putting it mildly. As it is, the Philippines is already unlikely to attain the Millennium Development Goal (MDG) No. 5 by the 2015 deadline — to reduce by three-fourths the number of mothers dying from childbirth complications, and to assure greater access to contraceptives.

Feeble, infirm

The National Economic and Development Authority (NEDA), which put together the latest Philippine Progress Report on the MDGs out this week, does say that the country may have a medium to high probability of meeting other health-related MDG targets. But experts would probably agree that “feeble and infirm” are apt descriptions for the delivery of health services in this country, especially to the poor.

And yet the Aquino administration is poised to maintain several key health programs of its predecessor, even though these had been plagued by inefficiency and political interference, among other things. These include health subsidies under the conditional cash transfer program and Philhealth’s sponsored program, which is co-financed by national and local government agencies.

One major point of divergence it has with the previous government regarding public health, though, is in the area of reproductive health.

Mr. Aquino had some quarters worried that he was about to renege on another campaign promise when he reportedly said he needed to review the reproductive health bill and rename it the “responsible parenthood bill.”

But statements made just last week by Health Secretary Enrique Ona assured most of the Aquino government’s support for artificial contraceptives, which would be among the range of choices to be offered to couples.

The support would include funds for the availability of contraceptives in government health centers. Mr. Ona also said that the government would support sex education, strongly opposed by the local Roman Catholic Church hierarchy and lay groups.

Arroyo’s failure

Mr. Aquino’s immediate predecessor, Gloria Macapagal Arroyo, was known to frown on government programs that incorporated artificial contraceptives, including initiatives promoting maternal health, as well as those aimed at preventing HIV/AIDS or the human immunodeficiency virus and acquired immune deficiency syndrome.

In large part, say development and health experts — and even Ms. Cabral — this is why the Philippines will be unable to achieve MDG No. 5. In 1990, the Philippine maternal mortality rate (the number of women dying from pregnancy or childbirth-related complications for every 100,000 live births) stood at 290. This figure was supposed to be reduced to 52 by 2015. But the current maternal mortality rate is 162, which translates to about 12 women dying each day.

Most of these women are poor. After all, according to the 2008 National Demographic and Health Survey (NDHS), a woman in the lowest wealth quintile will bear an average of 5.2 children in her lifetime, compared to an average of 1.9 children for a woman in the highest wealth quintile.

In general, this is because the poor have less access to more family planning methods, even though they may want to space or limit their childbearing.

Income divide

For sure, proper medical attention and hygienic conditions during delivery are crucial in lowering the risks of women dying during childbirth. But in this area, there appears to be a huge divide between rich and poor women, between the educated and uneducated, and between urban and rural residents, says the United Nations Population Fund.

In the National Capital Region, for instance, almost nine in 10 deliveries are attended by skilled health professionals, versus only two out of 10 in the Autonomous Region in Muslim Mindanao, 2008 NDHS data show.

Indeed, the fact that she lives in Metro Manila may be why Claire Briones has yet to encounter any real problem while giving birth. Still, she says she dreads having any other medical emergency. At 35, Briones has four children; she is a single parent.

In theory, Ms. Briones’s family may qualify as one of the beneficiaries of the Conditional Cash Transfer (CCT) scheme that was the flagship antipoverty program of the Arroyo administration and which is being continued by Aquino.

Known previously as the ‘4Ps’ or the ‘Pantawid Pamilyang Pilipino Program,’ the CCT’s health component includes maternal health care for pregnant women, responsible parenthood seminars, and regular health checkups and vaccinations for children below five years old.

But because the program is built on providing cash subsidies to indigent families, the question of sustainability has been raised against it.

Target: 4.7 million families

For this year, the scheme’s target coverage is one million families. That translates to a monthly funding requirement of P500 million in health subsidies alone. Aquino, however, plans to expand coverage to all poor families — a figure that reached 4.7 million at last count. CCT health subsidies would thus come to about P2.35 billion a month.

The specter of ever-rising subsidies becomes all the more acute given the program’s apparent lack of any timeline (save for the maximum of five years that each beneficiary family can avail itself of the scheme’s benefits).

Interior and Local Government Secretary Jesse Robredo says that the CCT program had improved “health and education outcomes” in Naga City when he was mayor there. But he says that subsidies provided to the poor should be time-bound. “If not,” he says, “then [the program] is clearly not working.”

Ms. Briones does not seem to have heard of the CCT. But she says she was once a member of Philhealth, the national health insurance program that began in 1995.

Mr. Aquino has promised Philhealth coverage for all Filipinos within three years. He may not have to do all that much to achieve that if one were to go by Philhealth’s claim of having 85% of the population as its members. Yet even assuming that Philhealth’s figure is accurate, ensuring universal access to health care is obviously more than handing out Philhealth cards.

Even current Philhealth members think twice before seeking treatment, considering that the insurance covers only a small portion of the fees in accredited facilities — about 20-35%, according to Ms. Cabral.

Leverage, palakasan

Ms. Briones says that even when she was still a Philhealth member, she would bring her children to the barangay health center instead of a Philhealth-affiliated facility. With the earnings of her tiny neighborhood sari-sari store barely enough to feed all her children and keep them clothed and clean, Ms. Briones simply has no budget for medical expenses. She says she was able to use her Philhealth card just once, when she gave birth to her youngest child two years ago.

Ms. Briones was actually a beneficiary of Philhealth’s indigent program, in which a local government splits the premium payments with the national government. According to Philhealth’s 2010 first quarter report, the indigent program has 4.98 million beneficiaries or about 25% of its entire membership.

But even Ms. Cabral concedes that the program has been used for less than altruistic purposes. “Local government officials will actually use this as leverage for political favors, for votes, etcetera,” she says.

Ms. Briones herself says that she would not have gotten a Philhealth card had she not known the barangay coordinator assigned to her neighborhood. And now that the coordinator had passed away, Ms. Briones says she has been unable to renew her membership. She says the new coordinator lives elsewhere and tends to favor her own neighbors.

“Palakasan kasi (It depends on who you know),” Ms. Briones says.

Last year, NEDA also reported in its Updated Medium-Term Philippine Development Plan 2004-2010 that Philhealth’s sponsored program has been largely dependent on “the willingness of [local governments] to enroll their constituents.”

NEDA Social Development Staff assistant director Cleofe Pastrana says as well that in the past, many local governments were unable to sustain their part of the premium payments for Philhealth’s indigent program.

“That’s why the money at [the budget department] cannot move,” says Ms. Pastrana, “because without the [local government] counterpart, the money for health insurance wouldn’t be provided.”

The recalcitrance — and sometimes sheer unwillingness — of local governments to support national health programs or follow suggestions by the health department has left the likes of Ms. Cabral exasperated.

Devolve health service?

The way Cabral sees it, the most important reform that the health system needs is in the area of devolution. “We need to make up our minds whether the devolution of health services is good or not,” she says.

To which Mr. Robredo retorts: “It’s not a question of devolution, it’s getting the right people for [the task].”

He admits, however, that local governments seem to be out of the loop regarding national health priorities. He cites the case of the MDGs, among which the health-related ones focus on prevention.

“It’s not sexy at the local level,” says Mr. Robredo of the MDG thrust. “The issue there is ‘how many have I provided health assistance to’.”

But he argues that local governments would be encouraged to prioritize MDG-related programs if achieving the targets resulted in tangible rewards for the towns and cities, such as more funds.

Yet additional monies may not be enough to encourage local government executives to, say, allocate the necessary budget to keep their health centers stocked with contraceptives. That would, after all, mean, going head to head with religious leaders who wield great influence especially over rural communities.

Wanted: Direction

In 2004, then Health Secretary Manuel Dayrit issued Administrative Order 158 or the Contraceptive Reliance Strategy that gave local governments the task of providing contraceptives to their constituents — either for free or at cost.

The strategy’s failure can be seen in the lack of free contraceptives in public health facilities, which NEDA’s Pastrana says caused the very slow progress in contraceptive use rate. In 2003, the rate was 49%. Today the comparative figure is 51% — quite a long way still from the MDG target of 80%.

Some observers are optimistic that with the Aquino administration’s stance on reproductive health, local governments may give AO 158 a chance.

But there are those like Donato Macasaet, executive director of CODE NGO or the Caucus of Development NGO Networks, who say they would be surprised if Aquino would be able to achieve the health targets — particularly the one on maternal health — that the Arroyo administration had missed miserably.

Mr. Macasaet, though, says that he would be content if the Aquino government provides even just the direction so that the MDGs would be attained “if not in 2015, at least soon after.” –CHE DE LOS REYES, PCIJ