Justice may yet prevail
BY AMADO P. MACASAET
Health for all Filipinos and social solidarity
A.G ROMUALDEZ JR., M.D
‘The disparities in health conditions between and among socio- economic groups result at least in part from unfair and unjust inequalities in access to health services of acceptable quality.’
THIRTY-TWO years ago at Alma Ata in the old Soviet Union (now called Almaty, Kazakhstan), health leaders from over a hundred countries declared their intention to achieve health for all inhabitants of this planet by the year 2000. In signing on to the declaration, the Philippines agreed to the goal of health for all Filipinos by the end of the twentieth century.
The deadline has long come and gone and still the health status of poor Filipinos in the bottom 40 percent of income groups lags behind that of their rich countrymen in the top 20 percent. Although those in the next 20 per cent are generally healthy, their status is not secure as a single episode of serious illness would impoverish them and cast them into the category of the poor and unhealthy.
The disparities in health conditions between and among socio- economic groups result at least in part from unfair and unjust inequalities in access to health services of acceptable quality.
Only the rich can afford to pay the high proportion of out of pocket payments required to avail of the entire range of effective health interventions. Healthy diets and exercise options are open only to those that can afford expensive options. Newer preventive measures such as recently developed vaccines for pneumonia and influenza are costly. High-end curative interventions for heart, lung, or kidney ailments, as well as cancer are affordable only for the highest income groups. Only wealthy disabled individuals can afford costly rehabilitation services.
Middle class families who can pay out of pocket for most basic services and medicines can maintain their health in ordinary circumstances. However, more expensive interventions often stretch their financial capacities sometimes beyond breaking point.
Most of the poor do not even have pockets. They depend on government or charity for the entire range of health services necessary to maintain or restore health.
The social determinants of health comprise a multitude of factors, many if not most of them outside the scope of the health sector. Nevertheless, health care financing – the way funds needed for health services are raised, allocated, distributed and paid out – plays a big role in defining the equitableness of any health system.
In the Philippine health system, except for the very limited range of services in ordinary health centers, most care is paid for through a "fee for service" system – that is, fees are collected per unit of service at the time and place of delivery. Without an efficient system of government subsidies, only those with ready cash or effective pre-paid options can avail of these.
The fact is that government subsidies for health are so inefficient and ineffective they end up worsening inequities. Individuals and families from high-income groups, who least need them, consume considerable proportions of these subsidies precisely because they are the most influential.
Pre-paid options for payment of health services are either private insurance or health maintenance organizations (HMOs) or the legislated public health insurance scheme – better known as PhilHealth. The private pre-paid schemes, being for-profit, are inappropriate for the income groups that have the highest risk for poor health. Unfortunately, the way PhilHealth is presently managed and organized, it is not yet able to adequately cover the health needs of its premium paying beneficiaries.
It is evident that to address the issue of inequity in the Philippine health sector, a government-led approach is necessary – to ensure higher levels of coordinated tax-based subsidies and conversion of PhilHealth into a true social health insurance scheme. This requires the acceptance of the notion of "social solidarity" – that those who are well should care for those who are sick and that those who can afford it should pay for the needs of those who cannot. This is a necessary pre-condition to truly achieving health for all Filipinos.
The question is: Do we Filipinos care enough about each other to get there?
An editorial in the most recent issue of The Lancet commented on a recent plan of the South African government to offer children as young as 12 years old and teenagers voluntary HIV testing in high schools. The editorial posed a number of questions to the team that will undertake to implement such a plan.
The Lancet asked, "But how should a health worker determine whether consent provided by a 12-year-old or adolescent is sufficiently informed? Will those who test positive get access to antiretroviral therapy? How will health workers ensure confidentiality? Will children be pressured by peers or parents to divulge their test results? Will condoms be given to those who come for testing? And how often will testing be offered? The task team should also be allowed to consider whether schools are the best place for children to learn their HIV status."
Although the HIV/AIDS situation in this country is far removed from that of South Africa, it may be a good idea for our social services sector to begin pondering these types of issues. The recent figures on HIV from the Department of Health are quite worrisome as the number of HIV positives reached an all-time monthly high last December and an all-time annual high in the year 2010.
Moreover, this real threat of a serious HIV/AIDS problem here should also encourage the religious sector to open their minds to the need for effective reproductive health information and services especially for young Filipinos. Maintaining an ostrich-like attitude may expose Filipinos to much greater dangers than the feared outbreak of generalized sexual promiscuity.
Email: alberto.romualdez@ gmail.com