Wednesday, May 23, 2012

Socialized Healthcare 5: Alterrnative Views on Universal Healthcare

Rights should always be coupled with responsibilities. Some people agree by saying that "With greater rights and freedom comes greater responsibilities." That is one way of saying it; another way is "With greater (personal) responsibilities comes greater (personal/individual) freedom." As Friedrich Hayek said, "People who are afraid of responsibilities are afraid of freedom itself."

In many discussions on health policy, what is often asserted and formulated is that "health is a right" and hence, "universal healthcare is a right." I have no problem with this formulation if this should also be added, that "health is a responsibility", and I am referring to individual (and parental/guardian, civil society, community) responsibility, not just government responsibility as is commonly understood. Thus, "health is a right, health is a responsibility" is easily intertwined.

Below are three articles in BusinessWorld by one of my friends in the local health sector, Reiner Gloor, Executive Director of PHAP, on universal healthcare. I agree with many -- but not all -- of his arguments here. I can sympathize with greater government health support and subsidy for the poor suffering from infectious or communicable and tropical diseases. But I have little or no sympathy for government subsidy for lifestyle-related diseases like illnesses due to heavy smoking, heavy drinking, heavy eating of fatty or junk foods, heavy sitting or sedentary lifestyle.

Reiner is speaking from a private sector and civil society point of view, not government's. So these papers have a balanced perspective on the issue of universal healthcare.


April 27, 2012

Medicine Cabinet -- Reiner W. Gloor

Universal health care coverage provides safety net for the poor


For many poor people, health has become a difficult economic choice between getting better or poorer.
Often characterized by high out-of-pocket spending, health financing systems in low- and middle-income countries have contributed to the vicious cycle where diseases worsen poverty, while at the same time, poverty results in rising incidence of diseases.

The World Health Report 2010 estimated that about 150 million people globally suffer financial catastrophe when they avail of health services. Similarly, 100 million people are pushed into poverty due to direct out-of-pocket spending.

In the Asia-Pacific region alone, about 80 million people experience financial catastrophe and 50 million others are impoverished due to health payments.

These happen since in low- and middle-income countries, health is paid for privately or mainly from out-of-pocket health care systems. The same is true for the Philippines that reported a private out-of-pocket share of 54.3% while government funding was 26.2% and social insurance, 8.5%.

This was validated by the Social Weather Stations (SWS) survey of Filipinos on Health Services and Financing which revealed that for those who have consulted a doctor when they were sick, seven out of 10 of them paid from their own pockets.

The video documentary, "The Road to Universal Health Coverage", emphasized that when households spend a substantial part of their income on health, the results can be catastrophic.

In fact, the same SWS survey disclosed that almost three out 10 Filipinos deferred visits to doctors even if they were sick because they felt that they cannot afford to pay for health care. Seven out 10 respondents also believed that many families get impoverished when a member gets sick and has to be hospitalized.

In shielding families from financial catastrophe and other disastrous social outcomes of direct out-of-pocket health payments, the video documentary highlighted the pressing need for countries to adopt and implement financing strategies leading to universal health coverage.

Universal health coverage, as defined by World Health Organization (WHO) Director General Margaret Chan, means in practical terms that all people in the country should receive some degree of financial protections from the cost of basic health services.

Furthermore, it means that no one in need of health care, whether curative or preventive, should risk financial ruin as a result of paying for health care.

The documentary, which is a joint project of the WHO and the Asian Institute of Management Dr. Stephen Zuellig Center for Asia for Business Transformation, featured countries in the Asia and the Pacific that have started to implement strategies centered on raising sufficient funds for health prepayment financing mechanisms, reducing heavy reliance on out-of-pocket spending, as well as improving efficiency and cutting wastage in the health system.

The governments of Mongolia, China, Laos, Cambodia, Vietnam and the Philippines have operationalized schemes that extend insurance coverage to more people, offer more and quality services, and pay more for health care costs.

For instance, Mongolia’s health financing system has provided citizens access to primary health care free of charge.

China, on the other hand, has recently implemented the New Rural Cooperative Medical Scheme that has reached about 90% of the whole rural population. China has achieved a breakthrough in its rural health insurance program by increasing central and local government subsidy to rural populations.

Meanwhile, Cambodia’s Health Equity Fund is designed to strengthen the safety net for the poor by paying for their health care and providing transportation and food subsidy. Hence, the Health Equity Fund seeks to reduce financial barriers to access health services by the poor. At the moment, the equity fund has covered 70% of the total population living under the national poverty line.

Laos has also introduced community-based insurance to complement the national social insurance. Out of the 23 districts covered by the community-based insurance, 11 are in rural areas.

In the Philippines, the documentary featured the government’s conditional cash transfer program for the 5.2 million Filipino families living below poverty line. Under this initiative, poor Filipino families are given a conditional grant provided that they meet monthly health and education requirements.

WHO stressed that universal health coverage is vital for growth, security and prosperity. The Philippines, along with its neighbors in the Asia Pacific, have already institutionalized some forms of health financing systems. These financial health systems can be enhanced to offer more protection for the poor so that they may access quality health care regardless of their ability to pay. It is, after all, the essence of universal health care. 

May 4, 2012
Medicine Cabinet -- Reiner W. Gloor

Social solidarity in health

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For every P100 spent on health care, about P54 is paid directly from the pocket of Filipinos. For the poor, health spending could even be higher. Given the high out-of-pocket spending, health has become an additional expense, especially for most of the poor who barely have enough for food and shelter.

According to the National Statistical Coordinating Board’s Family Income and Expenditure Survey (FIES) of 2009, about 30% of the country’s population lives below poverty line.

The bottom 30% of the population spent 59.9% of their money for food, and another 16.2% for house rental, fuel, light and water. Transportation and communication was 3.9% while clothing was 1.9% and medical care, 1.7%.

For those living in Metro Manila, the same survey also revealed that spending for health care declines as one’s income decreases. The survey showed that those whose annual incomes were over P250,000 spent 2% for health care while those who earned less than P40,000 allocated a measly 0.4% of their budget for medical care.

The combination of poverty and high out-of-pocket spending has resulted in catastrophic health spending, giving rise to a vicious cycle where diseases worsen poverty, while poverty results in the rising incidence of diseases.

The World Health Organization (WHO) emphasized that catastrophic health expenditure and its accompanying health, social and economic consequences can be minimized with the adoption of health financing strategies that protect the poor and vulnerable.

In the Philippines, a readily available health financing strategy is Republic Act 7875 otherwise known as the National Health Insurance Act of 1995. The law paved the way for the establishment of the Philippine Health Insurance Corp. (PhilHealth), tasked to provide insurance coverage to all Filipinos and whose mission is to ensure adequate financial access to quality health care services. It adds that access to care must be a function of a person’s health needs rather than his ability to pay.

The 3rd Quarter 2011 Report of PhilHealth showed that more than 78 million Filipinos -- or 82% of the population -- has been covered by the government’s insurance arm. Almost 39 million are being covered under the sponsored program, of whom about 19 million are the poor identified by National Housing Targeting System (NHTS).

But as pointed out by Dr. Ramon Paterno of the University of the Philippines Manila National Institutes of Health (UP-NIH), insurance coverage must be “viewed in terms of breadth, depth, height and utilization by population groups that are most in need of financial protection.”

Utilization is important to establish as mere population coverage does not guarantee that the poor and sponsored members are able to actually use and benefit from their insurance coverage.

Such is the intention of universal health care or Kalusugan Pangkalahatan (KP) that mandates PhilHealth to deliberately put those with less first in line, with the end view of shielding them from financial catastrophe when availing of health care.

Under KP, the Department of Health (DoH) has instructed PhilHealth to redirect its operations towards the improvement of the national and regional benefit delivery ratios, or the cumulative likelihood that any Filipino is eligible to claim benefits; is aware of his entitlements and is able to access and avail of health services from accredited providers; and is fully reimbursed by PhilHealth as far as total health care expenditures are concerned.

Under KP, PhilHealth is also aiming to provide financial risk protection for all wherein 100% of Filipinos, especially the poor, are covered. As PhilHealth President and CEO Eduardo Banzon put it, “no one gets left behind.”

In-patient and outpatient benefits will also be expanded and made simpler so that everyone may be empowered to utilize what belongs to them. Expanded outpatient benefits mean care beyond the current TB-DOTS, maternal care, malaria and certain preventive vaccines coverage, among others.

Given the WHO warning of a continuing non-communicable diseases (NCD) epidemic in low- and middle-income countries, special benefit packages for certain catastrophic diseases will, likewise, boost health outcomes.

The DoH is also putting PhilHealth in charge of enforcing the “no balance billing” policy in government hospitals where members who belong to the poorest income quintile and their beneficiaries will not be required to pay out of pocket for costs for their confinement. This policy hopes to reduce, if not totally eliminate, heavy out-of-pocket health expenses.

High out-of-pocket expenditure can drive even the rich into poverty. While KP seeks to address the health needs of all Filipinos, it will place deliberate attention on those disadvantaged by sickness and poverty. Such is the principle of social solidarity.


May 11, 2012

Medicine Cabinet -- Reiner W. Gloor

Kalusugan Pangkalahatan

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The First Quarter Survey of the Social Weather Stations (SWS) disclosed that about five in 10 Filipino families consider themselves poor.

The same survey conducted on March 10 to 13 revealed that around 11.1 million families are self-rated poor, 10 points higher than the 45% or the 9.1 million families in December 2011. While self-rated poverty hardly changed in Metro Manila and Balance Luzon, it was highest in Mindanao and the Visayas.

According to the survey, self-poverty rose sharply by 34 points in Mindanao, from 38% to 72%, which is the highest in more than eight years since November 2003. It also increased in the Visayas, which is nine points higher from 52% in the previous quarter to 61%.

Meanwhile, the Self-Rated Poverty Threshold is the monthly budget that poor households need in home expenses in order not to consider themselves poor in general. Compared to the previous quarter, the median poverty threshold for poor households rose to P10,000 in Balance Luzon, P12,000 in Metro Manila, P8,000 in the Visayas and P7,000 in Mindanao.

The median food-poverty threshold for poor households rose to P6,500 in Metro Manila, P5,000 in Balance Luzon, P4,500 in the Visayas and P4,000 in Mindanao.

Given the self-rated poverty and food poverty thresholds, people living in Mindanao only have P3,000 left to spend for other household expenses such as house rental, transportation and communication, utilities, education, personal care and medical care.

As evidenced by the Family Income and Expenditure Survey (FIES) of 2009, medical care was pushed further away from top priorities to give way to other family needs. The bottom poor of the population spent even less for health care at 1.7% while the upper 30% of the population spent 3.0% for their health.

Results of the FIES demonstrated that the majority of Filipinos, especially the poor, barely have enough for food and other important household expenses. And if forced to choose among all needs, food will be the top priority while health is among those that is sacrificed.

Earnest efforts have been exerted and several milestones achieved to improve overall health in the country with the implementation of the Health Sector Reform Agenda (HSRA) in 1999 and the FOURmula 1 for Health in 2005.

Despite all these important policies and undertakings, the Department of Health (DoH) has observed that poor Filipino families have yet to experience equity and access to critical health services. And as a result of wide disparities and inequities, the poorest of the population often have the most dismal health outcomes.

Given the pressing need to address health concerns of the majority, the administration has adopted universal health care as the core of the Aquino Health Agenda (AHA). Unique to the AHA is its deliberate focus on the poor with the aim of ensuring that the disadvantaged receive the benefits of comprehensive health reforms. In the process of the UHC implementation, the DoH is determined not to leave anybody behind.

Also called Kalusugan Pangkalahatan (KP), universal health care aims to ensure equitable access and affordable health care for all Filipinos, especially those belonging to the lowest two income quintiles living on less than a dollar a day. The lowest income quintile (Q1) has an average monthly family income of P3,460 while the next lowest quintile (Q2) is P6,073.

On top of the KP agenda is the strengthening of the National Health Insurance Program (NHIP) to provide more substantial financial risk protection for the poor by improving the benefit delivery ratio of PhilHealth. After enrollment, the benefit delivery ratio involves eligibility to claim, awareness of benefits, access and availment of services, and full reimbursement by PhilHealth for health expenditures.

Also a thrust of KP is the improved access to quality hospitals and health care facilities. The DoH observed that poor families are more likely to avail of health services at public facilities. However, government health facilities are not fully equipped and are understaffed.

Under KP, the DoH said that government-owned and -operated hospitals and health facilities will be upgraded to expand capacity and provide quality services to help attain Millennium Development Goals, attend to traumatic injuries and other types of emergencies, and manage non-communicable diseases and their complications.

Prior the 2015 reporting, the Philippines is still short of its target in reducing maternal and infant mortality. It is for this reason that public health programs will be directed at “reducing maternal and child mortality, morbidity and mortality from tuberculosis and malaria, and the prevalence of HIV/AIDS, in addition to being prepared for emerging disease trends, and prevention and control of non-communicable diseases.”

Asked recently by an international news network on how he sees the Philippines in 10 years, President Aquino promised to make crucial reforms in just four years. The implementation of Kalusugan Pangkalahatan that overhauls the health system to work for the poor will be an important measure.

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See also:
Socialized Healthcare 1: More Government = Less Health Care, March 29, 2006
Socialized Healthcare 2: Discussions in Facebook, September 04, 2009
Socialized Healthcare 3: Free Market and Better Health, September 22, 2010

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