[Talk] Health Leadership Summit - Medical Anthropology and Universal Health Care

On December 3, 2018, the Ateneo Professional Schools (APS) and Ayala Healthcare Holdings, Inc. (AC Health) organized a conference on Universal Healthcare (UHC), entitled Health Leadership Summit 2018: Universal Healthcare at the Ateneo Professional Schools Auditorium, Rockwell Center, Rockwell Drive, Makati City.

As one of the speakers, I gave a talk on "how medical anthropology can contribute towards health for all Filipinos". I gave three roles for anthropology and for the social sciences in general - namely, (1)  identifying gaps in the so-called three dimensions of coverage (2) informing the kind of healthcare in UHC; and (3) evaluating and critiquing ‘UHC’ and document its ‘lived effects’.

As the country moves towards health reforms, it is of vital importance that social scientists engage with the medical communities to make sure that the voices of patients and laypersons are heard and listened to - as to what kind of 'health' we're really talking about when we speak of UHC. 

Health-spending behaviors: the temporal dimension of 'out-of-pocket spending'

by Gideon Lasco, MD

Out-of-pocket spending or out of pocket expenditure is defined by the World Bank as "any direct outlay by households, including gratuities and in-kind payments, to health practitioners and suppliers of pharmaceuticals, therapeutic appliances, and other goods and services whose primary intent is to contribute to the restoration or enhancement of the health status of individuals or population groups." Broadly defined, we can look at it as the percentage of total health expenditure borne by individuals and their families. OOPS is seen as a measure of the quality of a health care system: a higher OOPS means that there are not enough safety nets.

There is, I believe, compelling reasons to further dissect out-of-pocket spending versus the temporal profile of illness (clinical factors), and factor in what we already know about health-seeking behaviors (sociocultural factors). Let me lay down the foundational statements to explain what I mean:

(1) In the semantics of health, "Sakit" being the term for both disease and pain can suggest that pain may be essential in our folk conception of disease. This could explain in part why consults are delayed in illnesses that are initially painless such as tumors and the like. There is also the the concept of "Malayo sa bituka" (Far from the guts) which is another justification to delay consult

(2) If we speak of health as a 'business', our health care system is not a monopoly. There are alternative systems of health care which, playing by the laws of supply and demand, have an advantage by offering cheaper solutions and better, 'friendlier' services. These are the traditional healers who may be the arbiters of both medical management and health spending of the initial phase in the temporal profile of an illness.

(3) Strong family ties in the Philippines could lead to recruitment of more funds once the threshold has been reached where illness is considered grave, i.e. "Malma na" or "Malala na". The patient who initially had no money for a consult now has funds for a CT scan and an MRI, because the relatives from the States have remitted and a hectare of farmland has been mortgaged.

These three indicate that out-of-pocket spending may not be getting allocated according to temporal need (as defined by the clinician). There may even be instances when a patient could actually afford treatment, but it was not distributed appropriately per unit time. Indeed, a typical breast cancer patient in the Philippines may be spending the same amount of P1,500,000 as compared with a patient in Thailand (one of the better performing countries as per Dr. Banzon) but the outcomes may vary profoundly.

Why? Because a substantial portion of the Filipino patient's P1,500,000 was spent on the latter course of the illness: this was the time when she was willing to pay, this was the time when the "Malala na" threshold and thus the health insurance policy of every Filipino - strong family ties - is activated. This may also be the time when the patient begins to avail of hospital services having found no benefit from traditional healers and herbal medications. The opportunity cost of these alternative therapies too would weigh heavily in this discussion.

It will be interesting if we can generate plots that chart not only expenses per illness, but to plot expenses also against the the temporal profile of an illness, from the perception of illness to diagnosis to outcome (successfully treated, died, etc.). How much does a breast cancer patient spend in the Philippines? This question can be further expanded into "How much does a breast cancer patient in the Philippines spend throughout the course of her illness?" A good graph would show a gradual increase in spending but what I would expect to see is an initial under-allocation (clinically this will manifest as "lost to follow up" or "poorly compliant to medications") and then, towards the end, an over-allocation (and sometimes futile allocation) of funds. Doctors will end up hearing "Doc, gawin nyo ang lahat!" - a blank, desperate check for doctors to do everything. This could be an attempt to compensate for a perceived neglect on the part of the relatives, or simply a reflection of how serious the disease has become as a result of the above-described heatlh-seeking behaviors.

What will be the implication of these findings, if confirmed and quantified? To a clinician, this would simply mean the need for more patient education. But to a health economist, these temporal profiles can actually quantify opportunity cost and localize the particular weaknesses and points of improvement. Moreover, although OOPS is seen as negative indicator with respect to universal health care, it must be recognized for what it is worth: a resource that can be optimized if it is spent when it is of maximal benefit. Policies can then focus on prevention of futile spending, emphasis on preventive care, combating opportunity-grabbing alternative therapies, and a more aggressive appeal for patients to comply to initial management.

Properly managed out-of-pocket spending may also ease public spending, enabling its allocation to more pressing needs. The dynamics of private and public spending continue to be in a state of flux but in the meantime, we can micromanage both components to make it optimal. For instance, knowledge that the insurance policy of "strong family ties" is activated only with the pronouncement of 'serious illness' may be used by the physician as an ally in aggressively pursuing surgery in a Stage II cancer, where it could still be of maximal benefit. The economist can likewise use this cultural trait by allocating more (at least initially) in primary and secondary prevention where we have identified that there is an underallocation of private spending, but where a great need for financing lies.

I drew from a cultural perspective to support my points, but it can also work the other way. Analyzing where and when out-of-pocket spending goes can also help enlighten us more about the way people deal with illness. Indeed, health-spending behaviors (essentially OOPS, rephrased) may well be an excellent reflection of health-seeking behaviors can be an important focus on inter-disciplinary studies in the future. 

This is just one point where culture weighs in on the continued discussion on health financing. In a future article, I would also like to look at how a cultural perspective can help explain some of the problems that PhilHealth is facing with regards to universal coverage.

Three challenges for governance in health care in the Philippines

by Gideon Lasco, MD
Universal Health Care Study Group,
National Institutes of Health, UP Manila

Public discourse operates in opposites, particularly in the health sector. We see this in the ongoing debate on the reproductive health bill, where opponents and proponents are known as "anti-RH" and "pro-RH". In the US, the 'Obamacare' is attacked as a 'leftist'  policy, even as certain Republican counter-proposals are labeled as 'right-wing social  engineering'. In the Philippines, critics of PhilHealth object to 'privatization' as if public and private sectors were in opposition to each other. Public vs. private, pro vs. anti, left vs. right: does it always have to be "versus"?

In a recent talk as part of DOH-supported "Secretary's Cup" - a series of talks, debates, and town hall meetings on Universal Health Care - former DOH Secretary Alberto Romualdez defines governance as "not just about government, but deals with how the government and other institutions arrive at decisions and implement them towards meaningful changes that are beneficial to the people." The government's role, thus, is to aim at building consensus and forming partnerships, replacing the operative word "versus" with "and", paving the way for synergism and constructive, not oppositional relationships.

In this article, we discuss three relationships, which have to be reconciled to achieve good governance in health. These relationships also delve into the heart of health problems in the Philippines.

Local and national: Transcending bureaucracy in health
In 1991, the Local Government Code drastically altered the bureaucratic landscape by transferring the management of public health program and government hospitals at the municipal and provincial levels, from the DOH to local government units (LGUs). Not long after, the advantages and disadvantages of this new, decentralized system began to emerge. While it enabled LGUs to deal with their own particular health needs, it also opened the possibility for LGUs to neglect health care delivery. Moreover, health became enmeshed in local politics; good programs ascribed to a political opponents are spurned, even if the program was actually helping the people. Health officials are deployed for medical missions intended to gain political capital for the incumbent.

In a Universal Health Care scheme, the Department of Health would have to build strategic partnerships with local governments. While it is clear that there has to be a centralized body to coordinate macro-level functions, such as health information gathering, policy formation, and the operation and management of tertiary hospitals, there are also strengths in empowered local governments. It must also encourage the strengthening and expansion of Interlocal Health Zones - adjacent towns and cities that cooperate on health at the district level. These Zones have already demonstrated  better health outcomes where they were successfully implemented. Dr. Alberto Romualdez, who spearheaded the Health Sector Reform Agenda in 1998 as DOH secretary, has advanced the notion that the district health system ought to be the level of devolution, and that a referral system must be in place to weave things together: from the smallest rural health unit to the district hospital.

PhilHealth can act as leverage to optimize local-national partnerships, by providing incentives to local governments that perform well, and as well as setting standards in the accreditation of LGU hospitals, ensuring quality and safety, and providing additional capital with which enough human resources and quality health services can be guaranteed.

Finally, by building a constituency on health sector reform, which is what the Secretary's Cup aims to achieve, a political capital on health is built, creating incentives for local and national politicians to work together towards better health outcomes.

Private and public: Building public-private partnerships  
One of the flagship projects of the Aquino administration is the pursuit of public-private
partnerships (PPPs). In the health sector, health facilities enhancement was seen as the major focus of PPPs, with the P54-million NKTI Hemodialysis Center, a collaboration with Freseneus Medical Care Philippines, as a flagship project. Additionally, there are also examples of private sector engagements with LGUs that are remarkable for its successful outcomes. For instance, the Zuellig Family Foundation has helped initiate and sustain heath reforms in 485 municipalities located in Geographicaly Isolated and Disadvantaged Areas (GIDA), leading to significant decreases in maternal and infant mortality.

On the other hand, several groups have voiced their concern that these so-called 'partnerships'  may actually lead to the privatization of health care, which in turn would cause the spiraling of heath costs and the disenfranchisement of the indigent poor. These fears were exacerbated when it was announced that charity beds in public hospitals might be eliminated in favor of 'PhilHealth beds'.

Safeguards need to be instituted to ally fears. Just as importantly, the Department of Health needs to communicate to the general public what the PPPs mean for ordinary citizens. It is imperative for the stakeholders to project the whole picture of health reform, because focusing on just one part can slant the news. For instance, the claim that charity beds would be 'eliminated' was true, but it was just one part of the story: in fact, this 'abolition' is contingent upon the universal coverage of the indigent poor, who would then be able to avail the rechristened 'PhilHealth beds'.

In instituting safeguards, PhilHealth can once again play a pivotal role. By adopting 'case payment' schemes in which rates for particular procedures are fixed, patients are protected from overpricing, but these policies should also allow for some flexibility so as not to stifle the freedoms of medical practice. By setting standards for hospitals, PhilHealth is also able to ensure parity in terms of health service delivery, for private and public facilities alike.

Moreover, the Department of Health's strategic thrust towards 'health facilities enhancement' needs to be pursued aggressively. By enhancing government hospitals to be at par with private facilities, patients' perception of public health care will improve. By being competitive in terms of quality health services, a good performing public health care delivery system is perhaps the best deterrent to contain costs of private hospitals.

With PhilHealth emerging as a major player in health care, it must be managed carefully. Universal Coverage (PhilHealth coverage for every Filipino) does not necessarily translate to Universal health Care (good health for every Filipino), but it is an important prerequisite. Hence, the government needs to place more effort in making sure that everyone gets covered. As we mentioned earlier, the “correct-ness” of policies such as the change from 'charity beds' to 'Philhealth beds' depends on this. The National Household Targeting System, while effective, is still imperfect. Indigenous and marginalized peoples need to be integrated into this system without feeling threatened by the paperwork involved.

Professionals and laypersons: The team approach in health care delivery
Finally, health care must be seen not as an authoritarian imposition of doctors and industry upon patients and consumers; but as a team effort among doctors, nurses, midwives, patients, as well as among producers, regulators, and consumers of pharmaceutical products and health services. In a larger context, this 'teamwork'  approach mirrors the 'social solidarity' concept that rationalizes the social health insurance scheme of PhilHealth.

The 'community health teams' program of the Department of Health is a good move towards this direction. In recognition of the dearth of doctors in rural areas, the CHTs serve to augment the health needs of communities, particularly those that have indigent families. It also mobilizes nurses and midwives, by providing them with experience, training, and also an exposure to community health. In his paper on Health Human Resources published in the Acta Medica Philippina, Dr. Ernesto Domingo departs from the conventional notion of doctors as automatic leaders, saying, “Requiring the presence of a physician even for clusters of barangays is not only unrealistic, but also uneconomical and unsustainable in the long run.” Indeed, it is about time to mobilize and empower the health professionals we have rather than stick to outdated notions of hierarchy.

Involvement in health care must likewise extend to the patients themselves, and the community as a whole; the only thing that can beat a 'community health team' is a community that works as a health team. The bayanihan spirit, if applied to health, can mean community members engaging in healthy activities, cooperating with local health centers in the immunization and regular check-ups of children and pregnant women, as well as  public health endeavors such as the elimination of dengue-bearing mosquitoes in their areas, and planting of leafy vegetables and medicinal herbs. These acts may seem small, but by staying healthy and by not being dependent on hospital-based care for minor illnesses that the community can handle anyway, the health care system is unclogged, allowing it to focus on patients who need it the most.  

Conversely, patient empowerment can be maladaptive if coupled with mistrust in the health system overlaid with perceptions and experiences of unaffordable drugs and unfriendly health care providers. This leads to self-medication and its corollary ills of antibiotic resistance and numerous side effects, as well as the pursuit of alternative and traditional medicine which, by diverting patients from legitimate and life-saving procedures, can be even more harmful.

Patient education, thus, needs to be emphasized, with a focus on how to navigate the health care system. In line with the Department of Health's strategy of collaborating with other government agencies, the Department of Education can contribute to patient education by strengthening the health curriculum of students. Patient “miseducation”, by way of misleading advertisements, should likewise be dealt with. Regulatory agencies such as the Food and Drug Administration (FDA) need to be strengthened, and they must seen and perceived to be acting in the interest of patients.

In addition, patient groups and consumers groups need to be organized. Patient groups can clamor for more benefits from PhilHealth; consumer groups can become allies of regulators in ensuring quality and safety of products that are available in the market. What Secretary Esperanza Cabral proposed when she was in office – to translate “No Therapeutic Claims” into “Hindi Ito Gamot” is significant not only in who was involved: government vs. industry, but also in who was not involved: the consumers who are the users of these products in the first place. Perhaps what legislation or regulation cannot achieve, consumers can.

Moreover, the 'Daang Matuwid' battlecry must be applied to government hospitals; the system of patronage, where those with friends among the hospital staff can easily get admitted in charity wards, should be eliminated so as not to alienate patients who have no 'connections'. Financial protection should be extended to vulnerable populations, so they will not seek potentially unsafe alternatives.

Finally, a 'team' paradigm requires reforms in the curriculum of health professionals, which should emphasize not just patient education, but also the reciprocal concept of patient feedback (i.e. physician education). Performance in health must be measured not only in terms of health outcomes or economic gains, but also in terms of patient satisfaction.

Conclusion: Universal Health Care is the way
Universal Health Care, in the context of governance, can thus be defined, to paraphrase JFK, as 'health for the people, by the people'. Through consensus-building and rapprochement, the oppositional relationships can be transformed into partnerships.

Today, with the Aquino administration and the DOH under Secretary Enrique Ona supportive of Universal Health Care, and with the increased confidence in the government both by the people and by the private sector, we are presented with the perfect opportunity to push through with these reforms, the legislation needed to enable them, and the constituency needed to build political and social capital to make sure that our leaders place health as a top priority. By articulating Kalusugan Pangkalahatan, the Department of Health is opening the way for a meaningful discussion on how to achieve UHC. Questions such as, “Should private hospitals be exempt from the no balance billing policy of Philheath?” and “Should DOH should exercise oversight functions?” are some of the debate questions in the “Secterary's Cup” but they should also be debated  upon in pubic discourse until consensus is reached.

The urgency of moving towards Universal Health Care is underscored by the persistent and emergent health threats that continue to put our people at risk: ominous health indicators such as the rising cases of HIV/AIDS and the persistently high maternal mortality rates, and just as importantly, the everyday risk of bankruptcy that many Filipinos continue to face. They remain vulnerable to 'catastrophic illnesses': a single car accident or a cancer diagnosis could spell doom not only to the patient, but also his family. How many houses, farmlots, and carabaos have to be sold as the price and health and hope? With people's lives and well-being at stake, the chance to move towards a health care for every Filipino is an opportunity that must be lost.

Manila
August 12, 2012

Drugs, supplements, and Universal Health Care

by Gideon Lasco, MD

Attaching the word "universal" to "health care" is far more difficult in real life than in paper, for it involves reconciling the oftentimes disparate interests of various stakeholders. This is where regulation comes in: it tries to balance these interests while ensuring quality health care that is safe, equitable, and affordable.

In the ongoing “Secretary's Cup”, a series of talks, debates, and town-hall meetings organized by the Department of Health and its partners, "regulation" is highlighted as one of the six building blocks of Universal Health Care (UHC).

One of the key themes in regulation is the management of health products or medicines. From antibiotics to vitamins, drugs are part of our everyday lives, and we see them as fundamental mediator of health and wellness in our bodies. In this article, we examine areas where regulation is most needed.

Generics and branded drugs
The prices of medicines in the Philippines rank among the highest in Asia. In response to increasing demand for cheaper medicines, the Philippines enacted laws in 1988 and 2008 promoting generics, and parallel importation of branded drugs.

The results have been mixed. Today, generic drugstores are ubiquitous, and government-run Botika ng Barangay outlets cater to many communities. On the other hand, many people continue to distrust generics. A significant number of doctors share the view that inasmuch as they want to support generics, they do not wish to entrust their patients' health on generics that they say are of doubtful efficacy.

This is where regulation comes in. With sufficient credibility, the Food and Drug Administration (FDA) can narrow the perception gap between branded and generic drugs with its pronouncements of safety and efficacy.

Meanwhile, Ponstan, a pain reliever, costs less than two pesos in India and almost 16 pesos in the Philippines. Bactrim, an antibiotic, costs just 56 centavos in India and P18.16 in the Philippines.

Drugs and food supplements
Another important regulatory concern involves “food supplements”. In theory, they are not drugs, freeing them from the stringent requirements for drug approval. But in practice, they are marketed as drugs and treatments for particular conditions, notwithstanding the obligatory disavowal that follows their TV advertisements: “No approved therapeutic claims”.

These supplements fulfill people's needs that are not dealt with or sanctioned by the medical establishment, such as skin whitening and weight loss. Other supplements also promise to treat conditions such as cancer, diabetes, heart disease, whose treatments would be far more expensive if availed of from conventional medicine.

There are serious issues of safety among these products. As 'non-drugs', the ingredients of these drugs have not been examined thoroughly. They may contain harmful ingredients, and at high doses, they might be toxic to the body, unbeknownst to their adherents. For instance, comfrey, an herbal supplement widely promoted in the 1990s, turned out to be potentially harmful to the liver.

Moreover, there is also the issue of opportunity cost: If a patient takes a supplement to treat his or her cancer instead of going for chemotherapy, and in doing so, forfeits the opportunity to avail of life-saving treatment, who is to blame? Ultimately, it is the government's responsibility to ensure that consumers make informed choices. It must examine the way these products are marketed. Therapeutic claims, explicit or implicit, must not be advertised unless validated.

Traditional and modern medicines
Related to supplements, there is a challenge of integrating (and regulating) traditional remedies, particularly herbal medicines. In the early 1990s, the DOH led by Dr. Juan Flavier embarked on a campaign to promote herbal medicines as remedies for common ailments such as cough, culminating in the promotion of the “Sampung Halamang Gamot” (Ten Medicinal Plants). Lagundi, one of the ten, has been well-researched and the University of the Philippines National Institutes of Health has endorsed its efficacy and safety as a cough remedy.

Traditional and modern medicines should be treated equally by regulators. Herbal medicines, despite their being “natural”, must be evaluated for possible side effects and toxicity. But as lagundi has demonstrated, it also has the potential to be at par with other medicines in terms of effectiveness, and thus, they need to be taken seriously. Considering our wealth of plants and healing traditions involving plants, further research is needed to validate their therapeutic (and economic) potential.

Conclusion: Medicine and medicines
In this article, we looked into dynamics of branded and generic drugs, drugs and 'supplements', as well as traditional and modern medicines. In managing these relationships, it is the responsibility of the regulators, such as the FDA, to protect the interest of consumers. Moreover, in the larger framework of health reforms, it is important to recognize that universal access to Medicine should always be accompanied with universal access to medicines that are safe, effective, and affordable.

Manila
September 14, 2012

REFERENCES

Pizaro, O (2011). “Review of the Cheaper Medicines Program of the Philippines”. Philippine Institute for Development Studies. Available at: http://www.dbm.gov.ph/wp-content/OPCCB/fpb/b_DOH-CheaperMedicines/i-Cheaper%20Medicines%20Program%20Review.pdf

Lizada (2007). Food Safety in the Philippines. USAID. Available at: http://www.scribd.com/doc/4938633/Food-Safety-in-the-Philippines-Problems-Issues-and-Opportunities-for-the-Small-Farmers-and-Produ

Health Financing: Who Pays for Health Care in the Philippines?

by Gideon Lasco, MD

Mang Torio, a farmer in Central Luzon, was in his middle 50s when he began to feel a lump on his throat. At first, he thought it was just a passing malady, but after a few months, the symptoms worsened. He decided to consult a doctor, and he was diagnosed with nasopharyngeal cancer - a rapidly spreading tumor that carries a poor prognosis: it can be fatal within several months or a few years. Even though there was little chance of recovery, his family put together what little funds they have to pay for the chemotherapy, surgery, and several weeks of hospitalization. Five months after the
diagnosis, Mang Torio was dead, his rice fields had been mortaged, and his five children were left without any funds to continue their education.

The sad story of Mang Torio is an everyday reality in many public hospitals in the Philippines. And it demonstrates how disease is not only a health problem, it is also a major financial burden. This is particularly true for diseases that require drastic measures and hundreds of thousands of pesos at short notice. Most people simply do not have enough funds to cover the expenses, yet life, priceless that it is, must be saved at all costs, and Filipinos will do everything to raise the required amount - from selling or mortaging farmlands to making emergency loans. The social and financial cost of these diseases, such as cancer, stroke, and heart attack, is so tremendous that they are called "catastrophic illnesses".

Addressing this vulnerability is one of the goals of universal health care. And one of the tangible solutions is a national health insurance program - this is what PhilHealth has been striving to be since its inception in 1995. In the Kalusugan Pangkalahatan program launched by the Aquino administration in 2010, "financial risk protection" is also listed as one of the three strategic thrusts towards Universal Health Care.

Who pays for health care in the Philippines? The answer to this question is always a combination of government, private sector, and individuals, but what underscores the importance of universal health care is that the proportion of what individuals shell out is too much. In health policy parlance, this is termed "out of pocket expenditure" (OOP). According to the World Health Organization, 20-30% OOP of health care is the healthy proportion. In the Philippines, the rate is a staggering 57%. This 57% does not only represent catastrophic illnesses, but also daily health expenditures. Patients purchase drugs, consult their doctors, and pay opportunity cost for their consultations and hospitalisations.

The rest of the health expenditure is spent by the government, through various agencies, including public hospitals that are subsidized. Politicians also dispense of government money, through their congressional allocations, to help their constituencies. Charity organizations, including the Philippine Charity Sweepstakes Office (PCSO) and the Philippine Amusement and Gaming Corporation (PAGCOR) actively engage with tertiary hospitals like the Philippine General Hospital; social workers usually facilitate how health care is subsidized, how much is subsidized, and who gets subsidized. These donor-individuals and agencies perpetuate the notion of health as a form of charity and as a tool of political and corporate patronage, and does not move towards a social consciousness of health as a shared responsibility of the people.

The move for governments to take an increasing role in health, and an increasing share in paying for health care, is justified whether one sees health as a means or an end. Those who see health as a means invoke the role of health in development and economic productivity. On the other hand, those who see health as a end in itself focus on “health as a right”. These perspectives are in agreement in seeing out-of-pocket expenditure as something that must be decreased if we are to achieve Universal Health Care.

On the other hand, it is not enough to ask how we finance the healthcare of individuals. The other side of health financing, which is probably more challenging, is how to get the funds in the first place, for government to be in the position to assume a greater share of health spending? There are two schools of thought in this matter, one advocating for a social health insurance scheme, in which voluntary contributions are given by its beneficiaries, usually according to their ability to pay (the rich pay more; the poorest of the poor pay nothing). The recently-enacted health care scheme in the United States, popularly known as “Obamacare”, is a move towards this direction, and through PhilHealth, this is where the Philippines lies as well. On the other hand, there are also those believe that this system should be rejected in favor a tax-financed system;  just get the necessary health costs from taxes. Countries that have adopted this scheme include the United Kingdom and Thailand. Although we are pursuing a socialized health insurance scheme, there are those that suggest that we move towards a tax-based system.

Within the current policy framework, however, how can we thus improve health financing? Let us discuss the solutions that are on the table.

The three dimensions of universal coverage 
The World Health Organization speaks of three dimension of universal coverage. These dimensions are also means by which out-of-pocket expenditure can be lowered. The three dimensions are: Who gets covered, What is covered, and how much is covered.

Expanding population coverage, particularly to populations without ready access to health care, would obviate the need for them to consume their own resources for health care. However, the amount of coverage needs to be sufficient for all the expenses involved. In countries such as Thailand, even the transportation expenses of patients are reimbursed, since they have identified access to health facilities as a major reason for not seeking medical consult. This is true for the Philippines as well, and we need to adopt innovative strategies to make people more comfortable with health care. Finally, coverage should extend to catastrophic illnesses. This has already been launched by PhilHealth in July 2012, with the unveiling of the “Z Benefits for Catastrophic Illnesses”. Drawing from the illustration I used at the beginning of this article, Mang Torio's diagnosis of nasopharyngeal cancer is not yet covered in the benefits package of PhilHealth. This means that even if he were a PhilHealth member today, his illness would still be a heavy financial burden.

Efficiency through regulation and rational health care
An efficient health care system means that the money spent on health translates to beneficial gains in individual and public health. When people spend so much money on drugs and supplements of little or no evidence of benefit, we can call it a form of inefficiency. The government can solve this problem by regulating these pharmaceutical and 'nutriceutical' products and approving only those with clear indications and proven efficacy and safety. The technicality that supplements that do not seek any 'therapeutic claims' is exempt from the stringent testing that drugs are subjected should be rejected on the grounds that therapeutic claims are implicit on any product that associates itself
with illness or wellness. The Food and Drug Administration is mandated to implement these regulations, but it needs political backing of the government if it is to succeed.

Equally important in achieving efficiency in health is the avoidance of unnecessary procedures and hospitalizations. Fortunately, there is an increasingly growing body called “evidence-based medicine” that subscribes to the primacy of rigorous scientific evidence in guiding clinical and hospital policies and practices. Procedures such as CT scans, MRI, and laboratory tests are validated according to their ability to diagnose. Also, concepts in clinical epidemiology, which looks at disease patterns and distribution, such as “number needed to treat” . The weight of these studies notwithstanding, one must acknowledge that there are also economic motivation to pursue excessive health care. Thus, these tendencies have to be kept in check by professional societies as a self-regulatory measures, and by the Department of Health. The PhilHealth, which is becoming the major payor of health care, is also in a position to push clinical practice towards rationality by scrutinizing how patients were managed, given the diagnosis and the patient's history and physical examination findings.

Moreover, regulation of hospitals should also take into consideration the economics of health care. For four CT scan machines in one small town is obviously too many; investors seeking to return their investments would resort to coaxing doctors that practice there to over-prescribe a CT scan, either directly or indirectly; this would lead to unnecessarily procedures and the toll will ultimately be paid by the patients themselves.

Reforming the pharmaceutical and healthcare industries 
Reforms on drug pricing also have to be made, as drugs comprise a major amount of health expenditure. If the cost of drugs in the Philippines were as low as that in neighboring Thailand, it would cut spending on drugs into half, slicing the out-of-pocket spending by several percentage points. But why are we not able to do this? The answer lies in weaknesses in the regulatory infrastructure, as well as a weak local pharmaceutical industry that fails to provide any competition to multinational companies. The trend towards generic drugs and the rise of generics-only drugstores might change this, but four years after the Affordable Medicines Act of 2008, little has changed in the cost of many essential drugs.

On the other hand, healthcare, too, has to be regulated. Again, PhilHealth can leverage its influence. Already, it is implementing case payments which fixes the amount of cash that a doctor (or a hospital) gets for specific procedures. This move forces health care providers to work within certain

Legislative and political action
Restoring a health-promoting environment requires legislation in many areas. In raising revenues, the “sin tax bill” will be a key component, but the political debates about this bill are still ongoing, and it is likely that the outcome of this bill will be less than that for which it has been intended. In expanding coverage to reproductive health, an RH bill must be pursued. In strengthening regulatory agencies such as the Food and Drug Administration, new laws and amendments need to be introduced, although at times, the current legal framework is sufficient; but what is lacking is political support in carrying out these laws.

Ultimately, the health reform is a political process, and public clamor for health care is the catalyst that will move our leaders to act on it. Equally important, thus, are activities that raise awareness on health, such the Secretary's Cup of the Department of Health and its partners – a series of debates, talks, and town hall meetings that aim to build a constituency around Universal Health Care. The media should also participate in giving health issues a fair share of the public discourse.

CONCLUSION
Health financing remains a pressing challenge in reforming the Philippine health sector. Today, a majority of health care is still paid for by patients and their families, and this leads to catastrophes that ultimately affect economic productivity, and reduce overall quality of life in the country.

The general measure of a well-financed health care system is by looking at how much individuals spend for health care, an index termed “out of pocket expenditure”. Consequently, the problems in health financing can be augmented by moves that will (1) decrease out-of-pocket spending and/or (2) increase government spending, which is in turn enabled by generating revenues.

Under these two major domains, we have identified the following solutions: Expanding coverage according to the three dimensions of universal health care; Implementing reforms in pharmaceutical and healthcare industries; Pursuing measures that will raise efficiency and rationality of health care; and finally, legislative and political action.

As we end this discussion, it is important to state the one truism in health policy that cannot be ignored: that development itself is an antidote to health care; in general, as a country develops, so does its health care. While difficult to prove, the point here is that there are complex factors affecting health care that goes beyond the purview of public health or health economics. Also termed as “social determinants of health”, these factors are an invitation for multi-sectoral, interdisciplinary collaborations.

Ultimately, the conclusion we can make is that health financing in the Philippines requires a comprehensive approach that supports regulatory and legislative reforms aimed at raising revenue and reducing inefficiency; a commitment to expand the 'three dimensions of universal coverage', and a mechanism to increasing the capacity of the government to pay for health care, through raising revenues, and a strengthened, comprehensive, and sustainable health insurance system.

Manila
October 16, 2012