BINUA, Lyn Jeen
SERRA, Chara Grace
4ASN1
Improvement of Public Healthcare in Rural Areas
I. The Problem
Having an efficient healthcare system contributes to the overall functioning of the
society. Particularly, this greatly affects the working population and the marginalized. As such, it
can be said that a country’s healthcare system can be treated as a tool to gauge a nation’s
socio-economic development and position. In the Philippines, the healthcare system has
already undergone series of changes throughout the years - the signing of the Universal Health
Care Law in February 2019, which seeks to provide healthcare to the entire Filipino populace,
being the latest. However, attempts to improve the general healthcare in the country, particularly
the public health services in rural areas, seem to be insufficient as of now.
In 1991, there has been a devolution of national services which caused the transfer of
administrative responsibility over local health units from the Department of Health (DOH) to local
government units (LGUs). This resulted to the inability of many LGUs to recruit and hire doctors
in their respective municipalities, most especially those in geographically isolated areas and
those with low annual incomes. Public and private sectors operate the Philippine health system
with the private sector remaining dominant. Along with this duality comes the fact that the
Philippine health sector is running for two groups: (1) those who have the ability to pay and (2)
those who have nothing. Generally speaking, the imbalance between the public and private
sectors is apparent - the service of the private sector being far better than the public sector as
might be expected as technology, facilities and medical practitioners in the private sector tend to
be of better standard than that of the public. Furthermore, hospitals and health centers that offer
the best services are usually situated in cities and metropolitan areas, especially Metro Manila,
with health educators and practitioners concentrated in the same places. In contrast, the
healthcare system in rural areas and the public healthcare in general, remains underdeveloped
as people are left with substandard services brought about by limited funding,
undercompensated health practitioners, undertrained barangay health workers, limited facilities,
and the like. However, while it is true that the private health sector reflects excellent
performance for those who can actually afford the cost, it remains indubitable that some private
hospitals turn out to be profit-centered, wherein the importance of the profit obtained from their
services tend to outweigh the importance of the quality of the service being rendered per se and
the desire to provide the necessary assistance.
Such problem of poor health services in rural areas wherein the population is left
helpless due to inaccessibility, lack of appropriate facilities and equipment, financial restriction,
and the lack of health practitioners, stem from a number of causes. The increase of hospital
charges and curative care, along with the tighter public health budgeting arising from
misprioritization by the government, poses considerable effects that fuel the continuity of poor
public health services. Furthermore, it is also necessary to note the so-called “medical brain
drain” which refers to the turning away of skilled doctors with the intent of working either in
privately run hospitals or overseas. Looking at this issue, one can conclude that this still boils
down to the lack of funding, or if not, improper budget allocation for the public health sector as
healthcare providers, as might be expected, would rather choose to be employed in institutions
that offer adequate compensation instead of being poorly paid and undercompensated in
government-run hospitals and health centers. As a consequence, rural areas face the challenge
of having understaffed hospitals, which in turn would result to having overworked health
providers. This would then affect the quality and inefficiency of the service being rendered. With
all of this being said, the collapse of the Philippine public health system becomes apparent.
Clearly, this poor condition of the Philippine public healthcare system could not remain
as it is; for the longer it stays like this, the longer people will suffer. The disparity between the
two aforementioned groups, (1) those who have the ability to pay and (2) those who have
nothing, will remain much more visible, as treatment and quality health services would turn out
to be a privilege enjoyed only by those who can avail it. As such, this can potentially cause
grave effects to the population at-large, leaving the underprivileged at stake and may also leave
supposed-to-be curable illnesses the cause of declining health status. It must always be
remembered that it is the responsibility of the state to protect and promote the right to health of
the people and instill health consciousness among them, as stated in Article II, Section 15 of
the 1987 Constitution. Furthermore, an efficient public healthcare system is a vital element in
maintaining a good workforce and smooth societal flow, hence the need to improve public
health services in rural areas.
II. EVIDENCES
Obviously, public healthcare in the Philippines is generally poor. Along with having unfair
and inequitable access to healthcare, public healthcare also remains substandard. The extent of
this social issue is so great that that better-quality services tend to be confined just within the
borders of cities most especially in Metro Manila. Given the archipelagic geographical nature of
the Philippines, rural and remote areas usually end up being left behind. “Low government
spending on the health sector; high out-of-pocket spending that impoverishes thousands of
Filipino families; persisting high maternal and newborn deaths that are among the highest in the
Southeast Asian region; high fertility rates among the poorest Filipino women; the continuing
challenge of infectious diseases like tuberculosis, dengue and malaria; emerging diseases like
HIV/AIDS and the interlocking crisis of non-communicable diseases; shortage in human
resources for health, particularly doctors” all define the urgency and extent of this social issue.
Adding these to the fact that poverty still remains as a challenge to the country, it is safe to infer
that there is really a struggle in gaining quality health services in the Philippines.
The issue concerning access to quality public health care in the Philippines persists most
especially in rural areas. Better service delivery and lower charges remain to be goals that need
to be fulfilled. A 2007 report by the Asian Development Bank (ADB) shows that higher-income
Filipinos prefer private health facilities, which they considered as providing better-quality
services and lower-income Filipinos usually go to public health facilities such as rural health
units and village health stations, which are generally perceived to provide low-quality health
services. The number of Rural Health Units (RHU) and Barangay Health Stations (BHS) which
act as providers of public health services at the municipal and barangay levels are also
declining, and the number of BHS is stagnating, thereby being unable to cope with the
increasing population. The Department of Health (DOH) reveals that public hospitals cover
around 40% of the totality which clearly shows that private hospitals outnumber government-run
hospitals, justifying the dominance of the private sector in the Philippine health system.
Furthermore, it is important to reiterate that hospitals that offer better services are highly
concentrated in the National Capital Region. Such is also true when it comes to the distribution
of healthcare providers and educators, as these individuals are forced to work overseas or in
cities since clinging to public service would mean facing a lot of challenges. Many hospitals turn
out to be understaffed and a nurse can expect to handle 20 to 30 patients. In this regard,
although the Philippines has an adequate number of these individuals, some areas, especially
the rural areas, remain lagged. Furthermore, there is only a meager or no hazard pay and travel
allowance for them which denotes undercompensation, and massive multitasking overlooking
quality and outcomes occurs since highly skilled nurses are in short supply. As a result,
trainings and certification programs are done in shortcut, compromising the quality of service
given. DOH moreover states that “there should be 20 hospital beds per 10,000 population” as
per the recommendation of World Health Organization (WHO). However, based from such
criteria, statistics show that almost all regions in the Philippines lack hospital beds except Metro
Manila, Northern and Southern Mindanao, and the Cordillera Administrative Region (CAR); and
the doctor-to-patient ratio turns out to be 1:33,000, a value that clearly denotes dire inadequacy.
Considering all of this, it is ironic that the National Demographic and Health Survey revealed
that out-of-pocket payments are significantly higher among patients confined in public hospitals.
This is particularly disadvantageous to the poor who needs services the most as it has been
proven that they are the main users of government health facilities.
Amidst this persisting social issue, attempts to develop such system have been made.
The Philippine Health Insurance Corporation or Philhealth was founded on February 5, 1995, a
government-owned and controlled corporation (GOCC) which aims to ensure the health of every
Filipino through social health insurance regardless of social status. It seeks to reduce
out-of-pocket spending as well as the inequities in health financing. To achieve this, premiums
have to be paid by members across the country. However, although it is indubitable that such
program has indeed helped the Filipino populace in general, certain cases prove that due to a
fragmented health system, Philhealth only benefits those with money who often have adequate
health insurance to fully pay medical bills. The lower middle class and the near-poor are often
forced to pay for the amount required by out-of-pocket payments which impoverish them. This
reflects the weak poverty targeting policy of the program which, in turn, favors well-to-do
families. A study conducted in 2006 shows that the less privileged only obtained P1.4 billion of
Philhealth reimbursements while P5.2 billion was directed to the richest 20% of the
beneficiaries. As such, leakage and undercoverage appears to be the weaknesses of the
program which both stem from poor targeting poverty strategies and insurance coverage. These
take place through errors in identifying members under a certain class which is a result of poor
evaluative measures in assessing the true poor.
Another initiative to address the problem of understaffed hospitals in rural areas and to
ensure quality healthcare service to the depressed, marginalized, and underserved areas, is the
creation of the Doctors to the Barrios (DTTB) program by the DOH in 1993. This deploys
doctors to various geographically isolated and disadvantaged areas in the Philippines to work in
primary care and public health. In turn, these doctors would receive package benefits. However,
at present, there are only 215 doctors deployed across the country. In 2017, it was reported that
626 slots of the DTTB remain vacant thus depriving a large portion of the population in poor and
far-flung areas of access to quality health care service. This boils down from the issue of
undercompensation, the pay being unattractive and uncompetitive, and the desire of potential
recruits for further training hence leaving the issue unresolved.
The recent signing of the Universal Health Law on March 14, 2019 is another leap in the
process of improving the healthcare system of the country. Under such law, all Filipino citizens
are automatically enrolled in the National Health Insurance Program which gives access to the
full continuum of health services they need while simultaneously preventing them from enduring
financial burden. This further prioritizes the Geographically Isolated and Disadvantaged Areas
(GIDAs) by requiring all graduates of allied and health-related courses under
government-funded scholarships to serve in public and priority areas for three years with
compensation. This will be under the supervision of the DOH. However, the fate of such law still
remains unanswered as it is still too early to list its flaws and limitations.
While it is true then that there has been a lot of attempts to alleviate the issue of public
healthcare in rural areas, the implemented programs and policies seem to have little effect on
the improvement of services. This therefore calls for an immediate action to modify or propose
new policies that can potentially address the issue more efficiently.
III. ALTERNATIVE POLICY RESPONSE
This paper proposes the improvement of public healthcare services in rural areas as this
remains as one of the key issues that concern the Filipino populace most especially the
marginalized and the underprivileged who need public healthcare services the most. Below are
three policy alternatives deemed to be beneficial in countering the collapsing public health care
in rural areas.
Proper allocation of funds
In the Philippine context, looking at the public healthcare system would lead to the
demand for an increase in government spending in the health sector. While this is the most
desirable way to alleviate the problem, proper allocation of funds must be practiced. Setting
policy frameworks is not enough as money should be put where the mouth is. There is a need to
focus on priority areas of the health sector. Substantial investments especially in public health
facilities should be allocated to ensure that health workers are equipped with needed supplies
and conducive environments. Furthermore, compensation for healthcare providers must also be
prioritized to solve the problem of undercompensation. Fixing the human health resource is vital
in fixing healthcare delivery system. As can be seen in reality and in the case of DTTB, one of
the reasons why there is an insufficient number of doctors and nurses in public health sector is
the fact that the forms of compensation are not competitive. The government should learn to shy
away from misprioritization and invest in needed healthcare technologies and facilities.
Refocus and expand the benefit packages of Philhealth
Since Philhealth benefits are fragmented confining some benefit packages to certain
portions of the population, there is a dire need to expand the benefits offered to decrease
households’ out-of-pocket expenditures. Along with this, the government should conduct
researches which seek to determine emerging areas in the health sector to determine areas to
be focused on. Expanding benefit packages would include pushing diagnostics and check-ups
for free even before someone gets sick. Furthermore, expanding pharmaceutical benefits
becomes strategic, as it has been found out that drugs and medicines account for around 40%
of the total out-of-patient expenditure. This policy in particular is an attempt to promote pro-poor
strategy and achieve an equitable health financing system in the country.
Recruitment and training of more local health workers by the LGU
Given the devolution of national services in 1991 which transferred administrative
responsibility over local health units from the Department of Health (DOH) to their respective
local government units (LGUs), it is proper to recommend that LGUs spearhead initiatives to
recruit more health workers and ensuring that they undergo a series of trainings to empower
them along with the current Barangay Health Workers (BHWs). This is to ensure quality service
as providing health services without guaranteeing a minimum level of quality is wasteful and
ineffective. Actions of BHWs are limited because of the lack of manpower and due to the limited
number of trainings given to them. Recruitment and training thus arise as a priority as these
individuals are the frontliners of healthcare in rural areas and in times of need, Rural Health
Units (RHUs) and Barangay Health Stations (BHS) are the most accessible health centers
especially in remote and far-flung areas. Therefore, the extension of training to
community-based healthcare practitioners becomes a need. Access and quality are interrelated
problem in the Philippine healthcare system and due to decentralization, municipalities must be
committed to providing appropriate health services. Furthermore, health personnel must be able
to work closely with barangay health workers in monitoring health situations in communities.
IV. CRITERIA
Proper allocation of funds, refocusing and expanding of the benefit packages of
PhilHealth, and the recruitment and training of more local health workers by the LGUs, are all
feasible alternative solutions to the problem being faced by poor families in rural areas. Seeing
that the alternative solutions require only a tweak in the already existing system, it would not
require a revolutionary effort to make these changes possible, but rather dedication and bold
efforts to nudge the country’s public healthcare into a level that it would be possible to deliver
better standards for both the patients and the people who dedicate their lives and careers to
serve them.
According to Senator Loren Legarda, the Chair of the Senate Committee on Finance,
there is a PHP15 Billion worth of funding given to a Department of Health (DOH) program called
the Health Facilities Enhancement Program (HFEP), that aims to provide quality and affordable
health care for Filipinos through the upgrading of health facilities. Beside the reclamation of the
HFEP spending plan, the Congress likewise distributed PHP4.797 billion to finish the PHP7
billion requirement for Human Resource for Health Development and expanded portion for
Medical Assistance for Indigent Patients Program. Senator Legarda disclosed that “We have
ensured that the 2019 national budget will cover the health care needs of our citizens, especially
the poor and marginalized, not only through the actual provision of assistance but also by
improving our hospitals and other health care facilities all throughout the country.” Although the
budget allocated towards the HFEP looks promising, its previous implementation track records
raises the question of its competency. The HFEP is among the programs of the Government
that have registered low obligation and disbursement rate throughout the years. During the
budget hearings in 2018, it was revealed that from 2008 to 2018, the HFEP had total
appropriations worth PHP138 billion but as of June 30, 2018, only PHP15.5 billion, or around 11
percent of the total funds, were actually disbursed. With this in mind, it raises the assumption
that the DOH and the LGUs has had troubles when it comes to the proper and efficient
utilization of the funds given to them.
Some of the PhilHealth benefit packages are more likely to cater to members belonging
to the upper end of the social status ranking. PhilHealth must expand some of their benefit
packages to also appeal to less fortunate. Some of the benefit packages that can be
implemented by PhilHealth are: (1) free check-ups even before someone gets sick, just so that
individuals may be able to know if they would have to watch their health; and (2) expand
pharmaceutical benefits, making drugs and medicines more affordable so that it may be made
available to the poor.
Senator JV Ejercito, chairman of the Senate Committee on Health and Demography filed
the Senate Bills No. 1380 and 1406 issuing that the Department of Health provide at least one
health worker to each barangays and an increase in the incentives earned by the Barangay
Health Workers (BHW). The Senate Bill 1380 is “An Act mandating the appointment of health
workers in every barangay, amending for the purpose Republic Act 7160 otherwise known as
the Local Government Code, further expanding the benefits of barangay officials and for other
purposes.” On the same strand, the Senate Bill 1406 is “An Act mandating the Department of
Health to provide at least one (1) health worker in every Barangay, increasing their salaries and
benefits, and for other purposes.” These Senate Bills are issued and implemented because
“despite the recorded number of health workers of the DOH, there are still barangays in the
country which do not have a barangay health worker or barangay health center to attend to the
health needs of the people”, Ejercito said. These Senate Bills acknowledge the fact that more
local health workers are needed in the rural areas in order to deliver quality services. To recruit
and to train more local health workers by the LGUs provide the rural areas an opportunity to
experience professional and licensed medical advices and services from properly trained
individuals. There is a problem with the availability of medical help and manpower in rural and
far-flung areas. The training and recruitment of more local health workers would improve the
quality of life of individuals.
The alternatives have not been implemented in the past due to the inability of the
Government and to an extent, the Department of Health and its officials and the LGUs, to
properly and efficiently distribute the funding and resources available to them.
Although these alternatives will require quite large amounts of subsidy as these
measures call for an improvement in the already established institutions, it will ultimately yield
positive repercussions that will benefit all those that might need them. To pour funding in to the
health sector must become one of the Philippines’ top priorities as the quality of the services
offered varies – depending on what you are able to afford. With reality in mind, it is not hard to
say that there is an overwhelming difference between the quality and quantity of the services
that are offered to the rich and the poor. For those who can afford the payment, they are the
ones who are most likely to experience better treatment and receive better care. On the other
hand, those who are of less fortune and those who are situated in far-flung areas, often end up
receiving poor quality hospital services and most of them have no other choice but to rely on
other forms of medical assistance – some more questionable than others. Applying the
cost-benefit and cost-effective analyses to the alternative solutions, it can be said that every bit
of amount that is to be spent on the betterment of the country’s health sector is worth it. If we
were to increase the funds received by the DoH, it will only take a matter of good planning and
proper budget allocation to catalyze a positive movement in the health sector. An increase in
funding can be an avenue for the improvement of health facilities, provide facilities with better
equipment, and an increase in the recruitment and training of local health workers. All these
would be exceptionally beneficial to those who are unable to afford the services offered by
private healthcare facilities and for those who are in the rural setting where it is difficult for
citizens to receive quality services. Every penny that is used wisely to banner this advocacy
could be the reason why a child would not have to suffer and die of an untreated disease. The
alternative solutions casts a light onto the health care problems that many rural and far-flung
areas experience and attempts to provide answers to better the lives of the poor and
unfortunate.
The proper allocation of funds as the first major policy will be put into action by
undergoing due process. Funding proposals indicating the amounts needed for priority
investments and expenditures will be passed to the Congress for hearing and deliberation.
After such matter has been passed, this shall be forwarded to the office of the president of the
Republic for approval, and distribution of funds to the Department of Health will follow. On the
other hand, the expansion of Philhealth benefits shall be administered by the insurance
corporation itself, focusing on decreasing out-of-pocket spending. The recruitment and training
of more rural health workers shall be entrusted to the respective local government units thus
giving them the lead to supervise. Such proposed policies are deemed legal and politically
acceptable as these policies are just mere products of slight modification from existing policies.
Dialogues between different health organizations and appropriate stakeholders for possible
collaborations can also enhance the policies being proposed as well as aid in the proper
implementation. Furthermore, the involvement of the general populace, like making themselves
more aware of the available health benefits, will also be a vital factor in supporting the long-term
success of the proposed policies.
V. OUTCOMES
Several policies have been made concerning the betterment of the country’s health
sector; several bills have been passed addressing the need to prioritize the state of health care
in rural areas; several acts have been written down focusing on improving the lives of the less
fortunate; several changes were made, yet the country’s reality does not reflect the intentions
that these changes advocate. They are all words that are somehow hard to put into action. The
alternative solutions that are laid out in this paper are all suggestions that would be able to help
in alleviating the health care problems that are being faced by the Filipino citizens living in the
rural and far-flung areas. These solutions would not at all serve its purpose of helping the less
fortunate if Government officials would rather put themselves first before the lives of millions. If
there are no dedicated and honest officials and personnel that are committed in making the
change happen, then it would still take a long time for the country to bridge the gap between the
rich and the poor when it comes to availing quality health care services. There is a probability
that maybe the alternative solutions may deliver a slight change, but it would not most definitely
not change the state of public health care overnight.
The alternative solutions reiterate that there needs to be more changes in the country’s
current policies addressing public health care services. The policies in this paper aims to solve
the fundamental problems in hopes of starting a ripple effect. If the alternative solutions are to
be executed properly, then several opportunities would open. If funds are to be properly
allocated and the money is to be where it is supposed to, then there would be better facilities
and equipment in public health care services; there would be more incentives that can be given
to both licensed medical practitioners and local health workers when they are recruited to work
in rural areas. If the PhilHealth refocuses and expands its benefit packages, more of the less
fortunate would be able to avail these services that could alleviate the cost of their medical bills
when the circumstance arise. If the LGUs are to train more local health workers that could serve
their communities and barangays, more help can be provided to those in dire need of it. These
alternative solutions are not groundbreaking, as it only seeks to correct the fundamental
problems that the country still faces. Nonetheless, they are what the country needs. It would
usher in balance and equality in the health sector; slowly but would surely bridge the gap
between private and public health care services, and between urban and rural health facilities.
There are several obstacles that the alternative solutions might face when they have
been implemented. The DOH is the fifth sector that receives the most amount of Government
funding. There had always been news about the Government’s low spending on public health
care and it shows. Low Government funding reflects low quality of services in public health care
facilities, most especially in rural areas. Even with the little amount that the health sector has,
still some officials have the indecency to steal from the already poor individuals. Corruption is
still eminent in the country and the elimination of it would not happen anytime soon.
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