Despite the promises of devolution, funding for health services is unable to keep up with local needs
High profile/High publicity projects such as the army offering free medical care on a flying visit cannot hide the problems of chronic underfunding of the national healthcare system
By MARYA SALAMAT
Bulatlat.com and Maggie De Pano Fellow
Surigao del Sur was not proud of their health figures six years ago: for every dozen mothers who died of pregnancy complications or while giving birth in the country in a year, one came from this province. It was the highest maternal mortality rate among provinces-269 in every 100,000-even higher than the national average of 230.
The provincial government moved quickly. It clustered adjacent municipalities and assigned a team of woman health workers to monitor pregnant women in each area. Their duty was to make sure these mothers went to skilled health professionals for regular check-ups, and delivered in birthing clinics or hospitals. The province also allocated more funds for the improvement of these health facilities, and enrolled almost all the declared indigents in the state's health insurance system or Philhealth.
By 2009, Surigao del Sur had brought down maternal deaths to 99 in every 100,000. The following year, Malaca?ang noticed and gave it the Galing Pook award, which recognizes innovative programs by local governments.
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But the good news ends there. Other priorities had been competing for the limited provincial budget, that sustaining the program became difficult. Starting 2009, the yearly decline in maternal deaths stopped. This year, the province will start paying the World Bank loans it incurred for the construction of additional birthing clinics and the upgrade of hospitals, even though these didn't turn into financially viable facilities.
Surigao del Sur is not a unique case. Since the national government devolved health services and facilities in 1992, a considerable percentage of local government units (LGUs) have failed to achieve financial sufficiency to deliver and maintain these.
In the Philippines, the number of maternal and child deaths-the most basic indicators adopted by different countries-reflects the widespread lack of affordable and accessible health care.
Good intention
As of 2009, the United Nations Population Fund estimated that 4,500 women died each year due to complications arising from childbirth, while 80,000 children died before they reach the age of 5-all of easily preventable causes. Data from various sources showed that 6 of every 10 Filipinos die without being attended to by health professionals.
Following the mandate of the Local Government Code of 1991, the Department of Health (DOH) transferred some 46,000 permanent employees or health workers (62% of its work force) to the provincial, city, and municipal governments. Government hospitals (93% of the total number) and over 10,000 health care facilities or buildings were also placed under the authority of the LGUs. The central government retained only the tertiary and specialty hospitals.
The intention was to reach and cover more citizens, especially the poor families, down to the far-flung areas, by empowering the LGUs to deliver quality health services.
However, the corresponding funding didn't come with the responsibilities that were passed on to the LGUs. Only 40% of the national government's internal revenue collection is given to some 1,700 provinces, cities, and municipalities to divide among themselves. This meager share is supposed to fund all the new services, not just health, that LGUs are supposed to deliver.
From 1992 to present, the IRA (internal revenue allotment), the yearly allocations for local government coming from central government, had increased nominally, but it never amounted to even a fifth of the total national budget as it peaked at just 18.29% of the national budget in 2006, at P166-billion compared to the national budget of P907.6billion.
The LGUs' health spending, in turn, peaked at just a fifth of their IRA for two years (in 1997 and 1998) from 1994 to 2007. But after its peak in 1998 it fluctuated and went down to 16.9percent by 2007.
Declining allocations
From 1994, a couple of years after devolution was completed, the LGUs' share in national total health spending rose from 15.8% (or P8.7 billion) to peak at 19.3% (P22.2billion) in 2000, based on revised data from the National Statistics Coordination Board (NSCB).
(Total Health Expenditure refers to the combined amounts of money shelled out by all Filipinos in a given year. In Philippine National Health Accounts, this consists of the allocations from the government (both national and local), social insurances, private sources, among other sources.)
But the LGUs failed to sustain the increasing allocations, much less keep up with increasing spending requirements on the sector. Nominally, health spending at the local level increased, from P17.8 billion in 2002 to P31.1billion in 2007. But their share of total spending has been on the decline-from 15% in 2002 to less than 13% in 2007.
The same is true with the national government's share in health spending. In 1994, the national government contributed 21% to total health expenditures. By 2007, it was contributing only 12.9%.
Partly it is because of budgetary restrictions. While health spending requirements doubled from P117 billion in 2002 to P234.3 billion in 2007, national and local budgets failed to keep up with the pace.
Thus, even if the overall national health spending annually increases, the government's total spending on health (P61.5billion) is now less than 1% (0.9%) of the gross domestic product (GDP).
The Philippines, therefore, falls short of the health budget of at least 5% of the GDP that's prescribed by the World Health Organization (WHO).
Lagging behind
The Philippines, in fact, has one of the lowest health spending as a percentage of GDP, and one of the lowest allocations of financial resources to primary health care.
The government under-spending in the health sector expectedly resulted in a decline in accessible health services.
In reducing maternal mortality, for instance, "the Philippines lags behind many countries in similar socio-economic conditions," said WHO representative Dr. Soe Nyunt-U during a conference on health financing in Davao City in February.
He said the Philippines is facing problems in the health sector similar to those of its Asia-Pacific neighbors. The government's chronic under-funding of health services leads to higher out-of-pocket spending by families. Compounding the problem in the Philippines is the fragmentation of health services among different levels of local governments, brought about by devolution.
Statistics show that the Philippines is not likely to achieve the Millenium Development Goals, according to the National Statistics and Coordination Board. "MDG data of the NSCB show that we have low probability of achieving the targets on Indicator 4.3 (proportion of 1-year old children immunized against measles) and Indicator 5.1 (maternal mortality ratio)," said Dr. Romulo A. Virola, secretary-general of NSCB.
Except for Region IV-A (Southern Luzon), all regions, including Metro Manila, have "low probability of achieving the target," he said.
For the maternal mortality target, Virola noted that only the National Capital Region, Southern Tagalog, and Central Luzon have ratios lower than the national rate. Additional investments in health, therefore, "are badly needed."
Many LGUs, however, do not seem to prioritize health spending, because "health is not a big political issue," said Dr. Alvin Caballes, a health economist specializing in local health systems and hospitals.
Although quarterly surveys of Pulse Asia over the years have shown that health has always been among the top five concerns of Filipinos, "no one is demanding health services of local governments," Caballes said. If ever they did, "it would seem that people are not too concerned about quality-at least to the degree that they will complain about the lack of it or make such deficiencies election issues."
High-impact, unsustainable
In an attempt to help LGUs address the funding problems in health services, the government adopted the Health Sector Reform Agenda in 1999. The HSRA allows public hospitals to raise revenues on their own, thus prompting these hospitals to either charge fees for otherwise free services and medicines. It also lets public hospitals accommodate private providers into their operations.
The devolution and the HSRA had stimulated some LGUs to be "more innovative by partnering with the private sector or non-government organizations, or integrating health objectives into long-term plans," for example, according to a 2010 study called "From Devolution to Consolidation: Local health system's arrangement and facility-based deliveries in the Philippines," by economists Joseph Capuno and Marian Panganiban. Some LGUs, their study said, are able to maximize "existing systems," such as availing of Philhealth services and foreign donations to address specific health problems.
But "Notwithstanding the proliferation of innovations in local public services, the impact of devolution on health outcomes and outputs remains ambiguous at best," Capuno and Panganiban concluded in their study.
One factor in the ambiguity is that the amount of public money spent on the health services does not necessarily indicate quality coverage.
For instance, say public health specialists, politicians embark on high-impact but unsustainable projects meant primarily for public relations purposes. These include one-time medical missions in vote-rich areas, and the distribution of Philhealth cards or medicines during election seasons.
Clearly, much of the reduced government's spending has flowed more to hospital and personal health care, perhaps because people always go to politicians for assistance in emergency cases. Of the national and local government's total health spending of P61.5 billion in 2007 (the latest health accounts data available), P27 billion went to such highly politicized but personal health care services.
In contrast, the national and local government spent a total of P20 billion on public health care, or services with benefits accruing to entire communities, such as immunization and disease control.
At times, these quick-fix programs meant for the poor even breed other problems in health service delivery. The Pantawid Pamilyang Pilipino Program (4Ps) of the social welfare department is an example. It provides cash grants to extremely poor households on the condition that they would use the money to improve their health and nutrition, among other things. It didn't consider, however, that with more families now required to go to government clinics and hospitals, there may not be enough doctors and other health professionals to attend to them.
In the end, the more desirable approach to the problem would be for the government, national or local, to invest in empowering families economically so they can afford to live in healthier conditions. This is according to the non-government organization Council for Health Development, which implements community-based health projects in many parts of the Philippines.
Dr. Eleanor Jara, CHD executive director, believes that "improvements in the health sector only account for about 20% of the improvement in health status [of citizens], while improvements in the social conditions account for the larger 80%."
She explains: "You cannot solve the health problems by health programs alone. Our mothers, babies, and people will only be really healthy if they earn enough from agriculture and from a genuine industry.... If you live in the slum or in rural areas with insufficient potable water and sanitation, your health is not assured. Treatments at health clinics, no matter how free, are only palliatives at best."
(This article was produced under the Maggie de Pano Fund for Investigative Reporting on Health. The Fund, which is managed by Newsbreak, is funded through a grant from Macare Medicals Inc.)??Bulatlat.com
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