FILIPINOS HAVE long been prone to self-diagnosis and self-medication, but in the years to come, D.I.Y. health care may become even more pronounced. After all, when society does not assume enough of the burden of health care, individual responsibility and self-preservation become the norm.
Compared to its counterparts in neighboring countries, the Philippine government has not been spending enough for the health needs of its people. According to official reports, our government allocates only 0.9 percent of total spending on health. This is lower than Thailand (11.6 percent), Malaysia (6.5 percent), and Vietnam (6.1 percent), and even less than what the economically distressed nations of Indonesia (3.0 percent), Cambodia (16 percent), and Bangladesh (8.7 percent) allocate for the health of their peoples.
It is not clear whether our government has no money because it is spending on the wrong things or cannot raise more revenues. What is certain is this: because the national government scrimps on health care while local government resources for health are limited and health insurance, inadequate, households end up bearing the bulk of the burden of health spending. Because public spending is deficient, more private resources have to pay for health expenditures.
In the coming years, we can only expect more self-spending activity where families make more out-of-pocket payments for services. And while self-sustaining and self-financing of health care are already becoming extensive, more people will rely on their immediate circle of contacts for remedial measures. Self-care and self-treatment of health conditions will be much more common. In this do-it-yourself setting, we would not even have to go to hospitals or diagnostic laboratories. It would be more convenient and much faster to call on family and get test kits from the neighborhood pharmacies. In this information age, it is also much easier to surf the Internet and access medical-information websites.
For the wealthy, D.I.Y. health care would work. Health is wealth, and the wealthy will be even healthier in the next 10 years and even beyond because of more self-education and self-diagnosis, better self-care and self-treatment, and increasing self-sustenance and self-financing. For the poor, however, even the simplest health problem could deteriorate into a matter of life and death because of their lack of access to health information and services, which in turn could lead to improper self-diagnosis and medication.
Health is a luxury for the needy. For them, thinking about what they can expect 10 years from now may even be difficult, when all they can hope for is just another day. It is an arduous challenge to improve the well-being of the ailing because of the divide among social classes, the gap between the rich and poor, and the disparity among first-class and lower-class communities.
GOVERNMENT HEALTH indices suggest that over the last 15 years our overall health status has improved. Tuberculosis and other infectious diseases are no longer the top causes of death and illness in our country. Diarrhea and other problems associated with environmental sanitation have decreased with improved water distribution and supply. The family planning program has provided a wide range of family planning services to many women of reproductive age, around 47 percent of whom were reported to be using contraceptives in 2000.
Yet while major health improvements have been evident in the last few decades, their pace and scope are now at risk of being overwhelmed by a growing population, a constrained economy, and a major challenge in health and development-the yawning gap between the few people who have so much and the many who have so little.
The “improvement in the economy” reported at the macro level excludes the fact that the Philippines has one of the most unequal income distributions in the world. Although reduced in many parts of the world, inequity is becoming worse in this country. In 1994, the family income of the richest ten percent of our people was 19 times higher than that of the poorest ten percent. Since then, that same affluent group has continued to increase its share of family income while the family income share of the majority of Filipinos has decreased. Economic improvement without equity cannot contribute substantially to human health and development, but there is no indication the trend will change anytime soon.
The differences dividing social classes have rarely been minimal. There is not only an information divide where the rich have the best computers and the best sources of knowledge-the poor are not even provided enough teachers, classrooms, and school books for basic elementary and high school education. It is not only harder for the poor to receive health education, it has also become much harder for them to understand the scant health information that is available.
When it comes to the national government’s approach to health, lack of money is only half the problem. Of the little that is set aside for health, just a pinch is allocated for public health and preventive-care services like family planning or reproductive health or even for diseases like malaria.
Even today, lower-income households see more abortions, unwanted pregnancies, and maternal deaths compared to those in the upper classes. Yet family planning and health information are focused in health centers and in messages placed in magazines that are not always accessible to the poor.
It is true that there is almost equal access across income classes for free family planning commodities like pills, condoms, and injectables. But only those who have money can avail themselves of the more reliable family planning services that have to be paid for, such as longer-term contraceptive methods like the intra-uterine device (IUD) or voluntary surgical contraception for males and females.
The poor are still ravaged by tuberculosis or TB and pneumonia. Although these diseases are no longer among the top three causes of death in our country, they are still in the top 10. The World Health Organization estimates that the Philippines has around 250,000 new cases of TB each year and the second highest number of tuberculosis cases in this region of Asia.
And while water supplies have improved, diarrhea is still the top cause of illness here, with one out of every 100 persons affected each year. It’s easy enough to figure out who are likely to have it. The more expensive housing in upper-class villages and communities can boast of so much water that golf courses are always green and swimming pools are kept full of clean water. On the other side of the fence are rural villages and teeming slums with dirty water and pitiful environmental sanitation.
SUCH DISPARITY is also evident among central cities and peripheral provinces, or first-class and lower-class municipalities. To make matters worse for the poor, more government services and accredited health-care facilities are in the affluent areas. These disparities are unlikely to even out in the coming years Among members of the Philippine Health Insurance Corporation (PhilHealth), for example, the wealthy and healthy are currently more likely to avail themselves of the insurance benefits than the ill but impoverished, who cannot afford to lose a day’s pay or the bus fare to consult a doctor. This trend will likely continue in the next decade.
When family planning and health-care providers do not reach out to the poor and those living in more peripheral areas, it is unlikely that the underserved would spare the extra cost of transportation and access to information and services. Not surprisingly, the number of infant deaths and maternal mortality in our country continues to be high. Apart from a disturbing picture of dying babies and dying mothers, the University of the Philippines Population Institute estimates abortion rates as ranging between 320,400 to 480,600 annually. These figures translate to one abortion for every five to six pregnancies.
The number of women hospitalized for high-risk deliveries and some even dying because of abortion and complications in our country is huge. Based on reimbursements records, these account for over 30 percent of PhilHealth’s spending and amounts to around P1.15 billion each year.
Women from households with higher income have greater use of, and possibly better access to, family planning services. Several studies already show that the number of children that each woman has is related to household-income levels. Richer couples have on average two children, which is the number that most women want. But while married women in poor households say they had wanted around three children at most, majority of them end up with at least one or two more, with many even having more than five children. These figures may or may not include the young children who have died. The rate of deaths of infants and under-five-years-old among the poor in the Philippines is double those among affluent Filipino households.
It has been suggested that it is not only the absolute amount of income that is important for health but also the relative disparity with which the income is distributed. One possible explanation for this is that the social stress associated with such inequity can lead to more smoking, alcohol abuse, and other unhealthy behaviors. It is also conceivable that when too much of the total income is in the hands of the rich who can afford private education and medical care, there is less money for the poor. There is simply less interest among those with money to contribute to funding for public education, public health, and social services. (Blame that partly on growing cynicism, which can kill philanthropic instincts. But plain greed and selfishness play a part, too.)
The correlation between the distribution of disease and the disproportionate allocation of resources is supported by another observation: there are fewer deaths when there was less inequity. This reflection is based on what has taken place in countries with increasing incomes but constant class differentials, and compared with poorer but more egalitarian societies. Hidden behind the health situation reported by our statistics, for example, is the marked inequity and the wide disparity in the health status among Filipinos. According to the Department of Health and our health administrators, there are persistent, large variations in health status across population groups and geographic areas. Again, while there are pockets of excellent health among the rich, the burden of disease is heaviest on the majority who are poor.
THE IRONY is that as the health and health care divide widens between the haves and the have-nots, we are seeing an exodus of health professionals headed for work overseas. This trend is likely to continue in the coming decade. Would that we could count on steady support from the countries that benefit from our countrymen’s labors and who have drawn our resources. Yet it is difficult to beg for aid and assistance from foreign donors and multinational corporations. It is more difficult to find solace in the infusion of dollar remittances from overseas workers, including those who should be looking after our own people’s health, when these come at the expense of families separated by seas and continents and of health institutions in dire need of trained and skilled personnel.
Still, for every 3,000 physicians who yearn for the chance to work abroad, many do choose to stay. For every 300 medical graduates pining for positions in expensive medical centers there are those who would work among the poor. For every 30 successful health professionals who have left our country there is someone who will come back home.
It is, however, distressing to realize that choosing to stay means a harder life for a physician’s family. It is depressing to witness a young nurse or midwife walking in mud as the latest car models roar by. It is disheartening to have barangay doctors reading torn medical books under the flickering light of a kerosene lamp while many other people enjoy a sparkling nightlife. It is demoralizing to be in a country that chooses to break up families and offer our health workers to the uncertainties of foreign employment rather than spending for the means to maintain the human resources that are vital to the health of our people.
Fifteen years ago, I worked as a rural health physician in Kabugao, in Apayao province. My wife was the chief of the district hospital. We lived there for two years with our daughter, who was just 11-months old when we first arrived. Our next child, my son was conceived in that part of the Cordillera mountains. The number of doctors in Kabugao has barely increased since we left, and it may stay that way (or even see a decline) in 2015. With the continuing lure of better pay and better opportunities in the city hospitals of our country and the health centers in other countries, how can there be more health workers in places like Kabugao? Can I myself even care enough to go back to work in the municipal health office I left so many years ago?
I may hesitate, but fortunately there are hardier souls out there. Even now thousands of rural health workers continue to labor in the most difficult and trying circumstances, while there are still doctors who can barely make both ends meet but are sticking it out in the hinterlands. Thousands more nurses have surrendered to a lonely life away from home-not in some foreign land, but in areas in the Philippines they know need them most. These are the heroes who may yet bridge the health gap between the rich and the poor and help heal the wounds of our society.
Jonathan David ‘Jondi’ A. Flavier is a medical doctor who specializes in health policy, planning, and management. He currently provides part-time technical assistance for health and development programs of the Department of Health, the Philippine Health Insurance Corporation, the Philippine Congress, as well as international and other private organizations.