Revisiting Universal Health Care
This year, 2024, is the fifth year since the passage of a landmark reform for the Philippine healthcare system, Republic Act 11223 or the 2019 Universal Health Care (UHC) Act. The law’s goal is to ensure that quality and affordable healthcare goods and services are accessible to all Filipinos without financial hardship.
The UHC Act provides a broad array of reforms for health financing, governance, and service delivery. It reorients the health system towards primary care through provincial health systems and make every Filipino a member of the National Health Insurance Program.
Sadly, just a few months after the signing of the UHC Law’s Implementing Rules and Regulations in October 2019, the COVID-19 pandemic brought our health system to its knees. Instead of focusing on the implementation of RA 11223, government had to scramble to secure critical health technology like ventilators and personal protective equipment, put in place a testing and tracing system, and iron out guidelines for community quarantine. The inequities in healthcare access and quality and the fragments in our system have never been so stark. The pandemic and its lingering consequences have partly but significantly delayed UHC implementation. UHC faces even greater challenges than we did in 2019.
The World Health Organization (WHO) and World Bank recently published their 2023 report titled “Tracking universal health coverage,” which found that “the world is off track to make significant progress towards UHC by 2030 as improvements to health services coverage have stagnated since 2015, and the proportion of the population that faced catastrophic levels of out-of-pocket spending has increased.” The WHO also noted that one out of five people in the Philippines and other countries in the Western Pacific Region faces “catastrophic” health expenses each year.
The report published an update to the Universal Health Care service coverage index (SCI) score, which captures coverage of essential services across the entire population of a country in 194 countries and measures 14 indicators in four categories: reproductive, maternal, newborn and child health; infectious diseases; non-communicable diseases; and overall health access and service capacity.
The Philippines’ UHC SCI score as of 2021 is 58, or medium coverage, a two-point drop from our 2019 score. We trail our Southeast Asian neighbors Vietnam, Malaysia, and Thailand, which have older UHC programs that were mostly put in place in the early 2000s, and we are scoring only slightly higher than Indonesia, Myanmar, and Laos. Other indicators are not improving either — out-of-pocket expenditures remain high at 41.5% to 46% as of 2021.
As we move forward from the pandemic, health advocates who championed UHC reform aim to identify the binding constraints to the law’s full implementation with the goal of achieving the aspiration of UHC as soon as possible.
One binding constraint which cannot be ignored is the issue of health financing. UHC gets its funding from PhilHealth contributions and sin tax revenues; to this day, there remains a large funding gap for full implementation.
According to the Department of Health (DoH), in the medium term, there is still a funding gap of at least P163.6 billion to meet the funding requirements for UHC. Policy proposals such as the recent push to suspend the PhilHealth premium hike in 2024 could only make the funding gap widen further. PhilHealth needs ample and sustainable sources of funding, especially given that the cost of healthcare will only continue to rise over time.
We also face the issue of insufficient human health resources. The pandemic showed us that bed capacity and healthcare facilities are not the be all and end all of a functioning and efficient health system, but rather that our doctors, nurses, midwives, medical technologists, and other health workers play the most essential role. After all, during the pandemic, no number of available beds compensated for the fact that health workers were falling ill and the workforce was being depleted.
Further, the SDG (Sustainable Development Goals) index threshold for human resources for health set by the WHO Global Strategy on Human Resources for Health has been raised to 4.45 physicians, nurses, and midwives per 1,000 population. This means that the Philippines is lagging behind by around 116,000 physicians, according to Dr. Antonio Dans from the National Academy of Science and Technology.
Attrition, not recruitment, is the main issue faced by our health professionals. Over the years, qualitative data have shown that Filipino health workers would prefer to practice in the country but are forced to leave to provide for their families. We need to find more effective ways to retain these health workers, whether it be through establishing bilateral agreements with recipient countries, strengthening our national Magna Carta for Health Workers, or broadening the health worker base by standardizing training and salaries for our Barangay Health Workers (BHWs).
Addressing these complex issues requires strategic and decisive leadership from the DoH, PhilHealth, and local government units. Dr. Ted Herbosa, the recently confirmed DoH Secretary, established a UHC Coordinating Council co-chaired by the Department of Interior and Local Government (DILG). This Coordinating Council is intended to strengthen internal coordination.
Despite the institutionalization of universal healthcare, we still have a long way to go to achieve the UHC aspirations. And although the pandemic delayed the implementation of UHC, it taught us numerous lessons which should guide our leadership in making crucial, pivotal decisions. Most importantly, the pandemic showed us that our health system is a backbone of our economy, which means that universal healthcare must be attended to with utmost urgency.