In what appeared to be a strange exodus, people scrambled for bus rides to return to their home provinces following the declaration of a lockdown in Metro Manila. The lockdown was announced as lasting from March 15 to April 12 by the Filipino government in a bid to contain the threat of the novel coronavirus disease (Covid-19).

The Unique Situation of the Philippines

Some decided to flee the metro for fear of contracting the virus there, having no resources to access medical treatment. Others, such as contract laborers in the city, worried about getting locked away from their families back home with no one to turn to.

The thought of a likely spread of the virus to much poorer provinces immediately sank in among many Filipinos. The Filipino healthcare system has long been problematic and challenged, and access to it for the poor has been mission impossible for years.

Labor Migration and Erratic Distribution of Doctors and Nurses

Labor migration and poor distribution is one of the long-running issues hounding the healthcare system in the country, greatly affecting the Government’s response to the current pandemic. “At the start we lacked enough medical professionals. You know that our front-liners are the doctors and nurses. Can you imagine if they all become persons under investigation or persons under monitoring, and they get quarantined? You can see how really difficult it is for us, no?” said Dr. Jose P. Santiago Jr., President of the Philippine Medical Association (PMA).

On March 16, Philippine President Rodrigo Duterte declared an enhanced community quarantine (ECQ) on national TV, which is essentially a lockdown in the entire Luzon Island until April 13. This was later extended until April 30. As of April 13, the country had 4,932 confirmed cases that included 315 deaths and 242 recoveries. Of these, more than 200 are health workers. Over 20 healthcare workers were reported to have died from the virus. At this time of writing, the Philippines has the most number of confirmed cases in the Southeast Asian region.

Volunteer Filipino Doctors Wanted

On March 21, the Department of Health (DOH) called for volunteer doctors and nurses for three referral hospitals for COVID-19 patients. But the public was outraged by the department’s meager offer to these volunteer front-liners: a mere 500 PHP (USD10) daily allowance, free accommodation, and free food. A compensation package is only available to those who might contract the infection. The department later apologized and assured the public of measures to increase their compensation.

“The Philippines is the top exporter of doctors and nurses in the world,” said Dr. Anthony Leachon, an independent health reform advocate. “And those who are left here to work are overburdened, overworked, but they are underpaid. So that’s the problem,” he further said.

Doctors and nurses departed the country at 16% and 19%, respectively, considered a notably higher rate than the overall industry average according to the 2012 Industry Career Guide: Health & Wellness issued by the Department of Labor and Employment (DOLE).

Medical Professionals are Leaving the Philippines En Masse

Meanwhile, a case study on the migration of health workers in 2005 conducted by the International Labour Office in Geneva found that nurses comprise the biggest category of health workers who migrate. Saudi Arabia, US, and UK are their top three countries of destination in the past decade, with Saudi Arabia being the consistently most-favored.

Jahzeel Grace Jandayan, a Filipino nurse, admitted she felt under-compensated in her home country, which prompted her to migrate to the UK before. “Back in 2009, I was only paid Php5,250/month (USD105) as a nurse at a government hospital in Cebu. What I did was to move to the UK on a student visa, eventually securing a work visa under the Overseas Nursing Program by the Nursing Midwifery Council there,” she said. “There was an oversupply of nurses back then in the Philippines, so there was a tough competition among nurse applicants, and the easiest way to enter the UK in 2010 was through a student visa,” she explained. Despite work being hard overseas, she somehow felt well compensated, receiving a £13.50 hourly rate.

Some Filipino Nurses are Paid Nothing

Not only are the nurses underpaid, sometimes they aren’t paid anything at all. The DOLE document also reported that new graduates in the Philippines usually work as volunteers first, with only a few hospitals paying or providing them a minimal allowance. Volunteer contracts will depend on the hospital, after which the management will assess if the volunteer will be accepted as a staff nurse. Other hospitals, though, have been accepting new graduates.

Jandayan, a nurse for 12 years now, attested to this as she had worked initially as a volunteer for six months at the government district hospital—without an allowance prior to being transferred to a paid job at a city health center. Because of the influx of nursing graduates in 2007, she recalled it was extremely hard to get a job back then. Volunteer work was like a rite of passage that nurses had to go through.

A physician in Central Luzon, who refused to be named for privacy reasons and who’s been in the medical profession for 24 years now, has thought of leaving the country, too. “I work as a part-time government doctor with a salary of 29,000 PHP (570 USD). I am also a visiting consultant in a private hospital, so I don’t have a regular salary. My professional fee depends on how many patients I have admitted in the private hospital.” She hopes the current government gives healthcare development a priority.

Besides lack of appropriate compensation, DOLE cited several other factors affecting the welfare of healthcare professionals in the country, including long and irregular duty hours, workload, high stress levels with the shortage of personnel, and strenuous travel involved in terms of shuttling patients between hospitals and clinics.

The increasing labor migration also brings forth an erratic distribution of health professionals across the country. “We have more specialists in the urban areas, especially in the National Capital Region (NCR). When you go to rural areas, we lack specialists, even though we have doctors,” Dr. Santiago said.

The World Health Organization’s ideal physician to patient ratio is one doctor for every 800 patients, but Dr. Santiago estimated that the country now has one doctor for every 1,300 patients. The Cuban model, however, suggested one doctor to 1,000 patients. “We’re close to it, but there’s still disparity,” Dr. Santiago said.

Poorer Regions are Worse off for Healthcare Access

An explainer from the National Economic and Development Authority (NEDA) showed that the NCR and the Cordillera Administrative Region have the most number of healthcare workers at 23.06 and 28.17, respectively, for every 10,000 of the population. The Bangsamoro Autonomous Region of Muslim Mindanao (BARMM), considered as the poorest region in the Philippines, merely has 6.86 per 10,000 population.

In the Southern Philippines, the BARMM that has been beset by decades-long conflict between military forces and local armed rebels and the increasing threat of ISIS-inspired terrorists. In some cases, healthcare professionals were branded as “anti-state activists,” according to the study, An examination of the causes, consequences, and policy responses to the migration of highly trained health personnel from the Philippines: the high cost of living/leaving—a mixed method study, published in March 2017. One informant in the study revealed that “doctors bring a gun instead of a stethoscope,” and more so “trained to shoot guys,” in case a security emergency arises in the performance of their duty at night.

According to Dr. Leachon, without job security and proper compensation, others ended up in odd jobs, such as those in call centers and in Health Maintenance Organizations. “Because they couldn’t go to a residency program in the NCR for instance, or get an item at the DOH, which is specifically related to their position,” he said.

Further research said that the cost of labor migration in sustaining an efficient healthcare system in third-world or developing countries was evidently high, as many of those who migrated were highly skilled, thus potentially compromising the quality of services and the availability of healthcare workers. This effect is now being seen with many Filipino frontliners quarantined for contracting the virus, hence the call for additional medical volunteers.

Duterte Bans Doctors from Leaving

To address this shortage, Duterte has temporarily banned the deployment of healthcare professionals abroad “until the national state of emergency is lifted” based on an order signed by DOLE secretary Silvestre Bello III on April 2. “It is of paramount national interest to ensure that the country shall continue to have, sustain the supply of, and prepare sufficient health personnel to meet any further contingencies, especially to replace, substitute or reinforce existing workforce currently employed, deployed or utilized locally,” stated the order.

However, the Foreign Affairs Secretary has firmly objected to the ban. “I reject this abomination,” secretary Teddy Locsin Jr. said in a tweet on April 11, vowing to fight for the welfare of overseas healthcare workers. “We will never surrender our constitutional right to travel and our contractual right to work where there is need for our work,” he tweeted.

Standing by his word, Locsin announced on Twitter on April 13 that Filipino health workers with existing contract overseas can now leave the country. “DONE. NURSES, other health workers with existing contracts of work abroad can leave. Future applications frozen until further notice provided all our 450,000+ nurses—exceeding by 250,000 ideal WHO ratio of people-to-nurses—must be given employment. [Thank you] Sal Panelo and Jun Esperon,” he said. President Duterte didn’t object to the final decision. 

Poor Hospital Infrastructure

There’s no question as to why other countries have opened their doors to many Filipino medical professionals seeking greener pastures. Dr. Leachon said Filipinos have built a reputation as being among the “best doctor and nurse graduates in the world.” Unfortunately, for those who have remained in the country, the infrastructure is poor, both for them and their patients, he lamented. “For example, for every 50 meters in Metro Manila, you have a hospital. In the provinces, our regional hospitals are far, and there are not too many tertiary and secondary hospitals there. You’ll only find them every 100 kilometers,” he said.

Since such is the case, some people in need of medical treatment will flock to Manila hospitals like the Philippine General Hospital (PGH). The problem is, the PGH is overcrowded and has “the worst infrastructure” regardless of whether they have the “best and the brightest medical professionals beating the worst cases there,” he further said. “It is just about half [a] kilometer from the Malacanang Palace and the DOH. So the biggest irony there is, how can you expect hospitals in the countryside to be better if the hospitals in Manila are not good?” he asked. “We already have a big problem that’s not being looked at or we refuse to see.”

Data from the National Health Facility Registry of the DOH as gathered by the Philippine Center for Investigative Journalism (PCIJ) said the Philippines in 2018 has 1,456 hospitals, of which only 463 or 32% are government-owned. Of these government-owned, 270 or 58% are in Luzon, 80 or 17% in Visayas, and 89 or 19% in Mindanao. The PCIJ report added that there are 1,710 hospitals as of June 2018 based on the National Database of Selected Human Resources for Health. “With a projected national population of 106,168,803 for 2018, the ratio of government-owned hospitals to the Philippine population is a horrible, 1: 229,306,” the report said. “Filipinos in provinces with smaller ratios of government-owned hospitals to population might be presumed to have better access to public healthcare services.”

Dreams of a Better Medical Future

Dr. Leachon, hailed as one of the Outstanding Filipino Physicians in 2008 by DOH, dreams of a PGH in every region that should be tied up with an academic institution. He based his template on the collaboration between Harvard Medical School and the Massachusetts General Hospital (MGH). “The Government will invest money in Region 1 to form a Region 1 general hospital linked to an academic institution. Just like the doctors at Harvard, they are the ones teaching at the MGH and every other hospital there,” he said.

Meanwhile, Dr. Edsel Salvana, an infectious disease physician, believes it’s high time for the Philippines to have Centers for Disease Control and Prevention whose main focus is public health. “It will precisely deal with emerging infectious threats such as this one and will have public health professionals, good laboratory capacity, quarantine powers, and access to emergency funding. This will also free up the rest of DOH to continue its other functions such as vaccination, disease surveillance, and community health.” Salvana is a director of the Institute of Molecular Biology and Biotechnology at the National Institute of Health at the University of the Philippines (UP) and a part of the Technical Advisory Group of the Inter-Agency Task Force (IATF) for the Management on Emerging Infectious Diseases.

Funding Healthcare in the Philippines

Funding downstream diseases more while disregarding the upstream diseases affect the sustainability of the healthcare system, too. “For the longest time the problem of the healthcare is also anchored on treating downstream diseases, which the Government is spending 10 billion PHP (198 million USD) a year on,” said Dr. Leachon. Case in point is dialysis whose number one cause is diabetes or hypertension. “I’m not saying they’re not important individuals or patients. We have 25 million hypertensives and six to eight million diabetics. If the Government could invest more instead on the prevention side to curb hypertension and diabetes, then the country will not end up with a lot of dialysis cases,” he said.

Leachon added that the true epidemic in the country is actually the non-communicable diseases, such as heart attack, stroke, cancer, and chronic obstructive pulmonary disease, among others. He said the burden of these diseases to the economy amounted to about 200 billion PHP (3 billion USD) based on the 2012 tally of Dr. Tony Dans, a UP professor of medicine. “The problem is, we are not doing anything on the upstream side,” said Dr. Leachon.

Looking to Singapore as a Healthcare Role Model

Leachon also pointed out that Singapore has the most ideal healthcare system as it combined preventive measures in the downstream diseases. “When you go to Singapore, you become a totally different Filipino. You will not smoke. You will not chew gum. You won’t litter. Because they have hefty fines. So they have preventive measures,” he stressed.

Dr. Santiago agrees, suggesting that the Philippine Government should look into how Singapore sustains theirs.

How government officials spend funds in healthcare also poses a great challenge, said Dr. Leachon. Philippine healthcare is decentralized at three levels, namely, national, provincial, and local. He said the problem arises if the mayor or governor is not health-oriented, and then the money will be re-channeled to another area the official wants to develop. Thus, the plan of action of the DOH secretary sometimes goes to waste even with the best of intentions, he said.

The Duterte administration approved a final budget allocation of 172.37 billion PHP for DOH this year, as compared to 165.92 billion PHP last year.  A report from Rappler said the National Expenditure Program initially had a lower allocation for DOH, but later increased in the approved 2020 General Appropriations Act following Congress deliberations. This, in fact, had brought confusion to some concerned Filipinos, which prompted the Presidential Communications Office assistant secretary Ramon Cualoping III to counter via Facebook a claim that the budget for health had been slashed.

But of the total health budget this year, the health systems strengthening program received only Php 19.33 billion, which is lower compared to the Php 25.9 billion budget in 2019, according to Rappler. The program covers service delivery, health human resource, and health promotion. Service delivery includes funding for the enhancement of health facilities. There was, however, an increase in the health facilities operation program from Php 32.5 billion last year to Php 42 billion this year. The program covers curative healthcare to operate blood centers and DOH-run hospitals and rehabilitative healthcare to operate government-run drug rehabilitation centers.

Learning From Crisis

Dr. Santiago said the pandemic had exposed the weaknesses of the world’s healthcare system. “It is not prepared for this,” he admitted, saying that there are so many takeaways from this crisis. One is the importance of sanitation and how this pandemic and other health concerns in the country such as polio, dengue fever, SARS, and AH1N1 are all related to it. The other is climate change and the need to no longer ignore it. “The environment that this virus feeds and mutates on should also be given focus,” he said.

While recognizing the gaps in the country’s healthcare system, Dr. Salvana believes it has been strengthened by the Philippine Health Insurance Corporation (PhilHealth) and the government. PhilHealth is a government-owned and controlled corporation that provides universal healthcare coverage for Filipinos. It assured the public that the agency will shoulder the full cost of treatment for all confirmed COVID-19 cases until April 14. After that, it will implement a new package rate scheme to infected patients.

Dr. Salvana agreed that no healthcare system in the world was prepared for COVID-19, noting that “our current resources are less than what developed countries have,” which was why the “Government decided to be proactive on our recommendation in order to save lives.”

However, quarantine procedures should have been done much earlier and should have been implemented nationwide, especially because there’s movement and migration of people early on, according to Dr. Santiago. “With the two confirmed cases, we should have started the lockdown and restrictions already. Early intervention should have made this crisis more manageable,” he stressed.

How to Fight COVID-19

Safety and security consultant, Elpidio Daniel, couldn’t agree more. “This battle against COVID-19 is most effective if the actions are rapid,” he said. He added that a nationwide ECQ in the first blast, and without delay, could have been more effective in containing the current pandemic. Although he acknowledged the efforts and intentions of the President, he said there had been confusions undeniably in the implementation of the guidelines on the imposed lockdown. “Good and complete communication is the key” to avoiding the pitfalls of misinterpretation or miscommunication of the guidelines, he said. “Guidelines on paper will surely not be as exact as the actual situations on the field and this is where the common sense and reasoning abilities of the head of the enforcement team is needed,” he further said. The guidelines on the lockdown should have been “tailor-fitted to the actual situations on the field.” Otherwise, the people will bear the brunt of confusion and suffering, he added.

Similarly acknowledging the efforts of the Government, Dr. Leachon suggested that the Government should have tapped the corporations in the country early on to help because “they have the workforce, the manpower, and the corporate thinking process.” Rejecting the help of private institutions or individuals who are willing to provide insights is one of the failures in disaster management, he said. “You need people with experience in lobbying and policy-making. You need someone who’s been there and who fought with success. They should have called all former health secretaries of health—it’s called a summit,” he further said. He commended, however, the “preemptive” move of the president to announce early the extension of the lockdown, thus giving more time for the country to address the health crisis, as reported by CNN Philippines.

On April 1, Dr. Leachon has been tapped as a special adviser to Peace Process secretary Carlito Galvez, Jr., chief implementer of the National Action Plan COVID-19 and provides medical expertise to the National Task Force on COVID-19.

But DOH Secretary Dr. Francisco Duque III is not in an unfamiliar territory, so to speak. He also served as health secretary from 2005 to 2010 during former President Gloria Arroyo’s term, and at the time, it was AH1N1 epidemic that struck the country. Based on the DOH’s “A Legacy of Public Health” second edition book, he successfully managed the said crisis in 2009. “The Department’s effective handling of the health emergency, which brought the world to its highest pandemic alert level, was later commended by the World Health Organization. The Philippines was also cited among the three countries that had the best risk communication strategy during the crisis,” it said.

In a previous report by GMA News Online, Dr. Duque was quoted as saying, “We were the first to activate a preparedness plan and our colleagues were glad because we acted swiftly. Our Health Department, Bureau of Quarantine and National Disaster Coordinating Council all staged an effective communication program to avoid panic and economic and social disruption.”

What Should Happen Next?

Dr. Leachon could only assume that Dr. Duque might be afraid of the President that he could not simply comment or suggest, contrary to his relationship with former president Arroyo whom he’s friends with. The President may also be getting filtered messages or information, instead of sound advice, from the people close to him, he said.

Meanwhile, Dr. Santiago thinks Dr. Duque would give sound advice to the President, but perhaps “more forceful advice” is needed. He said the Health Secretary had an early response to AH1N1 before that’s why he was able to contain it. Plus, there’s an entirely different challenge with COVID-19, not knowing who’s infected yet. He added that the spread is so fast, and the infection rate is unlike that of SARS and AH1N1. “That’s why we shouldn’t be complacent or reactive but instead proactive in cases like this,” he stressed.

Dr. Santiago believes this is not the time to be blaming each other, though. “Let’s put off the fight and bring on the blame after this battle. For now let’s help each other, regardless of what really happened. Let’s focus on this now, otherwise we are going to lose this battle,” he said. He recalled a previous Senate hearing he had attended wherein some politicians ended up blaming Dr. Duque for the crisis. “We went there for the purpose of finding solutions to the COVID-19. And Duque [was] really doing his job well at the time. It should not be the time to be blaming each other,” he said. He added that it’s time for the local chief executives to shine in this pandemic, stressing the need “to show their commitment as elected public officials.”

Dr. Leachon also shared that in situations like this, leaders would be measured by their character, by their response to the crisis, and by how they communicate and rise above the problem.

The Future of Universal Healthcare in the Philippines

How will the pandemic affect the future of the Filipino healthcare system, with its newly signed law?

Dr. Santiago said that it is definitely going to affect the already challenged healthcare, as it has incurred a lot more expenses for the government. He said the implementation of the newly signed UHC law in the country to improve the system would be “difficult, very challenging, and very problematic,” especially with the health crisis at hand.

Dr. Leachon said the pandemic is a “game-changer” that sets a new normal, such as observing social distancing and practicing hygienic measures. He however hopes that that this experience will “improve our public healthcare system so that we are prepared for the next pandemic.” Aside from proper compensation, he stressed that appropriate training and a retention program should also be provided to health professionals, so they will stay in the country for the universal healthcare and not go elsewhere.

Signed in February 20 last year, the passage of the UHC law, which seeks to address several problems in the current healthcare system, has been referred to as a milestone for the Duterte administration. Among these issues are providing PhilHealth coverage for all Filipino citizens that will significantly reduce the high out-of-pocket expenses from the people; correcting the fragmented and overlapping roles and responsibilities of various health agencies; improving the remuneration and incentives for all health workers; addressing human resource shortages and disparity; and enhancing the local health systems in LGUs, among others.

According to NEDA, funding for this new law will come from sin tax collections as well as partly from the revenues of the Philippine Amusement and Gaming Corporation and the Philippine Charity Sweepstakes Office. Duterte has recently signed new tax regulations on products such as tobacco, electronic cigarettes, and alcoholic beverage, imposing higher tariffs and penalties contested by many manufacturers, sellers, and consumers. The sin taxes generated from these products will help fund the UHC programs of the administration.

Asked whether the UHC law could change the course of healthcare in the country, Dr. Santiago said it looks “very promising.” But at the same time, he recognizes that there are still many issues to be ironed out, such as further improving the clause on remuneration for healthcare professionals. “Although it’s stated in the law that it’s a 10-year implementation period, so it’s too early for us to tell,” he said.

As for Dr. Leachon, he said:  “If you were able to address those [three main problems in the system stated earlier], only then I can say that the UHC is successful.”

For now, one year following its signing into law and with no end yet in sight for the current COVID-19 pandemic, confirmation of the much-needed salvation being promised by the new healthcare law for all Filipinos remains to be seen.

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