By Anthony C. Leachon, MD
Capital Primary Care Coalition Group
The Philippines is in the midst of a healthcare crisis. Even as infectious diseases such as tuberculosis and pneumonia persist as leading causes of mortality (accounting for 200,000 deaths a year), a new scourge has descended upon us – an epidemic of non-communicable diseases such as stroke, heart attack and cancer that kills 300,000 Filipinos a year.
This double burden has strained the healthcare delivery system to its limits, exacerbating inequities in healthcare access and health outcomes from womb to tomb.
For example, despite 100 percent coverage, only 33 percent of the poor are able to utilize their PhilHealth benefits, compared to 88 percent among the rich. Even more disturbing, 66 percent of deaths among Filipinos are unattended by any healthcare provider.
The inability to manage this double burden can be traced to three chronic problems that have plagued our healthcare delivery system.
First, we face a chronic healthcare workforce shortage, as we continue to be the number one exporter of nurses, and the number two exporter of doctors in the world. This shortage is at its worst where healthcare workers are needed most – in rural and urban public facilities, where they are both underpaid and overworked.
Second, our healthcare system has evolved into a fragmented system characterized by 46 separate but overlapping healthcare programs driven by donor initiatives rather than population needs. This has hindered our ability to integrate, harmonize and prioritize solutions to problems in health.
Third, our healthcare system is also fragmented administratively, with local government units placed in charge of frontline healthcare delivery. This has politicized the healthcare workforce and has made it difficult for the DOH to orchestrate a unified healthcare program.
In this paper, we propose a radical transformation that will affect the structure, delivery, utilization, and funding of healthcare. We propose a transformation from a fragmented, undermanned healthcare system, into an integrated, coordinated and unified primary care system that will enable healthcare for all, regardless of ability to pay.
This change will entail cultivation of a workforce of primary care providers – doctors, nurses, midwives and community healthcare workers – who can develop a personal relationship with their patients. These healthcare workers will serve as the first contact for patients for a broad range of preventive and curative services. They will also function as their personal navigators in a complex healthcare system composed of specialists, technologists, healthcare facilities and payment systems.
Investment in a universal primary care system can help curb the three main problems of our healthcare delivery system.
First, it can alleviate the workforce shortage, because primary care providers can address most healthcare problems at their level, at an affordable cost, doing only the necessary tests, and giving only the needed treatments. In addition, investment in a primary care system will enable private healthcare workers to serve public patients.
Second, program fragmentation can be minimized because competence in various healthcare priorities can be incorporated into a curriculum for primary care. Instead of multiple programs that are planned and implemented separately, we can develop a single unified primary care workforce that is capable of processing a broad range of healthcare needs.
Third, transformation to a primary care system provides a good opportunity to address the problem of administrative fragmentation (decentralization). If government begins to pay for primary care services, then government can set rules, regulations, and quality standards for availing of those payments.
Transforming into a universal primary care system will entail a change in the mindset of policy-makers, administrators, healthcare providers and the public at large. Five milestones will need close attention.
1. Recruitment – Primary care must be sourced from a broad range of willing healthcare providers in both the public and private sector. These providers may include family physicians, general internists, general pediatricians, general practitioners, nurses, midwives, and community health workers. Providers need to render service within an accredited healthcare facility (e.g. a private clinic, an infirmary, or a barangay health center).
2. Retraining – Precisely because primary care aims to provide holistic services for a broad range of ailments, primary care is not easy. To assure competence in the rendition of primary care services, willing providers will need to undergo intensive retraining in primary care, or show prior proof of competence in this field. Training in primary care should become a cooperative venture between the DOH, academe, and healthcare professional organizations such as the Philippine Academy of Family Physicians.
3. Retention – Curbing the brain drain of healthcare professionals will entail the provision of fair payments and just benefits. This should be sourced from the national health insurance system and when necessary, from general appropriations at the national and local level. Payment systems can range from capitation, to fees for service, performance-based payments, or even salaries. The choice will depend on the local circumstances but for sure, the system of job orders, casuals and contractuals must be abandoned.
4. Regulation – Once the national health insurance system begins to pay for primary care, government can regain control of the healthcare delivery system. PhilHealth and DOH, for example, can set requirements for 1) accreditation of clinic facilities 2) accreditation of primary care providers and 3) availment of benefits by PhilHealth members and beneficiaries. It can define health priorities and strategies, and set targets for quality of care through a system of performance-based payments. It can even set the desired ratio of primary care providers to specialists to optimize healthcare delivery.
5. Reassessment – As in any system change, continuous reassessment through monitoring and evaluation, needs to be undertaken to determine if healthcare is improving for all Filipinos. Key indicators include caregiver knowledge, quality of care, health outcomes, patient utilization, out of pocket expenses, patient satisfaction, caregiver satisfaction, and administrative efficiency.
All five milestones will need commitment and significant investment, in order to complete the transformation into a primary care system. A good starting point is PhilHealth’s TSeKaP package or Primary Care Benefit Package 3 (PCB-3). While several changes are needed, the PCB package has the proper focus and “nuts and bolts” to facilitate the transition to a primary care system.
Currently, the government is committing a total budget of PhP 28 billion for the provision of TSeKaP to 15.6 million families under PhilHealth’s sponsored and indigent programs. However, to ensure the financial sustainability of the package and the primary care system that it will support, DOH together with PhilHealth must target coverage of all PhilHealth members for primary care.
Expansion will require commitment of an additional PhP 37.5 billion, but this will optimize pooling of risks and maximize the average primary care budget for every Filipino. As shown in several countries, this investment can actually yield savings from reduced medical expenses.
Transforming into a primary care system of healthcare delivery will enable radical changes in how we address health problems. We believe this change is not only necessary; it is also achievable within the framework of the existing healthcare delivery system. For sure, details of the transformation will vary in different settings. For this reason, we recommend the conduct of pilot studies in a rural, urban, and corporate setting. These studies can help identify, understand and address the variety of problems that may emerge in various local settings.
Universal Health Care is not a new idea, and neither is Primary Care, which is the fundamental strategy for achieving it. Many countries have gained ground in the pursuit of UHC through transformation into a Universal Primary Care system. Many more are in the midst of struggles to achieve this dream.
Economic realities are largely responsible for our downward spiral into an undermanned and fragmented healthcare system. It has been a long and painful wait for equal access to healthcare services. With the economy moving forward under the leadership of the current administration, Primary Care is no longer just necessary, it is now also within reach. The time to complete this change has come. Abay Kalusugan para sa bawa’t mamamayan.
Vital Signs Issue 78 Vol. 4, August 1-31 2015