UNIVERSITY OF THE PHILIPPINES MANILA
College of Arts and Sciences
Department of Social Sciences
Development Studies 199.1
D r. E d b e r t o Vi l l e g a s
OFFICIAL DEVELOPMENT
A S S I S TA N C E ( O D A ) A N D
H E A LT H : A C A S E S T U D Y O N
THE PHILIPPINE GENERAL
H O S P I TA L
AN UNDERGRADUATE THESIS
SUBMITTED BY
Ve r m i e N. A c h a r o n
2008-15947
BA Development Studies
CHAPTER I
RESEARCH PROPOSAL
STATEMENT OF THE PRO BLEM
In the recent State of the Nation Address, President Aquino has laid out
his plans for the country and indicated his administration’s priorities in the National
Budget he submitted to the legislative branch. Compared to the previous year, it is
identifiable that the budget has slightly lower debt servicing, higher military spending
and greater allocation for economic and social spending. However, we must be critical in
our analysis of this budget list because there are certain implemented policies that could
be deemed fake anti-poverty schemes (conditional cash transfers and dole-outs), making
them actually anti-development policies that hold biases to increase private profit.
The health sector is not excluded in this scheme and is in fact a glaring example
already. The Priority Health Policy Directions of the Aquino administration gives special
attention to three things: towards universal health care through a refocused PhilHealth,
health facilities and the attainment of Millennium Development Goals. But the financing
strategy of the administration emphasizes that the government has limited role in
subsidies and distribution of health funding1. Therefore, public health institutions would
have to heavily rely on external resources.
One of these external resources is the Official Development Assistance
(ODA). And 9% of these funds are channeled to Social Reform and Development where
1
Ona, et.al. Aquino Health Agenda: Universal Health Care. 2nd Philippine Health Outlook Forum. October 2010
2
health is a key factor. Mostly, projects include upgrading and expansion of major
hospitals and research institutes.
Taking the case of the Philippine General Hospital where various departments and
institutions have become beneficiaries of foreign aid, the study will aim to answer the
following questions:

Is there a need for official development assistance within the health
sector?

Does ODA truly provide the needs of its recipients?

Does ODA affect the services provided by their recipient departments to
the patients of PGH?
3
DEFINITION OF TERMS
1. Financial flows - inflow of resources to aid recipient countries includes:
Bilateral flows – provided directly by a donor country to an aid recipient
country; Multilateral flows – channeled via an international organization active in
development (e.g. World Bank, UNDP).
2. Grants - Transfers made in cash, goods or services for which no repayment is
required.
3. Health Care - The prevention, treatment, and management of illness and the
preservation of mental and physical well-being through the services offered by the
medical and allied health professions in the communities (primary), hospital
(secondary), specialized consultative health centers (tertiary).
4. Health Financing – methods of gaining sources of revenue and allocation of
resources in health services.
5. Health Status - the result of the interaction of the population, the health sector and
the health-related sectors.
6. Loans - Transfers for which repayment is required. Only loans with maturities of
over one year are included in Development Assistance Committee (DAC)
statistics. Data on net loans include deductions for repayments of principal (but
not payment of interest) on earlier loans. This means that when a loan has been
fully repaid, its effect on total net ODA over the life of the loan is zero.
4
7. Official Development Assistance (ODA) - Grants or loans to countries and
territories on the DAC (Development Assistance Committee) List of ODA
Recipients (developing countries) and to multilateral agencies. Grants, loans and
credits for military purposes are excluded. Transfer payments to private
individuals (e.g. pensions, reparations or insurance payouts) are in general not
counted.
8. Tied and untied – Tied official grants or loans where procurement of the goods or
services involved is limited to the donor country or to a group of countries which
does not include substantially all aid recipient countries; while untied aid is for
which the associated goods and services may be fully and freely procured in
substantially all countries.
5
THEORETICAL FRAMEWOR K
This paper will use historical materialism as its framework because the researcher
believes that the methodological study of society, economics and history will evidently
feature the dynamics between the government, the public health sector and private
foreign institutions. Since the general objective of the paper is to determine the
implications of an external financial source – ODA to the foremost institution of public
health, the Philippine General Hospital, then the framework would allow the researcher to
assess the relationship of the economic substructure with the superstructure of politics
and health. Furthermore, policies, institutions and different phenomena will be analyzed
using the political economic perspective. Because the researcher thinks that in the macro
and micro level, there is an encompassing conflict of interest. And the interaction of
political, public and private institutions will demonstrate their interactions especially in
the aspect of health. It will depict whether or not there are capitalistic desires to maximize
profit under the pretense of assistance at the expense of the people and how will the State
respond to advances such as these.
6
METHODOLOGY AND RESEARCH DESIGN
The researcher will incorporate both quantitative and qualitative methods in order to
apply descriptive and inferential statistics in the problems taken up by the paper and to
enhance the understanding and critical review of the related concepts. However, due to
the nature of the thesis, it mainly involving the study of society, the quantitative approach
will be used only to supplement while qualitative analysis will stand both as foundation
and key technique of data gathering.
Primary and secondary data shall be collected using a number of methods:
surveys, questionnaires and structured interviews. The total population would be 70-75
and the respondents would comprise of 40 patients and at least 30 health workers from
the Philippine General Hospital. This population was chosen through purposive sampling
and each person was chosen through accidental sampling methods. The sampling
technique and the type of questions in the survey will ensure that the data that will be
gathered are reliable. Structured interviews will also be conducted with finance officers
and administrators of concerned local and foreign institutions (if given the chance) to
give the paper depth and ample validity in all levels.
HYPOTHESIS
Once the study is conducted, the researcher wishes to validate her hypothesis: The
health of the people which is a primary driving force in a country’s development is not
prioritized both by the government and ODA as is seen in the case of PGH.
7
REVIEW OF RELATED LI TERATURE
Policy for the Health Sector. Manila: Asian Development Bank, 1999.
Over the last 35 years, it can be said that health conditions in the Asia and Pacific
regions have improved and it can be seen in the positive statistics regarding mortality and
total fertility rates. However the fact remains that the region of South Asia still retains the
highest rates of infant mortality and child malnourishment. And the ones who are directly
burdened by this poor state of health are the poor, women, children and the indigenous
people. The steadily increasing inequality in the economic distribution of wealth has
made it more difficult for the poorer sectors of the society in coping with their health
financial crises. Also, cases of smoking, HIV/AIDS and use of illegal drugs have risen in
number
Despite the focus of Policy for the Health Sector in health and population, the
latter is not discussed in detail because there is another publication which solely
addresses it. The same applies for nutrition. Therefore the book has given ample attention
to the subject of regional health condition, various issue and options concerning the
aforementioned victims of ill health, and finally the involvement of the Bank in the health
sector.
In the past years, there have been serious efforts from world leader to establish
that universal access to health is a critical aspect for social development and poverty
reduction. And so it has been their target to commit developed and developing countries
to allocate finances for official development assistance. However, there has been a
seriously decline of external resources for the health sector. And though it has begun to
8
pick-up again, there is still a wide discrepancy between the real sums of ODA for the
Asian and Pacific region.
It was in 1978 when the Bank’s first loan in the health sector was approved and
since then though there is an absence of an upward trend, there is the continuous flow of
loans. The trend suggests however that the nature of Bank lending has shifted from civil
works to primary health care and greater investment in software. And it was also reported
that the Bank has started working closely with various partner institutions, bilateral and
multilateral organizations, in terms of co-financing in order to improve the quality of the
design of health sector loans.
The Bank focused on setting a clear agenda in order to prioritize the poor, women
and indigenous peoples. The first key issue that they wanted to confront was the
mobilization of resources for the public health sector through an increased budget
allocation, use of external assistance, social insurance, user charges and facilitating or
mandating private expenditures. The second is to build managerial capacity through
strengthening the management of service delivery, policy development, financing,
regulation, monitoring and evaluation. Third is the testing of innovative approaches to
effectively separate the novel from the truly effective ones. Fourth is the introduction of
effective, new and affordable technologies. Fifth is focusing on functions which
constitute public goods. And this deals with the research and information collection,
modification of health-related behaviors and the regulation of the private sector. The last
key issue is the increase in collaboration between the public and private sectors. This has
many forms including contracting out the delivery of health services to private providers
or NGOs, contracting auxiliary services (equipment maintenance, food service, laundry
9
services, etc.), training private pharmacy operators or basically pulling in private drug
sellers, working with traditional healers and employing private sector management
approaches in public sector hospitals.
Howard, Lee M. “What are the financial resources for ‘Health 2000’?” Health Care
Who Pays? Selected Articles from the World Health Forum. Geneva: World Health
Organization, 1988.
In order to improve the health of the population, planning developments should be
in more than one socioeconomic field. And to successfully asses the resources (domestic
and external) from the public and the private sectors, current data on national health
budgets and flow of donor health funds should be readily accessible. Unfortunately, this
is not the case for most developing countries. Thankfully, UN and the Organization for
Economic Cooperation and Development have at least aggregated economic data. And
from the studies done by OECD, it was stated that the public services in the poorest
countries do not meet the basic health requirements for more than a quarter of their
population.
The article further discusses the resources of developing countries by identifying
first the external resources. By definition, it implies all external private and public sectors
from developed and developing countries and has four general
types: (1) Donor
countries with official (bilateral) programmes (2) Multilateral organizations (3)
Nongovernment and voluntary associations including foundations, including foundations
(4) Private-sector trade. However, it was also stated that developing countries should
fully rely on these external resources because the principal resources should come from
10
within the countries themselves. It is in line with the World Health’s Assembly of aiding
the developing countries to become financially self-reliant and efficient managers of their
own health strategies.
There are two interpretations for the “health for all” target. The first one means
that each country should establish a nationally affordable system and the resource
requirement would approximate the national resource availability. The size of the sector
would simply reflect the national political priorities and would determine the intent of the
government. This interpretation requires a rigid timeframe in contrast with the second
definition which suggests that the country should progressively accelerate the level of
health improvement alongside other development factors using the available internal and
external resources. Since in the second interpretation, primary health care will not only
mean accessible health care but would also include components such as water supply,
family planning and other programs, then the financial requirement would be closely tied
to development growth. However, regardless of the interpretation, the practical concern
should include training and preparation of health managers so that they will be capable of
pursuing the delegated programs amidst the continuous changes in social commitment
and economic growth.
The article concluded that in the twenty years that would follow the World Health
Assembly of 1979, developing countries should not regard external resources with undue
optimism. They should develop and gain their primary source of wealth within their
nations and from there work on strategies for health within those constraints. Aid from
external resources dedicated to health will only increase marginally therefore it should be
11
allocated carefully and strategically to providing knowledge, training and preparation in
the national level.
E. Tarimo. “Good intentions are not good enough”. Health Care Who Pays?
Selected Articles from the World Health Forum. Geneva: World Health
Organization, 1988.
The Alma-Ata Conference and the global strategy for health for all have called
upon governments to increase their budget for health in order to make primary health care
more accessible especially to the poorer sectors. However this alone is not enough since
inflations disrupt the economic stabilities in many countries. And while there are efforts
within the community (contributions and donations), the government should give more
support. For the countries that already have reasonable allocations for health, there is a
need for to ensure that the funds will be spent equitably and efficiently because usually
allocations were granted to urban specialized hospitals only. And so there is the need to
put pressure on political commitment to create a transparent and dynamic accounting
system.
That kind of health system reform would also require the participation of different
political, social and economic participation. The creation of a high level decision-making
mechanism within the government would ensure that the equity in health care,
community participation and inter-sectoral exchange would transpire. It will also answer
the common problem of lack of technical support, where the essential network that would
work on health development and research would be able to supply adequate studies,
orientations, training and policy options not only to the government but also to concerned
12
organizations. However, it is essential that these national health councils or ministries
remain true to the goal and not become political hindrances once created.
The author directly discusses his ideas within the situations of health care system
in the countries in Africa. He notes that there are various debates concerning the kind of
health infrastructure, worker, drugs and traditional medicines. There is confusion on the
content of key programmes, the number and places where new infrastructures would be
built under the chosen programmes, the number and types of health manpower needed,
supply of essential equipment, and the facilitation of their training, among others. In
addition to the difficulties provided by the distances between health units and the
transportation costs, the financial aspect of providing affordable medicines. It was
advised that a national list of essential medicines should be made, but few countries have
heeded. There is also the existence of traditional medicine and practitioners that continue
to service the African population as part of their history and culture. It should neither be
ignored nor completely replaced by Western medicine since by doing so would only
cause trouble in the implementation of national policies.
The role of external agencies was also taken up in the conference and a call was
made for the prosperous countries to increase their support for the primary health care in
developing countries. However, there is a lack of involvement in the referral level which
goes alongside the goal of creating local initiatives and self-reliance. It was also
emphasized that donors need to provide the “appropriate” assistances, ones that would
answer the local needs and would not channel the national budget to just maintenance
costs. A good mix of health units and different types of it should be the focus.
13
Overall, there is an improvement in the state of health in Africa. However, it does
not encompass the slum-dwellers or those living in the slum areas – the very people who
genuinely need primary health care. Because there is a serious lack of data for use in
monitoring and evaluation, regular processing, analysis, interpretation and dissemination
of information which leads to long delays in action and policy implementation. Unless
the key elements of budgetary reallocations, increase in resources, and better
management would be given due review, then the good intentions of achieving primary
health care for all will not be realized.
Gottret, Pablo, and George Schieber. Health Financing Revisited: A Practitioner's
Guide. Washington: The World Bank, 2006.
To be able to meet the Millennium Development Goals (MDG), official
development assistance and development assistance for health should be increased in
order to successfully support poor countries in their endeavor to provide essential
services for their people. There has been an almost 25% decline in the 1990s but the
numbers have started to rise again and the allocation for health has increased significantly.
And although the largest percentage of official development aid is received by Africa, it
only constitutes 9% of the entire flow to the developing region.
Recipient governments in return should prepare their countries to absorb the funds,
and manage it in a predictable way that would ensure its sustainability even when the
backing stops. It is important that policies would help the health system develop using
evidence-based strategies and within the existing budget and programs. Basically external
resource absorption relies on macroeconomic, budgetary, management and service
14
delivery aspects. Good governance, sound financial institutions and lack of corruption is
also needed.
On March 2005, world leaders and heads of multilateral and bilateral
organizations discussed the need for improvement of ownership, harmonization,
alignment, results, and mutual accountability in aid effectiveness under Paris Declaration
on Aid Effectiveness. A new strategy, coordinating donor funding through sector-wide
approaches, will be employed to the limitations of project-based forms of donor
assistance, to ensure that overall health reform goals are met, to reduce large transaction
costs for countries, and to establish genuine partnerships among donors and recipients
wherein both have rights and responsibilities. The key action is to enhance the country’s
overall policy-making processes and budget and public expenditure management. This
sector-wide approach will heavily rely on new instruments, such as poverty reduction
support credits, the IMF’s Poverty Reduction Grant Facility, and medium-term
expenditure frameworks.
Economic
Support
for
National
Health
for
All
Strategies .
Geneva: World Health Organization, 1988.
During the International Conference on Primary health Care in Alma-Ata (1978),
the World Health Assembly commissioned that the people of the world should attain a
new level of health that would allow them to become socially and politically productive.
Other goals included was the provision of a more equitable distribution of resources
especially concerning healthcare through the bridging of the gap between the ‘haves’ and
the ‘have-nots’. These goals encompassed a global scale that would ultimately aim for an
15
improved usage of the world’s resources. It was reiterated that the health care should be
more accessible especially to the communities through practical, scientifically-sound and
socially accepted methods.
However the Global Strategy for All under the 34th World Health Assembly
(1981) emphasized on health being an essential investment in development. This was
established after identifying that it is the socioeconomic development policies that truly
determine how the country would achieve its health goals.
A few years later according to the same body, there is a growing political
awareness and will from a lot of governments to initiate a reform within their health
systems. Some of these reforms were in the form of new infrastructures and expansions
of community-based health services. However, these efforts were not always met with the
expected results due to factors like political and economic instabilities. An example was
the worsened state of the global economic situation which started in 1977 and has
drastically affected the health budget especially of the poor and developing countries. But
the flaw does not only rely in the external economic setting. Some governments remain to
be ‘weak partners’ in mobilizing support for the socioeconomic development policies.
This is obvious in their inefficient use of existing health resources.
Therefore the book gave special attention on the options for strengthening and
expanding economic support for national strategies for health. One of the five broad
needs that should be addressed is the study of the roles and responsibilities of potential
partners: the government, communities, nongovernment organizations and the private
sector.
16
The plan of action included a financial master plan which identifies the resource
gap and proposes options to close that gap in order to achieve the designed goals. One of
the steps given was the exploration of all possible sources of finance. This financial
support system lists taxes, community financing, social security, private payments,
voluntary contributions and foreign aid. All mentions financial mechanisms should work
within or in line with the national strategies for health.
Philippine National Health Plan (1995-2020): Health in the hands of the people.
Department of Health.
The document was completed under the supervision of the National Health
Planning Program, a project launched by the Department of Health. It is a long-term
directional plan spanning from the year 1995 to 2020 and involved the participation of
various sectors from the government, private and non-government sector, people’s
organizations and other health-oriented groups. It is a country plan providing
coordination mechanisms for planning within and outside the health sector. It includes
directions and strategies concerning the efficiency of the country’s health care system.
This is the plan’s guiding concept: health is a basic human right and it is both a
means and an end of development. And this is why the State and other sectors have to
work diligently in elevating the state of health for all Filipinos. It also realizes that health
is interconnected with other components of the socio-economic system. Therefore, the
document defined health status as the product of the interaction of the population, the
health sector and the health-related sectors.
17
The plan’s vision mandated that by the year 2000, the socio-economic
development would allow all Filipinos to attain a level of health that will support them as
they live as socially and economically productive citizens. But at the turn of the 21st
century, the country will face different challenges brought by the onset of
industrialization, urbanization, agricultural productivity, modernization of roads and
infrastructures. And while there are positive impacts, the country should be prepared to
handle the consequences these changes will bring to the health of the people. But through
better education, communication facilities and new technologies, lifestyle related health
and social problems would be efficiently handled.
Also, the overall framework of the plan will work in accordance with
internationally mandated principles of primary health care that aims to reduce the gap of
inequity in health status and the development of the community as the primary institution
of all health development efforts. Various sectors will strive to coordinate and cooperate
in order to achieve these goals while the combination of public and private funds
including third party schemes would stand as the system’s financial support.
The plan then provided a number of strategies to ensure the completion of its
goals. The first strategy is to promote equity in health where priority will be given to the
vulnerable and marginalized, would use the primary health care as a key approach and
would put emphasis on promotive and preventive health care. The second strategy deals
with the minimization of specific health problems though the promotion of the health of
the vulnerable sectors of the population and immediately addressing problems like
communicable diseases, HIV/AIDS, oral health, mental health, environmental and urban
health among others. The third strategy aims to create a responsive, dynamic and highly
18
efficient health care delivery system. This will be manifested in the strengthening of
health organizations management, continuing health policy, program and strategy
development, health facility development, health human resource development, health
care financing, health information system, research and development and the maximized
use of appropriate technology. And lastly, the final strategy is about the transformation of
health into a comprehensive and sustained national concern. The components of this
strategy includes people empowerment and participation through consultative processes
in health planning and policy formulation, advocacy and social mobilization, community
organizing and development, and building partnerships in health.
Tadem, Eduardo C. "The Crisis of Official Development Assistance to the
Philippines: New Global Trends and Old Local Issues". 2007. (PDF)
Official Development Assistance (ODA) has been a key economic factor in the
Philippine’s road to development for decades already, but it does not mean that it is an
unflawed mechanism. In the international scene, the flow of foreign assistance has started
to pick-up again but in the dominant form of debt relief and rehabilitation/relief efforts
especially in Iraq and Afghanistan after the events following the September 11 attacks in
the United States.
According to the Organization for Economic Cooperation and
Development (OECD) Development Assistance Committee (DAC), their target goals are
still a long way off since member countries continue to give only modest allocation to
their ODA/GNI (Gross National Income) ratios. Furthermore, Japan who is the largest
ODA donor in Asia revised their ODA charter in 2003 to accommodate its country’s own
19
interest as the new charter pledges that their external need for energy and resources can
be supplied by developing countries which are recipients of their ODAs.
Even the then 2004 IMF Managing Director Rodrigo de Rato expressed his
disappointment on the inefficiency, unpredictability, and being uncoordinated of aid
flows. As well as it being ‘tied’ deals for almost 49%. He said that to be able to meet the
2001 Millennium Development Goals, countries who pledged to fulfill human
development objectives should scale up their financial and technical support. This is
closely connected to the entrance of foreign consultants who apparently offered more
than advice and technical support but only drove costs at a higher price after dictating
solutions that cannot be applied locally.
As for the Philippines, annual average of ODA commitments continues to
decrease, as clearly manifested by the 58% fall of ODA from Japan. Despite the shifting
of US’s entire ODA portfolio from a combination to pure grants, there are still more
loans granted as it increased from 82% to 84% in the years 2001-2006. ODAs continue to
fail as well in the attainment of Millennium Goal No. 8 which particularly aims to
increase the share of human development as ODA allocations for health, education and
housing decrease from 11% to 7% while infrastructure developments increased its share
from 50% to 67%. The regional distribution of ODA remains problematic as well.
Luzon’s share is the biggest followed by Visayas then Mindanao demonstrating that the
distribution of aid continues to favor the more developed regions as opposed to the lessdeveloped areas which need the financial aid more. This also reveals a new trend
underlining geo-political concerns (such as peace building, conflict resolution, and
undermining support for armed rebellion) over development issues.
20
The rampant occurrence of corruption and lack of transparency add up to the
problematic schemes that mar the mechanism of foreign assistance funds. Moreover,
ODA projects were also associated with reports of human rights violations and
environment degradation. In fact, nine large-scale ODA projects were branded as socially
and environmentally harmful, specifically to the indigenous communities.
In the past years, there have been three studies that were able to summarize the
performance of foreign assistance in the country. The first one was made by some
economists from the University of the Philippines and they have resolved that most of the
projects financed by ODA were unproductive. The second was in 1998 and concluded
that it is highly biased since it only focuses on economic sectors in fast-growing and
highly urbanized areas. And lastly a COA report from 2004 commented that the loans we
were granted do not actually help us develop economically since they only become
sources of loan repayments as opposed to its goals of creating projects for human
development.
21
SCOPE AND LIMITATION
The study will deduce its conclusion after analyzing the content of the
questionnaire answered by a population of 70-75 respondents, including an additional
number of administrators, officers and key informants who answered a structured
interview. The objective was to determine the state of health care financing in PGH using
the opinion of patients and health workers concerning the services, facilities, career
development opportunities, etc. as validation points.
However, due to the time constraints and limitations of the researcher as a student
this study cannot conclude for the public health sector’s situation on a national scale as it
only aims to expand and develop already existing concepts.
SIGNIFICANCE OF THE STUDY
Many perceive the current administration with abundant faith and hope. But does
it really signify a drastic change in the system we have today? President Aquino has been
both vague and straightforward in his plans for the health sector. His administration is
forthright on the use of newly revamped financial strategies but is it really for the Filipino
people whose majority relies on the little government subsidy allocated for health his real
bosses? Or for the private sector and the external forces which have time and time again
influenced the directional policies implemented?
This study is significant simply because its thesis inquires on the priority of the
State and its associates in the international platform, because essentially the health of a
population should be equitable and accessible, same in all countries, regardless of its
Developed or Developing classification.
22
CHAPTER II
BACKGROUND OF THE ST UDY
HEALTH IN THE PHILIPPINES
It was in the 1970’s, after the problematic economic crisis ushered by the Marcos’
administration, when initial efforts had been made to dissect and understand the
Philippine health system. During that time statistics had its limitations due to the volatile
nature of the political scene and doctored figures reported from the field are not wholly
reliable. But analysts have soon concluded that there was a pressing need for the
examination of the nation’s state and the health system has become a reflection of the
Philippine society’s strengths and deficiencies, achievements and failures2.
According to the 1987 Constitution of the Philippines, “the State recognizes that
health is a basic human right”. And as of today, the Department of Health has established
three primary goals in accordance to World Health Organization. The Philippine health
system must strive for (1) better health outcomes (2) a more responsive health system and
(3) equitable health care financing.
Throughout the years, the status of the health of the Filipinos has become more
positive. The average life expectancy at birth of both men and women has improved from
66.8 years on 1995 to 70.5 in 2005. And according to the Philippine Health Statistics of
2004, crude birth rate decreased from 30.2 to 20.5 births per 1, 000 population, and crude
death rate decreased from 6.2 to 4.8 deaths per 1, 000 population between 1980 to 2004.
2
Tan, M. L. (1987). The state of the nation. In J. Co & M. L. Tan (Eds.), Restoring Health Care to the Hands of the
People.).
23
Table 1. Ten Leading Causes of Morbidity Philippines, 1998-2007
Rank
1
1998
Diarrheas
2000
Diarrheas
2002
Pneumonias
2
Bronchitis/Br
onchiolitis
Pneumonias
Bronchitis/Br
onchiolitis
Pneumonias
Diarrheas
8
Influenza
Hypertension
TB
Respiratory
Diseases of
the heart
Malaria
Influenza
Hypertension
TB
Respiratory
Diseases of
the heart
Malaria
Bronchitis/Br
onchiolitis
Influenza
Hypertension
TB
Respiratory
Diseases of
the heart
Malaria
9
10
Dengue Fever
Chickenpox
Chickenpox
Measles
Chickenpox
Measles
3
4
5
6
7
2004
Acute lower
respiratory
tract infection
and
pneumonia
Bronchitis/Bro
nchiolitis
Acute Watery
Diarrhea
Influenza
Hypertension
TB
Respiratory
Chickenpox
Diseases of
the heart
Malaria
Dengue Fever
2006
Acute lower
respiratory
tract infection
and
pneumonia
Acute Watery
Diarrhea
Bronchitis/Bro
nchiolitis
Hypertension
Influenza
TB
Respiratory
Diseases of
the heart
Acute Febrile
Illness
Malaria
Dengue Fever
2007
Acute lower
respiratory
tract infection
and
pneumonia
Acute Watery
Diarrhea
Bronchitis/Bro
nchiolitis
Hypertension
Influenza
TB
Respiratory
Diseases of
the heart
Dengue Fever
Malaria
Chickenpox
Source: Overview of the Philippine Health System and Implementation Framework for Health Reforms. DOH: 2008.
There has been no drastic change in the ten leading causes of morbidity
throughout the past decade but the Department of Health estimates that there will be a
rise of new challenges as dengue outbreaks become more erratic and high risk behaviors
leading to HIV/AIDS start to propagate more intensely in the society. In addition, despite
the reduction of deaths caused by communicable diseases, Filipinos are still doubleburdened by non-communicable diseases (disease of the heart among others remain to be
the cause of majority of deaths in the country) and the variety of deaths caused by
accidents (which rates have doubled from 1994-2004).
Infant, under-five and maternal mortality rates have also generally improved
according to the Family Planning Survey in 2006. However, there is the obvious disparity
of health outcomes among the different regions. Inequality in these health indicators can
be attributed to inefficient administration and socio-economic reasons.
24
In 2006, more than 27 million Filipinos still live below the poverty line and
consequently suffer from worse health outcomes simply because they do not have access
to health care when they need it3. There is also great unequivocal disparity of access and
use of health care between the rich minority and the poor majority, leaving the latter to be
subjected to worse situations of health and mortality status.
Figure No. 1 Inequities in Mortality
Source: World Health Statistics 2011
According to the former health secretary Dr. Alberto Romualdez Jr., this
significant difference and the failure to address it is one of the main reasons why in
almost all standard of health status, especially regarding health care expenses, the
3
Romualdez, A. The Time is Ripe for Universal Health Care. The UP Forum. Vol. 10, No. 6, November-December
2009.
25
Philippines lags behind most countries in comparable levels of socio-economic
development.
Figure 2. Percentage of GDP of government and private health spending and total
expenditure in the Asia Pacific region
Source: WHO Provisional 2007 NHA data
Data from the World Health Organization, as shown in Figure No. 2, indicate that
the share of expenditure on health in the total budget allocation has decreased
significantly from 2000-2006 but an increase in the share of private sector spending and
out-of-pocket expenditure4.
According to Dr. Thelma Navarette-Clemente, the principal roles of present day
hospitals as a socio-humanitarian institution are: to diagnose, treat illness, promote and
maintain health, to participate in the continuing education of doctors and para-medical
4
WHO Provisional 2007 National Health Accounts
26
workers, to do research, and to provide community services. And when these roles are
not performed anymore, it only meant that these hospitals are in crisis.
One of the factors that contributed to this crisis is worldwide economic financial
problem5. Shock waves that reverberated across the international financial system led to a
string of bank failures. And the global economic crisis affects the local economy through
three major transmission mechanisms. Firstly, lower consumption in importing countries
means lower export of Philippine products, resulting in downsizing or closure of exportoriented firms, and the accompanying unemployment or under-employment. Secondly,
lower remittances of OFWs living and working abroad. Lower remittances means lower
domestic consumption, which tends to slow economic growth. Families of returning
OFWs are also at risk of falling into poverty if the OFW cannot find alternative domestic
employment. Thirdly, lower foreign direct investments translate to slower economic
growth and lower domestic employment 6 . These in turn can adversely affect the
country’s health sector in three painful ways7:
1.
The resulting rise in unemployment and poverty increases households’
vulnerability to health shocks and is likely to lower their overall health
status. Without savings and adequate social safeguards, unemployment
and impoverishment following the economic slowdown results in lower
food intake and poorer housing and sanitation conditions.
2. The resulting higher unemployment and poverty also reduces the ability of
households to meet the financing of their health service needs. Both lead
to increased out-of-pocket (OOP) expenditures for health, which without
5
Navarette-Clemente. Hospitals Amidst the Present Economic Crisis. Restoring Health Care to the Hands of the
People. Task Force People’s Health, 1986.
6Diokno, Benjamin E. Understanding the Global Economic Crisis. The UP Forum. January 2009.
7Impact of Global Economic Crisis on the Philippines Health Sector. Health Policy Notes. Department of Health.
27
savings, transfers, and other support from relatives or friends, or other
forms of social safeguards.
3. The economic slowdown reduces the ability of government to provide
social services which are much-needed by an increasing number of
vulnerable households.
Figure No. 4 Trends for Philippine Health Budget
Source: Philippine Institute for Development Studies
The recent crisis will then amplify the neglect that the government has been
subjecting the health allocation to. It is very visible in Figure No. 4 that while the budget
for health might have been stagnant but had increased in recent years, the allocation for
health has been on a downward trend.
Similarly, this trend is reflected in the subsidy received by the Philippine General
Hospital. As seen in Table No. 2, there may have been increases in the allocation from
2001 to 2010, however in the face of increasing expenditures the balance remains to be in
deficit form.
28
Table No. 2 Subsidy-Expenditures of Philippine General Hospital
YEAR
GOVERNMENT
EXPENDITURES
BALANCE
SUBSIDY
987,623,439
1260148293
2000
-272,524,854
1,109,765,034
1490298830
2001
-380,533,796
1090333000
1420116892
2002
-329,783,892
1031751927
1444582467
2003
-412,830,540
1026819809
1456735184
2004
-429,915,375
1083661524
1603718196
2005
-520,056,672
1218786973
1732490643
2006
-513,703,670
1206701592
1735435198
2007
-528,733,606
1253313098
1888651976
2008
-635,338,878
1422724127
1992769517
2009
-570,045,390
1530562131
2248344940
2010
-717,782,809
AVERAGE
1,178,367,514
1661208376
-482,840,862
Source: PGH-Institute of Research and Planning Development
In order to diminish these deficits, PGH has their own self-sufficiency schemes
like the PDAF (Philippine Development Assistance Funds), locally funded projects, nonPDAF cash donations and UP subsidy. There is also the income of the hospital and the
revenue from the sale of drugs.
PGH’s administration may be trying to meet ends meet but this is to the detriment
of the indigent patients who are now being charged for tests and use of facilities8. The
institution is also starting to gear towards privatization as exemplified by the opening of
UPM-PGH FMAB (UPM-PGH Faculty Medical Arts Building). Starting last June 18,
2009, the establishment has a 25 year lease contract with Daniel Mercado Medical Center.
According to IRPD’s Annual Report, UPM-PGH FMAB was created for three reasons:

To become an incentive for the faculty, to augment their trivial
incomes
8
IBON Facts and Figures. Paying for Social Services Vol. 30, No. 10. May 2007.
29

To be able to offer a wider range of comprehensive patient services
and teaching opportunities

To generate additional income
However, this could possibly threaten the pharmacy within PGH. The competition
is between FMAB’s pharmacy with convenient store and the PGH pharmacy which
generates Php 37 million, out of which Php 25 million is allotted to free medicine for
charity patients. If the return of funds would indicate higher revenue from FMAB then
there might be a chance of complete acquisition of all pharmaceutical stores within PGH
in the future. Instead of going to PGH, profit will directly go to the private company. This
will become another burden for the patients who are already deep in their necks with
expenses.
PGH’s scarce budget is being used as a scapegoat in order to sanction the
deepening hold of private institutions within this supposedly hospital for the
economically deprived. But with external partnerships becoming more encouraged and
the continued neglect of the government, the true shade of commercialization of health is
making its presence more vivid in the present.
OFFICIAL DEVELOPMENT ASSISTANCE (ODA)
The start of the new millennium shepherded the influx of a new breed of ODA,
with events such as the 9/11 bombing incident in the US triggering donor countries and
agencies to evaluate policies, strategies and implementation schemes. The immediate
result was the focusing of ODA relief to relief and rehabilitation efforts in the Middle
30
East. There was also the redirection of donor countries’ attention to sustain and reinforce
international efforts to end global poverty and social inequality.
ODA as defined by the OECD (Organization for Economic Cooperation and
Development) are the “flows of official financing administered with the promotion of the
economic development and welfare of developing countries as the main objective, and
which are concessional in character”. In order to determine if flows from bilateral
contributions or multilateral assistance are ODA material, it needs to contain three
elements:
1. It is to be undertaken by the official sector i.e. states and government
bodies
2. Its main objective should be the promotion of economic development
and the welfare of recipient countries. Military assistance does not
qualify as ODA
3. The aid should be granted at concessional financial terms9
The Millennium Development Goals (MDG) created in 2000 consisted of 8 goals,
18 targets and 48 monitoring indicators. Goal 8: Develop a global partnership for
development particularly pressured ODA donors to address pressing issues. With respect
to this, the Asian Development Bank (ADB) outlined the new roles of ODA in poverty
reduction and included targets such as the enhancement of program for debt relief for
heavily indebted poor countries (HIPC) and cancellation of official bilateral debt. It also
9
Concesionality provision means that loans should have a grant element of at least 25%, Tadem, Eduardo C. "The
Crisis of Official Development Assistance to the Philippines: New Global Trends and Old Local Issues". 2007. (PDF)
31
added certain indicators to increase ODA flows and ensure its effectiveness in recipient
countries10.
However, years after the MDG’s were set, economist Jeffrey Sachs commented
that the system is not effective in attaining the goals with inefficient financial and
technical support. International Monetary Fund Managing Director Rodrigo de Rato also
said in 2004 that “current aid flows are insufficient, unpredictable, and often
uncoordinated among donors”.11
The first form of ODA in the Philippines was through post-war rehabilitation
grant assistance from the US after 1946. But it was in the 1970’s when foreign aid
contributions dramatically increased, in number of commitments, from grants to loans,
and bilateral to multilateral.
During the Marcos administration, ODA has acquired an odious reputation since
it was primarily used for corruption, bribery, human rights violations, environmental
degradation and other implementation flaws. Therefore when the Aquino administration
took over, new indicators were implemented12.
From 1986 to 2000, it was notable that bilateral assistance showed deterioration in
the loan-grant mix. 84% were in form of loans while only 16% were grants of the total
ODA commitments from both multilateral and bilateral donors.13
Indicators include: 1. ODA should be 0.7% of donor countries’ GNI 2. ODA should be proportionally allotted to
basic social services (basic education, primary health care, nutrition, safe water and sanitation) 3. Proportion of bilateral
ODA of OECD/DAC donors should be untied grants
11 UN Millennium Project, 2005
12New indicators: (1) growth rates of ODA commitments, (2) the ratio of loans to grants, (3) sectoral allocation, (4)
geographical distribution, (5) disbursement and availment rates, (6) ratio of ODA to external debt, (7) proportion of
program loans to project loans, (8) the tying of aid, (9) social and environmental issues, and (10) various
implementation problems, Ibid.
13 NEDA
10
32
Table No. 3 ODA Commitment to the Philippines,
2001-2006 (In US$ Million)
Source: NEDA
The period of 2001-2006 was marked by the entrance of two new ODA players:
China and Korea. The improved numbers of ODA in the Philippines made the
government confident in increasing its dependence to fund its programs and projects.
According to Eduardo Tadem 14 , this is precarious because the ODA system is still
teeming with criticisms and neglected issues.
There is no change in the composition of ODA with a huge percentage of aid still
being tied which is related to the issue of foreign consultants. There has also been
negative reaction from local competitors since ODA does not help the industries in the
Philippines grow because of unfair platforms in the market. There are also
disparagements in the sectoral allocation, geographic distribution, ODA as share of
14
Tadem, E. The Crisis of ODA to the Philippines: New Global Trends and Old Local Issues
33
external debt, corruption and transparency issues, and social and environmental
concerns15.
ODA AND HEALTH
In recent years, health has taken a more prominent position at the center of the
international development agents (see Figure No. 5). Since 2000, health is directly
represented in three of 8 MDGs (Goals 4, 5, and 6) 16 and makes an acknowledged
contribution to the achievement of others, particularly to the eradication of extreme
poverty and hunger, education, and gender equality. This has led to an increase in the
number and range of actors in the health field and resources. Much of it however is
targeted towards specific diseases with interventions to address health development
priorities often being left behind. 17
Figure No. 5 Aid to Health as a share of total ODA
1973-1998: 5-Year moving average
Source: Development Assistance Committee data
15
Ibid.
MDGs: 4. Reduce Child mortality 5. Improve maternal health 6. Combat HIV/AIDS
17 From Whom to Whom? ODA for Health Commitments 2002-2009. WHO
16
34
There has been a clear change in the forms of development assistance for health
over time. The objectives have shifted from single-purpose efforts to control particular
diseases or to improve efforts to expand health system capacity and strengthen national
health policy frameworks through systemic reform and global initiatives for improving
disease control.
There are also important variations in the mode of development assistance for
health, with more donors allocating more resources to programmatic and adjustment-style
lending and moving away from highly specific project-based approaches. It is difficult to
describe variations in development assistance for health beyond the most superficial
categorization of objectives. However, an estimated 65% or more of resources in the
sector (across all categories of objectives) are allocated for physical goods (civil works,
pharmaceuticals, medical equipment and supplies), 10 to 15% for technical assistance
and training, and the remainder for a range of (ideally incremental) recurrent expenses. A
small proportion of assistance is allocated for policy research and evaluation at the
country level and for other economic and sectoral analysis, most of it done by donor
agency staff or consultants.
In the Philippines, Dr. Reynaldo Lecasa Jr. described the society in relation to its
health care system as “semi-colonial and semi-feudal. The Philippines needs its health
care system to be colonial, commercialized, curative-oriented, hospital based and urban
based. US foreign monopoly capitalists and their local cohorts initiated, developed and
preserved this orientation of our country’s health care system to attune it to their
economic interest.”18
18
Health of the People, Health of the Nation. 2003
35
When the Alma Ata Declaration or the “Health for All by the Year 2000” was
created in 1978, as a signatory the Philippines was compelled to agree that “economic
and social development, based on a new international economic order, is of basic
importance to the fullest attainment of health for all and the reduction of the gap between
the health statuses of the developed and developing countries.” Consequently, we must
succumb to the dictates of IMF-WB to adopt structural adjustment programs as part of
the country’s health policy reforms. ODA in the form of loans, grants, and technical
assistance was also used to steer overall policy directions in the health sector. 19 These,
alongside the government’s policies of privatization and budget cuts continue to
dissociate health care service to the Filipinos who need it most.
19
Ibid.
36
CHAPTER III
PRESENTATION AND ANA LYS IS OF DATA
The researcher integrated qualitative and quantitative questions in surveying the
target populations in the Philippine General Hospital. Information was also collected
from various offices and administrative references. In order to obtain a holistic analysis
on the implications of external financial resources, both health workers and patients were
surveyed for data and opinions. There are a total of 73 respondents which were selected
using accidental sampling method due to time constraints.
Table No. 4 Number of Employees in PGH, as of January 2012
SALARY
GRADE
STATUS OF APPOINTMENT
PERMANENT TEMPORARY CONTRACTUAL
NUMBER OF
EMPLOYEES
1
2
65
37
2
102
2
3
4
320
154
14
115
334
269
5
6
18
440
1
39
19
479
7
8
40
99
9
6
49
105
9
10
33
22
4
33
26
11
12
36
1
57
93
1
13
14
32
23
14
46
23
15
16
970
5
59
1029
5
17
18
145
44
145
44
19
20
85
1
85
1
21
22
1
54
23
24
13
26
28
TOTAL
2601
558
1
560
54
12
98
12
111
4
1
4
1
673
358
Source: PGH-Human Resource and Development Division
37
3632
According to Table No. 4, PGH currently employs 3, 632 employees under three
statuses of appointment: permanent, contractual and temporary. Permanent employees are
the majority being 71.61% of the population. But temporary and contractual workers still
make up 18.53% and 9.86%.
Table No. 5 Distribution of Health Worker Respondents
Distribution of Health Worker Respondents
Administrative Personnel
7
Administrative Personnel /Nurse
1
Administrative Personnel /Physician
1
Dentist
1
Medical Technician
1
Nurse
14
Physician
7
University Researcher
1
Total
33
The researcher, despite her best efforts only managed to survey 33 respondents
from the health workers’ population (see Table 5) due to the limited data gathering
period. Requests and survey questionnaires were submitted to 14/18 wards and
departments but most failed to respond and return the questionnaires within the expected
date.
The respondents’ monthly income was subjected to inquiry in the questionnaire
and 53% of them answered that their wage is not sufficient to sustain their personal and
the needs of their families (see Figure No. 6). But 31% also said that they are content
with the amount they are receiving.
38
Figure No. 6 Satisfaction in Wages
Excessive
Insufficient
Sufficient
Undecided
Very Insufficient
5%
3%
8%
31%
53%
The following question is closely related as well since it asked the health workers’
opinion regarding their wage in correlation to the kind of work they are performing.
Figure No. 7 depicts that their opinions are diverse but the primary choice with 34% of
the answers say that they are being paid less than what they presume they should be
receiving. More than half of the respondents are clearly not satisfied with the rates they
are being paid with.
Figure No. 7 If the wage received is appropriate to the quality of
work
Excessive
Insufficient
Very Insufficient
Sufficient
Undecided
3%
13%
28%
34%
22%
The two figures clearly indicate that the health workers think that they are
severely underpaid.
39
Figure No. 8 Other Source of Income
Yes
36%
No
64%
And to be able to augment their needs 36% of them claimed that they have other
sources of income (see Fig. No 8). Most doctors who answered ‘Yes’ have their private
clinics or practice their profession outside PGH; some doctors and nurses are also clinical
instructors. The rest have their small businesses and sidelines. The bigger percent who
answered ‘No’ are struggling to make ends meet by budgeting their insufficient monthly
income.
Figure No. 9 Chance for career development
No
15%
Yes
85%
The next part of the questionnaire dealt with the issue of career development. This
question was included in the study since some of the ODA offered included training and
scholarships. As shown in Figure No. 9, a staggering 85% answered ‘Yes’ to the question
whether their position/job in PGH allowed them to grow professionally in their careers.
This is understandable since most of the jobs there are health related and there is a
constant need for expansion of knowledge.
40
Figure No. 10 Career Development Opportunities
Long-term Specialized Training
(abroad)
1%
Long-term Specialized
Training(local)
1%
5%
Masters/Doctorate degree
(abroad)
20%
11%
1%
Masters/Doctorate degree (local)
Others
4%
8%
Seminars/Conference (abroad)
Seminars/Conference (local)
15%
Specialization (abroad)
Specialization (local)
32%
2%
Short-term Specialized Training
(abroad)
Short-term Specialized Training
(local)
For the 25 health workers who answered ‘Yes’, they were then asked to identify
the kind of career development opportunities they were able to attain. Six categories were
given: seminars and conferences (local and abroad), specialization (local and abroad),
masters and doctorate degrees (local and abroad), short – term special training which lasts
a few days until weeks (local and abroad), and long – term special training which lasts a
few months until a year (local and abroad). They can choose whichever are applicable to
their experience and Figure No. 10 depicts the career advancement methods that were
taken. Most health workers have attended local seminars and conferences, followed by
local short-term special training and local specialization.
41
Figure No. 11 Influence on Work
Strongly Disagree
1
Strongly Agree
11
Neither agree nor disagree
1
Disagree
1
Agree
19
When the researcher asked if these career development opportunities were able to
influence their work in the hospital, Figure No 11 would show that there is almost a
consensual affirmation. Therefore, health workers in PGH really respond to these
opportunities positively.
Figure No. 12 Funding for Career Development Opportunities
3%
7%
2% 3%
7%
Foreign institution
Foreign institution: sponsorship
Government fund
Hospital fund
Others: sponsored
34%
42%
Out of Pocket
Private/NGO
Seminars/Conference (local)
2%
However, when asked regarding the funding of these opportunities, Figure No. 12
shows that the health workers shouldered most of the finances required.
42
The second
largest contributor as a finance resource is the option ‘hospital fund’. The difference
between the hospital fund and the government fund is their actual source. The hospital
fund may mean that HRDD (Human Resources Development Division) or a specialized
association (for doctors and nurses) within PGH shouldered the costs; while government
fund could come from DOH or a government official. It is obvious that in this case, ODA
or foreign resources do not play any significant role in the providing opportunities for
career development.
Figure No. 13 Seminars Attended/Conducted in PGH for 2010
320
66
57
60
22
4
20
15
23
30
Source: PGH Annual Report 2010, Institutional Research Planning and Development
Figure No. 13 also verifies that most of the seminars and conference held or
conducted in PGH were spearheaded by organizations within PGH (PGH-Others) and the
43
concerned administrative division (HRDD). According to my interview with two
personnel from HRDD20, as much as they want to organize activities like these for the
employees, their division is not given substantial budget. And the reason for the huge
discrepancy between the activities organized by their division and the other associations
within PGH essentially depends on the source of their funds. HRDD relies solely on the
budget allocated to PGH so their activities are somehow limited to administrative
personnel. While those under the category PGH-Others include the separate associations
and divisions that cater to doctors and nurses respectively. Due to the nature of their
work, these associations have wider networks and sources of sponsorships. Following the
two top contributors is the external source: medical institutions. This makes sense since
these are most likely the same institutions the medical associations within PGH are
connected to. Regarding foreign resources, it was not indicated in the records if some are
connected to ODA. But it should be noted that the 4 cases wherein local private
corporations were mentioned, these corporations are actually transnational companies
(i.e. Nestle)
Figure No. 14 Work Abroad
20
10
Yes
No
2
1
Undecided
No Answer
The last question directed exclusively to the health workers is: If given the
chance, would you choose to work abroad? Why? Figure No 14 shows that more than
half would choose to leave the country. Some of the reasons they gave are:
20
Arlene B. Lantican and Mary Ann Oda C. Ebesate, HRDD. 01 February 2012.
44

‘greener pastures’/bigger compensation would augment the financial
insufficiency and to be able to incur savings

To be able to provide for the family better

Subspecialty training and to gain more experience in the field

Better working conditions and benefits for workers
But some of them noted that it will only be temporary. On the other hand, the
reasons given by those who answered ‘No’ are the following:

They are content with their work here in the Philippines and in some cases
it’s only a matter of perspective and choice of lifestyle

They feel better working for the Filipino people

Cannot leave the family

Overage already
It’s noteworthy that in both choices, the significance of the family is heavily
considered. This shows that regardless of the means, Filipinos still regard the value of the
family highly. The undecided health workers said that their choice would depend on
whether chances here in the Philippines will improve or not, and the nature of work
abroad.
The data and analysis for the other questions will be discussed in the latter part of
the chapter along with the answer of the patients since they have significant correlation.
45
A total of 40 patients were surveyed from 8 departments/wards and were chosen
by accidental sampling as well. It should be noted that the patients themselves are not
always the respondents. Of course this is due to the fact that some are not well enough to
give answers. Therefore, Figure No 15 shows who answered in lieu of the patients.
Obviously, most are family members.
Figure No. 15 Relationship of Respondent to Patient
2% 2%
13%
Aunt
20%
8%
Child
Children
2%
Grandmother
28%
Parent
25%
Patient
Sibling
Spouse
Like the health workers’ questionnaire the patients were also asked about their
monthly income. Some were a little bashful about talking about this topic but thankfully
all the respondents answered in the end. The distribution of values can be found in Figure
No. 16.
Figure No. 16 Monthly Income
No regular income
30,000+
20,001-30,000
15,001-20,000
10,001-15,000
5,001-10,000
1,000-5,000
10
1
1
0
8
11
9
46
Table No. 6 Classification of Patients in PGH
Pay
Charity
A. NEW
Class D
Class C
Class B
Sub-total
B. OLD
Class D
Class C
Class B
Sub-total
Unclassified
Grand Total
WARD
6
OPD
ERC
CPU
WD
TOTAL
6
7,059
98
2
7,159
14,544
125
0
14,669
14,565
240
0
14,805
270
4
0
274
256
5
0
261
36,694
472
2
37,168
19,705
43
0
19,748
34
26,947
7,022
29
6,645
9
580
1
373
7,051
11
21,731
6,654
53
21,512
580
14
868
373
10
644
34,406
82
0
34,406
122
71,702
Source: PGH Annual Report 2010, IRPD
If the data in Figure No. 16 will be compared to the official data provided in
Table No. 6, we can see that people from lower-income brackets really make most of the
patients in PGH.21
The next question is an inquiry if the respondents are able to take a portion of
their monthly income aside as health related savings. Figure No. 17 shows that there were
11 respondents that answered ‘Yes’ and 29 who answered ‘No. It means that more than
half of the respondents are most likely unprepared for health expenses.
Figure No. 17 Health savings
Yes
28%
No
72%
21
Of the total 71, 702 patients classified by the Medical Social Services Division, 99.05%, 0.77%, 0.00%, 0.18% were
Class D, Class C, Class B and Unclassified, respectively. Class D or fully indigent patients were mostly patients from
charity wards.
47
If more than the majority does not have savings for health expenses, then how do
they financially sustain themselves? Figure No. 18 tells that story.
Figure No. 18 Health Funding
16
14
12
10
8
6
4
2
0
Count
Savings
12
Debt
13
Insurance
3
Gov't Official
11
PCSO
10
Others
14
In the questionnaire the respondents were free to indicate all the possible choices.
The ‘Others’ that actually ranked top was mainly ‘solicitations usually from relatives and
family members’. It simply means that if the immediate family cannot afford the
expenses, the extended family would chip in and try to help out. The second in rank is
‘Debt’ which is self-explanatory. In some cases, the patients have already sold most of
their possessions or have given them up for collateral for these debts. This is the direct
consequence of having no savings because they are left with no other choices. Third in
rank is ‘Savings’. This should not be confused with the true health savings that they do
not have in the first place. The ‘Savings’ in Figure No. 13 really indicates the money that
was previously allotted to something else, like tuition fee, rent, bills, etc. It means that in
the cases where the patients would have to shell out money that they do not have for
health purposes, they are forced to redirect their finances so other aspects in their lives
48
would be impacted negatively. Some expenses are also covered by PCSO. And then some
respondents have solicited from government officials. The least contributor is the
‘insurance’ option. Obviously because most of the patients are poor and indigent, there is
little chance that they have private health insurance.
The ‘insurance’ option from Figure No. 18 is also different from the one in Figure
No. 14. Because in a separate question, the patient was asked if they have any of the
following: GSIS, SSS, Medicare, and PhilHealth. Those who have were then directed to a
following question which asks their opinion about these insurances’ sufficiency.
Figure No. 19 Health Insurances Sufficiently Cover Expenses
15%
Agree
35%
Disagree
15%
Neither agree nor disagree
Strongly Disagree
5%
Undecided
30%
Based on the figure, despite the 35% of the respondents who agreed that these
insurances were sufficient in covering their health expenses, the weight of those who
disagreed has more bearing. Those who answered ‘Neither agree nor disagree’
commented that it depends on the situation. And the ‘Undecided’ respondents are those
who have not fully accepted their remunerations from those institutions.
Table No. 7 is all about identifying the top expenses of the patients regarding
health. In the questionnaire, they were asked to rank the following according to how
49
much they were spending on each category: consultation fee, check-up, food, medicine,
travel fare, hospital fee, laboratory and others.
Table No. 7 Top Health Expenses
Rank Expenses
Medicine
1
Laboratory
2
Food
3
Travel Fare
4
Hospital Fee
5
Consultation Fee
6
Check-up
7
Others: Blood bank
8
Medicine comes on top because in most cases, they are expensive and must be
sustained. And to people whose incomes are not that high (or regular even), this will
become such a huge burden. The laboratory fees came in second because even the
laboratories within PGH have increased their fees. And in the event that the equipment is
unavailable, the patients will be forced to go to private laboratories that would cost much
more. Food and travel fare becomes burdensome especially if the patient is confined for a
longer period. Because in the case of charity patients, only the patient will get the ration
and the ‘bantay’ will have to buy his own. And since some of the patients come from
rural areas, if travelling will be required frequently, the travel fare will also become a
problem. Hospital fee in this table pertains to the fees of an operation. Consultation and
check-up fees are at the very minimum. There was also only one case where the patient
had to buy blood from the blood bank, but it was a unique expense.
50
Figure No. 20 Reasons for choosing PGH
30
25
20
15
10
5
0
Cheaper Specialized
than
doctors and
Good
private
health
facilities
hospitals
workers
Series1
20
22
7
Good
health
service
6
Cannot
Recommen
Other:
afford fees
Near/conve
ded/referre
availability
in other
nient
d
of donor
hospitals
3
25
4
1
The next question asked about the reasons why the patients chose to receive
health care from PGH. As seen in Figure No. 20, the option ‘Recommended/referred’
coming out as the first in rank validates PGH as the ‘referral center of the country’ 22. The
patients were advised to transfer to PGH for consultation or for confinement by doctors
from other hospitals or in the case of those from the rural areas – their provincial
hospitals or health centers. This option is also associated with the second reason which is
the reputation of having excellent and specialized doctors and health workers. If the case
is too complicated usually it is referred to the PGH since the health workers there have
already handled a diverse kind of patients. And the third most significant reason given by
the patients is ‘cheaper than private hospitals’. Again, this reiterates the economic bracket
of the composition of patients that go to PGH.
In Figure No. 21 the researcher has authenticated that the population of the
patients are almost divided equally in terms of their experience with PGH and other
22
From a survey questionnaire from a physician wherein he called PGH as the ‘referral center’ of the Philippines
51
public hospitals. 19 said that they had experienced the service of other hospitals while 21
just really go to PHG.
Figure No. 21 Experience from other public hospitals
Yes
48%
No
52%
This 48% who answered yes was then asked a follow-up question: in their
opinion, which hospital gave them better health services. Figure No. 17 shows that more
than the majority chose PGH over the other hospitals. Their answers were as such
because in most cases they indeed went to different hospitals but in the end were referred
to PGH.
Figure No. 22 Better health service
Other
26%
PGH
74%
52
The 26% in Figure No. 22 who chose the other hospitals said that in special
instances, they were better off in specialized hospitals (i.e. Dr. Jose Fabella Memorial
Hospital when giving birth). Some chose other hospitals over PGH due to the facilities in
general. But this issue will be more discussed in detail using Figure No. 23.
Figure No. 23 Patients' Ratings
30
25
20
15
10
5
0
Exceptional
Count of HW rating
13
Count of Facilities rating
2
Count of Services rating
3
Good
11
5
8
Fair
13
25
21
Poor
1
6
5
Very Poor
0
2
1
Undecided
2
0
2
The researcher summarized the result of three questions in Figure No. 23. In the
questionnaire the respondents were asked to rate the health care service they have
received from PGH under three categories: the health workers, the facilities and the
general services. As seen in the graph, most opinions are concentrated on the ‘Fair’
choice. It simply means that the patients are fairly satisfied by the performance of PGH.
But among the three categories, the ratings of the health workers are largely positive. The
patients noted that not only were the health workers exceptional in their field, most were
also compassionate and understanding. While the researcher was conducting her surveys,
she was able to gain qualitative observations by chatting with the patients and paying
attention to the activities in the wards/departments. There were times when she was able
53
to catch some doctors in their rounds as they check-up on their patients. One time, a
doctor instructed the companion of the patient to buy a certain medical instrument for the
patient but the companion said that they cannot provide if the supply in the ward is
unavailable because they currently have no more cash. The researcher was surprised that
after the companion explained their situation, the doctor grabbed for his own wallet and
said, ‘O sige ako muna bahala dito.’ Even the nurses said that that is a normal occurrence
especially in the Charity ward because some doctors cannot gamble with the conditions
of their patients and would choose to donate some of their money if there was no other
option.
Figure No. 24 Price : Quality of Work of Health Workers
Health Workers
Patients
36
18
9
6
4
0
Cheap
Adequate
Expensive
Figure No. 24 depicts the opinion of the respondents (health workers and patients)
regarding the ratio of price and the quality of work given by the health workers. 74%
believed that the patients are paying the adequate amount for the service done by the
health workers of PGH. 14% believe that it is too cheap because the quality of work is
54
too difficult. And lastly, 12% believe that as a government hospital, the rates of health
workers are still expensive. The opinions of the health workers are more diverse than
those of the patients based on the distribution of their answers.
Figure No. 25 Price : Facilities
Health Workers
Patients
31
16
10
7
6
3
Cheap
Adequate
Expensive
Figure No. 25 depicts the opinion of the respondents (health workers and patients)
regarding the ratio of price and the facilities in PGH. 64% believed that the patients are
paying the adequate amount for the facilities. Some said that it may be far from the
highest quality but the standard of facilities of a public hospital here in the Philippines
makes it easier to find such condition adequate. 22% believe that it is a lot cheaper, but
they said they were comparing it to other public hospitals. And lastly, 14% believe that as
a government hospital, the rates of the facilities are still expensive.
Last in this series of ratings is shown in Figure No. 26 which depicts the opinion
of the respondents (health workers and patients) regarding the ratio of price and the
general services provided by PGH. These services include the maintenance of the
surroundings, the processes to get documents done, food, etc.
55
Figure No. 26 Price : Service
Health Workers
Patients
36
22
7
4
2
Cheap
Adequate
2
Expensive
The result of the last related figure is similar to the result of the two previous
figures: with the ratings more concentrated on the ‘Adequate’ option. 79% believed that
the patients are paying the adequate amount for the services. Actually some even
remarked that it was better than what they’ve expected or heard from various sources.
Only 12% believe that it is cheap or they believe that some services should have higher
fees. And lastly, 7% believe that as a government hospital, the rates of the services in
PGH are expensive. The people who chose this category stated that there should be more
programs implemented to stratify the patients and give sufficient aid to those who are
really in need.
Questionnaires for both the health workers and patients are completed by the
same three open-ended questions:
1. In your opinion, should the government prioritize the health of its people?
Why do you think so?
56
2. According to your observations, do you think the funding from the
government is sufficient for the PGH to be able to provide quality and
accessible health care service? Why?
3. Do you think PGH could accept/solicit financial aid from private and foreign
institutions? Why?
Figure No. 27 Summary of open-ended questions
45
40
35
30
25
20
15
10
5
0
Undecid
Undecid
Undecid
Yes
No
Yes
No
ed
ed
ed
Should the government
Is the gov't giving sufficient Should PGH solicit/receive
prioritize health?
funds to PGH?
external financial resources?
40
0
0
8
26
6
24
7
9
33
0
0
0
32
1
23
6
4
Yes
Patients
Health Workers
No
As seen in Figure No. 27, 100% of the respondents answered ‘Yes’ to the first
open-ended question. Some of the reasons for their answers are the following:

A healthy population is advantageous because they become more
productive, therefore positively contributing to bringing wealth to the
country.

Sicknesses could be acquired by anyone regardless of their economic
background so health related funding should be prioritized because
57
large parts of the population are poor and have no other sources of
income.

The taxpayer’s money should be felt in the social services such as
health care services from public hospitals and it is the government’s
obligation to provide for the basic needs of the people.

If the funds for health increases, at least the people will be ensured that
their money is serving them back and is just not being corrupted or
being used for the self-interest of politicians.

The worth of life should be chosen above all things and priorities.

Health is not just being free from diseases; it is about the quality of life
wherein people should be healthy physically, mentally, spiritually and
cognitively. Therefore, the government should invest in raising
awareness and consciousness so that there will be better chances of
preventing illnesses.

Health especially public hospitals should be prioritized because
majority of the people go to these institutions. They should be in the
forefront of medical advancements because they have more lives
depending on them.
For the second question, 80% of the respondents said that the funds for PGH are
not sufficient. The reasons given by the patients are the following:

The facilities are old, unavailable and not maintained well.

Not all of the health needs are accommodated (lack of beds, space,
supplies, etc).
58

Not all of the health expenses are covered even for the indigent
patients. According to those who belonged to the lowest income
bracket, their expenses should be covered and should include even the
medicines.

There is a huge discrepancy between public hospitals here in the
Philippines, specifically PGH and public hospitals of other countries
which really provide a sizable budget for the sector.

If the budget was sufficient for all the people in need, then the poor
people would not have to undergo such grueling processes in order to
get discounts. If the funds are enough, everyone should receive
according to their needs without all the fuss.
For the same question, all the health workers (except for one) chose the ‘not
sufficient’ option as well. Some of the explanations they gave are alike some already
mentioned by the patients. Though the following are some of their opinions as people
who work within the system and are exposed to the internal problems:

The hospital expenses are too high and none from the budget is left to
procure new equipment or even fix those which are broken.

The allocation for health is appropriate so funds are not going to fields
where it is needed most. And sometimes, the budget is also cut, held
back or redirected. There is a problem in the fiscal services
(procurement, dispensation od consumables, etc.) so resources are not
being maximized.
59

There is a lack of supplies (medical and for offices), manpower and
the medicines are old. Some of the equipment is obsolete. The
personnel are not receiving enough compensation due to lesser funds
for MOOE. Wages are low and benefits are being lessened as well.

The patients’ number is too many and not all of them can be catered by
PGH.

PGH’s policies are slowly starting to gear towards privatization.
Still for the second open-ended question, 11% which came from the patient
respondents answered that they think PGH’s funds are sufficient enough. The reasons for
their answer are the following:

PGH can still accommodate patients from rural areas.

It’s not such a big issue if patients would pay out of their pockets. It’s
just the way things are nowadays, nothing is completely free.

The funds are enough but it won’t hurt if they could give an increase.
Lastly, 9% were undecided regarding the matter. However, they elaborated on
their choice and these are the issues that they raised:

If ever there is problem, it’s in the system. Only the administrators
could truly answer if the funds are enough. What if the funds are
sufficient based on the needs of the hospital, however the funds do not
completely go to the divisions?

It’s too early to say. It’s been only a short time in order to promptly
judge the entire hospital regarding this issue.
60
For the last question, Figure No. 22 illustrates that 64% thinks that it is alright for
PGH to accept/solicit financial aid from private and foreign institutions. 19% of the
respondents disagreed and the remaining 17% are undecided. Some of the reasons
supplied by those who said ‘Yes’ are the following:

It is only part of one’s responsibility to society (corporate
responsibility) to help if you have the capability. But it the financial
assistance should go where it is meant and greatly needed.

Because there are too many indigent patients in PGH, and since the
present funding cannot wholly support them, the external resources are
welcome as long as the donor does not ask for anything in exchange.

Should be used to allow the hospital to totally improve the quality of
its service.

Though it would be a great help, this should only be a last resort to
ensure that the institution will be able to sustain quality health service.
For the respondents who neither agrees nor disagrees with the inquiry, these are
some of their explanations:

Some contracts are not transparent enough and in the end, the
institution might sacrifice something in exchange for donations.

These transactions could be politicized or corrupted.

It will ultimately depend on how these financial aids will be handled
and what would be the implications in the long-run.
61

If external forces will start infiltrating the administration of PGH
through donations/outsourcing, the hospital development policies
should always serve as guidelines.

If the donor is not asking for anything in return, then it is fine.
However, aid should be given voluntarily. PGH should not solicit.
Those who disagreed with the statement think that PGH should remain
independent financially because:

The financing of PGH should be solely done by the government. It is
their job and if they are failing, evaluations should be made and the
PGH should exert its rights as an institution.

Allowing external forces to meddle with the affairs of PGH might give
a negative light to the reputation of PGH since the hospital may
become susceptible to biases and profiteering companies.

Somehow encourages the privatization of PGH.
62
ODA AND HEALTH
Regarding ODA, the researcher learned that there is no ongoing ODA in PGH at
the moment. She tried to obtain data regarding the past ODA projects but concerned
institutions failed to positively respond for her request for information. So instead, the
rest of the data will be discussing ODA in the Philippine health sector in general
According to the sources of DOH, 28 of the 31 projects with foreign developing
partners are still ongoing (see Figure No. 23). 80% of these projects are within the 5-year
duration 16% are in the category of 6-10 year duration, and 4% exceed the 10-year
duration.
Figure No. 28
Source: DOH – Health Policy Development & Planning Buerau
From 2000 to 2005, ODA commitments for infrastructure averaged a share of
66.7 percent of total ODA. This constituted a 16.6 percent increase compared to
infrastructure’s share of 50.1 percent during the 1987 to 2000 period. Agriculture, natural
resources and agrarian reform had the second largest average share of 17.33 percent for
63
2000-2005. Industry and services was third with an average share of 7.7 percent, while
social reform and community development was fourth with an average share of 7.0
percent. At the bottom of the list was governance and institutional development with an
average share of 2.67 percent. Total allotments for the combined agriculture, land reform
and industrial development sectors showed an increase to 25 percent from the 1986-2000
share of 21.23 percent. The sectoral discrepancies show no drastic change (see Table No.
8).
Table No. 8 Distribution of Total ODA Loads
As of December 2007
Source: NEDA 16th ODA Review
Sector/Sub-sector
Agriculture, Agrarian Reform and Natural
Resources
Industry, Services, Trade and Tourism
Infrastructure
Social Reform and Development
Education and Manpower Development
Health, Population and Nutrition
Social Welfare and Community
Development
Shelter and Urban Development
General Social
Grand Total
No. of
Loans
Amount
$ Million
%Share
30
1672.31
17.6
9
61
24
11
6
5
706.28
5532.02
1152.99
472.33
374.91
176.50
7.25
56.76
11.83
4.85
3.85
1.81
1
1
130
29.25
100
9746.501
0.3
1.03
100
For the sector of “human development” there was a significant decrease in ODA
commitments from the already minuscule 1987-2000 share of 10.95 percent to only 7.0
percent in the 2000-2005 period. It would appear however that the increase in shares for
infrastructure support, and agricultural and industrial development came at the expense of
the human development component of ODA. The lowest points were in the years from
64
2000 to 2002, when “human development” took in an average share of only 5 percent per
year. Although the average share eventually doubled between 2003 to 2005, the pattern
bodes badly for the countries’’ and its donors’ ability to comply with MDG targets for the
Philippines by 2015.
Figure No. 24
Allocations under Social Reform and
Development Sector
Education and Manpower
Development
3%
9%
41%
15%
Health, Population and
Nutrition
Social Welfare and
Community Development
32%
Shelter and Urban
Development
General Social
Source: NEDA – 16th ODA Review
Health, population and nutrition division only receives a measly 3.85% share in
the distribution of total ODA Loads as part of the Social Reform and Development
Sector. This clearly indicates that the financial aid entering the country is not truly MDGbased, stuck in short run and biased towards projects plagued with inconsistencies in
financial transparency (i.e. Infrastructures).
65
CHAPTER IV
CONC LUS ION AND RECOM MENDATION
Various statistics and inferential findings establish that the current state of health
care system in the Philippines is not easily accessible to most of its constituents. The bulk
of indigent Filipinos continue to make ends meet amidst the high prices of commodities
and lack of financial security, yet even their health cannot be safeguarded by the
government. The decreasing and insufficient budget for public hospitals is effectively
diminishing the chances of most Filipinos at quality health care service.
Workers are generally overworked and underpaid and the case is not different
with health workers. Most doctors, nurses and administrative personnel would take the
chance to leave the country if opportunities would present itself – ensuring that the
phenomena of Brain Drain will not go away anytime soon. The work setting, financial
compensation and benefits abroad are more alluring than the bleak chances of
improvement in the governing system here.
As a Third World country, the Philippines is entitled to development aid that
should essentially support the country in alleviating itself from chronic poverty and
dismal living conditions. But based on the present schemes, the realization of such goals
are certainly unattainable. Instead, with the controversies and misappropriated
allocations, it only helps foster the semi-colonial and semi-feudal state of the country.
Exploitative international monetary institutions, imperialists and corrupted local elite will
not divert from their own goals which is ultimately to the detriment of the people.
66
Regarding the health condition of the country, the researcher adopts the
recommendations of IBON foundation on true reforms highlighting the following:

Health care service should not be market-oriented but instead should
invest on community health and medicine, and focus on reaching out
to all constituents regardless of socioeconomic background and
geographical differences.

Health care should be holistic. It should start with awareness and
education and become a communal effort.

Health workers should receive just compensation and should be given
the opportunity to reach their potentials as professionals.

Policies political and economic should be for the inherent development
of the country. Influence and suppositions of multilateral trading
bodies should be rejected if it would only worsen the situation of the
country.

Private sector is encouraged to participate in the market in order to
create a more competitive scene locally but it should be for national
progress not only for profit. But in the case of public health care
service, the government should play a more active role.
Regarding ODA, the researcher has gathered the following recommendations:

Aid should not be used as means to economically exploit developing
countries such as the Philippines. International cooperative goals such
as MDGs are not intrinsically negative but the government should be
critical and more assertive in protecting the sovereignty and welfare of
67
the country because profit-oriented forces would exhaust all means in
order to sustain themselves.

Development aid should systematically include the active participation
of donor countries, even up to the community level. So that
effectiveness will not be diminished by unprecedented factors on
culture, religion and traditions. This will also ensure the sustainability
of projects even in the absence of aid in the long run.

The international community should be more coordinated in their
efforts (multilateral and bilateral institutions) to be able to have an
efficient check-and-balance scheme.

Aid should always be aligned with national reforms and policy
programs of recipient countries.
The researcher was bound by time and other constraints so she recommends that further
and more specific studies should be done concerning the topic.
68