By Samuel P. Medenilla & Cai U. Ordinario
NEARLY 140 days after President Duterte signed into law the Universal Health Care (UHC) Act, its implementing rules and regulations (IRR) have yet to be finalized. And almost every stakeholder awaits this with bated breath.
Labor groups are among these stakeholders as their demand for the regularization of thousands of contractual workers received an unexpected shot in the arm with the implementation of the UHC law, or Republic Act 11223.
To note, the law and its IRR come at a time when a study released through Mercer (Philippines) Inc. believes medical and health care are becoming expensive, especially for poor Filipinos.
Public Services Labor Independent Confederation (PSLINK) advocacy head Jillian T. Roque said they are now eagerly awaiting law’s IRR, particularly its provision on the regularization of medical workers.
Roque is referring to Section 23 of UHC law, which states “to ensure continuity in the provision of health programs and services, all health professionals and health care workers shall be guaranteed permanent employment and competitive salaries.”
In an interview, she told the BusinessMirror, “We don’t know how this made it to the law. But this is a big victory for us.”
Roque explained they will use the provision to demand the regularization of public sector employees, who are not given regular status.
Regularization of workers
FEDERATION of Free Workers (FFW) Vice President Julius Cainglet said they will also use the provision to make a similar push in the private sector.
“It implies that the provision for permanent employment and competitive salaries applies indeed to ‘all’ health care professionals and workers,” Cainglet said.
“Labor groups will definitely invoke this, together with the presidential directive to ‘end’ contractualization,” he added.
For their part, Private Hospitals Association of the Philippines (PHAPi) President Dr. Rustico Jimenez told the BusinessMirror that PHAPi will be seeking a clarification from the Department of Health (DOH) if the said provision will also apply to the private sector.
Jimenez said they will comply with whatever the DOH decides on the issue.
The 2016 data of the Philippine Statistics Authority (PSA) showed that out of the 137,173 workers in the private health and social work activities industries that have 20 or more workers, 19,501 were non-regular.
Of these non-regular workers, 11,188 or 57.3 percent have a probationary status.
Casual workers and contractual workers each made up about 20 percent of the employees in the non-regular category with 3,962 and 3,707, respectively.
The remaining 3 percent of those employed in the said category are seasonal workers or apprentices.
Intent of the law
EFFORTS by the labor sector to maximize the use of the UHC law in their anti-contractualization campaign, particularly in the private sector, may face a legal question.
Quezon 4th District Representative Angelina D. Tan, one of the sponsors of the UHC law at the Lower House, said their intention when they approved the said provision was to regularize the large number of job orders in government medical facilities.
“We were only talking about the government setup,” Tan told the BusinessMirror on June 18 during the first leg of the DOH’s public consultation in Metro Manila for the crafting of the IRR for the UHC law.
Labor Assistant Secretary Benjo Benavidez agreed with Tan, stating the provision is also limited to the public sector due to its wording.
“It used the term permanent employment, which is jargon of the Civil Service. For the private sector, its counterpart is regular employment,” Benavidez said.
Furthermore, the labor official said the constitutionality of the UHC law provision may also be put into question if it is applied to the private sector.
“It may be found unconstitutional in a sense because you cannot mandate permanent employment because we have the Labor Code of the Philippines,” Benavidez said.
“Under the Labor Code we have probationary, regular, seasonal and project-based employment,” he added.
Going progressive
BASED on the current draft of the UHC law’s IRR, the DOH, in consultation with the Department of Budget and Management (DBM), is tasked to “progressively” raise the number of permanent worker in government medical facilities.
It also states all health workers to be hired in priority areas must be given permanent positions.
DOH-licensed private medical facilities are merely encouraged by the IRR to hire a certain number of health care workers with competitive salaries determined by the government’s health department.
Health Undersecretary Mario C. Villaverde explained that the provision for the private sector is currently an aspiration to ensure it will not interrupt their operation.
“Of course, we considered the survival [of private sector medical facilities],” or particularly, “how they could maintain the sustainability of their operation because they also have to have some return of investment,” said the lead DOH official in charge for communicating the UHC law.
“If they close down, we will lose more health services,” he added.
Villaverde, however, said they hope the private medical facilities will eventually regularize all their employees.
“It is one factor that can improve the quality of our medical services,” he added.
Health workers
EVEN if the UHC law’s provision for regularizing workers is currently limited to the public sector, it is still expected to benefit thousands of workers with non-regular employment arrangement.
Citing data from the PSA, Bureau of Local Employment (BLE) Director Dominique R. Tutay said the number of workers under “human health and social work activities” has been slowly increasing.
Since 2012, the number of workers in the said category rose from 438,000 to 469,000 the following year.
Their number grew to 480,000 in 2014; 494,000 in 2015; and, 502,000 in 2016. Their number dropped to 484,000 in 2017 before recovering to 517,000 by last year.
“These numbers include both regular and contractual workers,” Tutay said. “But it should be noted that [the number includes] social workers.”
Separate data sets sourced from the DOH and the PSA specifically showed the number of government doctors, nurses, dentists and midwives also increased since 2012.
In 2012, the total number of government medical workers was composed of the following: 2,983 doctors; 2,072 dentists; 5,294 nurses; and 17,514 midwives.
In 2016, the latest available data from PSA showed these numbers at: 3,177 doctors, 1,953 dentists, 6,009 nurses and 17,200 midwives.
Toll on staff
VILLAVERDE admitted that, as it is, there is still a shortage in the number of medical workers to sufficiently provide for the medical services to the country’s growing population.
He noted that the current ratio for public doctors is 1 is to 20,000; the same ratio applies to nurses.
“For midwives, the ratio is 1 is to 5,000,” he said. “This is not enough.”
As of September 30, 2018, the Professional Regulation Commission (PRC) has registered 141,067 doctors, 905,027 nurses and 176,832 midwives.
The prevailing lack in manpower leads to unhealthy working conditions for medical workers.
Among them is a nurse who spoke to BusinessMirror on condition of anonymity. She has worked at the Philippine General Hospital (PGH) for at least five years now.
The 28-year-old nurse shared how they would usually be serving 10 to 20 patients per day, which is more than the ideal four to five patients per nurse.
“Even if we lack nurses and medicine, we still have to admit every patient, as the PGH is the end-referral hospital in the country,” she said. “You can go to private hospitals; but if you no longer have enough funds, your end point is PGH.”
Because of this, she added, “we can’t provide the quality of care that we would have wanted to give to our patients. We really need help on this.”
The condition of nurses like her also takes its toll on their health, making them prone to burnout and even to different kinds of diseases.
The right number
VILLAVERDE is hoping the shortage in workforce would be finally addressed by the provision in the UHC law that allows institutions to hire more medical workers.
However, rather than just relying on population alone, he said they have partnered with the United States Agency for International Development (USAID) to find out other salient factors to more accurately determine the number of additional medical practitioners they will need.
Among the factors they are considering is the workload of the employees as well as the terrain where they are deployed.
Also included in their planned reform, he said, is to update their existing ratio of medical workers per population.
“We are studying how we could update our standard. I think this is no longer enough, since we have more programs compared to the 1980s, when we first set the said standard,” Villaverde said.
Finally, he said they are also looking at how they could address the insufficient number of medical professionals available in the local labor force by offering scholarships to qualified students with a three-year return service contract.
During the public consultation, Villaverde disclosed they plan to make the scholarship more attractive by developing it into a program wherein its participants could get a Master’s degree and even career opportunity in DOH.
He cited their pending two-track program for doctor scholars, wherein applicants could either chose to become a doctor-to-the barrio and get a Master’s degree in public administration, or pick an academic track and take a medical specialization to be determined by the DOH.
Tutay emphasized the importance of increasing the number of professional medical workers amid the increasing demand.
“There is really a need for more workers in the health sector because of our increasing population,” Tutay said. “And then, second, you have to serve both the overseas and the local market.”
Other questions
UNTIL the government can hire additional medical workers, the DOH said it will have to tap the private sector to help implement the UHC law.
However, Philippine Medical Association (PMA) Legislation Committee Chairman Dr. Oscar D. Tinio expressed concern over the IRR of the UHC law. Tinio claims the law’s provisions on the role of the private sector still remain vague.
“It [the IRR] should be clear on the role of the private sector, physicians and clinic. It should also state who should pay medical facilities which participated and ensure the payment will be completed promptly,” Tinio said.
He added there is more uncertainty especially since the UHC law indicates they would now have to negotiate their contracts with the local government units instead of, previously, with the Philippine Health Insurance Corp., or PhilHealth.
“Do they have an existing contracting system? Completed integration of the local health facilities of the government? They have yet to answer this so we don’t know what will happen as of this time,” Tinio said.
Handling expectations
THE PhilHealth, to note, is currently in the process of beefing up its work force in preparation for the surge in the number of clients.
“This is now undergoing study by the consultant of the GCG [governance commission for government-owned and -controlled corporations]. Their review [on the additional employees] is expected to be completed this year,” PhilHealth Senior Vice President Rodolfo del Rosario Jr. said in an interview.
The initiative, del Rosario said, is also expected to allow their existing casual employees to finally become regular workers as stipulated in the UHC Act.
As of July, Del Rosario said an initial 128 new plantilla positions have been granted to PhilHealth’s legal and investigation department.
The PhilHealth is currently bracing for the expected increase in the number of its monthly clients, which is expected to double from 1 million to 2 million with the full implementation of the UHC law.
Expenses, costs
WHILE the IRR for the UHC law is being finalized, Mercer said Filipinos could experience even more expensive health-care costs this year on the back of more expensive medicines and medical services.
In the “Mercer Marsh Benefits 2019 Medical Trends around the World” report, medical inflation in the Philippines is expected to increase to 13.7 percent in 2019 from 13 percent in 2018.
This will make the Philippines the second most expensive country in terms of medical expenses in Southeast Asia. Vietnam currently has the highest medical costs in the region at 14.2 percent this year, lower than the 14.5 percent in 2018.
“The gap between medical inflation and actual inflation continues in the Philippines. Companies must make employer-sponsored medical plans competitive, and prioritize solutions that will provide quality health care in the long -term,” according to Maria Theresa E. Alday, Mercer (Philippines) Inc. CEO and health and business leader.
Medical costs, the report stated, are bound to continue increasing and will even outpace inflation by close to three times this year and even higher in 2020.
Mercer Marsh stated in its report that health care is becoming more expensive due to “high-cost pharmaceuticals, new diagnostics and procedures, and overprescribing of low-value health tests and procedures.”
A significant increase
GLOBALLY, the top three health risk factors influencing medical cost are still metabolic and cardiovascular risk, dietary risk and emotional/mental risk.
However, on a regional level, there is variation in the top risk factors. For Asia, environmental risks, which account for 52 percent of risk factors, are causing more citizens to spend more for health care.
Mercer Marsh said poor health in the region is being caused by the ill effects of high pollution levels, specifically in many of the region’s major cities.
The report showed a significant increase in the incidence of respiratory diseases, gastrointestinal diseases and those of the circulatory system.
In its fifth year, this latest report surveyed 204 insurers across 59 countries. It assessed how health conditions, supplier factors and consumer habits are driving cost, as well as providing insights into how insurers are responding.
Looking to the future
IN response, Mercer Marsh said the number of insurers investing in initiatives to enable quality-focused care, to better guide members to the right care options for them more quickly, has more than doubled. Globally, 29 percent now name this type of investment as a top strategic priority.
Mercer Marsh said insurers are responding by helping members make smarter health-care choices, with 63 percent of insurers providing education, tools and incentives to drive positive behavior.
The Middle East and Africa had the highest rate of adoption of programs of this type, with 71 percent of insurers proactively using such consumer-focused tactics with plan members. Globally, 78 percent are now considering or already support virtual health consultations.
“It is clear that health is a business imperative. Supporting and nurturing the physical, emotional, financial and social well-being needs of employees returns many benefits to businesses,” Alday said.
“With the future of work demanding a healthy and engaging environment for employees, it is critical that companies assess how medical plans can be reviewed through both cost optimization and employee engagement lenses,” she continued.
Total expenditures
BASED on the Philippine National Health Accounts (PNHA), total health expenditures at current prices grew 8 percent in 2017 to P712.3 billion from P659.3 billion in 2016.
Every Filipino spent P6,791 for health-care needs in 2017, a 6.3-percent growth from P6,389 in 2016. In real terms, per capita health expenditure of Filipinos amounted to P6,090, which is an 8.1-percent growth from P5,894 in 2016.
Household out-of-pocket payment (OOP) reached P372.8 billion or 54.5 percent of Current Health Expenditures (CHE) in 2017.
This was followed by government schemes and compulsory contributory health-care financing schemes at P225.9 billion or 33 percent. Voluntary health-care payment schemes contributed P85.7 billion or 12.5 percent.
More than half of OOP amounting to P186.6 billion, or 50.1 percent, went to pharmacies. Private general hospitals came in second at P97.5 billion, or 26.1 percent; followed by providers of ambulatory health care at P50.3 billion, or 13.5 percent.
Hope for the best
FOR Dr. Policarpio Joves, president of the Philippine Academy of Family Physicians, the issue is with the IRR’s provision which demands salaries for medical workers be made competitive with that of their public-sector counterparts as a condition for private-sector medical facilities to be accredited by DOH.
“This will force the private sector to raise the salary of its employees,” Joves said.
He noted, however, that this will be unsustainable for the private sector in the long run, especially as it is burdened by a no-balance billing policy of the government that bans hospitals from collecting direct medical expense from patients for the duration of the confinement.
“The government and the private sector are not equal. In the government, their personnel and electricity is paid for [through taxes]. In the private sector all wages and utilities are paid by the patients,” Joves said.
If implemented, he said the policy will lead to the closure of many medium-sized hospitals, leaving patients with poorer medical services.
Both Tinio and Joves appealed for providing the private sector with certain incentives to effectively participate in the implementation of the UHC law.
“The government should be able to provide for everything [in the implementation of the UHC law], but for now it is putting some burden [of the implementation] on the private sector. That is why they should not marginalize us [in the IRR drafting],” Tinio said.
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