Fix Health System Ills and Empower Citizens to Stop the Pandemic

In every health course I teach, I always remind the audience with the definition of health. It is easy to equate it with absence of disease, however the World Health Organization reminds us that it is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. In 1984, the Ottawa Charter expanded this notion and emphasized the value of health promotion as a process of enabling people to increase control over, and to improve, their health. These two universally-accepted and adopted definitions speak of health as: (1) having a scope beyond biomedical; (2) inevitably interrelated with social, political and economic realities; and (3) empowering individuals to make decisions for their own well-being. Even with these, a lot of Filipinos are still unable to freely decide in favor of their own health most especially at this time of COVID-19 pandemic, mainly because the system does not allow them to do so.

Much like other developing countries, the Philippine health care system persistently faces a lot of challenges. In a nutshell, our health system can be described as deeply fragmented, owing mainly to the decentralized setup. Nationally, the Department of Health is overall in-charge, but as we go down to the provinces until the barangays, local chief executives are the main decision-makers. This complex setup, compounded by uneven capacities, resources and readiness of LGUs to prioritize health, snowballs into poor health outcomes and a generally unresponsive health system. 

Before COVID-19 came, the picture of “old normal” was far from ideal. Accessing health services was a major problem for Filipinos. In 2016, according to the Department of Health, majority of Filipinos opt to seek care in public facilities (70%), however most of our hospitals are privately-owned (65%)1.  In primary care settings, there is also a lack of barangay health stations and rural health units especially in far-flung areas where private health care providers are usually rare. Health workforce is also maldistributed, hence the roll-out of DOH deployment programs to augment existing health human resource gaps especially in geographically-isolated and disadvantaged areas. Lastly, even with social health insurance, assistance and subsidies, 53.9% of health expenditures are out-of-pocket in nature, with Filipino households mostly bearing the burden.2

When the cases of COVID-19 started to rise and local transmission was confirmed in early March, the Department of Health and various government and non-government agencies at different levels have already started mobilizing resources to contain and combat the disease. There were also initiatives to do rapid count of mechanical ventilators and available personal protective equipment in hospitals.  Clinical professional societies started drafting clinical practice guidelines based on experiences from other countries and limited evidence available. The public health sector also initiated engagements with local government units to streamline response including incident command systems, setting up community isolation units, and in building the capacity of health workers especially BHERTs (barangay health emergency response teams) which will take on daunting tasks as frontliners in the community.

Diagnosing COVID-19 in a reliable and timely manner is a key element in successfully managing the pandemic. As of April 16, 2020, we have 5,453 confirmed cases of COVID, and this number doubles every 11-13 days as inferenced from the most recent DOH data. In early March, the Research Institute for Tropical Medicine in Muntinlupa City, which uses molecular diagnostic technology called real-time polymerase chain reaction (RT-PCR) to diagnose COVID, was the sole accredited COVID-19 confirmatory testing center in the country catering to all hospitals serving as specimen collection sites. Foreseeing possible congestion and delay in specimen collection and results releasing, more subnational confirmatory centers opened in late March. As of April 16, there are already 16 testing centers spread out nationwide—5 of which are located in major cities outside NCR namely Baguio, Legazpi, Iloilo, Cebu and Davao.

Even with this significant win in testing, the Philippines still lags behind its Asia-Pacific neighbors in terms of controlling COVID-19 cases. In fact, we have recently overtaken Malaysia as the country with the highest number of cases in Southeast Asia. Even with a similar economic profile and health care system, Vietnam has far less cases and deaths compared to the Philippines. Vietnam’s COVID-19 containment strategy focused on two low-cost measures: (1) aggressive contact tracing and (2) their leaders’ palpable awareness of the severity of the new virus3, which included directing health officials to prepare on all fronts coupled with tightening of border controls and forced quarantines. South Korea, a far more progressive country than Vietnam and the Philippines, capitalized on mass testing on top of rigorous contact tracing, and informed & decisive leadership. Now, South Korea reports less than a hundred new cases per day and has since sustained this downward trend.

Being a lower-middle income country much like Vietnam and with its over 100 million people, the Philippines would most possibly be unable to afford testing all Filipinos for COVID-19. Theoretically, even if our leaders decide to do so, we will need to conduct a more massive mobilization of resources (which we may not have) and possibly resort to foreign aid in whatever form. Looking back on the “old normal days”, we have not even completed furnishing urban and rural areas with sufficient health facilities and health workers. We still have not solved the puzzles on referral systems, nor have we controlled maternal and neonatal deaths. Although a breakthrough, Universal Health Care Law’s full and streamlined implementation is still not within immediate sight. Especially with COVID-19 now getting all the attention, the gargantuan tasks of ensuring there is sound governance and in coordinating all efforts among decision-makers nationwide still remain as overwhelming tasks necessary to fully achieve health for all. 

There has been a move, however, to scale up testing capacity and cover certain groups such as those with presenting with flu-like symptoms especially frontline health workers, those with pre-existing chronic conditions, among others. This is a strategic move, and in my opinion the soundest direction the country can take considering resource limitations.  Last night, Valenzuela City reported 5 new confirmed cases of COVID-19 classified under the persons under monitoring (PUM) cohort, which means they should not have been tested had they followed the set protocols. With this and the step towards expanded (not mass) testing, it is with fervent hope that the Philippines will be able to detect more cases, accurately reflect the data, timely manage patients and further tilt the balance towards more recoveries and less death.

This is, of course, coupled with the expert recommendations we all know. Handwashing using running water and soap would still be best, especially if hands have visible dirt. Otherwise, use of alcohol would be a great second choice. Practice of cough etiquette, rationally using personal protective equipment and social distancing will certainly help, and may even extend to be part of the “new normal”.  

Our leaders, whose role has been undeniably proven crucial in times of health emergencies, should also continue to prioritize capacitating the country’s health system if we want to save more lives and prevent unnecessary deaths.  We have seen how government resources can be easily mobilized and how the private sector is willing to help—so why can’t we stress on the “old normal” and think of it as an emergency too? There has to be a mindset shift. We should refrain from downplaying all these health issues which came before COVID-19 as something we can just tolerate. 

COVID-19 taught Filipinos the biggest life lessons the hard way.  Awareness and taking care of our own health needs would definitely allow us to live longer. We also got to appreciate the courage of health professionals, and along the way, Filipinos cried out to defend their rights and privileges. Moreover, we learned that we can always demand for accountability and quick action even in the confines of our own home. Even in this time of lockdown and it is only through virtual means we can communicate and organize ourselves, we are definitely being heard. All of these lessons on empowerment which spurred in the COVID-19 should definitely be carried on in the “new normal”. Because definitely, we cannot afford to have anything similar to this endangering our finite years on Earth.