1. Addressing Health Human Resource Gaps in the Philippines
Tony Leachon, MD
Philippine College of Physicians Foundation
Coalition for Primary Care
May 4,2016

2. Disclosures
PhilHealth , Independent Director as Representative of the Monetary Board
President, PCP Foundation Inc.
Member, Coalition for Primary Care
References : Research work of Dr A.Dans, DOH,PHIC , PCP, PSGIM, AER, Coalition for Primary Care

3. Agenda Background : Philippine Healthcare UHC : Where are we now ?
Healthcare Workforce Crisis
Recommendations :
Primary Care system
5 R’s
Summary

4. Many explanations have been proposed
Many explanations have been proposed. We believe the problem is clear and simple. If there are no healthcare workers, there can be no access to healthcare.
Lastly, and most disturbingly, 47.6% of deaths among Filipinos are unattended by a medical doctor or allied health provider. This is indisputable proof of a workforce crisis.
[SLIDE 9]
Philippine Health Statistics, 2009.
47.6% of deaths among Filipinos are unattended by a medical doctor or allied health provider.

5. Health Human Resource, Philippines.
Doctors
Nurses
Midwives
Active in Professional
Regulation Comm.1
66,000
500,000
74,000
Employed in
Government Facility2
2,838
4,576
17,000
Ratio per 10,000
population3
0.2
0.4
1.7
Of the 66 thousand physicians, 500 thousand nurses and 74 thousand midwives who are actively practicing their profession and registered with the PRC, only 3 thousand, 5 thousand and 17 thousand respectively, work in a public facility as of 2013.
[SLIDE 5]
Professional Regulation Commission, 2014.
2.This translates to 0.2 or less than 1 physician, 0.4 or less than 1 nurse and 1.7 or less than 2 midwives per 10,000 population, or a total of 2.3 or less than 3 healthcare workers per 10,000 population. This number is 10x less than the 24/10,000 recommended by the WHO, as the minimum number needed to address just the Millennium Development Goals (MDG’s) of maternal and child health alone.
3.The shortage of healthcare workers affects not just the supply of doctors, nurses and midwives, but also the supply of dentists, pharmacists, WHO website:
occupational therapists, physical therapists, speech pathologists, medical technologists, and other allied medical professionals, including our partners in healthcare, the community health workers.
Romualdez AG et al. The Philippines Health System Review. World Health Organization 2011.
Health Human Resource Development Bureau. National Database of Selected Human Resource for Health: Dec, 2013.
1 PRC database, 2014
2 Philippine Statistical Yearbook, 2010.
3 Total 2.3 HCW’s/10,000 pop;
WHO recommends 24/10,000.

6. Supply of Health Care Workers’ is Decreasing
We are #1 exporter of nurses
We are #2 exporter of doctors
ASEAN integration will open doors.
Supply, on the other hand, is already at a critical low and further threatened by maldistribution and continued migration of HCW’s. The exodus is fueled about by low salaries relative to other countries, lack of benefits, poor work environment as well as perceived deterioration of the socio-political environment.
As a result, despite the local shortage, the Philippines remains the largest exporter of nurses in the world supplying 25% of all overseas nurses in It is also the 2nd largest exporter of physicians, next only to a much larger country - India. This efflux of HCW’s can only get worse with implementation of the ASEAN integration program in 2017, which will facilitate mobility of medical practitioners within the region.
[SLIDE 11]
Ronquillo K et al. Human Resources for Health Migration in the Philippines. A Case Study and Policy Directions. Aug
Matsuno, Ayaka. "Nurse Migration: Asian Perspective." Docstoc. Web. 06 May <
UP System website:
ASEAN website:
The inability to manage this double burden can be traced to 3 chronic problems that have plagued our healthcare delivery system. First, we face a chronic healthcare workforce shortage, as we continue to be the number 1 exporter of nurses, and the number 2 exporter of doctors in the world. This shortage is at its worst where healthcare workers are needed most – in rural and urban public facilities, where they are both underpaid and overworked. Second, our healthcare system has evolved into a fragmented system characterized by 46 separate but overlapping healthcare programs driven by donor initiatives rather than population needs. This has hindered our ability to integrate, harmonize and prioritize solutions to problems in health. Third, our healthcare system is also fragmented administratively, with local government units placed in charge of frontline healthcare delivery.  This has politicized the healthcare workforce and has made it difficult for the DOH to orchestrate a unified healthcare program.

7. Top 10 Causes of Mortality, Philippines 2010
Number
affected
Rate per
100,000
Cause of Death
1. Diseases of the Heart
102,936
109.5
2. Diseases of the Vascular Sy stem
68,553
72.9
3. Malignant Neoplasms
49,817
53.0
4. Pneumonia
45,591
48.5
5. Accidents
36,329
38.6
6. Tuberculosis, all forms
24,714
26.3
The Philippines is in the midst of a healthcare crisis.
Infectious diseases such as tuberculosis and pneumonia continue to kill a hundred thousand Filipinos each year, just as they have for the past several decades.
[SLIDE 1]
Philippine Health Statistics, 2010
7. Chronic Lung Disease
22,877
24.3
8. Diabetes Mellitus
21,512
22.9
9. Nephritis/nephrotic syndrome/nephrosis
14,048
14.9
10. Perinatal disease
12,086
12.9
Philippine Health Statistics, 2010

8. Double Burden :3 Chronic Problems
1.Chronic healthcare workforce shortage
PH # 1 exporter of nurses, and the number 2 exporter of doctors in the world. 
This shortage is at its worst where healthcare workers are needed most – in rural and urban public facilities, where they are both underpaid and overworked.
 2. Fragmented system
characterized by 46 separate but overlapping healthcare programs driven by donor initiatives rather than population needs. 
This has hindered our ability to integrate, harmonize and prioritize solutions to problems in health.
3.Healthcare system is also fragmented administratively, with local government units placed in charge of frontline healthcare delivery.  
This has politicized the healthcare workforce and has made it difficult for the DOH to orchestrate a unified healthcare program.

9. Universal Health Care(UHC) Inaugural Address 2010
“Provision to every Filipino of the highest possible quality of health care that is accessible, efficient, distributed adequately funding, fairly financed, and appropriately used by an informed and empowered public."
It is also known as Kalusugan Pangkalahatan, which the Aquino administration describes as the "availability and accessibility of health services and necessities for all Filipinos."
The inability to manage this double burden can be traced to 3 chronic problems that have plagued our healthcare delivery system.
First, we face a chronic healthcare workforce shortage, as we continue to be the number 1 exporter of nurses, and the number 2 exporter of doctors in the world. This shortage is at its worst where healthcare workers are needed most – in rural and urban public facilities, where they are both underpaid and overworked.
 Second, our healthcare system has evolved into a fragmented system characterized by 46 separate but overlapping healthcare programs driven by donor initiatives rather than population needs. This has hindered our ability to integrate, harmonize and prioritize solutions to problems in health.
Third, our healthcare system is also fragmented administratively, with local government units placed in charge of frontline healthcare delivery.  This has politicized the healthcare workforce and has made it difficult for the DOH to orchestrate a unified healthcare program.

10. Universal Health Care(UHC) Republic Act 10606
A government mandate aiming to ensure that every Filipino shall receive affordable and quality health benefits and services such as :
Human resources
Health facilities
Health financing

11. One Peso DOH Consultant 2011-2013

12. Sin Tax Law Signing Dec 20, 2012 Slide #1
Describe origins of Coaltion for Primary Care
- Began as Sin Tax Coalition
- Evolved into a reactive watchdog for Sin Tax spending
- Eventually became a more proactive advocacy lobbying for primary care
Sin Tax Law Signing
Dec 20, 2012

13. 2003 2013 Poorest Poor Middle Rich Richest 18% 23% 24% 28% 33% Income
PhilHealth
Utilization
2003
NDHS 2003
33%
48%
54%
70%
88%
71%
Poorest
Poor
High Middle
Rich
Richest
Low Middle
Income
PhilHealth
Utilization
2013
Faraon et al, 2013
This is expected given that we have been unable to build the workforce required to achieve these goals.
Secondly, in 2003, the problem of PhilHealth came to the fore. PhilHealth benefits were being utilized more by our rich than our poor. After ten years, in 2013, the inequity became worse. While PhilHealth utilization has improved, the gap between rich and poor has actually increased. The poor who are in dire need the PhilHealth services are not benefiting from these services.
[SLIDE 8]
Faraon et al. Significant Predictors of Underutilization of Inpatient Benefits among PhilHealth Members in Selected Barangays in Manila. Acta Medica Philippina
NDHS 2003

14. Are patients benefiting?
Out-of-pocket spending remains high at 57%
The top conditions paid by PhilHealth do not match priority health conditions and are focused on costly interventions P
Pneumonia H
Hemodialysis I
Infections (UTI) C
CS / Cataract

15. Sin Tax Funds to PhilHealth
Republic Act No (or the Tobacco and Alcohol Tax), signed by President Aquino on Dec. 29, 2012
gives the government the financial capacity to cover the full subsidy of the premium coverage of 14.7 million poor Filipino families (or more than 45 million Filipinos), amounting to P37 billion for 2015 and an increase of the Department of Health budget to P103 billion (an increase never received before).
DOH Sec Enrique T.Ona , PDI July 2015

16. What the Sin Tax Law has already achieved
150 Php in 2015
Revenue generation

17. Prevalence of Never, Current and Former Smokers
Prevalence of Never, Current and Former Smokers. Philippines, NNS
Prevalence (%) 70
59.1
63.7
54.5
55.0
54.3
Never Smoker 60 50
32.7
34.8
31.0
Current Smoker 40 30
25.4
23.3 20
12.8
10.2
14.7
Former Smoker
15.5
13.0 10
1998
2003
2008
2013
2015

18. Sin Tax Law Health Updates NNS 2015
Prevalence of smoking among adult Filipinos went down from 31.0% in 2008 to 23.3% in 2015.
This means there are ~4 million less smokers in the country today because of the Sin Tax Law.
The drop is not from people who stopped smoking. It is from people who avoid starting to smoke.
At least 70,000 deaths have been averted since 2013.
Health benefits were greatest in price sensitive populations – the poor, rural folk, the very young and the very old.

19. Strategic Questions How Doctors Think
1.Where are we now ? Diagnosis ? State of The Nation’s Health
2. Where do we want to go ? Towards UHC
3. How do you get there ? Eg Plan of Action

20. (The Philippine Healthcare System)
Where are we?
(The Philippine Healthcare System)

21. Good News and Bad News about the Philippine Health Situation
PhilHealth coverage has increased from 51% in 2010 to 88% in 2015 (PhilHealth) 1
But PhilHealth utilization remains low, especially amongst the poorest (only 33%) 2
The health budget increased from PhP28.7B in 2010 to PhP205B in
But the number of Filipinos who die without seeing a HCW increased from 45% to 66% 4
We are the number 1 exporter of nurses in the world 5, and the number 2 exporter of doctors 6
In the public sector,
There are only 5 HCW’s per 10,000 population (ideal = 25)
There is only 1 doctor per 20,000 (ideal = 20) 7
1 Philhealth, 2 Faraon et al, 2013, 3 Department of Health, 4 Philippine Health Statistics, 5 Matsuno et al, 6 World Health Organization, 7 Dans et al
utilization = (# who successfully avail of Philhealth) / (# who eligible to make claims)
(the denominator is sick people who are bona fide members)
Coverage = the # who are enrolled / total population

22. Why healthcare workers leave 1
Unemployment (unfilled positions for HCW’s)
Underemployment (underpaid for workload)
Misemployment (job orders and casuals)
Unjust working conditions (eg - politicalization of appointments, non-issuance of magna carta benefits)
Why healthcare workers stay 2
To serve the country
To be with their family
1 Ebesate J, 2012, 2 Lorenzo M, 2005

23. (Ideally ,A Primary Care System)
Where do we want to go?
(Ideally ,A Primary Care System)

24. The Philippine Healthcare Situation
Too Little Health Care
Too Much Health Care
Mr. Jose
42 years old
From Busuanga
- High Blood
- Diabetes
- Tuberculosis
No consultation
No medications
Mrs. Rosete
50 years old
From Quezon City
- Diarrhea (gastro)
- Stroke (neuro)
- High Blood (cardio)
- Diabetes (endo)
- Kidney ds (nephro)
- Gout (rheuma)
- Pneumonia (pulmo)
1 – is sa naslanta ng Yolanda; walang doctor sa isla; bihira ang gamot.
mabuti pa nga raw kung bumagyo, may dumarating. Naghihintay atakihin.
2 – si mrs cruz taga bataan - may doctor – anim!
Nang huling maconfine dahil sa severe pneumonia, gumastos ng 500,000 after 5 days,
Lumipat sa PGH dahil naubos ang pera. Ang apo tinanggal sa school dahil hindi nakapagbayad ng matrikula.
66% of deaths among Filipinos are not attended by a doctor, nurse or midwife
PHS 2011
1.5M families a year pay for catastrophic health expenses.
Ulep et al 2013

25. 1 care – prevention, treatment of common and simple illnesses
A Primary Care System
1° CARE
ALLERGIES
HEART DISEASE
SKIN DISEASE
SURGERY
INTESTINAL DISEASE
BLOOD CONDITIONS
INFECTIOUS DISEASE
WOMEN’S HEALTH
PREGNANCY
BRAIN DISEASE
CANCER
LUNG DISEASE
2° CARE
3° CARE
Slide #4 version C
LAWAK vs LALIM
1 care – prevention, treatment of common and simple illnesses
2 care – special skills
3 care – specialized facilities
Healthcare workforce can then be likened to scuba divers who scour the depths but limit their scope of conditions
And the snorklers, who sacrifice depth for breadth of coverage
KIDNEY DISEASE

26. Funds have increased but services have deteriorated
THE PROBLEM
Funds have increased but services have deteriorated
INADEQUATE
WORKFORCE
INEQUITY
IN HEALTH
INADEQUATE
FACILITIES
INADEQUATE
TESTS/MEDS

27. Healthcare SYSTEM reform: Tunay na KP!
THE PROPOSAL
Healthcare SYSTEM reform: Tunay na KP!
FUNDS FOR WORKFORCE
(AT THE FRONTLINES)
PRIMARY CARE
OUTPATIENT PACKAGE
FUNDS FOR FACILITIES
(AT LGUs, RHUs)
PHILHEALTH
FUNDS FOR TESTS & MEDS
(PREVENTIVE CARE FINALLY)

28. A Primary Care System
A Healthcare System that enables patient access to
healthcare providers with 3 main functions:
1. FIRST CONTACT
& COMPREHENSIVE CARE
Patient
Primary Care Provider
2. COORDINATOR OF HEALTH SERVICES
3. PRINCIPAL POINT OF
CONTINUING CARE
Laboratories
Pharmacies
Specialists
Facilities
Slide #5
Definition of primary care

29. (How to Reform the Healthcare System)
How do we get there?
(How to Reform the Healthcare System)

30. Roadmap to a Primary Care System
RECRUIT
RETRAIN
RETAIN
REGULATE
REASSESS
Threshold density 5:1000 (WHO)
Graduate doctors, nurses, midwives
Current practitioners
Private & Public sector
Segue to #6
The 5 milestones oversimplified

31. Roadmap to a Primary Care System
RECRUIT
RETRAIN
RETAIN
REGULATE
REASSESS
Workshops on DOH priorities:
- Infectious Diseases
- Non-Communicable Diseases
- Health System Navigation
Segue to #6
The 5 milestones oversimplified

32. Roadmap to a Primary Care System
RECRUIT
RETRAIN
RETAIN
REGULATE
REASSESS
Pay for outpatient care!
In public sector – provide and augment salaries of HCWs
In private sector, subsidize payments for healthcare.
Segue to #6
The 5 milestones oversimplified

33. Roadmap to a Primary Care System
RECRUIT
RETRAIN
RETAIN
REGULATE
REASSESS
Facility – electronic records
Health workers – accreditation
Patients – require primary care
Segue to #6
The 5 milestones oversimplified

34. Roadmap to a Primary Care System
RECRUIT
RETRAIN
RETAIN
REGULATE
REASSESS
Segue to #6
The 5 milestones oversimplified
Better Quality of Care
Better health
Reduced healthcare expenses
Reduced out of pocket payment

35. Roadmap to a Primary Care System
RECRUIT
RETRAIN
RETAIN
REGULATE
REASSESS

36. Summary
Despite the rising budget and increasing Philhealth coverage, healthcare is deteriorating.
The deterioration is mainly due to a shortage of healthcare workers caused by massive  migration
Healthcare workers who stay (especially those in rural areas) are patriots who want to serve the country.
The government need to take better care of those who care for our health.
Primary care is vital in achieving genuine UHC.
Walang kalusugang pangkalahatan, kung walang mag- aalaga sa taong bayan! – Coalition for Primary Care