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THE FUNDAMENTALS IN HEALTH AND FUNDAMENTALISM IN POPULATION POLICY
Reaction to DOH Secretary Manuel Dayrit’s Assessment on Health and Population
By Professor Roland G. Simbulan Vice Chancellor for Planning and Development U.P. Manila
I have titled my response to Secretary Manuel Dayrit’s assessment of the Department of Health’s accomplishments under the Arroyo government as “The Fundamentals in Health and Fundamentalism in Population Policy”.
The Politization of Health Services
I am quite distressed that healthcare services, in reference to DOH programs with acronyms like GMA 50(Gamot na Mabisa at Abot Kaya) or PhilHealth’s GMA 500 have become part of the national patronage system to magnify the personal power of the incumbent president. It cheapens the dignity of our healthcare system and its workers when they are made to peddle political gimmicks like the National Food Authority’s GLORIA LABANDERA mobile foodstalls.
This “you-owe-me” message sends the signal that beneficiaries of DOH programs are feudal subjects dependent on the personal benevolence of the sovereign monarch, rather than as citizens with formal rights to health care and services. Let us remind ourselves that the resources the president gives away do not personally belong to her; the citizens do not receive the benefits that come their way as private favors but as entitlements under a system of law defining the relationship between public authorities and citizens. To proclaim public programs and projects as the personal achievement of any public official is to degenerate to a form of patrimonial governance that allows the personal exploitation of the means of administration. It is not good governance, for it politicizes even health care services that can become unsustainable if a new administration comes into power. At worse, this political habit treats the fulfillment of our people’s basic needs as conditional on the personal benevolence of elected officials.
Prioritizing Health and Social Services
The trends in the national budget do not reflect the pronounced constitutional and national priorities for health and other basic social services, even in the context of limited financial resources. Despite budgetary deficits, I submit that the country’s limited finances should prioritize social services. This country should look at the Cuban model even alone for the priority it gives to its health care system, which is considered as one of the best among developing countries. Last month, I had the privilege of listening to the lecture in UP Diliman of the Cuban Foreign Minister Felipe Perez Roque who discussed Cuba’s social expenditures for 2004. Despite the continued economic, commercial and financial blockade and embargo by its superpower neighbor, the United States, Cuba earmarked 59% of its 2004 budget for education, public health, social security and welfare, culture and housing and community services, accounting for 37% of Cuba’s GDP. Cuba’s local pharmaceutical industry produces 67% of the medications required in its healthcare system.
It would be useful to reflect on the chronic budgetary discrepancy in the Philippines’ National Expenditures Program for the past three years. Together with debt service (both interest and principal amortization), the defense budget has one of the highest growth rates in the national government’s expenditure program. From 2003 to 2004, debt interest payment grew by 24% and principal debt amortization grew by 13.3% while defense grew by 6.4%. In contrast, appropriations for social services even decreased by 5% from the 2003 appropriations. Thus, while the government will be spending about P109,589,041 everyday for defense in 2004, it will be spending only P0.43 per person daily for health and P9.40 for each public elementary and high school student daily. What the government considers as priorities in both the budget and its development plan can only be too obvious.
The Big Picture: Globalization and the Commodification of Health Services
The country’s ailing health care system has consistently been experiencing budgetary cuts. These budgetary cuts are not only the result of the lesser priority given to basic services compared to the increasing debt servicing and defense expenditures. It is also in line with the policy dictates of the IMF-World Bank to reorient the bureaucracy towards privatization and to implement austerity programs to ensure debt servicing. In the Philippine Memorandum of Intent for IMF Loan Structural Reforms, titled Memoranda of Economic and Financial Policies of the Philippine Government, March 11, 1998, it is stated in Sec. 27 that:
“We will endeavor to move forward the Government Re-engineering Program which was initiated in 1994…We expect the reduction in staffing will result from the merger or abolition of redundant agencies, the devolution of activities and programs of local government, and the further privatization of public services…”
Translated in real terms, the World Bank’s policies include cutbacks in government spending on health, thus leaving the responsibility of health care to the person who needs the service and privatization of medical and health care services by transferring government services, which in the past were subsidized, to big business.
Now we should watch out how the Health Sector Reform Agenda is being implemented in the context of the thrust and orientation as spelled out by our government’s commitment to the IMF-World Bank’s structural reforms.
On the issue of management and financial efficiency, while it is true that, according to Sec. Dayrit, “ In a SWS survey from 2002-2003, the DOH was named as the 3rd government office that is sincere in fighting corruption”, it still has a long way to go. According to the Philippine Center for Investigative Journalism(PCIJ) in their book INVESTIGATING CORRUPTION(2002):
“Results of surveys by Social Weather Stations appear to support the perception that the DPWH, Department of Education and the Department of Health, which get huge slices of the national government’s annual procurement pie, consistently appear on the list of government agencies perceived by citizens to be among the most corrupt.” It is disturbing to note that the private enterprises which SWS polled confirm that business firms set aside an average of 19% of the contracts they get from the government for bribes or kickbacks, according to the PCIJ.
Need to Develop Local Pharmaceutical Industries
The DOH must help develop a local pharmaceutical industry that will have the capability of producing pharmaceutical chemicals and intermediate active ingredients for local manufacture, thus reducing the country’s dependence on imported drugs and foreign companies which dominate and hold a 70% share in the local market. Full support must be given to local companies manufacturing generic products so that every Filipino can gain access to safe, effective and affordable drugs.
Global Marketization of Health Workers
The Department of Health does not seem to have any mechanism or master plan to manage the very serious brain drain of our health and medical practitioners to other countries. I was looking for this in the report, even as the DOH recognizes this problem which has intensified even more in recent years. In fact, we get the impression that the global marketization of Filipino health workers has become even a policy of the national government, with the proliferation of nursing schools, now numbering more than 140. Our entry into the General Agreement on Trade and Tariffs(GATT) which GMA sponsored when she was senator has now made not only our basic services market-driven, but the training and education of our health workers as well. All this at the expense of the national health care system.
The Devolution Issue
I beg to disagree with the idea that devolution is the culprit for the mess that the health care delivery system now finds itself in. This is not the issue here. The issue is the patronage system and the politization of our basic services whether on the national or local level.
The New Local Government Code was precisely legislated so that local authorities can play a key role in making sustainable development activities happen, since many of the problems facing the country have their roots in local activities. Local authorities have the advantage of being the arm of government closest to the people. They should therefore play a vital role in educating and mobilizing the public and local communities around sustainable health programs. My problem with devolution is that, in implementing the IMF’s wishes, devolution has only conformed to the cost-cutting measures and revenue-enhancing programs of the government. Revenue-enhancing programs wherein poor patients are made to pay for services such as blood pressure taking, room and linen use, hospital food and even immunization. The local government code now allows LGUs to involve private corporations in the maintenance and operation of local hospitals which were once run by the Department of Health. More and more, under this set-up, big business is being given the primary role in the production and provision of basic services like health. It diminishes the role of the national government from being the main provider of health care services to that of being a mere health regulator.
What we fundamentally need is an administration that is firmly committed to improve significantly the access of the population to basic social services through substantial increases in the national appropriation for these purposes and mobilization of support from the private sector, particularly local communities, NGOs and business groups.
The government must affirm that health is a basic human right, and that family planning, nutrition and sanitation are necessary conditions for good health. Government must see to it that the delivery of health services is community-based and flexible enough to respond to the different needs of particular communities. First priority should be given to primary health care, preventive measures against communicable diseases and malnutrition, and basic sanitation. The cooperation of local NGOs, civic societies and sectoral groups can be most easily enlisted in these tasks, resulting in savings of government funds and manpower. These community resources should also be involved in monitoring and evaluating program implementation in their communities.
“Fundamentalism” in our Population Policy
What is described as “natural family planning methods” or “responsible parenthood” is actually a safe but weak means of implementing a population program that refuses to antagonize the No. 1 opposition to family planning, the Roman Catholic Church. Studies have shown and proven that this has a very poor success rate in terms of birth control. The fear of the Church and the strong influence of the Church have stunted the country’s population policy which has remained in the realm of demography studies and research. This is why the Philippines still has one of the highest annual population growth rates in Asia. Ask the women’s groups and those involved in reproductive health advocacy and they will describe our population policy as toeing the Roman Catholic Church’s “fundamentalism” when it comes to reproductive health and family planning issues.
Adequate Health Services Remain Inaccessible to the Poor
Whatever claims government makes to the contrary, more families at the bottom of the social strata still consider health care a luxury instead of a basic necessity. The poor will more likely have far worse health outcomes in the coming days as a result of mass layoffs of industries and the spiraling costs of living. More notable is the fact that poverty-related diseases are still the main source of illness among Filipinos, despite the much-daunted economic growth in our newspapers. Indeed, the main indicator of development, which is health status, demonstrates how far the country is from real and genuine progress. All of which goes to show that administration claims to having markedly improved the health of Filipinos are nothing more than what Hercules, the Nemean lion, Cerberus, and the other characters mentioned truly are. They are a myth.
And while we do not doubt the dedication and patriotism of our health workers who have chosen to serve this country, we cannot ignore the shortcomings of government in addressing health care problems. The effort made by health workers have indeed been Herculean; in contrast, the Arroyo administration’s support for health care has been Lilliputian. And now, in election season, let us not be misled by the Medusas in our midst, lest they mesmerize us and turn us – and our hearts – into stone.
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