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= Philippine Healthcare =

Overview
The World Health Organization defines health care as an overall maintenance and solution to the health needs of a person, family, or community. It is a system that addresses these health needs are fulfilled through prevention, treatment, rehabilitation, and palliative care. WHO states that the system needs financial stability, well-trained human resources (along with proper salary), proper information/data, and proper maintenance of up to date facilities to be able to deliver quality services, medicine, and researches.

The health care in the Philippines has been defined by the WHO as "fragmented", meaning there's a large gap between the quality and quantity of health services for the poor and the rich. With different reasons such as low budget, low number of man power, or general neglect for the poor, the Philippines has always been unable to keep up with the high standards of healthcare abroad. Comparing data from 2014 between Philippines, United States of America, and Canada, Philippines only spent 4.7% of their GDP on health while USA and Canada spent 17.1% and 10.4%. Efforts are being performed to bridge the gap. Last February 20, 2019, The Universal Health Care (UHC) Bill was signed into all, aiming to provide proper healthcare services for all.

Current Status
The Department of Health (DOH) is the overall policy-maker and regulator of health services and products in the Philippines. In 2017, Health Secretary Francisco T. Duque III presented his strategic approach (FOURmula One Plus) in running the department’s health reform agenda, and vowed to prioritize the review of the Universal Health Care Bill.

FOURmula One (F1) is a health sector implementation framework currently followed by DOH with a new tagline: Boosting Universal Health Care via FOURmula One Plus (F1 Plus). The framework has four reform components: Health Service Delivery, Health Regulation, Health Finance, and Good Governance in Health. On December 10, 2018, DOH released the Universal Health Care (UHC) and FOURmula 1 Plus (F1) Health Priority Actions for 2019. It includes the policies, programs and plans of the Department of Health to be prioritized to create a strong foundation for the implementation of the Universal Health Care reforms.

National Health Insurance Program
Philippine Health Insurance Corporation (PhilHealth) is a tax-exempt government agency established in 1995 primarily to coordinate and formulate policies regarding health insurance. The National Health Health Insurance Act of 1995 instituted the National Health Insurance Program, and established PhilHealth for the administration of the program. The program provides health insurance coverage for all Filipinos especially citizens who cannot afford health services mainly through premium contributions.

Currently, PhilHealth has five member categories with different package eligibilities: members in the formal economy, members in the informal economy, lifetime members, sponsored members, and indigent members. Monthly contributions from members in the formal economy come equally from the member and employer while contributions from members in the informal economy are based on household earning and assets. Subsidies are provided for sponsored members (i.e. orphans, street children, abandoned and abused minors, out-of-school youth, senior citizens, PWDs and abused women under the care of DSWD), indigent members and members of the informal sector with the lowest income. As of December 31, 2018, PhilHealth has 53,816,468 members and 104,488,979 total beneficiaries including the members’ dependents.

The Universal Health Care law, signed on February 20, 2019, includes provisions of PhilHealth laws including population coverage or membership, services coverage and cost coverage. Aside from the health insurance coverage, the scope of the law also extends to the DOH, institutionalizing its updated financing strategy.

Emergency Medical Services
The Philippines currently has the Emergency Medical Service System Act (EMSS) which enables the efficient deployment of Emergency Medical Services around the country. The act establishes the national standards for EMS in the Philippines and ensures that highly trained individuals will be deployed to EMS teams. EMS Training Institutions are available for interested individuals. Those who have completed the necessary training will receive a certificate from TESDA. These individuals will be skilled in different areas of Emergency Medical Services such as basic life support, basic first aid, management of ambulance operations and services, effective use of life support equipment and procedures, and other similar skills. The EMSS Act also implements the deployment of EMS Teams in both the national and local levels of government. The EMSS Act adopts a national universal emergency hotline where Filipinos can immediately avail of Emergency Services at any time. The EMSS Act has made the establishment of a National Command Centre with a universal hotline number. In accordance with this, all Local Government Units must have their own command centre for Emergency Medical Services as well as their own dispatch centre. The EMSS Act has also made it necessary for public places such as malls, parks, and transport terminals to have at least 1 automated defibrillator within the premises at all times.

The Pre-Spanish Era: Pre 1656
Health care in the Philippines extends as far back as the 15th century. Prior to the arrival of the Spaniards, life and by extension health care, was centered around the animate and inanimate world.

Traditional Filipino medicinal herbs were used for a wide variety of ailments. Anonas leaves were applied to the stomach for indigestion. Betel-nuts leaves and areca nut leaves were common for injuries, chewed and then applied. Sambong was used to treat kidney stones, rheumatism, coughs, colds, hypertension, and diarrhea.

Spanish historian Miguel de Loarca said the natives were “good physicians and had a remedy for every poison.” The seeds of the igasud were chewed as an antidode for poison. It was renamed Pepita of San Ignacio by the Spanish. Other antidotes include boiled bark of palanigan and the bark of the bagosabak. While the Spanish were impressed by the medicinal knowledge of the Filipinos, they still believed that Western health care would have to be taught to the Filipinos.

The Spanish Era: 1565 – 1898

 * Further Information: Spanish colonial period

As the Spanish were exposed to the unfamiliar environment of the Philippines, they were stricken with foreign disease. To combat this, they created hospitals specially for their health. Some of the first health institutions in the country were handled by Spanish friars.

Hospital Real
Built in Cebu in 1565, Hospital Real was the first hospital in the Philippines. It was relocated to the Manila to accompany the government. The hospital aimed to nurse the Spanish army and navy, those inflicted with disease, and military casualties. Miguel Lopez de Legazpi had permission from King Philip II to set up the hospital exclusively for Spanish soldiers and sailors, whereas it denied service to Spanish and mestizo women. Although Hospital Real received funding from the Spanish Government, it lacked finances, manpower, and supplies. Administration of Hospital Real was transferred to both the Order of St. Francis and the Confraternity of La Misericordia. Hospital Real was destroyed during an earthquake on June 3, 1863.

Hospital de Naturales
Fray Juan Clemente, a 54-year-old botanist and lay brother, was instrumental in conception of the Hospital de Naturales. He often made medicine for the many people who begged outside the convent, until eventually the number of patients grew too large for accommodations. Clemente raised funds in order to build better facilities. In 1578, two wards of nipa and bamboo were constructed by Clemente. Called the Hospital de los Indios Naturales, or Hospital de Naturales, the hospital flourished under Clemente. Friars tended to the sick, as well as their spiritual needs. The hospital also provided free medical supplies such as oils, herbs, and ointments. Hospital de Naturales was also able to provide medical supplies to other infirmaries and hospitals. Hospital De Naturales came under the patronage of King Philip II, earning it government subsidy. Protection was also guaranteed by the governor-general. Clemente died after 20 years of working at Hospital de Naturales. A few years after, a fire destroyed the hospital once more (the first time in 1583). The reconstruction of the hospital led to the development of the Hospital de San Lazaro.

Hospital de San Lazaro
Although previously the Hospital de Naturales, the hospital was renamed after Japanese emperor Iemitsu sent 150 lepers. Although viewed as a hostile act to the church for its growing influence in Japan, the lepers were taken care of by the hospital, the clergy, and the community. As such, the Hospital de Naturales became known as the Hospital de San Lazaro, after the patron saint of lepers. The Hospital de San Lazaro was demolished twice. Initially when the city of Dilao was threatened by invasion from Chinese pirate Chen Ch’e Kung, and finally after it was taken over and utilized by the British as a military vantage point. San Lazaro can now be found at Rizal Avenue. It is believed that the land on which the hospital stands belonged to a Chinese mestizo who suffered leprosy. His will stated that his lands be used to aid those with leprosy.

The American Era: 1898 – 1918
After the end of Spanish rule, the Filipino Revolutionary Government was established, including a Bureau of Public Health. Although the Americans had been an ally in the fight against the Spaniards, the Americans soon seized control of the Philippines, with the mission to “uplift and civilize”.

Under General Wesley Merritt, a Board of Health for supervising public health was established on September 29, 1898. The Board of Health’s biggest challenge was smallpox, which they battled by standardizing vaccine production and campaigning for vaccination.

Despite American efforts, public sanitation was dismal, and diseases were still spreading. Manila faced Bubonic plague; smallpox still spread in provinces; lepers roamed the streets. Laws requiring vaccination and isolation of infected were ignored by the public. On July 1, 1901, The Board of Health for the Philippine Islands was established. The Board soon became the Insular Board of Health as provincial and municipal boards were created.

The Insular Board of Health was given the power to draft legislation for sanitary and medical practices in the Philippines. They were tasked with studying diseases and prevention methods, as well as overseeing public health.

The Filipinization of Health: 1918 – 1941
Under the Jones Law and the governance of Governor-General Francis Harrison, the Filipinos were slowly allowed to practice self-governance. The Department of Public Instruction, one of the four executive departments of the government, was in charge of the Philippine Health Service. The Department of Public Instruction was managed by Dr. Victor Heiser, during whose term the Philippine General Hospital was put up. The Filipinization of Health Services started when Dr. Vicente de Jesus, the first Filipino Assistant Director of the Department of Public Instruction, became Director in 1919.

Succeeding Harrison was Leonard Wood. Together with ex Governor-General William Forbes, Wood found the health status of the Philippines to be below par. Cases of typhoid, tuberculosis, and other preventable diseases were rampant. Facilities and trained medical personnel were insufficient to care for the almost ten million Filipinos. Under Wood’s administration, importance was given to health education, especially for mothers and young children. Prevention rather than treatment was a key strategy, and Act No. 3029 required school children to go through a health examination at least once a year. There were also initiatives to increase the number of Filipino health workers, such as the establishment of the School of Public Health and Hygiene.

After Wood, [https://en.wikipedia.org/wiki/Theodore_Roosevelt_Jr. Theodore Roosevelt, Jr.] became Governor-General in 1932. He abolished several medical agencies and combined them under the Bureau of Health and Public Welfare. Roosevelt focused on educating the public on health. Through the Bureau of Health’s pamphlet publication “The Health Messenger”, public radio, posters, and festivals for lectures on health, Roosevelt was able to increase public health awareness. On May 31, 1939, the Department of Health and Public Welfare was established through Commonwealth Act 430. By now, the Tydings-McDuffie Act had been ratified, and the Philippines was on its way to independence.

Budget Allocation and Expenditure
The total government health spending is increasing in nominal terms however, its share in the total Gross Domestic Product (GDP) is unchanging at 3.5 to 3.6 percent which is below the ideal 5 to 6 percent set by the World Health Organisation. In the Philippines, health spending can be accounted by different sources, namely: national and local government subsidies, social insurance, private insurance and private out-of–pocket of households. PhilHealth, the country’s national health insurance program, is governed by the National Health Insurance Act of 1995 or the Republic Act 7875 which replaced the Medicare Act of 1969. PhilHealth is mandated to provide health insurance coverage and ensure affordable, acceptable, available and accessible health care services for all citizens of the Philippines and is mandated to regulate public and private providers through accreditation in compliance with its quality guidelines, standards and procedures. The country's total health expenditure (THE) went up by 11.7 percent, from PhP 471.1 billion in 2012 to PhP 526.3 billion in 2013. This could be mainly attributed to the large amount expended for health care by Private Sources, majority of which (82.6 percent) were disbursed by households (Private Out-of-pocket) for their health needs in 2013. Discounting the effect of inflation, THE grew by 8.5 percent from PhP 362.1 billion in 2012 to PhP 392.8 billion in 2013. With THE growing faster (11.7 percent)than the population (1.7 percent), per capita health expenditure at current prices was registered at PhP 5,360.0 in 2013, a 9.8 percent increase from PhP 4,881.0 in 2012. At constant 2006 prices, per capita health spending rose by 6.6 percent, from PhP 3,752.0 in 2012 to PhP 4,000.0 in 2013.

Public and Private Health Sector
The Department of Health (DOH) lists 1,071 licensed private hospitals, and 721 public hospitals in the Philippines. The Department attends to 70 of the public hospitals while local government units and other state-run agencies manage the rest.

Private hospitals in the country have better technical facilities than the public hospitals, assuring patients of higher quality services than public institutions can provide. In public health facilities, a 2007 report by the Asian Development Bank (ADB) described "diagnosis as poor, resulting in repeat visits; medicines and supplies are inferior and rarely available; staff members are often absent, especially in rural areas, and are perceived to lack medical and people skills; and waiting time is long, schedules are inconvenient, and facilities are rundown."

About 40% of hospitals in the country are public. Of the more than 700 public hospitals, approximately 10% are supervised by the DOH while the remaining are managed by local government units (LGUs) and other national government agencies. The DOH categorises both public and private hospitals based on their service capabilities: Level 1 (primary), Level 2 (secondary), to Levels 3 and 4 (tertiary). Level 1 hospitals have very limited capacity comparable only to infirmaries. These account for more than half of the total number of hospitals in the country.

In all categories, private hospitals outnumber government hospitals. The discrepancy is most apparent in tertiary hospitals where the number of private hospitals is four times that of public hospitals. In terms of distribution, Level 1 and Level 2 hospitals are relatively well dispersed across the country. Level 3 and Level 4 hospitals, however, are highly concentrated in Central Luzon and Metro Manila. Of the country’s 17 regions, only four meet the WHO recommendation of 20 hospital beds per 1,000 population.

Public Healthcare Systems
Although doctors and nursing staff in public hospitals are highly proficient, public healthcare in the Philippines is highly limited. Because health care providers and health educators are concentrated in urban areas, such as Metro Manila, there is a scarcity of healthcare manpower in the rural areas. This strain on public healthcare is worsened from both treating the large number of Filipinos who rely on public healthcare and from the trend of Filipino medical staff migrating to Western countries. This has resulted in understaffing in many hospitals, resulting in delayed patient treatment.

Philippine Health Insurance Corporation
Public healthcare in the Philippines is administered by the Philippine Health Insurance Corporation (PhilHealth), a government owned corporation. Philhealth subsidises a variety of treatments including inpatient and outpatient care. Outpatient benefits would include: non-emergency day surgeries, radiotherapy, hemodialysis, blood transfusion, Primary Care Benefit (PCB), and Expanded Primary Care Benefit (EPCB).

Private Healthcare Systems
Although doctors and nursing staff of public hospitals are as efficient as doctors practicing in the private sector, private facilities are much better equipped and treatment is typically faster in terms of patient accommodation. According to DOH, 70% of Filipino health professionals are working in the private sector, serving about 30% of the population. Only approximately 30% of health care workers are employed by the government to address the health needs of the majority of Filipinos.

Drug Prescription
Most pharmacies in the Philippines provide medicines approved by the Bureau of Food and Drugs. While pharmacists in some countries provide drugs to patients even without a doctor’s prescription, pharmacists in the Philippines have to follow strict guidelines on the sale of drugs. According to Republic Act No. 2382 (Philippine Medical Act), only licensed physicians are authorized to prescribe medicines. Similarly, according to the Republic Act No. 5921 (Pharmacy Law), only registered pharmacists can dispense and sell drugs.

Opportunities in the Philippines Medical Device Market
The Philippines decided to make an economic development after all the political turmoil behind it. The Philippines open up the economy to foreign trade and investment. The Philippines Healthcare Market is counting on the imports of medical equipment, medical devices, and medical disposables into the country. Almost all medical equipment (close to 100%) and more than 65% of medical disposables are imported into the Philippines Healthcare Market.

Local manufacturing in the Philippines in the medical disposable segment is primarily gloves, syringes, needles, hospital beds and hospital furniture. Medical equipment like x-ray equipment, infusion systems, incubators, anesthesia machines, sterilizing equipment, nebulizers, and monitors are frequently bought in the Philippines. Countries exporting medical equipment to Philippines include USA, Germany, Japan, and Singapore with major market leaders including GE Medica, Picker, Advanced Technology Laboratory, Access Cardiosystems, Control-X Medical, Inc., Medical Illumination International, Inc., Varian Medical Systems, Argyle, American Orthopedic, Smith and Nephew, Siemens, Fujirebio, Fukuda, Fukugawa, and Hitachi.

Imported Medical Products
The one that regulates medical devices and equipment in the Philippines is the Philippines Food and Drug Administration. Medical products that are imported in the Philippines Healthcare Market include :


 * Actocardiograph System
 * Blood Analytical Equipment
 * Catheters
 * Chemical Analysis Instruments
 * Ct Scan System
 * Dental Implants and Dental Accessories
 * Diagnostics
 * Dialyzers
 * ECG
 * ENT Treatment Equipments
 * MRI Systems
 * Orthopedic Implants
 * Surgical Instruments
 * Ultrasound Scanner
 * Ultrasound Systems
 * Wound Healing
 * X-ray Systems

Regulatory Approval for Medical Products in the Philippines
Approval of all health technologies is under the Ministries of Health by the Bureau of Food and Drugs for medicines and Bureau of Health Devices and Technology for medical devices. The government has enforced the FDA Act of 2009 to strengthen the regulations of medical products in the Philippines. requirements that are needed for the registration are Licence to Operate (LTO) where any establishment in the Philippines from single proprietorship to public and private limited companies can apply for the LTO as long as they are engaged in the healthcare field as importers/distributors/wholesalers/manufacturers/traders, and Product Registration where a company that has LTO can apply for the registration certificate.

Universal Health Care
The Universal Health Care (UHC) Bill was signed into law (Republic Act No. 1223) by President Rodrigo Duterte on February 20, 2019. The UHC Bill automatically enrolls all Filipino citizens in the National Health Insurance Program (NHIP), guaranteeing equitable access to quality and affordable health care services for all.

The UHC Act is the culmination of decades of progress and two years of dedicated political and technical work. It is the first UHC Act of its type in the Western Pacific region; this is particularly remarkable considering the strong presence of the private sector in the Filipino health system. The Act prescribes system reforms in accordance with the multiple financing and service delivery mechanisms at work in the Philippines.

In accordance to the Bill, PhilHealth will be renamed Philippine Health Security Corporation (PHSC) to emphasize the agency’s role in providing financial security in health rather than just helping people pay for health services. With this reform, the agency will provide uniform benefits for all; develop a single but comprehensive primary care package including medicines; create supplementary coverage by Health Maintenance Organizations (HMOs) and private health insurance; provide network-based licensing, contracting, and accreditation of facilities.

PhilHealth members will be identified as either a Direct Contributor or Indirect Contributor (non-contributors). Direct Contributors are paying members who are by default deducted for the premium through their payroll. Indirect Contributors are non-paying members who will be fully subsidized through tax collections.

The Bill will also utilize different agencies to deliver different healthcare services according to their classified scope. The Department of Health (DOH) will conduct the population-based health interventions, which include: financing of population-based services, improvement of doctor-to-patient ratio, increase of the number of hospital beds and equipment, and the establishment of hospitals in remote areas. PhilHealth will focus on the individual-based health interventions, which include: financing of individual-based level services, and delivery of individual hospitalization, rehabilitation, and emergency healthcare provision.

Medical Tourism
The Philippine Medical Tourism Program (PMTP) is a DOH project, which intends to make the country a global leader in “providing quality health care for all through universal health care.”

The program will further improve the Philippines’ healthcare manpower capabilities and facilities in both public and private sector to make the Philippines the country of choice for health care. The program aims to attract more visitors from abroad availing of medical services while simultaneously ensuring that the quality of currently offered services are suitable by Global Health Care standards. With the program, the local health care industry can generate substantial income to boost the Philippine economy.