The Philippine The Philippine Health Care Health Care

System:System: An UpdateAn UpdateJaime Z. Galvez Tan, MD, MPHJaime Z. Galvez Tan, MD, MPH

jzgalveztan@gmail.comjzgalveztan@gmail.com+63917 853 7798+63917 853 7798

A Community Participatory A Community Participatory ExerciseExercise

On a separate sheet of On a separate sheet of paper, write one word paper, write one word

that you feel would best that you feel would best describe the Philippine describe the Philippine

Health Situation Health Situation

The Philippines The Philippines 20062006

High population growth High population growth raterate

Trends in Population and Development

At 2.36% population growth rate:

2 M annual increase in population or 5,479 per day increase

206 babies born every hour or 4 every minute

85 M estimated population at the end 2005 (NSO)

The Good The Good News…..News…..

BUTBUT

Infant Mortality Rate

38.4 3630

0

20

40

60

80

100

1993 1998 2003

Year

per

100

0 li

ve b

irth

s

Source: National Statistics Office, 2006

020406080

100120140

PerThousand

Philippines 100 35

Thailand 132 29

Korea 115 10

1950-55 1995-2000

Infant MortalityInfant Mortality

… declining but still higher than other Southeast Asian countries

Child Health

Maternal Mortality Ratio

209

172

0

50

100

150

200

250

1993 1998

Year

Ra

tio

Source: National Statistics Office, 2006

172160

10695

80

4

0

50

100

150

200

Phils. Viet. Thai. China Malay. Singa.

Source : 1998 NDHS, US Census, Thai Health Police

Maternal Mortality Across Asian Countries

1989-90 1992 1993 1996 1998 20012003

Underweight

Stunting

Wasting

Overweight

0.6 0.70.4 0.5

0.4 1.0 1.4

5.0 6.66.7

5.2 6.0 6.3

5.3

39.9

36.834.3 34.5

34.0

31.4

29.934.5

34.0

29.9 30.8 32.0

30.6

26.9

0

5

10

15

20

25

30

35

40

45

% p

rev

ale

nc

e

OverweightOverweight

Trends in the Prevalence of Malnutrition Trends in the Prevalence of Malnutrition among 0-5 Year-Old Children,among 0-5 Year-Old Children,Philippines 1989-90 to 2003Philippines 1989-90 to 2003

UnderweightUnderweight

StuntingStunting

WastingWasting

Yes Declining Yes Declining Malnutrition but…Malnutrition but…

A cohort of A cohort of 3.3. million3.3. million children children 0-5 years old remain in chronic 0-5 years old remain in chronic malnutrition throughout their malnutrition throughout their pre-school years.pre-school years.

This means one fourth of Filipino This means one fourth of Filipino pre-school children are always at pre-school children are always at high risk of mental and physical high risk of mental and physical retardationretardation..

1989-90 1992 1993 19961998

20012003

Underweight

Stunting

Overweight

0.10.2 0.6

0.4n

0.8 1.3

44.842.8

42.2

39.140.8

41.1

35.834.232.5

30.5

28.330.2

32.9

25.6

0

5

10

15

20

25

30

35

40

45

50

% p

rev

ale

nc

e

OverweightOverweight

UnderweightUnderweight

StuntingStunting

Trends in the Prevalence of Malnutrition Trends in the Prevalence of Malnutrition of 6-10 Year-Old Children,of 6-10 Year-Old Children,

Philippines 1989-90 to 2003Philippines 1989-90 to 2003

Yes among elementary Yes among elementary school children, declining school children, declining

malnutrition but…malnutrition but…A cohort of 3.6 million school children A cohort of 3.6 million school children

age 6 to 10 years old remain in chronic age 6 to 10 years old remain in chronic malnutrition during their school years. malnutrition during their school years. They would likely not perform well and They would likely not perform well and most likely drop out.most likely drop out.

This means one fourth of our future work force This means one fourth of our future work force will be physically and mentally deficient.will be physically and mentally deficient.

Proportion of Mothers Delivered By A Health Professional

28.2 34.2

59.8

0

20

40

60

80

100

1993 1998 2003

Year

Pro

po

rtio

n

Source: National Demographic and Health Surveys ; National Statistics Office, 2006

Proportion of Mothers Delivering at Home

71.565.5 61.4

0

20

40

60

80

100

1993 1998 2003

Year

Pro

po

rtio

n

Source: National Demographic and Health Surveys; National Statistics Office, 2006

Quality of Antenatal Care Quality of Antenatal Care 20032003

Percentage of women who received the Percentage of women who received the following during antenatal care:following during antenatal care:

Blood sample taken – 37.6Blood sample taken – 37.6 Urine sample taken – 46.7Urine sample taken – 46.7 Informed of signs of pregnancy Informed of signs of pregnancy

complications – 49.1complications – 49.1 Height measured – 59.7Height measured – 59.7 Weight measured – 87.9Weight measured – 87.9 Blood pressure taken – 90.3Blood pressure taken – 90.3

NowNow

The Bad The Bad News……News……

1965 1970 1975 1980 1985 1990 1995 2000 2002

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%P

erce

nt

Year

Death by Attendance in 5-year I ntervals, Philippines 1965-2002

Unattended

Attended

Source: National Statistics Office, 2006

Proportion of Infants Exclusively Breastfed

42.7

57.752.5

26.4

40.1 35.4

13.220 16.1

0

20

40

60

80

100

1993 1998 2003

Year

Pro

po

rtio

n

<2 months

2-3 months

4-5 months

Source: National Demographic and Health Surveys; National Statistics Office, 2006

Proportion of Fully Immunized Children

69.458.2

65.3 64.5 65.2 61.3 62.9 59.9

0

20

40

60

80

100

1993 1997 1998 1999 2000 2001 2002 2003

Year

Pro

po

rtio

n

Source: National Statistics Office, 2006

10.48.2 8.5

35.338

40.1

0

5

10

15

20

25

30

35

40

45

199319982003

Deficient SR< 10 ug/dL

Deficient and Low SR < 20 ug/dl

Prevalence of Vitamin A Deficiency among 6m – 5y old children, 1993- 2003

Vitamin A Deficiency: a major cause of childhood illnesses and deaths

49.2

25.7

42.0

56.6

29.6

35.6

65.9

29.1

37.4

0

10

20

30

40

50

60

70

6 mos - < 1 y 1 - 5 y 6 - 12 y

%

199319982003

Prevalence of anemia among children: 1993, 1998, and 2003

Anemia: a major cause of poor school performance Anemia: a major cause of poor school performance and school drop-outand school drop-out

0

50100

150

200

250300

$

Bottom 30% Middle 30% Top 40%

Income Class

Expenditures for Medicine within the Mean Health Expenditure

Source: The Filipino Poverty Report Card, World Bank, Social Weather Station 2001

Why the Good News Why the Good News but….but….

Why the Bad News….Why the Bad News….

An analysis of the An analysis of the some of some of the the immediate causesimmediate causes

2.53

2.03

1.81

1.55 1.6

1.84

1.4

1.1

0

0.5

1

1.5

2

2.5

3

%

1998 1999 2000 2001 2002 2003 2004 2005

Year

Proportion of the Health Budget in the Philippine National Budget

Source: National Statistical Coordination Board, 2005

2.9 2.9

3.2 3.2

3.4 3.43.5

3.43.3

3.2

3

2.7

2.9

0

0.5

1

1.5

2

2.5

3

3.5

%

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Year

Percentage Share of Health Expenditure to GNP, Philippines, 1991-2003

Source: National Statistical Coordination Board, 2005

Local Government Health Expenditure

27.6 34.58

118.7

174.52208.6

249.58

316.84346.78

387.02

444.12 445.16

356.76

0

100

200

300

400

500

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

bil

lio

n U

S d

oll

ars

Source: National Statistical Coordination Board, 2005

Philippine Health Insurance Program, 2003

70%

43% 27%

15%

11%

2%2%

Non-members

Privately Employed

Government Employed

Individually Paying

Indigents/Sponsored

OFWs

Others

Source: NDHS, 2003

If all data accounted for, at least 100,000 Nurses left in the last 10 ten years – the highest volume in

history

Note: full USA data not Note: full USA data not accounted for accounted for

Source: Source: Professional RegulationCommission, 2004

Deployment of Filipino Nurses, 1994-2003

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

VOLUME

YEAR VOLUME

1994 6,699

1995 7,584

1996 4,734

1997 4,242

1998 4,591

1999 5,413

2000 7,683

2001 13,536

2002 11,911

2003 18,450

TOTAL 84,843

Average (10-year period)

8,931 nurses/year

Nursing Licensure Board Passers

61.45 58.2454.22

50.0255.79

49.86 49.253.5

44.75 48.18 49.68 51.6

010203040506070

Year

board passers

Source: PRC, 2005

Source: Source: Calculated, PRC Data, 2004

Performance of Schools in the NURSING Licensure Examination, 1994-1998, 2001, and 2002

 YEAR Passing Rate

of less than 50%

% Passing Rate

of 50% & above

% Total

1994 - 1998

68 38% 113 62% 181

2001 116 48% 124 52% 240

2002 150 63% 87 37% 237

68

113 116124

150

87

0

20

40

60

80

100

120

140

160

1994 - 1998 2001 2002

PassingRate ofless than50%

PassingRate of50% andabove

Source: Source: Professional Regulatory Commission, 2004

Nursing Board Performance 

YEAR Number of Examinees

% Increase

Number of Passers

% Increase

Passing Rate

1994 41,459 - 25,477 - 61.45

1995 38,689 -7% 22,532 -12% 58.24

1996 25,163 -35% 13,643 -39% 54.22

1997 19,546 -22% 9,776 -28% 50.02

1998 17,101 -13% 9,541 -2% 55.79

1999 13,152 -23% 6,558 -31% 49.86

2000 9,270 -30% 4,601 -30% 49.63

2001 8,269 -11% 4,430 -4% 53.57

2002 9,449 14% 4,228 -5% 44.75

2003 15,606 65% 7,526 78% 48.23

2004 25,294 62% 12,581 67% 49.74%2005 50,280 25, 951 51.60%Average

(12-year period)

22,785 examinees/year

12,267 registered nurses/year

The Phenomenon The Phenomenon of Doctors of Doctors

Becoming NursesBecoming Nurses““Nursing Medics”Nursing Medics”

Only in the Philippines Only in the Philippines before 2005before 2005

(now no more)(now no more)

Doctors Becoming Doctors Becoming NursesNurses

Around 3,000 doctors have left as Around 3,000 doctors have left as nurses since 2000nurses since 2000

In 2003-2005, more than 4000 In 2003-2005, more than 4000 physicians took the Philippine Board physicians took the Philippine Board of Nursing Licensure Exams of Nursing Licensure Exams

Currently around 3,000 doctors are Currently around 3,000 doctors are enrolled in 45 nursing schools enrolled in 45 nursing schools offering customized courses for offering customized courses for physicians all over the countryphysicians all over the country

Nursing Medics: Who Are Nursing Medics: Who Are They?They?

Around 80% of government physicians Around 80% of government physicians have taken up or are enrolled in nursinghave taken up or are enrolled in nursing

They come from all kinds of specialtiesThey come from all kinds of specialties Their age range from 25 years old to 65 Their age range from 25 years old to 65

years oldyears old Years of practice as a physician range Years of practice as a physician range

from zero to 38 yearsfrom zero to 38 years More females than males; More females than males; They come from all regions of the countryThey come from all regions of the country

Source: Source: KII, Personal Study 2004

Consequences Series #1Consequences Series #1

Decline in the interest of young Filipinos Decline in the interest of young Filipinos to study medicine – evidenced by a drop to study medicine – evidenced by a drop of 50% in NMAT examinees with 2001 as of 50% in NMAT examinees with 2001 as baselinebaseline

Decline in the enrolment in medical Decline in the enrolment in medical schools – an average of 30%; 3 medical schools – an average of 30%; 3 medical schools have closed downschools have closed down

Decline in the applicants for medical Decline in the applicants for medical residency positions to become specialists residency positions to become specialists

NMAT Examinees (1994-2004)

0

1000

2000

3000

4000

5000

6000

7000

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Year

Exa

min

ees

Source: CEM, 2004

Overseas Filipino Workers (OFWs) Overseas Filipino Workers (OFWs) RemittancesRemittances

YEARYEAR US$US$

19991999 US$ 6.79US$ 6.79

20002000 US$ 6.05US$ 6.05

20012001 US$ 6.03US$ 6.03

20022002 US$ 7.19US$ 7.19

20032003 US$ 7.64US$ 7.64

2004 2004

20052005

US$ 8.50US$ 8.50

US$US$ 10.210.2

Source: Central Bank of the Philippines, 2005Source: Central Bank of the Philippines, 2005

0

2

4

6

8

10

12

1999 2000 2001 2002 2003 2004 2005

OFW Remittance in Billion US Dollars, 1999-2005

In Billion US$

NMATNMAT

NMAT Examinees (1994-2005)

50495360

5814 5730 5948 6121 6245 61925853

44754070

2912

0

1000

2000

3000

4000

5000

6000

7000

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Consequences Series #2Consequences Series #2

200 hospitals have closed down within 200 hospitals have closed down within the past two years – no more doctors and the past two years – no more doctors and nursesnurses

800 hospitals have partially closed (with 800 hospitals have partially closed (with one to two wards closed) – lack of doctors one to two wards closed) – lack of doctors and nursesand nurses

Nurse to patient ratios in provincial and Nurse to patient ratios in provincial and district hospitals now 1: 40 to 1: 60district hospitals now 1: 40 to 1: 60

Loss of highly skilled nurses in all Loss of highly skilled nurses in all hospitals across the countryhospitals across the country

Why these bad bad sad Why these bad bad sad sad news!sad news!

An analysis of the An analysis of the some of the some of the major major underlying causes underlying causes

IncomeIncome

Annual average family income: Annual average family income: US$2,619 (FIES 2000)US$2,619 (FIES 2000)

Poverty incidence: 34% or 25.8 million Poverty incidence: 34% or 25.8 million people (NEDA 2001)people (NEDA 2001)

Poverty Self-Rating by Filipinos:Poverty Self-Rating by Filipinos: March 2001: 64% are poor (50 March 2001: 64% are poor (50

M)M) Oct 2005: 75% are poor (64 M)Oct 2005: 75% are poor (64 M) (Pulse Asia Surveys 2001-2005) (Pulse Asia Surveys 2001-2005)

1998 1999 2000 2001 2002

1080

1040

1030 1030

1020

1000

1010

1020

1030

1040

1050

1060

1070

1080

In US DollarsSource: WDI Online, World Bank

Philippine Per Capita Gross National Income

EmploymentEmployment

Total labor force: 35 MillionTotal labor force: 35 Million Total Unemployment Rate: Total Unemployment Rate:

10.1% (LFS Oct. ’03)10.1% (LFS Oct. ’03) Total Underemployment Rate: Total Underemployment Rate:

15.7% ( LFS Oct. ’03)15.7% ( LFS Oct. ’03)

1997

1999

2001

2003

0%

2%

4%

6%

8%

10%

12%

Year

Unemployment Rate, Philippines 2003

Source: http://www.bsp.gov.ph/statistics/spei/tab46b.htm

World Economic ForumGlobal Competitiveness Report

Corruption Index Ranking1 = Least Corrupt

2002: Rank out of 80 Countries 2003: Rank out of 102 Countries

43

6877

88

34

76

5

45

61

39

92

5

0

10

20

30

40

50

60

70

80

90

100

Singap

ore

Mala

ysia

Thail

and

Vietna

m

Indo

nesia

Pnilipp

ines

2002

2003

National BudgetNational Budget

Budget deficit 2004: US$5B or Budget deficit 2004: US$5B or 35% of the national budget35% of the national budget

% of National Budget for debt % of National Budget for debt servicing: 30%-45% (2002-04)servicing: 30%-45% (2002-04)

What Can NGOs and POs What Can NGOs and POs Do About the Situation?Do About the Situation?

Advocacy Based StrategiesAdvocacy Based Strategies Local Government Based Strategies Local Government Based Strategies Community Based StrategiesCommunity Based Strategies

Advocacy Based Advocacy Based Strategies #1Strategies #1

Lobby for national policy coherence in Lobby for national policy coherence in health human resource development health human resource development (HHRD). (HHRD).

Lobby (text, write, email, call) the heads of Lobby (text, write, email, call) the heads of the 15 government agencies involved in the 15 government agencies involved in HHRD to regularly meet and speak with HHRD to regularly meet and speak with ONE voice.ONE voice.

These are: DOH, DOLE, POEA, OWWA, These are: DOH, DOLE, POEA, OWWA, CHED, PRC, PhilHealth, PITAHC, DOF, CHED, PRC, PhilHealth, PITAHC, DOF, DFA, NEDA, DBM, TESDA, DOST, DTIDFA, NEDA, DBM, TESDA, DOST, DTI

What NGOs & POs can do?What NGOs & POs can do? ConvergenceConvergence PartnershipPartnership Budget InvolvementBudget Involvement Monitoring/quality standardMonitoring/quality standard Community Management/community basedCommunity Management/community based Policy involvementPolicy involvement Political Reform/Good PoliticsPolitical Reform/Good Politics People empowerment in governancePeople empowerment in governance Development of indigenous resourcesDevelopment of indigenous resources More women leadersMore women leaders Community awareness/education for allCommunity awareness/education for all Health empowermentHealth empowerment equityequity

The Extra ChallengeThe Extra Challenge

NGOs, POs and CommunitiesNGOs, POs and Communities Can Do It !!!!!!Can Do It !!!!!!

Let’s Do It NOW !!!!!Let’s Do It NOW !!!!!

Thank You Very Thank You Very Much!!Much!!

Maraming Maraming Salamat Po!Salamat Po!Jaime Z. Galvez Tan M.D., Jaime Z. Galvez Tan M.D.,

M.P.H.M.P.H.

jzgalveztan@gmail.comjzgalveztan@gmail.com

+63917 853 7798 mobile+63917 853 7798 mobile

19982003

19982003

19982003

Underweight

Underheight

Overweight

LEGEND:

30.226.7

40.836.5

n 1.3

0

10

20

30

40

50

% p

revale

nce

Comparison in the Prevalence of Malnutrition Between 1998 and 2003 among 6-10 Year-Old Children

1998 2003 1998 19982003 2003

Under-five Mortality Rate

63.554.9

42

0

20

40

60

80

100

1993 1998 2003

Year

Rat

e

Source: National Statistics Office, 2006