 if not the most important topic for any population or individual. In 2019, our legislators passed the Universal Health Care Act or Republic Act 11223. The landmark law expands access to health services by automatically enrolling all Filipinos in PhilHealth's National Health Insurance Program. It seeks to ensure that all Filipino citizens have access to a comprehensive set of health services without financial hardship. According to our social economic planning secretary Ernesto Pernia, our medium-term plan recognizes human development not just as a means of economic development but as an end in itself. That is why the signing of the UHC law is a victory score for the health sector. We are glad that we have reached this milestone. And President Duterte on signing the law said by automatically enrolling our citizens into the National Health Insurance Program and expanding PhilHealth coverage to include free medical consultations and laboratory tests, the UHC law will guarantee equitable access to quality and affordable health care services to all Filipinos. After almost a year, the implementing rules and regulations were finally written and signed by the Secretary of Health, Dr. Francisco T. Duque. In this episode of Health Issues, we will explain what universal health care law really means. This is Dr. Teddy Herbosa and we will be talking to Dr. Emerito Faraon about the salient features of the UHC law and the issues and concerns regarding the progressive attainment of universal health care for all Filipinos. Our guest today is Dr. Emerito Jose Faraon MD. MBA is an assistant professor of the College of Public Health, former assistant to the Dean for Academic Affairs and former chair of the Department of Health Policy and Administration in the College of Public Health of the University of the Philippines, Manila. He teaches courses in Hospital Administration, Public Health Administration, Health Economics and Research Methods in Health Informatics. Emer, welcome back to Health Issues. Good afternoon, Dr. Teddy Herbosa. It is an honor again to be here. I guess we have a very exciting afternoon. Yes, let's start with the basic question. What is universal health coverage or universal health care as we call it in the Philippines? In the Philippines, actually there is still a debate on the care part and the coverage part. It's actually universal health care for us. But I think there was a long debate on the care and the coverage because the World Health Organization sees it as coverage. So, for the Philippines, it's universal, meaning all Filipinos are covered. They will not suffer from financial catastrophe. And these services are all accessible, affordable and of quality. Very good definition. So, what is the universal health care law in the Philippines? The universal health care law ensures that everyone from the barangay to the national level will be following a certain framework on how it is going to be delivered. So, it was discussed a long time. For a long time it was just an advocacy. And now, after years, I think even before it was just a journal article. So, propagated by the universal health care study group. And I think span at least two administrations to presidents before it was finally signed to law by this administration. And I think it was described by the website of the Department of Health, a progressively policy. Progressive attainment of universal health care. So, it's not an endpoint yet. Yes. So, it's a progressive work in progress. It's work in progress in doubt. So, when you say universal health care or universal health coverage, who are we trying to cover? All Filipinos. So, basically all Filipinos. So, if I'm a foreigner, I'm not covered? I don't think so. It is the resources, our resources for Filipinos. Because before you still have to show your card, you have to be a member. But now, I think just as long as you are a Filipinos citizen, and that is what the universal there means as far as the country is concerned. So, our constitution actually provides that health care is a right. And that right is supposed to be provided by government, but this kind of right is a progressive right. It's not like right to life, talagang you're alive. You're actually alive. But the right to health care or access to equitable, affordable health care is a progressive one, correct? Because it's an imperfect way of delivering it. It's dependent on how the government will give it to you. And government is of two types, local and national. And that there is a complexity in the local because we have a different way of interpreting the law. Much like the Bible, everyone interprets it differently. So, let's talk about that. It seems that universal health care law is actually about tweaking or reforming the health system. Yes. Can you describe the health system prior to the law and where we plan to bring this health system in the future with the presence of the law? I think before, well, depends where you start. Before it was actually before the Pimintel law, which was the devolution law, it was centralized. So, all services stem from our lead health system, which is the Department of Health. Like DEPED. DEPED is centralized. All schools are under DEPEDs and are run by and employed by teachers from DEPED. But what happened during the Pimintel law? Pimintel law, you're referring to the local government code. Local government code, 1992. 1992 code. What happened there? So, now it's just like the parent having children. The children can already defend for themselves. So, you part. So, these are the mayors. These are the local government units. So, they decided to give parts of the health system to the local government, correct? Decision making. Decision making. Resource allatment. Employment. Yes, all of those things. So, after that, what happened? Department of Health took care of like 70 hospitals, right? Yes. And regional centers. Yes, sir. And then the local government, the governors took care of? Of the local primary health. The hospitals, the provincial hospitals. Yes. And then the mayors took care of the health centers. The health centers. Centers and the health districts. So, very interesting. So, we fragmented our health system in a way or we decentralized. Some people say fragmented. Some people say. It centralized. Decentralized and closer to the people. It depends on the perspective. So, I think it has its advantages. It also has its disadvantages. If you are very efficient with your managerial, administrative prowess in the local setting, then it will work. So, we have to define a term that comes out often in Universal Health Coverage. It's called equity. Another big word. This local government code created inequity for the poor. Yes, because these resources, not all municipalities, not all local government units are rich or first class. Municipality is first class, second class up to fifth, sixth class. Fifth, sixth class. The sixth class are the poorest. First class is more well-being. So, the income resources are not the same. And with income, because that's the primary thing, comes human resources, equipment, even the skills needed. And there's always the tendency, of course, to go to the more populist areas. So, when I say you go for universal health care or universal health coverage, yes, I agree with you in principle. Yes, I do want that if I am the mayor. But my capacity, my skills, my resources, I don't think I can do it the way you envisioned it. So, I think there is that sort of divide. So, equity, while equity will be there. In equity, the drive for equity is there, the principle of the law. But in equity will exist because much as I, if I was the mayor, would like to deliver the services as you envisioned it. I cannot because I'm limited by what I have. So... But that also came in the time where in the government we didn't have enough funds for health. The health budget wasn't high. So, the private sector continued to develop. You can get access to health care but you will have to pay a private hospital for all the modern care, medicines, anti-cancer. But the poor were left with minimal. The government funding was minimal and the meager budget had to be divided to a larger population. And there's also the question of quality. Because of that, the quality will also suffer. Yes. So, they say that there's this study I haven't found it yet. But it sounds logical. So, word association between government hospitals and a private hospital, they say that the people go to the private hospitals for quality. But it is expensive. Then they go to the government hospitals not so expensive but affordable. But it's affordable or probably free or comes with a discount. So, can you define that? So, what is affordable health care? So, we've defined inequity as the divide between the economics of the health services delivered. So, what is affordable? Affordable is something that will not drive you into financial catastrophe. Affordable is something that after getting sick, I will not be very poor afterwards. I will not, I will still be able to pay the tuition fee of my children. I'll be able to pay the rent of my whatever. Maybe we can describe to the viewers like some of the health systems in other countries like the Scandinavian countries or even the UK where there is a national health service as long as you are a citizen you will get health care. You are covered. You are covered. From the time you are born to the time you are in the tomb you are covered by the government and if you need open heart surgery the government will take care of you. Yes. So, I think in those countries they're very, I mean, they were ahead of us in interpreting it and they are not, as you said, fragmented as we are. So, they might be also subdivided but there is that centralized notion of if they give money. You said single payer or a pool of money. A good percentage of that really goes to health such that if it's curative, preventive, everything, all those sets of services will be delivered to the person's concern. So, this passage of the universal health care law is like a stampad of approval that the government does value health and life of its human, of its people and its population. The fact that now they are creating a framework of a health system that is affordable and equitable to the Filipinos. Yes, but it's a progressive. Okay, so let's talk about progressive. What services can be delivered as of now? Like now when I ask people about feel health. Feel health will cover only like 30% of your expenses when you're hospitalized and it doesn't cover your outpatient diagnostic and your outpatient care. What changes with the law? What changed with the law is that I think the primary focus now I mean it's like educating the people at the same time. Debate from the curative. Debate from the massive treatment which as you know entails more cost for the government and for the people. That's why out of pocket is also increasing. So more on the primary health care services. Preventive side. So this is part of the as you know there's NCDs. We have the triple burden already of the disease. So that's NCDs non communicable diseases, infectious diseases and of course the diseases of and it will I hope it will also concentrate not only on primary health care but also on health promotion and prevention. Yes. So maybe we can define that to the people. So what is primary care? What is health promotion? What is primary prevention? Okay. Well we start first with primary health care. I think that's the basis. I think this was there long before 70's Alma Ata. Health for all. Yeah, for all by the year 2000. 1974. And so 2000 came and there was no health for all. Health inequity in the whole world. And if you get at Tesaro's probably you would see that health for all. It's actually universal. Universal, correct. So that's still universal health care. So it's I think it's just a rolling progressive thing but that primary health care never happened but for so many reasons of course it could be said that it creates jobs because if it's business driven you earn more money. So it gives these corporations more money more jobs. You create more jobs. But the notion of universal health care is preventive so that you do not end up with a terminal illness. And you get to catch the symptoms first. So that's the primary. That's why it's primary. So secondary and tertiary you probably end up in hospital getting confined. Of course there are those cases as well but nipping it in the bud. I think it's the So let me when the fill health law was created or the national health insurance act of 1994 when it was created the fill health was designed so that it would take care of the people's hospitalization needs. And that continued on but its support value or money was only a small proportion. So the people still had to pay a lot for hospitalization. What changes now because I think in the UHC law they're saying that fill health will pay for consultation in the primary health care clinic and laboratory test in the in the health care clinic. What changes now and how will this be implemented? As I said as long as you are Filipino you are covered. So patients when they come and they consult they have different illnesses so it could be terminal it could be chronic so it could be a primary ailment. So fill health as the financial arm of the universal health care would be able to deliver both kinds of services. So the whole spectrum be it primary be it secondary and be it tertiary. So the but the emphasis again it's in italicized words is primary. So I'm also winning away the patients from thinking chronic because part of it is also a education and health promotion but in a subtle way delivering it through the financing part. So I will not So they've now decided to focus on primary prevention and even secondary prevention. Yes. If you have non-communicable disease they prevent you if you have hypertension make sure they control your hypertension so that you don't get a stroke or a heart attack. Correct? Another key to that is the the referral system. So it's like hospitals level three hospitals those are tertiary hospitals are for those with chronic illnesses. So your barangay health station your rural health unit probably anything that is in the municipal area would be towards preventive and primary. Can you describe to me how that will happen? So I I am thinking about a headache or a stomach ache. So you come to the hospital the first notion of a Pilipino is go to my doctor and where is your doctor and of course in the hospital. So that will be kind of remedied or tweak it will you will be referred back to where you are. So something like that you will be in that service delivery network that's how they term it where you belong and if you have gone there already you have this certification that you have been seen and of course if the diagnostic show that you really indeed need tertiary care then that is the time that you will go there. So I think that that referral system that financing part is really tailored to go into preventive and you go if you're yeah chronic or terminal you go to the right mechanic shop if you're a car. How does that work? I have I have let's say diabetes I cannot go to my endocrinologist I have to go to a primary healthcare center Yes you have to go to the primary network first. I am referred to the endocrinologist and the usual notion of course is where you live so what is near to you so we're a sure place of residence so everyone will have a service delivery network so that's very different from the way people access healthcare today because the way people access healthcare today is Dr. Bosa do you know anyone who is a good endocrinologist and then I refer them to the endocrinologist and they go straight to them so you mean that cannot happen anymore or it can still happen if you can't pay yes but feel helpful not pay my visit to the endocrinologist no no there's this slow education through that kind of setup that you will that doctor probably or that expense whatever consultation that was will not get the correct reimbursement or will not be in reverse totally unless they jump the queue the the referral system okay now I'll ask you we have a lack of doctor most of our doctors are specialists because I was in med school everybody wanted to become a specialist I'm a surgeon so it took me years of training to become a doctor but who will take care who where will we get the primary physicians or we call that family and community medicine right so where are we going to get all this family physicians that will take care of a hundred million Filipinos it does not exist right now correct at this point so work in progress so the department of health I think is making talking to primary care positions building that network primary health care strengthening that so our schools produce the doctors I think there has been changes in the curriculum now to orient our medical not like the ones we did before wherein you enter school and of course after medical school enter into a residency program where you are expected to become a specialist correct now so our country our Filipinos are have a certain discrimination toward the generalist and primary care they prefer to see the specialist immediately because the thinking is the specialist is good because they had more years of training and that is a mindset that needs to be changed it needs to be changed yeah because my friends from the UK they cannot access a specialist without going to their assigned GP they call it in the UK GP a GP actually is a general practitioner but they can diagnose and without his referral without his gate keeping you cannot access an orthopedic surgeon and then doclinology is a surgeon like me and we don't have that yet now yeah so how do we build that that's the big question so it's a work in progress as I've told you the department of health right now is trying to beef up its primary health care approach starting with of course the universities the universities who produce the health professionals and orient them into more family community approaches primary health care how of course by changing the curriculum of course in the University of the Philippines we have talks already of changing the curriculum and you know that and in the college of medicine where I teach yes the goal is community oriented medical education yes so this is not the curriculum where we were oriented to before so but it as I said it will not happen overnight correct and so the education would begin with the educators who are the doctors facing the patients so the university and the other medical schools have a big role to play yes in shifting the focus of the young doctors the medical students to understand universal health care systems and primary care systems because they are the first ones to have contact with the patients so I think they also play a role in being educators to the patient on how to shift that mindset that if I have a stomach ache or a headache I should go to my specialist doctor in the hospital but you know I'll tell you that that was very hard because as a medical student when the person that came in to lecture in our class was a surgeon he was driving a Mercedes Benz he was wearing a nice signature tie and signature belt and shoes so I said I want to be like him you know he has lots of money then the person from family and community medicine would enter and he was war wearing jeans and t-shirt his hair was scruffy so he didn't epitomize a model that I wanted to be as a doctor how can we shift that role modeling for our young people I guess we have to go back to the basics our model doctor is actually Jose Rizal Jose Rizal I think didn't care for Mercedes Benz didn't care for but he trained in Germany but because there was no nothing at that point during that time so I think the model would be service service yes you can still get into residency yes you can still be a specialist but serve and observe the countryside first serve this community where primary health care is supposed to be delivered so actually I'll second your motion because I became a surgeon and I started operating in remote villages and the gratification is actually great in fact I'm flying off to Mindanao again in a couple of days to do free surgical mission to offer it to the people who have no access to specialists so I think there's a gratification as well to being what you're describing and it is just not communicated to the medical students that offering of service to the poor and to the people because the mindset is just like in internship you get to rotate to all disciplines now you get to rotate to the countryside first and then choose your residency if you still would like to go into family medicine or a specialist like a cardiologist so but that is I'm stating it very fast but actually it's a yearly it's a slow progress so from the university to the doctors out there practice out there practice to the patient patient now knows the referral system I think it will come in faces before you will really know the notion that it's universal health in fact when we passed the law and there was more money in the health system our government hospitals became more overcrowded because every Filipino with or without field health can now go to the hospital and access health services because before they will not go I would see patients in the ER and I would ask them why didn't you come to the ER last week when you were feeling bad I didn't have money but now money is no longer an issue because there is provided for that they cannot be denied health care and strengthening the local health system before you go to the hospital okay so now you've described the word the word is health system we've talked about manpower and professionalizing creating more GPs and family physicians and community doctors so that's going to be a struggle the university has a role in that so let's talk about the health system what will be the role of the department of health the role of the local government hospitals the role of medical centers or what I call apex hospitals how will the whole architecture look like because it's a fragmented system they will now create near perfect networks to deliver this because it's so many fragments parang matakot ako doon sa word mong near perfect I cannot say it's perfect so it's near perfect so it's still a work in progress as we go on so under the universal health care law there will be service delivery being made effective in the local health system the local health system as they defined it in the implementation sites would be composed of of course the barangay health stations the municipal health office the provincial health office with a tie up with either the district hospital the provincial health hospital acting as the part answering for the therapeutic treatment part while the local where you will begin your navigation should be the primary health care so you cannot go directly to the hospital without being cleared first by your either your municipal health officer your rural health position your public health associates there it's a team that is really focused on primary health care before going there so you could have a terminal illness but still you would probably be seen first in that primary health care setting before being I see that as implementable and doable in the public health system in the government but our health care system is also composed of the private sector and the private sector attracts paying people that will jump the gun we they pride themselves of specialists expensive tests that you you know they have they advertise their new city scan their new pet scan the latest ultrasound so how do we that is the mindset change is divided that is the mindset that we're trying to break and educate the people we so you said that in the constitution health is a human right and the universal health care law tries to guarantee that but with that comes also the education that they should be involved in the decision making of their own health so it should begin again in the primary setting so how do you how do you say that the marketing of the first class city scan it doesn't necessarily translate into getting well so so I think it should be the doctor underneath it's advertising it's marketing it's basically saying we have the best and most modern machine so it doesn't translate to better health care for Filipinos in trying to win that perspective the department of health I think will try or is already trying to shake hands with the private sector so they're trying now to involve even those physicians with private practices so you're probably a rich physician coming from a rich family so you have this family-owned clinic you will also be accorded that offer to join that network because that is the network that is composed both of the public and the private so the network will be a geographic network and people will will be both the public hospitals and the private sector hospitals should be inclusive yes and they know and they know the navigation system and they know the network so if you're the one with all the superb technology you will say hey did you go with the rural health unit first for the Barangay Health Station because you probably do not need this tests so that is the ideal notion of how the navigation and the the network should work so that's a local health system a local health system with the Apex Hospital with different spoke so hub and spokes model yes so you have at the periphery primary health care and then they refer to an Apex or the either the private or the medical center public medical center to provide tertiary care but you have to help them also learn that tertiary is different from primary so that at the not because there is this city scan that would a city scan will not heal the headache so yes but it will entail more experience and it not it does not necessarily translate that if you shell out big money you get cured correct so we're trying to improve on that mindset and tell these people that that's health literacy health literacy that's another topic we need to discuss not an overnight thing correct that that will happen because we have to make our people literate about what is vital in health care and what is just an icing on the cake yes but i see probably 20 years from now it is really a very very good system functioning and this universal health care law which we started now has a as a happy ending i have a few minutes left and i'd like to ask you about issues and concerns about this nice picture that you're painting going to this attainment of universal health care i think we will have many bumps because the way you describe it is we have human capital development to do we have health systems improvement to do we have education and we need primary care and we need health promotion and it's a lot of work and as an asymmetry what i call an asymmetry of information of what it really is what universal health care law so what is asymmetry of information and not not there is an imbalance of what the patient knows and what the doctor knows so there is also an imbalance of what the department of health tries to say and what the patient knows it is always the patient because that is our client who should know what it is really so and the second part is the governance part the the ones in the local first we need to put the patient in the center of this system yes so he is he is the one being served by the system yes we must be able to address his needs and must be able to make him satisfied yes and then the second one is the the the leadership and governance part of the health system so these are the local government heads so they are very very vital partners they are not doctors some probably are doctors and that makes it easier for them to implement UHC so i call that leadership and governance leadership and governance next part is really making sure that these systems they don't work by themselves yes they must be led and they must have a governance system that is not corrupt that is not that is efficient that is efficient very ideal correct yes and another i think missed point is health information so health information i i i i did not see it in the highlights in the IRR yeah even in the law i i did not see it being highlighted like service delivery leadership we're talking about health information digital health or are you talking about a centralized system knowledge management knowledge management knowledge management probably a better term okay so a knowledge management in that local health system such that the mayor who probably is not health oriented is not a doctor would probably be able to allocate his resources or her resources more efficiently towards the end goal i know what you're talking about because i've seen this with my classmates who studied in canada because canada has these otawa rules on knee play head injury rules so who goes to the next echelon of care is decided by evidence-based guidelines that helps the primary care physician and we need to develop those because we cannot get na kanidyan and apply it in the philippine health system but if you don't have an information infrastructure it will you know when you when you decide when you make a decision especially this authority you need good information you cannot decide just on a whim so you cannot decide just because that person voted for me it's not a good decision so you need updated reliable information and that is electronic probably so that it would be better so that is the part that will also help help promotion health education navigating the system making it work from primary health care to the tertiary level of care very interesting any final words to our view words here out there about universal health care we will hold your hand but bear with us I am from the academy so bear with us in the education part this will be made perfect soon well with that I'd like to thank you all for covering health issues and concerns regarding the universal health care law it seems this is work in progress we continue to strive for and achieve universal health care for all Filipinos and we do hope that this law will succeed and will benefit each and every Filipino out there Maraming salamat goodbye and thank you very much