THEMES & DEBATES

The Health of the Filipino People under the Duterte Administration

Seiji Yamada, MD, MPH.

Abstract health of the Filipino people will be affected by The Republic of the is character- what Duterte is able to accomplish during his ized by severe social and economic inequalities, six-year term. with 26% of the population in poverty. Gov- ernment spending on health and access to Introduction healthcare services has been limited. Garnering The election of Rodrigo Duterte to the presi- the vote of many poor Filipinos, Rodrigo Duter- dency of the Republic of the Philippines on te was elected to the Presidency of the Republic May 9, 2016 represented a departure from the of the Philippines on May 9 and inaugurated on usual political landscape of the nation. Inaugu- June 30, 2016. In the Western media, he has rated on June 30, 2016, Duterte took over from been vilified for his off-the-cuff remarks as the the Benigno S. Aquino III administration. Will "Trump of the Philippines" and for the law-and- Duterte’s administration lead changes in the order policies of his tenure as Mayor of Davao social and economic order? Will changes in the City he has been called “The Punisher” or social determinants of health lead to an im- "Duterte Harry." In reality, however, he is a provement in the health of the Filipino people? more complex figure, who made peace with This editorial briefly reviews the health of Fili- Muslims and Communists while serving as pinos and salient characteristics of the Mayor. Since his election, he has included left- healthcare system in light of the changes that ists in his cabinet and declared a unilateral may be enacted by the new President. ceasefire with the Communist insurgency. He Duterte does not belong to one of the mega- has vowed to institute social policies to uplift wealthy, hacienda-owning political dynasties the poor, including improvements in healthcare that have long controlled regional and national access. The oligarchy will not give up its privi- politics in the Philippines. For 22 years he has leges and its holdings easily, however. The been the Mayor of Davao City, the country’s third most populous municipality, located on Author, Degree: Seiji Yamada, MD, MPH. Mindanao, the southernmost large island in the Title: Professor archipelago. The law and order policies of his Affiliation: Department of Family Medicine and Community Health, John A. Burns School of Medicine, mayoral administration led to a lowering of University of Hawaiʻi at Mānoa. crime rates. Duterte made peace with armed Email: [email protected] insurgencies among Muslims and Communists Submitted: 7/20/2016 and accorded representation to Muslims and Conflict of interest: None indigenous peoples within the municipal admin- Peer-reviewed: No

Social Medicine (www.socialmedicine.info) Volume 10, Number 2, August 2016 - 70 - istration. Since he assumed the presidency, ex- vulnerable, and social justice shall be pur- trajudicial killing of drug dealers have led to sued, even as the rule of law shall prevail at accusations of vigilantism and human rights all times. abuses. My administration shall implement a human During his presidential campaign, Duterte approach to development and governance, vowed to improve the lot of the poor. In Febru- as we improve our people’s welfare in the ary 2016, he pledged that if elected president, areas of health, education, adequate food he would require all private hospitals to set and water, housing, environmental preserva- aside 20 to 30 beds for the poor, with their ex- tion, and respect for culture.2 penses paid for by the government. In a vow This was followed by an announcement of a that runs contrary to Catholic doctrine, Duterte unilateral ceasefire with the CPP-New People’s also pledged to make family planning more available to families that have difficulty raising Army-NDF. their children - in order to slow down popula- 1 tion growth. The health of the Filipino people Soon after his election, Duterte made an of- Classified by the World Bank as a lower fer to the Communist Party of the Philippines middle income country, the life expectancy at National Democratic Front (CPP-NDF) that the birth in the Philippines is 65 for men and 72 for Left could recommend ministers for four posi- women (2015).3 In the U.S. it is 77 for men, and tions in his cabinet (initially suggesting social 82 for women.4 The total expenditure on welfare, agrarian reform, labor, and the envi- healthcare per capita is $287 (2013);3 the U.S. ronment). Given that the CPP has been under- spends $9146 per capita.4 ground since its founding, this is unprecedented in the history of the Philippines. Duterte has Health services and health worker since named members of his administration distribution suggested by the Left. Of note, the post of the The low per capita health expenditure is re- Secretary of Health was not offered to the CPP- flected in the general lack of availability of NDF. The incoming Secretary, Paulyn Jean healthcare services. Moreover, existing ser- Rosell-Ubial, was an assistant secretary of vices are distributed unevenly, with many im- health in the outgoing Aquino administration. poverished, rural, and mountainous areas lack- Duterte suggested in his first cabinet meeting ing health workers and therefore health ser- that she travel to Cuba to learn from its health vices. Certain social groups such as Muslims 5 system. and indigenous peoples experience exclusion. Progressives maintain that seven of ten Filipi- In his July 25, 2016 State of the Nation Ad- nos die without receiving medical attention. In dress, Duterte declared the following: addition, many of those who have received With this, my administration shall be sensi- medical attention are unable to afford the medi- tive to the State’s obligations to promote, cations or procedures appropriate for their con- 6 protect, fulfill the rights of our citizens, es- dition. pecially the poor, the marginalized and the The salaries of government health workers are low. In 2012, professional nurses earned an

Social Medicine (www.socialmedicine.info) Volume 10, Number 2, August 2016 71 average monthly wage of 11,488 Philippine pe- pete with private institutions. As noted by sos (Php), approximately US $250. Medical Howard Waitzkin, doctors earned an average monthly wage of Php 7 Despite its often ambiguous definition, UHC 22,870 (approximately US $497). [Universal Health Coverage] usually refers Wages that are too low relative to the cost of to a financial reform extending insurance education and the cost of living prompt many coverage in varying degrees to a larger part health workers to work overseas. The Interna- of a country’s population. UHC does not tional Organization on Migration reported that mean “healthcare for all” (HCA) – a in 2012, 15,655 Filipino nurses were hired 8 healthcare delivery system that provides abroad. The Philippines is the country that con- equal services for the entire population re- tributes the largest number of nurses to the rest 9 gardless of an individual’s or family’s finan- of the world. It is third after India and the cial resources.11 U.K. in the number of physicians it contributes to the rest of the world.10 Hospital corporatization and privatization Under the Aquino administration, a number Healthcare financing of hospitals that were formerly government- The Philippine Health Insurance Corporation owned and run have been corporatized or pri- (PhilHealth) was established by legislation in vatized in public-private partnerships (PPP). As 1994 and amended in 2013. Enrollees make corporatized institutions are responsible for contributions to the health insurance parastatal their own funding, they focus on admitting corporation. In order to qualify for benefits, higher paying patients; even the poor are members must have made three monthly pay- charged user fees. For example, the Philippine ments within the previous six months. Phil- Heart Center has been transformed to attract Health then pays health providers and facilities private patients. The National Kidney and for the costs incurred for medical care. For the Transplant Institute has sought to transfer its indigent patients who had previously received indigent patients onto PhilHealth. This means, medical attention at nominal or no cost at gov- patients must face significantly increased out of ernment facilities, and whose care was therefore pocket expenses for hemodialysis, medications, funded by the government, PhilHealth shifts a and hospital admissions. Indigent hemodialysis portion of the cost to the user, who must make patients are being encouraged to switch to peri- membership contributions. As more patients toneal dialysis, which is difficult to conduct if utilize private facilities, government funding sterility cannot be ensured in the home. While that previously went to public facilities gets the above institutions are national referral cen- shifted into reimbursements to private provid- ters, regional centers are also undergoing corpo- ers. ratization and privatization. The Aquino administration thus directed The case of the Dr. Jose Fabella Memorial more funding to PhilHealth and less to direct Hospital came to a head during the transition service provision at public hospitals.5 With the from the Aquino to the Duterte administration. goal of Kalusugan Pangkalahatan (or Universal The 700-bed hospital, with “the world’s busiest 12 Health Coverage) the Aquino Health Agenda maternity ward” delivers ~60 infants per day was intended to transform healthcare financing in the summer and ~80 infants per day from 13 such that public institutions are forced to com- September to December. The Health Alliance

Social Medicine (www.socialmedicine.info) Volume 10, Number 2, August 2016 72 for Democracy and the Network Opposed to hungry. Land grabbing by the gentry and mul- Privatization of Public Hospitals and Health tinationals is often enforced with violence. Care Services have worked to keep Fabella As mining interests degrade the environ- Hospital open by organizing actions in front of ment, not only is farming land lost, but waste the hospital. While the outgoing Secretary of products and toxins contaminate the waters and Health, Janette Garin, said that Fabella Hospital the land. This has consequences for human will not be demolished, and that all workers will health. be retained,14 incoming Secretary Rosell-Ubial has said that she will be reviewing the plans for Potential for changing the social Fabella.15 determinants of health With portfolios such as social welfare, agrar- The social determinants of health ian reform, and labor assigned to the Left, the Among the social determinants of health that Duterte administration offers a potential open- affect the Filipino people are poverty, unem- ing for changes in the social determinants of ployment, landlessness, geographic remoteness, health. On the day of his inauguration, Duterte environmental degradation, vulnerability to dis- invited leaders of Bagong Alyansang Maka- asters, and social exclusion. While the Philip- bayan (BAYAN), who were holding a street pine economy attained a 6% growth rate in rally in support, into Malacañang Palace where 2015, 26.3% of Filipinos (26.5 million of 100.7 they presented him with a fifteen point “Peo- million) were living below the poverty line, de- ple’s Agenda for Change” covering the five ar- fined by the Philippine Statistics Authority as eas of economy, social policy, governance, the minimum income to meet basic needs, in- peace and human rights, and national sovereign- cluding food. Further, 12.1% (12.2 million) ty and foreign policy.18 One central item is were living in extreme poverty, defined as ina- genuine agrarian reform, with the free distribu- bility to afford three meals per day. Certain re- tion of land to landless peasants. When he was gions are more impoverished. In the Autono- an Anakpawis (a peasant & labor party) con- mous Region of Muslim Mindanao 59% of in- gressman in the House of Representatives, the habitants live below the poverty line and 30.1% new Agrarian Reform Secretary Rafael Mariano in extreme poverty.16 In 2015 the official unem- proposed such legislation.19 By breaking the ployment rate was 6.3%, and the underem- hold of large landowners and diminishing prac- ployment rate was 18.5%.17 tices such as sharecropping, such land reform One of the drivers of poverty is landlessness. can be expected to raise living standards and With land ownership concentrated in the hands thereby the nutrition and health of the rural of a hacienda-based gentry and, increasingly, poor. Undoubtedly, landed interests will op- with multinational agribusiness and mining in- pose such land reform. Nor is Duterte’s eco- terests, the landless peasant is forced to accept nomic team planning drastic steps. meager wages or sharecropping arrangements in which a significant portion of the harvest is Conclusion turned over to the landowner. Monocropping Posed at the beginning of this editorial were and the banning of land use for subsistence the following questions: Will Duterte’s admin- crops means that the landless peasant is often istration lead to changes in the social and eco- nomic order? Will changes in the social deter-

Social Medicine (www.socialmedicine.info) Volume 10, Number 2, August 2016 73 minants of health lead to an improvement in the landless workers continued to till the planta- health of the Filipino people? tion.22 Under the law and order regime prom- The answers will depend on whether the ised by Duterte, even the politically powerful Duterte administration has the mandate and the may be made to follow the rules, and Agrarian political power to implement the proposed re- Reform Secretary Rafael Mariano has vowed to forms. Duterte’s party, the Partido Demo- distribute 4,115 hectares of Hacienda Luisita.23 kratiko Pilipino-Lakas ng Bayan (PDP-Laban) Except for the period of Imperial Japanese now controls the Senate and the House of Rep- occupation, the Philippines was a colony of the resentatives. Their legislative agendas will U.S. from 1898 to 1946. The influence of the have some foci consistent with the agenda of U.S. continues to be seen in the dominance of a the Left, such as achieving peace accords with market economy that results in the persistence the CPP-NDF and ending the labor contracting of severe social and economic inequalities. system by which workers are perpetually tem- Healthcare is treated as a commodity rather than porary workers. However, other Duterte agen- a human right. Historically U.S. involvement in da items include establishing a federal form of the Philippines is in many ways akin to its in- government and restoring the death penalty.20 volvement in Latin America. The efforts of the Duterte also receives support from the Right, new Duterte administration to chart an inde- which expect him to continue many of the ne- pendent course have the potential to effect posi- oliberal economic policies of his predecessor. tive changes for the health of the Filipino peo- Duterte is, however, inclined to act more inde- ple. pendently of the U.S. The Philippines is firmly tied to the economic orbit of the U.S. by inves- Acknowledgements: The author would like to tor rights (“free trade”) agreements, and phar- thank the Health Alliance for Democracy, the maceuticals and equipment are largely imported Council for Health and Development, and Ar- into the Republic. The U.S. government, which celita Imasa for their contributions to this arti- also views the Philippines as a strategic bulwark cle. against China, will resist attempts by the Phil- ippines to follow an independent course. References: The oligarchy will not give up its privileges 1. Baquero EO. Duterte pledges free hospital care. Sun Star Cebu [Internet]. [cited 2016 Jul 4]. Available and its holdings easily. For example, the Cora- from: http://www.sunstar.com.ph/cebu/local- zon Aquino administration instituted its Com- news/2016/02/26/duterte-pledges-free-hospital-care- 459366 prehensive Agricultural Reform Program 2. Duterte R. State of the nation address. Philippines (CARP) in 1988. With its focus on the com- Daily Inquirer [Internet]. [cited 2016 Jul 25]. Availa- pensation of landowners by the tillers of the ble from: http://newsinfo.inquirer.net/799060/full- text-president-rodrigo-duterte-first-sona-state-nation- land, twenty years later 1.2 million hectares of address-2016 land was undistributed.21 In 2012 the Supreme 3. World Health Organization. The Philippines [Inter- Court ordered the complete distribution of the net]. [cited 2016 Jun 18]. Available from: http://www.who.int/countries/phl/en/ 6,453 hectare Hacienda Luisita, the estate of the 4. World Health Organization. United States of America Aquino- family. Under the admin- [Internet]. [cited 2016 Jul 24]. Available from: istration of Benigno S. Aquino III, however, http://www.who.int/countries/usa/en/

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5. IBON Foundation. Critical conditions: privatized http://www.rappler.com/move-ph/136419-doh-garin- health in the Philippines. Quezon City Philippines: fabella-hospital-not-demolished IBON Foundation, 2015. 16. Yap DJ. 12M Filipinos living in extreme poverty. 6. Coalition for People’s Health. The people’s health Philippine Daily Inquirer [Internet]. 2016 Mar 18 [cit- agenda. July 2016. ed 2016 Jun 20]. Available from: 7. Balangue GC. Health workers. IBON Facts & Figures http://newsinfo.inquirer.net/775062/12m-filipinos- 2013 36(9-10). living-in-extreme-poverty 8. International Organization on Migration. Country 17. IBON Foundation. End of the road and a new begin- migration report: The Philippines. City, Phil- ning? Quezon City Philippines: IBON Foundation, ippines: IOM, p. 67. 2016, p. 13. 9. Li H, Nie W, Li J. The benefits and caveats of inter- 18. The People’s Agenda for Change [Internet]. [cited national nurse migration. Intl J Nursing Sci 2014:314- 2016 Jul 17]. Available from: 317. http://www.bayan.ph/2016/06/17/national-peoples- 10. The International Bank for Reconstruction and De- summit/ velopment/The World Bank. Migration and remit- 19. Bergonia TS. Radical plan to give land for free to tances Factbook 2011. Washington, DC: World Bank, poor farmers. Philippine Daily Inquirer [Internet]. 2011. 2016 Jun 21. Available from: 11. Waitzkin H. Universal health coverage: The strange http://newsinfo.inquirer.net/791567/radical-plan-to- romance of The Lancet, MEDICC, and Cuba. Social give-land-for-free-to-poor-farmers Med 2015, 9(2): 93. 20. Javil RF. Incoming 17th Congress awaits Duterte’s 12. Styles, Ruth. Inside the world's busiest maternity agenda. BusinessWorld Online [Internet]. 2016 Jul 25 ward where women sleep five to a bed and 100 babies [cited 2016 Jul 24]. Available from: are born every day. Daily Mail [Internet]. 2013 Oct 30 http://www.bworldonline.com/content.php?section=N [cited 2016 Jul 10]. Available from: ation&title=incoming-17th-congress-awaits- http://www.dailymail.co.uk/femail/article- duterte&8217s-agenda&id=130885 2480170/Inside-worlds-busiest-maternity-ward- 21. The people’s agenda for change [Internet]. [cited women-sleep-bed-100-babies-born-day.html 2016 Jul 24]. Available from: 13. Whaley F. Manila Hospital, No Stranger to Stork, http://www.bayan.ph/2016/06/17/national-peoples- Awaits Reproductive Health Bill’s Fate. New York summit/ P. 113-114. Times [Internet]. 2012 Nov 9;Sect. A:10. [cited 2016 22. Herrera CF. reclaims Hacienda Luisi- Jun 18]. Available from: ta. The Standard [Internet]. 2015 Nov 3 [cited 2016 http://www.nytimes.com/2012/11/10/world/asia/10iht Jul 24]. Available from: -manila10.html http://thestandard.com.ph/news/-main-stories/top- 14. Serafica R. DOH: Fabella hospital will not be demol- stories/190955/aquino-family-reclaims-hacienda- ished. Rappler [Internet]. 2016 Jun 14 [cited 2016 Jun luisita.html 18]. Available from: http://www.rappler.com/move- 23. Fernandez MCA, Tayam KC. DAR: Hacienda Luisita ph/136419-doh-garin-fabella-hospital-not-demolished disputes to be resolved in 30 days 15. Geronimo J. Health chief to review transfer of Fabella Philippine Daily Inquirer [Internet] 2016 Jul 8 [cited building. Rappler [Internet]. 2016 Jun 14 [cited 2016 2016 Jul 24]. Available from: Jun 18]. Available from: http://newsinfo.inquirer.net/795091/dar-hacienda- luisita-disputes-to-be-resolved-in-30-days

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