How do poor Filipinos live

Health System Philippines: No Doctors for the Poor

THEMES OF THE TIME

District hospital on Südleyte: Why work as a doctor here when you can earn more money as a nurse abroad? Photo: Martina Merten
The Southeast Asian island nation is in a crisis: medical staff are emigrating because of low salaries, and nurses are taking care of health care in rural areas. After all, there are some lighthouse projects.

A man, probably in his 40s, crouches in front of the Anahawan District Hospital on the Philippine island of Leyte. He looks into the distance with a blank look. When asked if he was waiting for a doctor, Romeo shakes his head. Romeo is not waiting for anyone, perhaps for an inspiration on how to deal with his situation. His daughter, says the Filipino, is in the clinic's day ward, she suffers from a serious heart defect. The few doctors here at Anahawan District Hospital couldn't help her. Only doctors at a special clinic in Manila could help. But the capital of the archipelago is thousands of kilometers away, a flight there would cost Romeo several months' salary, not to mention the treatment costs. “What should I do?” Asks the man.
His fate is that of many Filipinos. Some are hit even harder. 50 percent of the population have no access to health care. 30 percent of the locals live on less than $ 2 a day. The population is also one of the fastest growing in the world. "The health care of the population is a question of priorities," says the Secretary General of the Health Alliance for Democracy (HEAD), Dr. med. Gene Alzona Nisperos, and the government's priority is not health care. “Money is only put into those areas where it is visible,” criticizes Nisperos. The financial participation of the Ministry of Health and other ministries in expensive private clinics is visible, because these bring prestige and foreign currency. Their number has risen steadily over the past few years. 700 of the island's 1,700 hospitals are now privately owned, and 300 of the 1,000 state hospitals are financed by the state. The remaining 700 - mostly smaller hospitals such as the Anahawan District Hospital - are, according to official information, run by the municipalities. “Often, however, the money tends to trickle away into the pockets of the mayors rather than spending it on the maintenance of smaller clinics,” says Nisperos.
A quick glance at Anahawan Hospital is enough to see that no money has been invested in maintaining the district hospital for years. The devices are old, the rooms poorly equipped, two old computers are available for the 50-bed house. Dr. med. Maya de Tesus is one of four doctors who work in the hospital. There are also 15 nurses working here. "After nine years of education and training, I earn $ 400 a month," says de Tesus with resignation. She is considering emigrating to the United States with her children. A nurse there earns three times as much as a doctor in the Philippines - an estimated 10,000 Filipino doctors to leave their country so far. Many emigrants retrain to become nurses before they leave, because as nurses, especially in the USA and Great Britain, they quickly get a job and earn well. Ten million Filipinos now live abroad and generate 13.5 percent of the domestic gross domestic product. Given these numbers, it is not surprising that the government is doing nothing to stop the trend. And finally, if Minister of Labor Arturo de Brion shortens other uncomfortable questions about “why”, Filipinos are a people who love to travel.
In Manila, the promising capital of the archipelago for many, the chances of a higher income are better. Because here, about a three-hour flight from the Anahawan Hospital, more and more private clinics are being built alongside a few state hospitals. Here, large companies rely on call centers and wealthy business people on shopping malls based on the American model. In the 15 million megacity, opposites collide that could not be greater. While in some parts of the city there is one slum after the other, a few street corners further you will find elegant high-rise buildings of renowned banks and fenced-off residential areas of wealthy locals. While the wealthy have a good time in massage centers and drink coffee for three euros a cup under palm trees, small children stand with outstretched hands on crowded streets and beg for a few cents. You are exposed to car noise and polluted air for 20 hours a day. Mostly they lack clean drinking water and sufficient food. If someone gets sick here - and this happens frequently, depending on the circumstances - an entire month's salary can be lost in one fell swoop. Or the disease is dragged on due to lack of money, becomes chronic and, in the worst case, leads to death. According to the national health insurance, diarrhea caused by contaminated drinking water is the most common cause of death, and bronchitis, pneumonia, flu and malaria are sometimes fatal. On the other hand, there are diseases of civilization in the ranks of the rich who resemble those of people in industrialized nations: diabetes, high blood pressure, obesity.
50 percent without access to medicines
While the high drug prices are not a problem for the wealthy, 40 percent of the population can only afford cheap drugs, according to Boehringer Ingelheim Philippines. For another 50 percent, drugs are out of reach. Most of the drugs are sold through pharmacies; in particular the chain “Mercury Drug” can be found on every other corner. The market power of individual privatized giants means that drug prices are three times the level of Thailand or Indonesia, they are five to 15 times as high as in India, reports a spokeswoman for the Ingelheim pharmaceutical company. The sale of generics, on the other hand, only accounts for four percent.
Precarious conditions: For some Filipinos, life in a garbage dump, here on the "Smokey Mountains" in Manila, is part of everyday life. Photo: Sabine Muscat
Giving more people access to cheaper medicines - this is what the German Society for Technical Cooperation (GTZ) is committed to. Together with the Philippine Ministry of Health and the Reconstruction Loan Corporation, she takes care of building pharmacies according to the franchise system. Margarett Luisa Mallari works in such a pharmacy; here in the Philippines they are called “Health Plus Outlet”. "Health Plus" is the name of the GTZ project, outlet means something like "point of sale". Mallari proudly reports that there are now 58 such “drug sales outlets” in the entire region of the Eastern Visayas - a group of islands - in which employees predominantly sell non-prescription generics. The Ministry of Health finances the training of the employees, which teaches basic knowledge about herbalism and first aid. Basic knowledge often helps a big step further, because the mini pharmacies are usually in the middle of the country surrounded by mud huts, palm trees and people who live on rice and coconuts. While the local population had to walk kilometers to the nearest pharmacy before the outlets were set up, they now have a kind of “sari-sari pharmacy” around the corner. Mallari is convinced that their number will continue to increase by the end of the year. The principle of the pharmacy franchise is easy to explain: The outlet belongs to the small business owner, behind which the National Pharmaceutical Foundation stands as a “master franchiser”. This is a private foundation approved by the Bureau of Food and Drugs as a pharmaceutical wholesaler. Mallari explains that costs for inventory and employees are to be deducted from the monthly income, and around a third of the income goes to the master franchiser.
Medical tourism as a source of income for the future?
In addition to lighthouse projects like this one, there is another streak on the horizon - albeit an ethically not undisputed one: medical tourism. With an aging population, rising health care costs and long waiting lists in Western and other Asian countries, the Philippines could take advantage of its location, the government decided a few years ago. After all, the costs here are many times lower, many doctors are excellently trained and also speak fluent English. In addition, medical tourism opens up the possibility of keeping doctors willing to emigrate in the country through new, high-quality jobs. The marketing strategy is similar to that in Thailand, Singapore and India: True to the motto “Ever thought of doing them both - on the same trip?”, Online portals and advertising campaigns were created through which tourists can book a vacation under palm trees combined with a surgical procedure. The Ministry of Health has invested money in building massage centers at hospitals, and some particularly renowned private clinics have built their buildings according to the standards of the US Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Hospitals accredited with the prestigious US facility usually have high quality and safety standards. Despite the efforts - there has been no boom in medical tourists so far. The GTZ estimates that 2.6 million holidaymakers fly to the Philippines every year, of which only 10,000 come for medical tourism purposes. Those familiar with the scene believe, however, that the market will still pick up.
Even if the number of visitors were to increase in the next few years: Romeo, the man in front of the Anahawan Hospital on Leyte, would no longer help either. Because even if the government keeps its promise and puts additional foreign currency into the health care of its own population - Romeo's daughter is long dead by then. Martina Merten

Philippines
- Population: 86 million (Germany: 82.4 million)
- Gross domestic product 2005: 105.2 billion US dollars (Germany: 2,240 billion euros)
- Unemployment rate: 7.8 percent (Germany: 9.1 percent). Underemployment is 20 percent.
- Share of health expenditure in gross domestic product: around two percent (Germany: around 10.7 percent)
Health System Philippines: No Doctors for the Poor

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