PHM Philipines: Commercialisation of health care is leaving the poor behind

21 Jun 2014

In the Philippines, 28 women out of 100 do not enjoy skilled attendance during delivery, a situation that shows a glaring lack of access to healthcare (World Bank data). According to PHM affiliated organizations in the Philippines, the current privatization policies of the Aquino government does not provide an answer to the enormous health needs. Especially the poorest of the poor die without ever having seen a doctor.

While in Belgium 8 mothers die of pregnancy-related causes, in the Philipines 2855 mothers die each year. 70 894 children under five years die every year in the Philipines, compared to 431 in Belgium (World Bank data). According to PHM partners in the Philippines - IBON, Council for Health and Development (CHD) and Advocates for Community Health – the enormous health needs of the population remain insufficiently answered to by the Philipine government.

What is the response of the Philippine government to this dramatic situation?

The Aquino government claims that "public-private partnerships (PPP)" are the only alternative to meet the health needs and the continuing population growth in the Philippines. By outsourcing public hospitals to the commercial sector, as announced by Health Minister Enrique Ona, one wants to save on government spending, while progressing in public health outcomes.

In many developing countries, the public health sector does not obtain sufficient resources. Can entering in public-private partnerships be the solution?

The most disadvantaged populations in the Philipines are living in slums in the cities. People migrate to the city in search for work opportunities and a better life. But what they find is poverty, a life in unsanitary conditions and exposure to pollution. Although slum dwellers are the most vulnerable to diseases they have the least access to health care.

The commercial sector in the Philippines invests mostly in specialized hospitals in the cities. Rural areas, where the majority of the population lives, and preventive primary health care are being overlooked by the private-for-profit sector. In addition, one has to pay high fees for health care by private for-profit providers.
?However, user fees result in low utilisation of and exclusion from health care  and further  impoverishment [Ponsar et al, 2011]. The poor therefore have to rely on the public health sector or poorly regulated informal providers.

The private-for-profit sectoralso entices health workers away from the public sector by offering better working conditions and higher salaries [Haddad et al, 2008]. The Philippines also trains health workers en masse for export. So there is a net surplus of health workers, but through the "brain drain" the poor in urban and rural areas are left behind with a shortage of doctors and nurses.

The outsourcing of healthcare to commercial investors goes at the expense of the public sector; it is diverting health workers and resources away from the public sector. In the Philipines, at the same time, the government budget for public health is being reduced. Public health care provision is often of poor quality due to a lack of funds.

Does the private-for-profit sector provide better quality health care?
If "quality care" is understood as "offering the best treatment according to the diagnosis, based on evidence and international treatment guidelines", this is not necessarily the case. Research in developing countries shows that, more often than their public counterparts, doctors in the private-for-profit sector do not respect international treatment guidelines.

In Peru and Chile higher rates of potentially unnecessary procedures, particularly ceasarian sections, were reported in private-for-profit settings after privatization of  obstetric services.
Studies in Mexico suggested that fee-for-service payment structures (which are more heavily present in private than in public care delivery settings) incentivized increased C-sections.[Basu et al, 2011] However, ceasarian sections should be performed on medical indication because they entail more health risks for the mother.?

Recent studies also suggest that in several developing countries, private-for-profit practitioners had a significantly worse knowledge of correct diagnosis and treatment. In Sub-Saharan Africa doctors serving in the for-profit sector are more likely to prescribe unnecessary antibiotics to children with diarrhea, instead of the recommended oral rehydration salts [Sood & Wagner, 2014]. Irrational prescribing practices could lead to antibiotic resistance, which poses the world population at risk.

It is still often stated that the private sector would be more efficient than the public sector.
We understand efficiency as “producing the best possible results with the available budget”. According to the 2009 Oxfam report “Blind optimism”, commercialization of health care increases public spending, while health outcomes deteriorate. Lebanon has one of the most privatized health systems in the developing world. The country spends two times more on health care than Sri Lanka, a country far lower on the development index of the United Nations. Despite the high public spending, the infant and maternal mortality rates are 2.5 and 3 times higher, respectively. Outsourcing healthcare to the commercial sector in China- still remembered for its former “barefoot doctors”- has led to a decline of less-profitable preventative health care; immunisation coverage dropped by half in the following five years. Likewise, following extensive privatization reforms in Colombia in 1993, population vaccine coverage declined and more cases of tuberculosis occured [Basu et al, 2011].?


What do the Philipine people think?
PHM's partners in the Philippines - IBON, Council for Health and Development and Advocates for Community Health – denounce policies of increasing privatization since they claim that it does not improve public health outcomes. Every day these organizations deal with the enormous needs of the population and the lack of access to health care. Advocates for Community Health trains local health workers in the Philipines. In addition, people are empowered to assert their right to health. Our partner organisations in the Philipines therefore demand access to affordable and quality public health services for all.


Ponsar, F., Tayler-Smith, K., Philips, M., Gerard, S., Van Herp, M., Reid, T., & Zachariah, R. (2011). No cash, no care: how user fees endanger health—lessons learnt regarding financial barriers to healthcare services in Burundi, Sierra Leone, Democratic Republic of Congo, Chad, Haiti and Mali. International Health, 3(2), 91–100. doi:10.1016/j.inhe.2011.01.002

Haddad, S., Baris, E., & Narayana, D. (2008). Safeguarding the health sector in times of macroeconomic instability: policy lessons for low- and middle-income countries. Ottawa: Africa World Press: International development research centre.

Basu, S., Andrews, J., Kishore, S., Panjabi, R., & Stuckler, D. (2012). Comparative performance of private and public healthcare systems in low- and middle-income countries: a systematic review. PLoS Medicine, 9(6), e1001244. doi:10.1371/journal.pmed.1001244

Sood, N., & Wagner, Z. (2014). Private Sector Provision of Oral Rehydration Therapy for Child Diarrhea in Sub-Saharan Africa. The American Journal of Tropical Medicine and Hygiene. doi:10.4269/ajtmh.13-0279


Natalie Van Gijsel – Médecine Pour le Tiers Monde (M3M)

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