Reflections on the Human Condition - Api-fellowships.org

even as public finances improved for the financial
sustainability of universal health care coverage. The
market for private sector health care recovered along
with the disposable incomes of the middle classes, and
the outflow of medical staff from the public sector to
the private sector quickly returned to pre-1997 levels. 45
The current drive to promote Bangkok as a regional
hub for medical tourism 46 as an export service industry
can only exacerbate this chronic staff shortage.
The Ministry of Public Health is well aware of the
tensions inherent in the “dual track” policy objectives
of achieving universal coverage while simultaneously
developing a regional medical hub. 47
Among the policy measures adopted to cope with this
dilemma are plans to markedly boost the enrolment
of medical doctors with special attention to applicants
from rural or provincial backgrounds, generous
incentives and professional recognition for rural doctors,
and renewed emphasis on health promotion as a costeffective
approach to improving population health.
It is nonetheless sobering that the USA, the archetype
of market-driven healthcare, with its domestic supply
of home-grown doctors further supplemented by
immigrant MDs, is still unable to provide insured health
care access for more than 40 million of its residents,
despite spending 15% of its GDP on health care.
Dr. Ammar Siamwalla (TDRI) for one, is apprehensive
that further unregulated growth of the private health
care sector, coupled with under-financing of public
sector health care, will lead to self-selection and opting
out by the middle and upper classes48, i.e. the vocal
and more influential segments of society who might
otherwise have a stake in agitating for universal health
care of quality, provided (or financed) by the state, as an
entitlement for all Thai citizens. It would be unfortunate
if a promising experiment in Thai health care reforms
gravitated instead towards a polarized system of deluxe,
five-star care for the rich, and decimated, demoralized,
and under-funded services for the destitute.
PHILIPPINES: THE MOUNTAIN MOVES
In the Philippines, the unbalanced distribution of
healthcare staff is similarly driven by internal migration
(see box right) but even more dramatically by transnational
movements which have reached enormous
proportion.
CHANGING LIFESTYLES AND HEALTH
Distribution of health facilities and health staff
within the Philippines
In 2000, there were 15,486 government and private
health facilities in the Philippines. Most of these
were rural health units, municipal health centers, and
barangay health stations; and on a population basis,
they were less unevenly distributed between regions.
For the hospital sector however, comprising 1,089
private hospitals and 623 government hospitals,
bed:population ratios ranged from 1:404 for the
Cordillera Administrative Region to 1:5,967 for
the Autonomous Region of Muslim Mindanao.
The National Capital Region did not emerge as a
particularly favored region because the concentration
of personnel and facilities here is offset by the large
metropolitan population, a sizeable fraction of
whom nonetheless face financial barriers to health
care despite its geographic proximity.
In terms of distribution of health personnel, 87%
of physicians worked in hospitals (65% in private
hospitals, 22% in government hospitals); 78%
of nurses worked in hospitals (49% in private
hospitals, 29% in government hospitals); 75%
of midwives worked in hospitals, about evenly
distributed between private and public hospitals;
74% of dentists worked in private hospitals and
other private establishments, while 10% worked in
government establishments.
In line with the 1991 Local Government Code
(decentralization law), 75% of the Dept Health’s
field staff (approx. 46000) were devolved to
barangay, municipal, city and provincial levels.
Meanwhile, the automatic revenue transfers from
central government to local government units
increased from 11% to 40% of the national budget
(20% to the barangays, 34% to municipalities, 23%
to cities, and 23% to the provinces). Provinces and
municipalities together received 57% of the revenue
transfers, but had to bear 92.5% of the costs of
devolved responsibilities (including health services).
Cities and barangays, responsible for 7.5% of the
devolved responsibilities, nonetheless received
43% of the transfers. Hence, while decentralization
may offer opportunities for more participatory
and democratic local governance, decentralization
without the commensurate reallocation of funds (or
devolution of fiscal powers), may be an abdication
of responsibilities by a central governing authority.
Along with privatization, decentralization may thus
be a parallel strategy for retrenching the welfarist
state.
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Ref lections on the Human Condition: Change, Conflict and Modernity
The Work of the 2004/2005 API Fellows