Flaws over flaws: Why can the Mandanas-Garcia ruling and UHC law not cure the illness of the Philippine healthcare system?

By John Rey Amestoso and Gerra Mae Reyes

It was 1986. The People Power Revolution just overthrew the tyrant, but his presence remained palpable, as millions of Filipinos were left malnourished, suffering from contagious diseases, or, worst, dead. Marcos Sr.’s iron fist punched the Philippine healthcare system to the point of paralysis.

As part of the recovery efforts, the 1991 Local Government Code (LGC) was formulated to devolve basic services and facilities, such as health, to Local Government Units (LGUs). After all, a decentralized system would better equip LGUs to respond more quickly to grassroots needs than the national government.

The idea was fairly simple and noble at the outset. But three decades have already passed, and changes are still yet to materialize in the country’s healthcare system.

The Case of the Philippine Health Devolution

So, is a progressive health devolution not tenable in the country?

“Mangyayari ‘yon, but it requires certain things to be in place,” said Dr. Gene Nisperos of the UP College of Medicine. He believed it would only work when people have real power over health decisions, and the government is accountable enough to relieve erring local officials. There must be an effective oversight mechanism to ensure its proper implementation, which is not the case in the Philippines.

For the longest time, health devolution in the country conveniently allowed local elites to misuse financial resources supposedly allocated for health services to strengthen political patronage, especially in areas ruled by dynasties. These opportunistic and corrupt politicians do not treat health as a right. They only see it as an electoral currency they are willing to bargain to stay in power.

With the implementation of the Mandanas-Garcia ruling, the local governments’ National Tax Allotment (NTA) increased by 40 percent or about P263 billion in 2022 compared to the previous fiscal year. And so, Dr. Nisperos asked, “If devolution didn’t work before, would giving LGUs more money make it work better this time?” A mere budgetary increase does not equate to better health services, as corruption in the local scene presents a clear danger. It requires a far more daunting task — overhauling the Philippine political system.

On the other hand, in response to the prospect of losing access to a significant portion of the national revenues, the Duterte administration issued Executive Order 138, directing the full devolution of the functions stipulated in the LGC by 2024. Experts estimated that devolution costs are twice the amount that local governments are entitled to receive under the NTA. This makes the risk of failure high once the policy pushes through without careful consideration.

The distribution formula used for NTA-share computation is also inherently problematic because it is heavily weighted toward the population and land area of each LGU category. While this may not be a concern for high-class LGUs with independent local revenue generation systems, the same cannot be said for NTA-dependent units receiving a minuscule share. This skewed calculation will likely result in substantial disparities in the quality and quantity of public health services across the country, as rich LGUs are seemingly favored while poor LGUs have to deal with greater economic instabilities.

The Department of Health earlier pronounced that the Mandanas-Garcia ruling could help sustain the execution of the Universal Healthcare (UHC) Law. But is this still the case when the discussed fiscal issues remain unresolved?

The UHC Law Through a Critical Lens

In as much as the Mandanas-Garcia ruling is problematic, so is the UHC law. Thus, even if the LGUs, powered by additional funding, happen to champion health and judiciously implement the law, the entire development process can still be defective.

The UHC Law is innately a health financing document, not a public-regarding law. This is because 10 of its 11 chapters are about PhilHealth, NHIP, and the likes. With UHC being centered on PhilHealth, the Philippine healthcare system is rampantly driven not by people’s needs but by the government’s conviction on how services will be financed.

As expressed by Dr. Nisperos, “’Pag pera na ang nagpapatakbo, hindi na ‘yan usapin ng health bilang karapatan — usapin na yan ng ‘sinong may pera’ at ‘magkano ang gagastusin diyan?’”

The government used to trumpet that the law was a groundbreaking advancement of the Filipino people’s right to health. But the UHC Act of 2019 does not perceive health as a right.

In fact, it institutionalizes inequality, as is made clear in Chapter 3, Section 9, which states that PhilHealth shall provide additional benefits for premium contributors. If health is indeed a right, no one should have more or less of it.

Moreover, the ceiling of the premium payment does not consider the enormous income gap between a migrant nurse and a landlord politician since both have to pay the same amount of contribution. Again, if health is indeed a right, one must not suffer more financial damage than others.

The effective implementation of the law is expected to change practically nothing, as it only echoes the current co-payment system for private health services and free medical care in public hospitals. Ultimately, the Philippine healthcare system remains a battle of money and connection.

In the realm of probable solutions, reversing devolution is the most doable course of action. Improving local governance to make devolution work might be one way to go, but this can only be possible through a system with greater accountability for government officials. However, in juxtaposing the character development of politicians and the reversal of devolution, the latter sits closer to reality, especially under a draconian rule.

This new year, no hope is left for the Marcosian government, whose values are anathema to the provision of people’s basic rights and needs. After all, what can we expect from the son and namesake of the dictator who siphoned off the country’s public wealth while the health system bled from inadequate resources and the exodus of health professionals? The open wound left by his father and those who came after exposed the country to dangerous pathogens, making it at risk of further infection.

The most lethal pathogens of the time, the Marcos-Duterte regime, will continue to weaken the country’s immune defense. And no tokenistic or shallow health reforms can provide temporary relief anymore.

Only through an antidote concocted from the collective rage of the Filipino people will a revitalized Philippine healthcare system emerge. ▼