Politicians who play God with our health

Dr. Arturo B. Rotor wrote Men Who Play God, his anthology on the practice of medicine in the Philippines, in 1983. I was in medical school when I read his stories and saw firsthand the failing health system of the Marcos administration under Martial Law which he was writing about. He wrote about doctors having to choose which patient in the emergency room would get a bed, providing access to life-saving care.

I was an intern in Hospital ng Bagong Lipunan in 1985, spending sleepless nights in the emergency room, asking patients’ relatives to buy fluids or IV medicines, hoping they could pull through and get admitted the following day. As a family medicine resident in the Philippine General Hospital (PGH) in 1989, I would turn to supplies donated by the Friends of PGH (a foundation) for life-saving care, before they would run out at the end of every month.

Doctors in public hospitals and clinics make choices every day, literally playing God, like Dr. Rotor’s characters in his short stories. It is a sad commentary that in the 43 years after Rotor published his book, the situation for doctors and health workers has not changed. Instead of playing God, it is now called triage in many emergency rooms, prioritizing the most critical patients. The less critical go home or wait until their condition warrants admission.

The Department of Health (DoH) has had a Medical Assistance Program since the 1980s as a means to refer indigent patients to better-off private hospitals. Over the decades, the program accommodated requests of politicians for the hospitalization of constituents, with funds available in DoH retained hospitals until consumed.

When the DoH launched Kalusugang Pangkalahatan in 2011, the National Health Insurance Program under PhilHealth expanded to cover more diseases, and hospitals started having more resources. Thus, from 2010 to 2013, the Medical Assistance Program was gradually reduced to zero as funding for PhilHealth increased.

Funding for the Medical Assistance Program was restored in 2014 but was less than 10% of the funds allocated for PhilHealth’s social health insurance program for indigents.

Before the COVID-19 pandemic and the 2019 Universal Health Care Act, PhilHealth got the lion’s share of funding for indigents from 2011-2019: P337 billion. Medical Assistance received P25 billion during the same period.

POLITICIANS AND THEIR HEALTH PATRONAGE RISE
Starting in 2019, the Medical Assistance program doubled, then grew some more. In 2022, at the height of the presidential elections, Medical Assistance grew to P21 billion, one fourth of the PhilHealth budget. By this time, politicians were largely in control of Medical Assistance funds, allocating millions to private and public hospitals and issuing guarantee letters to DoH regional offices which would authorize expenditures.

Under the current administration, Medical Assistance (renamed Medical Assistance for Indigents and Financially Incapacitated Patients or MAIFIP) gained the upper hand in funding.

From 2023-2025 MAIFIP received P132 billion while PhilHealth only received P60 billion, reversing course on the promise of Kalusugang Pangkalahatan and the UHCA.

MAIFIP IS A REVERSAL OF UHCA
DoH’s 2026 MAIFIP guidelines (Administrative Order or AO 2026-0031) will lead to barriers to health care for the poorest 40% of households in the country as it will bypass the existing UHC Act of 2019 which imposes no barriers to health care to all Filipinos.

A significant amount, P51.6 billion, has been provided by the General Appropriations Act that will require a means test to prove one is poor or financially incapable in order to access the fund. Last December, the Supreme Court affirmed that accessible and affordable health care is a Constitutional right. MAIFIP 2026 could infringe on that right by not making it accessible to all Filipinos.

MAIFIP also creates an administrative decision-making process outside the health care system. The provider of care will need approval from the administrator of the fund when the provider is in the ideal position to make that decision, making MAIFIP not only inequitable but ineffective in providing the right care at the right time.

Political intervention is not explicitly banned by the AO, and interventions by both politicians and high-ranking officials can still occur, as regional directors are still subject to legislative inquiry during the budget process.

Health care spending by the poor (the bottom 40%) has increased faster than that by higher income groups — this is evidence that they need access to health funding, according to the DoH.

Rather than continue with MAIFIP or institutionalizing this fund, the DoH and legislators should work on a 2027 health allocation that truly makes health care accessible by improving primary care to reduce overcrowding in hospitals. PhilHealth must change track, from funding 90% of hospital-based care and increase funding for primary care and preventive care.

Health advocates have not been supportive of MAIFIP since it began. The barriers are political and socioeconomic, making access selective. This AO does not address that at all. Previous guidelines also never mentioned political interference, but it was allowed.

The AO does not shield the Regional Directors from political interference. It also does not improve the chances of the poor to access care when, from the beginning, they avoid hospitals because of the cost. Surveys have shown (CBMS) that 20% to 30% of those needing health care stay at home and delay care.

Doctors and health workers continue to have to allocate limited health resources; they do it with science behind their decisions but yearn for the day when they do not have to make those choices.

Politicians, on the other hand, make decisions allocating resources through MAIFIP out of a desire to assert patronage.

Efficient and effective implementation of universal health care and public health principles will make that decision-making irrelevant.

Dr. Juan Antonio “Jeepy” Perez III, a Doctor of Medicine, specializes in public health administration and primary health care. He has worked on community-based health programs, Philippine local health systems, the TB program, health information systems, and public and private reproductive health and family planning programs in the Philippines. He was Undersecretary for Population and Development and Executive Director of the country’s Commission on Population and Development up to 2022 when he retired. He occasionally writes for Action for Economic Reforms.