MAKATI, Philippines – In the prologue to his memoir, Senator Juan Ponce Enrile writes:
“Yes, life over the years I have lived has changed in many ways. Living became easier, more convenient and a lot faster, but it also became more complex and dangerous. Food remains scarce to many people despite advances in industrial and agricultural production. A great number of the population merely subsist with meager pay or with no employment at all. At great social cost, many more are leaving their homes and loved ones, exposing themselves to unknown perils, just to seek livelihood in foreign lands. The environment has become degraded due to inordinate consumption and waste. Our seas, rivers and the very air we breathe have become polluted.
I have seen how poverty, squalor and decay stalked the land, and how injustice, violence and discord divided our people.”
No matter how you view him, this passage from Sen. Enrile’s memoir evokes a certain sadness and the realization of how hard it is to get the right things done the right way in our country. That one of the most powerful men in the country for the past 40 or so years shares this lament makes you wonder what it would take to fix the ills that we know surrounds us.
When I was in the United States, one of my mentors was a man named Ron Harkey (http://www.coachingforachievement.com/ron.html). Ron was in his late-50s when I got to collaborate with him. He is a legend in the financial services sales industry. Ron taught me a lot of things. He did so by breaking me down and building me up again. All the buzzwords that we hear about excellence being a habit, Ron lived it and when you worked with him, you better make it a habit too. Ron taught me how to build a business – that is, one client at a time. I learned what working hard really meant from him and that there is no short-cut to success. He was the living embodiment of what he mentored to those who chose to be mentored by him.
Ron is a proud American. He would always say that he would forever be thankful for having been lucky to have been born in what he proudly would proclaim as the greatest country in world. His phrase for it was winning the “genetic lottery”.
Looking back, when I left the country to study and eventually work in the United States, I now realize I was a relatively detached and sheltered person up to that point. Just short of 30 years old at that time, I still had not formed a stable view of the world and how I wanted to engage in it. I had skated through school and even work. I was never a consistent hard worker not having had the opportunity to step out of my sheltered existence to understand what it really was. I took short-cuts when available and rationalized many things to a fault. I relied on my own version of the “genetic lottery”, (modesty aside) an above average intellect inherited from my parents, to get by. I was very Filipino in that way, palaging (as Congressman Rudy Farinas aptly put it) may palusot. Now I know that such is not enough.
We, Filipinos, have this annoying habit of making reklamo but never really doing anything tangible to resolve these complaints. When people come to me under these circumstances, I always tell them why don’t you do something about it. Be it confronting the object of the complaint or at least initiating the process by which they can seek redress for their grievances and perceived (or real) slights. More often than not I receive a reply which goes along the lines of – huwag na lang mas lalo pang gugulo or worse, ayaw ko nga, ikaw na lang susuportahan na lang kita. Sus!
There is also this lack of discipline that is very maddening but is a fact of life in the Philippines. It seems like everyone thinks that laws, proper social norms and other standards meant to regulate behavior apply to everyone else except us. What ultimately happens, which becomes the bane of our existence (though we may or may not realize it), is that everyone accepts these “wrong” behaviors because everyone else does it – the “herd mentality”.
Our conscience shaped by the value system that we were taught when we were young and hardened by our experiences should logically act as the unconscious regulator of our individual or collective behavior. Who hasn’t felt that tinge of guilt at having bribed that traffic cop to escape a ticket? What about using our personal connections to get ahead in many things? Di ba hindi man pinapahalata sa loob-looban mo nararamdaman mo rin ang kahihiyan?
Filipinos go to great lengths para lang hindi mapahiya. This would include rationalizing actions, making up stories to outright lying. On the other hand, we also avoid actions where mapapahiya ang ibang tao. The latter behavior underlies the hesitation to make people accountable for their actions. There is a sense that if someone does something which will bring shame upon another person baka ma-karma. Corollary to this, it is very difficult to get a person to accept and admit mistakes as well as acknowledge that they don’t know something. I always tell people that what is more important is how they learn from their mistakes. Also, it is always better to say “I don’t know” when you don’t than to make something up and dig yourself a deeper hole. This is likely a symptom of an underlying inferiority complex that never really left us from the time we called it colonial mentality. At the end of the day, these behaviors confine us to narrow-minded thinking that belies a lack of maturity.
Two things bother me about where we are right now. The first is the seemingly gradual erosion of the level of behavior that is acceptable. This points to a degradation of the way values are being taught and cemented by experience. With this I am reminded of two things that have just played out in the national scene – the utter lack of remorse or accountability for plagiarism by a Senator of the Land and the aloofness of the impeached Chief Justice of the Supreme Court over his obvious malfeasance. When these supposed paragons of character instead resort to distorted rationalizations of their behavior, what does that say about the manner in which we choose our public officials?
The second thing that bothers me is the inconsistent and sometimes invisible calling to account for bad behavior. Marami pa rin talagang nakakalusot. What makes it worse and downright sad, is that we oftentimes nonchalantly pride ourselves sa ating mga palusot.
Unless we change as a people and engage ourselves in helping change things, we condemn ourselves to a mediocre and pitiful existence as people marked by the poverty, squalor, decay, injustice, violence and discord that Sen. Enrile describes. We will wallow in this existence because we have become accepting of what should not be accepted while at the same time resorting to “crab mentality” due to purely malicious inggit.
One cannot really ascribe to our nation and as a people a collective sense of pride. Filipino pride is an empty phrase because given the totality of things, what is there to be proud of? Yes – there are occasions (e.g. when Manny Pacquiao beats someone up) when we feel such an emotion but these moments are fleeting and in many cases, mababaw. But what have we really done as a nation to uplift the lives of those who still scrounge for garbage as a means of living, of those who die unnecessarily because getting sick is not an option (so they just die), of those who have lost hope or never had it in the first place.
To those of us who know better, it is about time to accept the state we are in, fight it and start our own individual process of change. This means being more disciplined, thinking more about what’s best for the many instead of what’s in it for me, not settling for puwede na, putting in the hard honest work (i.e. huwag na magpalusot), resisting the temptation of being drawn to the “herd mentality” and for God’s sake following traffic rules (sorry, my own pet peeve).
Changing a culture that has been built over at least five centuries of experiences seems impossible. Maybe it is. That doesn’t mean we cannot individually do our part to committing to this change. Just because someone else is doing something (no matter how obviously and blatantly wrong) doesn’t mean we should be doing it too in “lemming-like” fashion. You know what they say about those lemmings (these small rodents of the Arctic tundra), they’ll follow those in front of them even if it’s off the top of a cliff.
As for me, the probabilities are not in my favor of reaching the ripe-old age of 88 year that Sen. Enrile has so far lived to. But if by some miracle I do, I would want to be writing my memoir with a prologue that includes this –
I have seen how poverty, squalor and decay stalked the land, and how injustice, violence and discord divided our people. AND WE CONQUERED THESE.
Then I can look Ron Harkey (with a twinkle) in the eye and say – “hey dude, I fought for and won the “genetic lottery” too”.
- Enrile’s memoir: Story of sorcerer’s apprentice (opinion.inquirer.net)
- Unthinkable: Guess who came to Enrile book launch (newsinfo.inquirer.net)
This was originally written for Abraaj Capital and the Melinda and Bill Gates Foundation
This paper provides a glimpse of the Philippine Healthcare Sector and is not meant to be a comprehensive treatise on the subject. The first part looks at the relative standing of the Philippines from a global macroeconomic perspective. The second part looks at some characteristics of the Philippine healthcare space and the significant potential that it represents.
This discussion of the Philippine Health Care Sector begins with an oft-cited statistic – beds/10,000 population. The Henry J. Kaiser Family Foundation puts that number for the Philippines at 5 beds/ 10,000 population (Chart A). This puts it in the company of Benin and Uganda tied for 168th to 170th places among 182 countries surveyed which reported data.
This is very discouraging considering the fact that the Philippines is known as a significant exporter of healthcare workers globally. Among the 20 countries with the biggest populations, the Philippines only came out higher than Bangladesh as shown in the Chart B.
There are likely to be several outliers with the regard to the data which when stricken would make some difference to the data as presented above. The aggregate differences, however, are very difficult to ignore.
So – could it be possible that the ability or inability of Filipinos to pay for healthcare is the culprit for these seemingly unflattering comparisons? If we look at GDP per capita (Chart C), however, it would seem like the Philippines’ health industry situation based solely on our metric of beds/10,000 population should have more beds than it currently has which could be supported by its level of relative wealth.
Given this, some possible sources of this seemingly illogical state of things would be:
- Individual national priorities
- Unique regulatory obstacle
- Demographic and/or geographic factors
- Country-specific industry structures
For enlightenment we looked at comparative data from the World Health Organization (WHO). The following charts show the GDP per capita healthcare spending by our basket of countries adjusted for Purchasing Power Parity and Healthcare Expenditure as a percentage of GDP, respectively.
While any conclusion drawn from these statistics would, at best, be tentative, the Philippines falls within the bottom third in terms of healthcare spending on both a per capita and on a percentage of GDP basis. Now, having drawn this observation, it is also wise to be careful about making generalized conclusions from these two pieces of data.
To delve further into this, we looked at aggregate statistics from the ASEAN region. These statistics focus on healthcare-related comparative data.
The Philippines is the second largest country in terms of population in the ASEAN region. That alone shows its potential. In terms of healthcare expenditure, however, it ranks in the middle. While probably reflective of the size of the economy in terms of GDP, it could be argued that systemic problems in the Philippine healthcare system – some unique, some not – hold back the expansion of the industry.
The Provision of Healthcare in the Philippines
The Philippine healthcare industry is relatively underdeveloped with a significant potential for rapid growth contingent on the continued expansion of the economy, increased demand-side resources and the some regulatory reform.
While the number of hospital beds in the country is roughly equally divided between the public and private sector, government hospitals, whether run by the Department of Health or the Local Government Units (LGU) serve a disproportionate (70%) segment of the population. The public sector is in turn divided into facilities by the national-level Department of Health (DOH) and those facilities run by the LGUs.
Prior to the enactment of the Local Government Code (LGC) in 1991, the Department of Health (DOH) ran all the government hospitals. With the LGC, the management and governance of an overwhelming number of government hospitals was devolved to these LGUs consisting of provincial, city and municipal governments. This development has had mixed results but the most pressing problem has been to place an additional burden on these LGUs to fund these hospitals from their budgets. In many cases, this has resulted in under-investment in these hospitals to a point where some provincial hospitals had to be taken over by the DOH. There also is the question of the competency of these LGUs to manage the delivery of healthcare through the facilities that they manage.
The chronic funding pressure as well as the question of competency, by themselves, builds a case for the prospective outsourcing of the management of these facilities under the Public-Private Partnership (PPP) scheme. While a seemingly logical choice, issues with regard to the disposition of Civil Service employees as well as the question of facility ownership remain to be resolved and pose a deterrent to private-sector participation.
The private sector while serving only an estimated 30% of the population garners about 60% of aggregate healthcare expenditures. The services provided by the private sector are patterned after the American fee for service model. These are composed of free-standing hospitals, clinics run by sole practitioner physicians and a growing, albeit still infinitesimal, number of multi-specialty healthcare facilities.
The chart below shows the source of funding for healthcare expenditures (HCEs).
This chart tells many stories. One is that the national health insurance system under the banner of PhilHealth remains in its infancy. The data presented above is actually dated and anecdotal evidence suggests that the share of PhilHealth in funding HCE has risen to close to 20%. The story is similar in the private pooled insurance space (e.g. HMOs). Again, anecdotal evidence supports the hypothesis that it share of funding HCE has risen to about 15%.
The out-sized share (40% to 50%) of out of pocket cash payments again supports the story posited above that pooled risk payment structures are still not as pervasive as they could or should be. Until this equation changes, demand for healthcare services will remain relatively expensive and stunted.
The supply-side of the system also has significant room for improvement. Competition, to a certain degree, remains muted particularly in areas outside Metro Manila. In a noble but misguided attempt to improve physical accessibility of healthcare services, the DOH adopted a stricture which basically does not allow new hospitals to be built within a one-hour radius of an existing hospital. This has instead had the impact of dis-incentivising investment in new construction given the limited number of areas where the construction and operation of a new hospital would be economically viable – a veritable illustration of the law of unintended consequences.
It has also created monopolistic or oligopolistic markets. Competitive pricing is largely absent. This has removed the incentive for existing facilities to reduce costs by increasing efficiencies. With pricing, to a large degree capped by the limited ability of the Filipino consumer to absorb price increases, many hospitals run very thin profit margins. This, in turn, reduces the ability and the inclination of hospitals to spend on upgrades and new equipment. In the end, the consumer loses out by having relatively high prices which due to the under-investment does not directly translate to quality care.
The archipelagic nature of the Philippines has also been historically been resistant to the establishment of national health care players. Instead, what the Philippines’ overwhelmingly has today are entities owning single facilities. This is not efficient from the perspective that economies of scale are not being built by the providers of healthcare. This limits their ability to negotiate with suppliers particularly on big-ticket hospital equipment and pharmaceutical supplies.
The opportunity that the Philippine healthcare industry space provides is multi-faceted. From a demand standpoint, the size of the population, the still significant population growth rate and the gradual increase in relative wealth will spur growth for healthcare services.
On the supply-side, the providers of healthcare remain very inefficient causing the cost of healthcare delivery to be unnecessarily higher than it could and should be. A national player or players with the right mentality could target the roll-up acquisition of the many single-facility entities, introduce efficiencies and eventually build scale to put pressure on equipment and pharmaceutical suppliers.
The key will be increasing affordability. There will come a “tipping point” where the equilibrium price of healthcare services will be forced down to a degree which will spur a dramatic and substantial spike in demand. The timing for this to happen could be significantly truncated with a properly motivated push to increase efficiencies and reduce prices on the supply-side. Demand will move towards that state of equilibrium without any exceptional healthcare-directed stimulus.
While the experience that underlies the data, whether anecdotal or scientific, is contextually a Philippine experience, the formula of building scale, operating efficiently and thus delivering healthcare at a reasonable cost can be used in other countries in the region to drive demand and increase the quality of healthcare delivery.
Image courtesy of http://csereviewer.blogspot.com
MAKATI, Philippines – Much has been made of the conflict between serving one’s country and fulfilling one’s commercial contractual obligations. To serve one’s country is one of, if not, the highest honor(s) that an athlete can receive. No ifs, no buts.
Playing for your country, however, does not necessarily and in fact, shouldn’t come in conflict with an athlete’s commitment to a team or club from which he derives his livelihood. This is particularly true in football where FIFA’s rules consider the interests of both club and country. This is a concession to the realization that for football to be successful it needs both national teams and they international competitions that they compete in and clubs and club competitions to be successful.
FIFA’s rules governing national team call-ups are quite comprehensive and detailed. To shed some light on this, print verbatim Annexe 1 (Release of players to association teams) of the FIFA Regulations on the Status and Transfer of Players.
1. Clubs are obliged to release their registered players to the representative teams of the country for which the player is eligible to play on the basis of his nationality if they are called up by the association concerned. Any agreement between a player and a club to the contrary is prohibited.
2. The release of players under the terms of paragraph 1 of this article is mandatory for matches on dates listed in the coordinated international match calendar and for all matches for which a duty to release players exists on the basis of a special decision by the FIFA Executive Committee.
3. It is not compulsory to release players for matches scheduled on dates not listed in the coordinated international match calendar.
4. Players must also be released for the period of preparation before the match, which is laid down as follows:
a) friendly matches: 48 hours;
b) qualifying matches for an international tournament:
– four days (including the day of the match). The release period shall be extended to fi ve days if the match concerned is held in a different confederation to the one in which the player’s club is registered;
– prior to double-dates (Friday – Tuesday) listed in the coordinated international match calendar, the release period shall in any case be five days prior to the beginning of the time span fixed by the calendar (including the relevant Friday);
c) qualifying matches for an international tournament that are staged on a date reserved for friendly matches: 48 hours;
d) friendly matches that are staged on a date reserved for qualifying matches for an international tournament: 48 hours;
e) the final competition of an international tournament: 14 days before the first match in the competition.
Players shall join the association team no later than 48 hours before kick-off.
5. The players of associations that have automatically qualified for the final competition of the FIFA World Cup™ or for continental championships for national “A” teams shall be released for friendly matches on dates reserved for official qualifying matches in accordance with the directives that would apply for official matches staged on those dates.
6. The clubs and associations concerned may agree a longer period of release.
7. Players complying with a call-up from their association under the terms of this article shall resume duty with their clubs no later than 24 hours after the end of the match for which they were called up. This period shall be extended to 48 hours if the match concerned took place in a different confederation to the one in which the player’s club is registered. Clubs shall be informed in writing of a player’s outbound and return schedule ten days before the match. Associations shall ensure that players are able to return to their clubs on time after the match.
8. If a player does not resume duty with his club by the deadline stipulated in this article, the next time the player is called up by his association, the period of release shall be shortened as follows:
a) friendly matches: 24 hours;
b) qualifying matches: three days;
c) the final competition of an international tournament: ten days.
9. Should an association repeatedly breach these provisions, the FIFA Players’ Status Committee may impose appropriate sanctions, including but not limited to:
b) a reduction of the period of release;
c) a ban on calling up a player(s) for subsequent match(es).
2 Financial provisions and insurance
1. Clubs releasing a player in accordance with the provisions of this annexe are not entitled to financial compensation.
2. The association calling up a player shall bear the costs of travel incurred by the player as a result of the call-up.
3. The club with which the player concerned is registered shall be responsible for his insurance cover against illness and accident during the entire period of his release. This cover must also extend to any injuries sustained by the player during the international match(es) for which he was released.
3 Calling up players
1. As a general rule, every player registered with a club is obliged to respond affirmatively when called up by the association he is eligible to represent on the basis of his nationality to play for one of its representative teams.
2. Associations wishing to call up a player who is playing abroad must notify the player in writing at least 15 days before the day of the match for which he is required. Associations wishing to call up a player for the final competition of an international tournament must notify the player in writing at least 15 days before the beginning of the 14-day preparation period (cf. Annexe 1 article 1 paragraph 4 e)). The player’s club shall also be informed in writing at the same time. The club must confirm the release of the player within the following six days.
3. Associations that request FIFA’s help to obtain the release of a player playing abroad may only do so under the following two conditions:
a) The association at which the player is registered has been asked to intervene without success.
b) The case is submitted to FIFA at least five days before the day of the match for which the player is needed.
4 Injured players
A player who due to injury or illness is unable to comply with a call-up from the association that he is eligible to represent on the basis of his nationality shall, if the association so requires, agree to undergo a medical examination by a doctor of that association’s choice. If the player so wishes, such medical examination shall take place on the territory of the association at which he is registered.
5 Restrictions on playing
A player who has been called up by his association for one of its representative teams is, unless otherwise agreed by the relevant association, not entitled to play for the club with which he is registered during the period for which he has been released or should have been released pursuant to the provisions of this annexe. This restriction on playing for the club shall, moreover, be prolonged by five days in the event that the player, for whatsoever reason, did not wish to or was unable to comply with the call-up.
6 Disciplinary measures
1. Violations of any of the provisions set forth in this annexe shall result in the imposition of disciplinary measures.
2. If a club refuses to release a player or neglects to do so despite the provisions of this annexe, the FIFA Players’ Status Committee shall furthermore request the association to which the club belongs to declare any match(es) in which the player took part to have been lost by the club concerned. Any points thus gained by the club in question shall be forfeited. Any match contested according to the cup system shall be regarded as having been won by the opposing team, irrespective of the score.
3. If a player reports late for duty with his club more than once after being called up by an association, the FIFA Players’ Status Committee may, at the request of the player’s club, impose additional sanctions on the player and/or his association.”
As I said the rules are quite comprehensive and detailed. It does, however, leave some room for the association or federation and the clubs to agree to deviate from these upon mutual consent. So there.