Philippines’ fragmented health system fuels crisis in diabetes care

B.B., November 30, 2022

For fear of losing their hard-earned money, many Filipinos put off seeking treatment once they get sick. They often make excuses like they are too busy and tired or that a doctor's appointment, aside from being costly, may mean finding out something could be wrong with them. 

This reluctance to get checked can mean the opportunity for early detection and prevention of future complications. This is crucial, especially with diabetes. 

In the Philippines, 1 out of 16 Filipino adults lives with diabetes. 

According to the International Diabetes Federation (IDF) 2021 Atlas, 4,303,900 million of the then approximately 68,430,000 million total Filipino adult population have diabetes, with a 6.5 percent prevalence rate. The number may be higher as the IDF did not include younger people in their data. 

Left unchecked, diabetes can kill. The mortality rate among Filipinos from the disease has steadily risen through the years. In 2021, diabetes is the fifth leading cause of death in the country after ischemic heart diseases, cerebrovascular diseases, COVID-19 and cancer. 

Diabetes, quite simply, is a chronic disease wherein the body fails to produce or use insulin properly, resulting in high sugar levels in the blood and urine. 

The most common types of diabetes are type 1 and type 2. Type 1 (T1D) diabetes results from an autoimmune reaction and develops early in life. Type 2 (T2D) diabetes, on the other hand, develops over the years and is related to risk factors such as excess weight and lack of exercise; it is usually diagnosed in adults.

Every individual with diagnosed diabetes requires medications to manage their condition. The main types of medications for diabetes are pills and insulin. Depending on how severe the symptoms are or certain accompanying health conditions, some people with diabetes may need insulin injections, but others can manage with oral medications alone coupled with lifestyle and dietary strategies. 

Health expenditures for diabetes balloon to around P250,000 on average a year as IDF estimated. Out-of-pocket costs for diabetes medications can be a major expense, whether the patients are un- and underinsured.

“Napakahirap,” lamented Jasmine Javier, 36, as she described her decade-long experience living with diabetes. “Minsan gugustuhin mo na lang isaksak lahat ng insulin sayo para mawala na lahat ng kailangan mong intindihin.” 

It was 2013 when diabetes symptoms started to manifest in what first Javier thought was a simple pimple. “I thought na tigyawat lang siya. Sa likod siya tumubo, sabi ko parang ang sakit.” Upon consulting a clinic doctor, she was diagnosed with colitis — an inflammation along the colon lining that often induces skin boils. 

When the skin boils recurred in the following months, she decided to just ignore and weather them out, unaware that it was already a symptom of diabetes. Not until 2016, after being hospitalized due to another colitis inflammation inside her nose, she was officially diagnosed with Type 2 diabetes. 

“Dinedma ko lahat ng symptoms. Uhaw na uhaw ako palagi pero hindi naman ako naglakad ng napakalayo. Nung nag-worse na yung case ko, natakot nako. Sabi ng diabetologist nung nakita niya ko, lahat ng results connected sa pagiging type 2 diabetes,” she narrated. 

Javier started to inject insulin for a while to manage her diabetes. A few years later, she stopped without the doctor’s consent. Then the skin boils resurfaced. 

“Nag-insulin ako, iba ang insulin sa morning iba at sa gabi. Pero ini-stop ko lahat ng medications without prior notice ng doctor. After 2 years, nararamdaman ko na naman yung symptoms, kasi tinubuan na naman ako ng butlig sa tuhod,” she recounted in jest. 

This on-and-off taking of diabetes medications became a cycle for her until now. 

Through the years, Javier has been working a minimum-wage job with health insurance that covers only P1,000 of her diabetes medications. This leaves her with about P12,000 out-of-pocket costs monthly. “Hindi lang kasi medicines yung iniisip mo eh, yung mga bills din – tubig, kuryente, internet, tapos yung food mo pa. Talagang kulang na kulang ang sinisweldo namin.” 

While generic equivalents of diabetes medications are available locally, diabetes drugs remain expensive based on the averaged prices obtained from readily available data on medical supply stores’ websites and private and public hospitals.

The most affordable insulin medication at the Department of Health's (DOH) retained hospitals costs P500 per dose, making it P30,000 monthly for twice-daily usage. In private hospitals, the prices are much higher. On one hand, a box of 100 tablets of Branded Metformin 500mg, a frequently prescribed oral medication, is at P1,500. Sitagliptin Phosphate, also used to manage glycemic levels, averages around P62 per tablet, totaling P1,860 monthly for once-daily usage.

Adding up the medical supplies such as blood sugar monitoring devices and insulin syringes which cost roughly P4,200 plus monthly repurchase, a person living with diabetes without adequate health insurance coverage pays around P38,000 a month to manage their condition. 

Javier tried to seek help from the government for diabetes relief, but what she was met with were long lines, inhospitable staff and lack of medicines. “Sa ospital naman, sana hindi na rin harangin, yung sinungitan ka pa. Imbes na hihingi kami at lalapit, una ang susungit porket nanghihingi ng libreng gamot. Sana hindi ganun.”

The government provides some financial assistance for people with diabetes under the Department of Health’s (DOH) Philippine Package of Essential Non-Communicable Diseases Interventions, also known as PhilPEN. The government grant covers prescription costs, doctor visits and limited medications. But not only is the program deficient, its delivery is marred with systemic issues.

The cost of diabetes in the country runs to tens of thousands of pesos if not more, driving people into financial distress and debt. Patients like Javier who depend on life-saving medications are especially vulnerable to the impacts of inaccessible healthcare.

“Sama-sama na kasi siya — financial at emotional. Ganito lang sweldo mo tapos marami pang bawas kasi may loans ka. Bibili ka ngayon ng gamot, iisipin mo na naman yung pang-kinabukasan,” said Javier with a sigh.

Decentralized healthcare system 

One of the biggest factors causing this inaccessibility to healthcare stems from the devolved health services in the Philippines, underscored Doctor Jamie Dasmariñas, a community medicine practitioner who is part of the field assistance unit of the Council for Health and Development. 

“Ang nature ng healthcare system natin is devolved. When we look at service delivery, meron kang services coming from a national level and you have the LGU,” said Dasmariñas. “Majority of the decision-making that directly affects your patients within an area is dependent on your local government unit.”

To improve the efficiency and effectiveness of health service delivery, the Local Government Code of 1991 mandated the devolution to LGUs of the many functions previously provided solely by the DOH. Following the code, the DOH assumed the national technical authority on health while the LGUs took a bigger role in delivering basic services and operating facilities in areas of primary health care.

Based on section 17 of the Code, among the basic health services and facilities devolved to the LGUs are the maintenance of barangay health centers, implementation of national health policies, purchase of medicines and equipment, and access to secondary and tertiary health services.

Dasmariñas pointed out that the pitfall of health devolution is the resource constraint — financial, material and manpower — many of the LGUs are facing. 

“Kung hindi priority ng isang LGU ang funding for health, hiring of healthcare workers, or wala silang pera for it especially in 5th or 6th class municipalities, sila yung disadvantaged,” she noted. “Your access to healthcare now becomes dependent on how much your LGU would spend on what its citizens can access or how much you can spend out-of-pocket.” 

A 2018 review of the Philippine healthcare system reported similar challenges to health devolution. 

Not only are several LGUs unprepared to effectively assume these responsibilities, but the Local Health Boards (LHB) created for each LGU are also untrained for the position and lack the power to prioritize and sustain health programs. LGUs also face problems in allocating resources for health programs due to insufficient budgets and the lack of standardized data monitoring and healthcare guidelines. 

Though the DOH recognized these constraints as a policy dilemma before implementing the Code, the wisdom of removing top-level intervention in providing health services, especially at the local level, took over.

Meanwhile, another main feature of the country’s healthcare system is the Universal Health Care (UHC) Bill signed into law by former President Rodrigo Duterte in 2019. 

The UHC Act automatically enrolls Filipino citizens into the National Health Insurance Program and expands PhilHealth packages to cover free medical consultations and laboratory tests. These complementary health system reforms were enacted to supposedly give citizens broad access to the full range of medical services and protect them from the ensuing financial hardship. 

A critic of the UHC Act is that it is an indirect privatization where PhilHealth coverages are broadened without creating physical institutions to deliver health services.

“Meron kang perang naka-store pero kulang yung on-the-ground institutions — physical structures for hospitals, healthcare units, healthcare workers, medicines and laboratories,” said Dasmariñas. “Kahit meron kang PhilHealth coverage, the patients don’t have PhilHealth accredited institutions even those public in their localities, kaya hindi nila ma-access yung healthcare.” 

The law mandates every barangay should have at least one health center. It is at these centers where health care professionals deliver diabetes management and basic measures such as taking body mass index and blood pressure. 

According to Statista, an online statistics portal, only 42 percent of barangays nationwide had health centers in 2021. Several barangays then have to share a single functioning health center, as not even half of them have their dedicated facilities.

Aside from inadequate facilities, the number of health workers for the population is also limited. There is only one doctor for every 33,000 individuals, the 2021 national field health service report recorded. The gap is way wider for nutritionists, with one nutritionist serving around 150,000 individuals. 

Given these critical health system gaps, Dasmariñas described UHC as “PhilHealth on steroids.” PhilHealth is strengthened without the necessary ground facilities where the patients can access health services. 

“Nandun na kasi yung funding for operational expenses, sweldo ng healthcare workers at pag-procure ng mga gamot at facilities. Para siyang meron kang kuryente pero wala yung wiring na dadaanan niya,” she added. 

Challenged diabetes care

At present, diabetes clinics in several government hospitals offer free consultations and affordable medicines for the underprivileged. There are also programs to empower primary healthcare workers on how to manage diabetes properly. 

This is following Administrative Order No. 2012-0029 signed in 2012, which outlines the implementation of PhilPEN. The policy was passed to mitigate NCDs and their complications, particularly diabetes and hypertension, by providing access to basic medications and laboratory services. 

As maintained by Dasmariñas, the adoption and implementation of the PhilPEN program largely depend on the capacity and resources of LGUs. This means that it is not implemented the same way across the country. When the DOH runs out of supply, LGUs are also left to themselves to fund the program. 

“Ang burden binibigay sa entity such as the 5th or 6th class municipalities na kulang yung resources and power despite us having a policy,” she said. “If you talk to patients who access public healthcare facilities like barangay health centers or city health units, more often than not, either walang gamot, kulang or namimili sila kung sino ang bibigyan.” 

A 2016 study on PhilPEN implementation in Los Baños Laguna reiterated these critical health system gaps at the primary care level in local health units that hamper the effective delivery of the program. 

The study reported problems particularly in the training of the primary healthcare workforce, availability of some NCD drugs and diagnostic tests, and non-functioning and uncalibrated equipment. There is also a lack of awareness about PhilPEN leading to meager appreciation among the management and staff of LGUs. 

These critical health system issues, rooted in inadequate financial resources, compromise the prevention, early detection, diagnosis and management of NCDs at the primary care level.

On one hand, the Philippines government health care insurance company PhilHealth also provides benefits for diabetes-related admissions.

As per PhilHealth Circular No. 17s 2014, one member per family who has a 10-year cardiovascular risk greater than 30 percent is eligible for the PCB2 (PhilHealth Case-Based Benefit Package). Eligible recipients of this package can receive monthly supplies of only two medications: sulfonylurea glibenclamide and biguanide metformin.

The coverage is obviously better than having no provisions at all for diabetes medical outpatient care. However, the package remains incomprehensive, as reimbursements for medications and overall health coverage are limited for each household.

Despite the insurance benefits, most outpatient services, such as laboratory procedures and daily medications, continue to be out-of-pocket expenses unless patients are enrolled in other private health insurance programs.

“Kahit meron tayong policies like PhilPen, which is supposedly to prevent the complications of diseases like hypertension and diabetes, hindi nagbe-benefit yung dapat maseserbisyohan ng policy," said Dasmariñas. "Ang state of health ng ating mga mamamayan ay dependent on their socio-economic situations.” 

“It drives back to privatization of health where instead of broadening our access to healthcare facilities and services, a price is put on healthcare.” 

She furthered that besides the incomprehensive insurance system, the government is not keen on preventive measures in programming diabetes care. 

“Ang care for non-communicable diseases, you have to look at them holistically. As a doctor, lagi naming sinasabi cornerstone ng ating pag-gamot sa inyong sakit ay yung pag-aayos ng diet pero paano kung ang afford lang nang pasyente ay yung maalat at mamantika,” she said. 

“Kung hindi ang wellbeing ng mga tao ang focus ng ating service providers like the LGUs or national departments, mag de-deteriorate talaga yung health.” 

Under the current national diabetes care map, private-paying individuals with enough resources can opt to receive diabetes treatment in tertiary hospital settings where they have a choice of specialists while underprivileged patients either ration their medications, postpone treatment, or just neglect their condition. 

Alternative diabetes care communities 

Due to the perceived lack of government support and the distress that results from living with diabetes, support groups have sprung up online. These diabetes support groups provide a virtual place for people to engage with each other. Members within the group share information, find understanding and give or receive emotional and even financial support. 

Upon manual search of diabetes support groups in the Philippines, Facebook's top page recommendations show pages with member counts that range from 10,000 to 30,000 each. 

Among the top search results is the Philippine Diabetes Support (PDS) group with about 29,000 members. The group is under the Philippine Diabetes Support and Awareness Group Inc., a registered non-profit organization. 

Architect Cynthia Duntz, vice president of the PDS organization and an individual living with type 2 diabetes, said the group was created in 2017 due to a lack of diabetes education in the country. 

“There are many people who don’t know anything about diabetes or subscribe to traditional beliefs, things that were discovered ineffective or untrue," said Duntz. "That’s the main reason why PDS has been established.”

In the group, there are medical practitioners such as doctors, endocrinologists, pulmonologists, internists and dieticians who offer free advice to members. 

“If they see a question posted in the group, they comment on it. Minsan if meron taong hirap na hirap sa diet, may sugat na lumalala, the nutritionists connect with them to help,” said Duntz.

Since PDS does not have funding, Duntz admitted the group relies on sponsors for their awareness programs. 

“We have sponsors that educate us through webinars like Diabetes 101 and about nutrition and diet. One time, we talked about exercise even for PWDs,” she said. “Before the pandemic, may mga activities yung mga pharmaceutical firms, may mga donations ng oatmeals. Iniabot namin ito sa mga members.” 

PDS started as an FB group where people living with diabetes occasionally share their experiences. Now, the group has evolved into a platform for active emotional and even financial support. 

A scroll through the group feed would reveal posts calling for donations. In the comments section of these posts, it can be seen how the members offer help by giving out free medications like anti-diabetes drugs and insulin. 

Duntz welcomes this change in dynamics as she decried government neglect for diabetes care. 

“Members help because they can relate kasi pareho silang pinagdadaanan. Whatever help kasi I noticed that diabetes is not important sa ating government,” she said. “Sabi nila meron silang insulin access program but mostly Metro Manila lang. Namimigay sila ng maintenance medicines pero hindi nakakarating.” 

Meanwhile, Dannie Buenaventura, a member of the PDS group and a patient with type 1 diabetes, doubled down on how patients scramble for diabetes medications. 

“Yung services sa health centers, sana maspread nila yung awareness na meron. Kahit yung mga taong walang-wala na talaga dahil sa mabagal yung sistema, ayaw na rin nila pumunta at pumila,” Buenaventura said. 

“Nagsti-stick na lang sila dun sa pag-post sa PDS group para humingi ng tulong kasi minsan mas mabilis pa ang tulong dun ng mga tao kesa sa government.” 

The way forward 

Systemic challenges in Philippine healthcare put diabetes care at a disadvantage concerning resources and government support. Patients, in turn, often face out-of-pocket costs for medications, undermining equal access — a cornerstone of the human right to health. This dynamic disproportionately affects people based on their economic status.

The WHO's Alma-Ata Declaration of 1978 establishes health as a fundamental human right the government must uphold. This principle finds resonance in Article 2, Section 15 of the 1987 Constitution, which mandates the state to protect and promote the people's right to health.

Doctor Josh San Pedro, co-convenor of the Coalition for People’s Right to Health cited these two provisions in describing how the country’s healthcare system remains inaccessible for many Filipinos. 

“For preventive health services, it’s not the priority and is not developed in the country. Despite having several health facilities, basic health services are not accessible and are underdeveloped,” said San Pedro. 

“When it comes to diabetes care, despite having PhilPEN as DOH policy, with UHC it doesn’t necessarily translate because PhilHealth packages are still not developed for the outpatient benefits. The funding for lifestyle diseases and outpatient services are not widely available.” 

Moving forward, San Pedro urged advocates for a major overhaul of the public healthcare system as detailed in a bill filed in Congress called Free Comprehensive National Public Healthcare System. 

The bill seeks an overhaul that addresses the increasing budget and the number of health facilities and workers needed to provide proper healthcare for the population. 

“Hindi pwede na iba-iba ang standards natin per municipality dahil mas may kaya, facilities, or political will yung isang LGU compared to others. Diabetes in Maguindanao should supposedly be managed the same way as diabetes in Metro Manila,” said San Pedro. 

“Hindi dahil mas may resources ang isang LGU, dito mas may karapatan at access ka. It has to be national focused, especially if we want to improve access to healthcare across the board.” 

San Pedro underscored that addressing chronic diseases like diabetes should be holistic. This means addressing the social determinants of health by improving nutrition, funding for healthcare and agriculture to ensure food security and improve living conditions. 

“Para yung pagkain sa bawat lamesa ay masustansya. Pero paano nga naman magiging maayos ang sustansya mo kung wala ka namang maayos na tirahan at sahod so that you can afford these things,” he said.

For people living with diabetes like Javier, Duntz and Buenaventura, inaccessible diabetes medications are not only paid with pesos but also with health, lives and livelihoods. 

The public should urgently demand nothing less than a healthcare system that is responsive to their needs. In terms of diabetes care, this means ensuring better access and delivery regardless of insurance or wealth.

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