Health Care For All Filipinos

Sylvia Estrada Claudio


If I were the President, conditional cash transfers or CCT's would not be my flagship program. I would instead work on universal health care.

I know, I know. I am not the President. I am also not so arrogant as to presume to give Pnoy unsolicited advise or bad-mouth Sec. Dinky's thing. This is not about the pros and cons of the CCT, a subject that deserves it own Yellow Pad column.

But universal health care (UHC) is one of my hobby horses. It has been on my mind for the past year for several reasons, one of which is that Dr. Alberto Romualdez and a group of colleagues from UP Manila, put together a task force for the Centennial Lecture Series of the University of the Philippines and came up with a blueprint for UHC. The task force's output is exciting because it is straightforward in its proposal that we can achieve health care for all in a relatively short period of time.

According to the NSCB, our country's total health expenditure reached P180.8 billion in 2005
Using this figure the task force proposes that around 80 to 120 B pesos would be needed to achieve health care for all. The task force also proposes several funding mechanisms such as quantum increases in tax-based government spending, national government-tax increases, reallocations, local government-mandatory increases in proportion spent on health and significant increases in public health insurance support value for basic services. AER head honcho Men Sta. Ana, who I asked late last year, also thinks that sin tax increases and foreign borrowings could be tapped as well. It tickles my iconoclastic soul that activists like us would actually approve of foreign debt. But, many of us have always argued that debt that truly benefits the people would not be bad debt.

Thailand is an excellent source of inspiration. It's total health expenditures for the year 2007 are slightly less than the Philippines. Yet it has achieved universal health care. WHO statistics show that the Thai government provided for 73% of all health expenditures while the Philippine government provided only 35%. Simply put, Filipinos are paying for their own health care out of their own pockets. Naturally, the health statistics for Thailand are so much better.

Thailand achieved its universal health coverage over a period of years through a multi-pronged approach that involved, among other things, local-level initiatives.

So, I nagged another good friend, Dr. Dennis Batangan to work out a pilot program for UP Diliman. It is my dream to start piloting for universal coverage, so I thought this should happen in the place where I work.

What Dr. Batangan and I propose is to start a demand-driven and insurance linked health benefits project for UP Diliman. It begins simply as an information management system and health insurance project intended to expand the access of the UP Diliman Community to available health benefits. It aims to consolidate available information on health-related benefits intended for various sectors of the UP Diliman community and expand access to these benefits through demand-driven mechanisms and social health insurance schemes.

This is a first step towards ensuring equity in health benefits for all sectors of the UP Diliman community. It will also serve as a pilot effort towards universal health care coverage.

The project will be implemented in four phases namely: 1) a policy engagement phase. to ensure the commitment and support of the highest level of authority in the UP Diliman Community, the Board of Regents and the Barangay UP Campus officials; 2) a data integration phase that includes the designing of the data framework and capture forms to consolidate the available health benefits and insurance information for employees, students and community residents participating in the project. The data framework will also attempt to capture current demand for health services for the stakeholders concerned as well as health expenditures per capita and for UP Diliman as a whole; 3) a network expansion phase that involves the development of a directory for and organizing into a network of the health service providers the psychosocial , biomedical and alternative health service providers in the community. The information gathered from the network will be made available to the UP community through an internet portal and/or SMS services and; 4) a benefits convergence and development phase where institutions and organizations offering health related benefits will be guided on the process of converging or integrating their benefits for same beneficiaries and improving efficiency in the provision of these benefits. At the same time, new benefit packages for health related or psychosocial services will be developed or expanded for the benefit of the community.

The goal of the project for UP Diliman employees, students and community members have easy access to consolidated information on health related benefits they can avail of in times of need. In the process, the beneficiaries will also be provided inputs on how to expand the health benefits they are currently receiving through social health insurance schemes and development of other demand side benefits.

So, if I promise, promise, promise to cooperate with Pnoy's CCTs, can he spare me a bit of change to begin piloting universal health care in UP Diliman?

(Sylvia Estrada Claudio is a doctor of medicine and a PhD in psychology. When she is not attempting political trade-offs for her hobby horses, she teaches Women and Development Studies at the University of the Philippines in Diliman. She is a fellow of AER.)

Science and Philosophy Lessons for the Pro-Birth (who call themselves Pro-Life)

Several of my friends do not particularly like discussing the question of “when life begins”. I refer to this debate in relation to the reproductive health bills pending in the Philippine legislature. These friends would include non-Filipino veterans of abortion rights struggles in their own countries.

My friends, some of whom are philosophers by training, know that the “where life begins” question is really unresolvable. The philosophically sophisticated understand that a question like that is the stuff that has driven and will drive philosophy through the millenia. It is similar to other questions like, “does matter exist?”. The question is unresolvable. I am aware that the philosophy of natural science, (I love science!) merely assumes this without attempting proof: “matter exists”. I am also aware that the Buddha (love the Buddha) takes a different view: “all is illusion”. You have got to love philosophy for tackling the eternal questions and the calm philosphers bring to facing immense uncertainties.

Of course, the reproductive health bills do not change the punitive Philippine laws on abortion. So this “when life begins” debate should not be pertinent. But the pro-birth (I do not concede the term pro-life to them as my advocacy for the passage of RH bills is to save women's lives) opposition keeps insisting that contraceptives are abortifacient. They also insist that conception is equal to fertilization. According to the pro-birth people, contraceptives should be banned because the Philippine Constitution states as a matter of policy that the state, “shall equally protect the life of the mother and the unborn from the moment of conception”.

This argument alone is is more an example of the lack of scientific and philosophical training of those who espouse it. It is not an argument that should be dignified in the public debates. I know that certain advocates of this position are doctors, scientists and philosophers. But I have no fantasies about the guarantees that academic degrees confer. “Nil admirari”, my philosopher mother used to say. Admire no one. Certainly I am unhappy when people use their academic degrees to claim they are speaking the truth when they are not.

So let's see what science says and what logic demands. Science tells us that the argument that “contraceptives prevent the implantation of the fertilized ovum” is an unsupportable generalization. I cannot go into the scientific literature for purposes of brevity, but many lay people know that the condom prevents fertilization. Looking at the literature, there is SOME evidence that some contraceptives MAY prevent implantation of the fertilized ovum as possibly ONE OF SEVERAL mechanisms for their contraceptive effects.

But even if we were to concede this rather flimsy basis for their claim that modern contraceptives prevent implantation, it is a misrepresentation to say that these are abortifacient. There is a wide-ranging consensus in the scientific community that pregnancy begins at implantation. An abortifacient, by definition, terminates pregnancy prematurely. Thus, none of the contraceptives are abortifacients.

When pro-birth advocates like Rep. Anthony Golez claim that contraceptives are abortifacient they should at the very least specify that this is a minority opinion. When Rep. Golez states, as he did in the last public hearing at the House of Representatives, that he is giving his opinion as a medical doctor, he borders on the unethical. I am a medical doctor too and I am ethically bound to tell the public and my patients what the majority of experts are thinking on the medications I recommend or discourage. This is especially true if my position is that of the minority.

The last misrepresentation in this argument is that “fertilization equals conception”. As I mentioned in my intervention at the last hearings in the RH bill, conception is not a medical term. Terms like fertilization and implantation are scientific terms. But whether we can tie this to the term “conception” and the larger question of “when life begins” is a whole other matter.

Indeed advances in embryology show us that fertilization is not a “moment” but is a process that takes some time. Thus, to equate fertilization to “the moment of conception” is something of a fudge.

Pro-birth advocates, like ex-Senator Francisco Tatad, also take the line that “moral natural law” is a universal truth that should guide our personal and collective decision-making on this debate. Their version of this philosophical argument says that it is inherent in all of us to recognize a God. Additionally, their version of natural law states that it is inherent in us to recognize that we do not kill another human being, herein defined to include the fertilized ovum. I have no argument against the presentation of this philosophy. What is problematic is that they present this as if it is the only philosophical tradition that is pertinent to moral decision-making. The truth is it is a philosophy that tends to be overvalued in Catholic schools and largely relegated to a minor discussion in the secular University of the Philippines. Again, the point here is the misrepresentation. For philosophers like Mr. Tatad one wonders whether he was not taught other frames in the pontifical University of Santo Tomas; he forgot what he was taught or; he has failed to stay current with the changes in his discipline.

I agree with my philosophically sophisticated friends that debates around when life begins are probably futile in the determination of social policy. Constitutions of a number liberal democratic states inculcate this wisdom by working on a definition of “personhood”. But I do feel duty-bound to help increase our people's scientific literacy and to help craft social policies that are enlightened by the advances of human knowledge.

Yet I shall end this with a salute also to the wisdom of my philosopher friends who insist that we weigh the correctness of a political and philosophical premise on the basis of its effects. I always wonder why the pro-birth are blind to the unequal effects of their insistence that life begins at fertilization. To insist on this premise is to tie yourself to a position that allows you to argue for the control of women's bodies for your political purposes. Meanwhile, men's bodies remain free.

And so, I have been proposing to friends to think of the implications of a premise that states, “life begins at sperm production”. I doubt whether the pro-life religious men, philosophers and scientists would like the restrictions on their bodies such a premise would imply.

Support for the RH Bill

Intervention of Dr. Sylvia Estrada Claudio Director, University of the Philippines Center for Women's Studies at the Second Deliberation of the House Committee of Population and Family Relations on HB 96, 101, 513 1160, 1520 and 3387. December 1, 2010.


Thank you Mr. Chair, your Honors.

I have a prepared statement today but let me respond to the questions posed to the medical doctors by Representatives Biazon and Golez on the issue of when life begins.

I note that the Chair called upon me because Rep. Biazon also asked who does not believe life begins at fertilization. I do not, for two reasons. The first reason is that as an agnostic I do not subscribe to the beliefs of the Catholic Church. In this regard I would like to remind everyone that the Constitutional provision on religious freedom protects not just the right to belief but also the right to non-belief. But I will leave the representative of the Filipino Freethinkers who is also here today to elaborate this point.

The second reason I do not believe that life begins at fertilization has to do with my expertise as a medical doctor. Rep. Golez states that as a medical practitioner, he believes life begins at fertilization. He cites among other things the banning of Levenorgestrel by the government as proof that other experts believe the same thing. He implies that obstetricians and gynecologists may not be the best resource as to whether drugs like Levenorgestrel and other contraceptives are abortifacient. According to Rep. Golez, it should be those experts, like geneticists and biochemists, who do not prescribe these substances or devices who should be consulted.

With all due respect, I will remind Rep. Golez that the government reveresed its ban on Levonorgestrel. I was one of those who petitioned for a reconsideration of the ban through one of the organizations I work with. An expert committee composed of both medical and legal luminaries decided unanimously that Levonorgestrel was not an abortifacient. To be accurate there was one dissenting opinion and it was that of Rep. Golez. But at that time we protested the inclusion of his opinion because he really was not a member of the panel. At that time, he was merely the person from the DOH assigned to facilitate the hearings and panel deliberations.

As a medical doctor also, I would urge everyone here not to overvalue our opinions and expertise. Doctors should also be more humble. The question of when life begins is not a matter to be left to doctors or other scientists alone. Pertinent to this discussion I would like to note that “conception” is not a medical term. The terms fertilization and implantation are medical terms and we can describe and explain these processes to lay people. Any scientific discussion requires the precise use of terms. The Philippine Obstetrics and Gynecological Society is correct when it states that the mainstream medical and scientific community agrees that pregnancy begins at implantation.

As many of you in this room know, this is at the very least, the 4th Congress where an RH bill has been proposed. Many of us here have faced each other on this issue before. I do recognize though that there are people here who are new to the issue and their voices must be heard.

But perhaps before we continue our debates we should congratulate ourselves. Because of the engaged citizenship that the proposed RH bills have evoked, we are on the brink of enacting a social policy that has been understood by our people and crafted with their input.

So all I ask of your honors is to trust our people who have indeed come to a decision. Today's headline of a leading newspaper reveals that a high level of support exists for the enactment of the proposed RH bills according to a non-commissioned survey conducted by a reliable polling organization. This verifies an earlier survey showing the same results except that the newest survey shows higher levels of support for the bill.

Contrary to the claims of those who would belittle the survey results, it also shows that our people are aware of the major provisions of the proposed bills.

As an advocate for women's rights, I too must listen to our people. Like the Catholic Church I am against any form of population control either as a framework for an RH law and certainly not as a goal for its implementation.

Like the Church I do not think that lowering the fertility rate has any direct effect on poverty levels at the macro level. I disagree with the Church because I think that having less children does mitigate the burden of poverty at the level of the family.

My involvement with the women's health movement began because I felt there was a need to protect women from the population control programs of the past. This is the reason why I, and many other feminists, participated in the international actions that led up to the 1994 Program of Action of the ICPD.

I would therefore caution both sides who use demographic arguments like population density and replacement numbers to argue for or against the bill. Women have been hurt on both sides of this argument. Some would have us not give birth and others would force us into pregnancy. These are both violations of women's rights. Speaking again as a practitioner, I would caution against the use of any drug, device or technology for considerations other than a woman's well-being.

My support for an RH bill has always been because I am heartbroken by the harm and death that the lack of services brings to women and their families. No woman should die because of the lack of emergency obstetric services or due to violence from her intimate partner. No family should be left motherless because of preventable deaths.

I see the surveys. The Filipino people like the proposed bills. They agree with arguments for reducing population numbers in order to ensure the delivery services and national development.

Your honors, I accept the reasoning and judgment of our people. I hope you will too. Please pass a consolidated and comprehensive reproductive health bill as soon as possible.

Thank you.


NB Upon reviewing the decision of the technical committee that convened to hear our petition to lift the ban on Levonorgestrel, I realized I was mistaken in claiming that the committee was unanimous in its decision. There was one dissenting opinion. Anthony Golez also gave a dissenting opinion but I still hold the opinion that he should not have done this and that he acted beyond the role assigned to him in doing so.

We Could Try "Nice"

It isn't nice to block the doorway,
It isn't nice to go to jail.
There are nicer ways to do it.
But the nice ways always fail.

It isn't nice, it isn't nice.
You've told us once,
You've told us twice.
But if that is freedom's price,
We don't mind.

--Malvina Reynolds

The current controversy engulfing the university where I teach is one that could happen in any sufficiently open society. It is about whether a group of protesting faculty and students were right in painting slogans on walls; lobbing paintballs at one of our chancellors and destroying some chairs.

Yesterday I sent our Faculty Regent a song for those who believed the actions were justified. I have loved this song for a long time and I would urge people to look up Malvina Reynolds', “It isn't nice”.

The impulse to send the Faculty Regent the song comes from years of being an underground propagandist during the Marcos dictatorship. I have criticisms to make of those who used paint and destroyed chairs. Yet the song is a perfect vehicle to express their sentiments.

Only a few lines need be said about those who stood up for their beliefs in ways that were branded as impolite, improper, barbaric, unwise and criminal. Apart from the those who took up the early protests against the Marcos dictatorship, there are those who fought against apartheid, those who joined the civil rights movement in the US--- I could go on and on. I will add only that these movements were started by small groups who were initially vilified, only to be supported later by millions.

My criticisms have to do with why I have become a pacifist, though an angst-ridden one. Anyone who supports violent tactics and strategies needs to reflect on whether that particular form of violence (say, armed struggle as opposed to suicide bombings) can be justified. I am still convinced that there is a moral basis for violence. I am just setting the bar very high for when violent acts can be moral.

I think that using violence to defend oneself, one's loved ones and those in the immediate vicinity, against battering, sexual violence, torture, mutilation and attempted murder is eminently justified. I would not say that violence is only justified for these grand instances. I once slapped away the hand of my eldest son with enough strength to make him wail. At the time he was a toddler, trying to insert a pair of tweezers into an electrical outlet.

I do not think the methods used at the rallies in question were justifiable.

It is not just the University's officials who are condemning the methods. Several faculty members and researchers have expressed their disagreement in our discussions as well. I am also told that as the slogans were being painted on the walls, rank and file employees in the building were upset because the University would need additional funds to repaint. In their minds, the very people who had made an issue of the state's budgetary neglect of education, were squandering the very resources they wished to augment. Additionally, the discussions have now become about the methods of protest and not the issues of the protest.

I disagree with those who have tried to justify the violence by essentially taking the line that there is violence in society that is far more immoral than the case-at-hand. One cannot justify bad practice by stating that worse things have gone unpunished.

I must say that the tactics used do not rise to the level of truly gut-wrenching violence. In the opinions I have read or heard on the matter, I have noted some hyperbolic descriptions.

Furthermore, I do not condemn these actions just because these were impolite or bad mannered. Even the genteel may be roused to cussing when unduly provoked. I also urge the reader to look into the book entitled “Miss Manners Guide to Excruciatingly Correct Behavior”, to find out how and why a person should deliver a social snub—of which there are several varieties. The lack of politeness in the protest is self evident. The proposition that bad manners per se are condemnable is put to rest convincingly by the sentiments expressed in Reynolds' song.

The protesters have every right to go beyond the formal or sedate ways of handling dissent (more Board of Regents meetings, administrative cases, court proceedings, fora, petitions and scholarly papers). The history of revolutions and transformations shows this to be a necessity. But the decision to use non-formal methods is not necessarily a decision to escalate to violence. The methods of Gandhi and Martin Luther King are but two examples of this.

The question about tactics that should be answered is whether the wrong that is being protested justifies the slogans on the wall, the throwing of paint and the destruction of chairs. I have tried my best to follow the issues and believe that the protesters have very legitimate concerns. But I do not believe the tactics were just.

I believe this is why, confrontational tactics are being rejected by many ordinary citizens. We have too often planned protest actions that have resorted to minor forms of violence when, in the minds of a significant number, the moral basis for proceeding to violent action had not been met.

I am one of those who ascribe to the political ethic that the means must be justifiable in themselves. On a very practical level, questionable tactics are a barrier to revolutionary change. I am not the first to be discouraged by the fact that the people have not been more active in their resistance to the shenanigans of the Arroyo administration. I am not the first to note that the Left has been unable to provide the disgusted majority with tactics that evoke wide-spread action.

Folks from all walks of life have a deep desire for effective governance and democracy. This is true in all social institutions including the academe. If we are to be so arrogant as to call ourselves activists, we must come up with creative methods that can harness these passions in ways that do not trade off the future of activism for present gains.