Do we want patients consulting trapos (traditional politicians) for health assistance? It might become the norm as social health insurance (the Philippine Health Insurance Corp., better known as PhilHealth) gets defunded in favor of a medical assistance program that reeks of patronage politics.

We hear politicians singing hosannas for the Medical Assistance to Indigent Patients (MAIP) run by the Department of Health (DoH), which allows politicos to dole out Guarantee Letters (GLs) from their share of MAIP funds. MAIP only had a budget of P1.8 billion when it was created in 2015, but it is now the fastest growing item in the DoH budget. By fiscal year 2025, it will grow over 40 times its original budget when Congress soon approves a P74-billion MAIP budget.

On the other hand, the budget for indigents (the premiums of indirect contributors) in PhilHealth has declined from P79 billion in 2023 to P40 billion this year and will stay below its budget level in 2023, with the Senate contemplating a budget of P47 billion for indigent premiums in 2025.

This situation is not a new development, as politicians have always curried favor with constituents through ayuda (assistance) programs since COVID-19 hit in 2020. But this time the scale of health patronage is clearly exceeding the public health system’s regular funding.  PhilHealth’s Social Health Insurance Program for indigents has suffered the most under this unwritten policy. The health system embodied in Universal Health Care is being gutted to fund MAIP.

Indigent patients have always been intimidated by large public hospitals, which they can only go to if they have money in their pocket. Political patronage through MAIP may now mean indigents going to the politicians first before they even think of entering an emergency room or consulting a primary care physician.

COMPARING PHILHEALTH AND MAIPPhilHealth serves 17 times more patients than MAIP.

In 2023 the number of patients assisted by PhilHealth was 12,675,634. In comparison, based on available data from the DoH website, MAIP served 737,280 patients, in a similar period from July 2022 to June 2023.

On average, PhilHealth paid out an average of P4,900 per patient claim in 2023. In comparison, using Region 12 (Soccsksargen) as example, where data are publicly available, we note that DoH’s MAIP provided P3 billion to private hospitals and assisted 140,200 patients with an average of P21,398 per claim in the first nine months of 2024. In short, given the limited data available to us, we can estimate that PhilHealth was able to serve 17 patients for every patient under MAIP (with Region 12 as comparator) with roughly the same amount of funds.

GOODWILL OPPORTUNITYUnregulated MAIP funds provide an opportunity for politicians to gain goodwill to the detriment of the health system.

MAIP fund support is entirely discretionary on the part of the approving authority (politicians and government executives). The goodwill generated by the generous persons in authority is highly valued, and this translates to political support or votes from the beneficiary who now has a feeling of utang na loob (debt of gratitude) for the political benefactor.

This type of political patronage in health is probably more appealing to politicians who want to avoid the “share of percentage” from pork barrel projects paid back to them by favored contractors out of fear of a paper trail of corruption. The politician can exert influence through an apparently “corruption-free” manner through this type of health ayuda. But it is still essentially corruption, for it is a form of bribing voters.

MAIP started as an exclusive program for indigents who would have to show proof of indigency from the barangay captain where the beneficiary resided to be covered by the program. However, since mid-2023, the DoH has loosened this requirement to allow financially incapable patients to avail themselves of MAIP (now renamed Medical Assistance to Indigent and Financially Incapacitated Patients or MAIFIP).

This expansion of MAIP to non-indigents allows political patronage to reach an even broader segment of the population, something that is most important during election seasons.

TWO SYSTEMSTwo systems of financing healthcare are emerging.

While PhilHealth provides a similar package of assistance to all its 91 million registered members (as of June 2024) in need regardless of financial capacity, MAIFIP provides assistance to 17 times fewer beneficiaries without regulatory constraint and dependent only on what the approving authority will allow.

The emergence of two systems of health financing in the country is more than worrisome, primarily because one system feeds off the other and may end up with the health sector being saddled by two competing programs which increases inefficiency.

The DoH has noted that benchmark indicators of population health have yielded poor results:

• Infant mortality went up to 22/1,000 live births in 2022 (from 21/1,000 the previous year);

• Maternal mortality rate increased to 154/100,000 in 2021 (from 149/100,000 in 2021; and,

• Neonatal mortality is now 15/1,000 live births (increasing since 2013).

The recent decline in the above health indicators is evidence that our primary and secondary levels of health provision (mainly under local government control) have been severely tested by the pandemic and continue to underperform. Such weakness will put a heavy strain on higher levels of care run by provincial, regional, and National Governments and providers in the private sector.

The alarm bells are ringing for our healthcare system. The poor and underserved Filipinos feel the crisis. Our highest authorities have remained deaf. It is high time civil society raised a hue and cry about the dismantling of Universal Health Care.

Jeepy Perez, a doctor of Medicine, specializes in public health administration, primary healthcare, and has worked with nine Health Secretaries and three National Economic and Development Authority Secretaries since 1992. He was undersecretary for Population and Development and executive director of the country’s Commission on Population and Development up to Sept. 8, 2022, when he retired. He occasionally writes for Action for Economic Reforms.