Beyond Dollars and Cents

Carolina Austria

Carolina Ruiz-Austria looks at the real cost of sexual and reproductive health care in the Philippines, including the challenges and successes of different programs.

Dan, a tricycle-taxi driver in his late 30s recounted how he appreciated the candor and humor injected by a young doctor in talking about an often delicate topic among Filipino men, vasectomy. The association of drivers and tricycle operators he belonged to entered a partnership with a local NGO to conduct information campaigns on selected topics on reproductive health and family planning.

"But while information about reproductive health and family planning is always welcome and useful, we need access to free, accessible and affordable health services," he quipped.

Indeed for many Filipinos living on less than a dollar a day (at the moment, the exchange rate is around 46 pesos to a dollar), taking action on valuable, practical information about reproductive health often boils down to a decision between a pack of condoms and pills or the family's daily meal. A pack of three condoms costs about three to five pesos on average and a month's cycle of the most affordable birth control pills around twenty to twenty-two pesos.

Most tricycle drivers who do not own their vehicle earn only by commission — that is, if they are able to make a daily quota locally termed the "boundary." The majority of tricycle drivers in the Philippines are male and have typically been the targets of "male-involvement" focused initiatives in reproductive health programs.

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Studies have shown that Filipino males have consistently been rated low on condom usage and vasectomy is the least used method of family planning method, comprising 0.1 percent compared to 10.5 percent of female tubal ligations (in the context of contraceptive prevalence rate).

Researchers have also noted that "Filipino men greatly influence their wives' decision to practice family planning and the husband's consent is crucial to his wife's use of a particular method. In fact, the husband's opposition to family planning practice is one of the reasons cited by some women for not practicing family planning."

Indeed, it is easy to see how changing the attitudes of both men and women, challenging sexual roles and transforming gendered relationships of power is key in successful reproductive health programs. Still, in the context of poverty and inadequate health systems, reproductive health care services are also necessarily a complex issue of expenses and national budgets.

New thinking around the health system as "core social institutions" points to the profound links between poverty and the experience of marginalization, neglect and exclusion by the health system.

Lynn P. Freedman of Columbia University's Mailman School of Public Health notes that even though health as one of the social dimensions of poverty has often been acknowledged alongside the recognition of the intrinsic economic value of healthy populations to ensure economic growth, reforms have so far only treated health systems as a "technocratic challenge."

Indeed, the framework of health sector reforms this side of "development" has always tended to be built on the premise of "commercial markets as the most efficient way to produce and distribute health care."

The Philippines is one of a number of debt strapped nations to have embarked on a "Health Sector Reform Agenda" which reflects this orientation where "consumers" (like Dan) may not be entitled to free health services, much less free contraceptives. That's because while his wages are meager, Dan has a job.

"It used to be a free service [with condoms and pills] available from our local health center," he noted. "Now, we hear it is only available at Quezon City" (a city within Metro Manila but far from where Dan lives and works).

The reason for this lack of consistency in available health services is largely due to the policy of local devolution in basic services gone awry. Under a mandate of having devolved services, which used to be provided directly by the national government, the current administration has failed to provide adequate standards in meeting the needs of citizens who have been erstwhile directed to the local government units for their claims.

Having refused to support universal access to reproductive health care, president Arroyo literally gave local government chiefs full discretion in deciding what to include in their menu of local basic services. Some "pro-life" chiefs went to the extent of even banning artificial methods of contraception from basic health facilities and hospitals.

Of course, to feminists and sexual and reproductive rights (SRHR) advocates who insist that health-systems are so much more than a "mechanical structure," the challenge goes beyond bringing the conversation forward on state subsidies and allocations.

Squarely dealing with the redistributive aspect of a just health care system also means having to reframe our whole thinking on health services as an entitlement and not just simply products for consumption. Freedman also notes how research has revealed that subsidies for the poor by the "better-off" are often schemes exposed or constructed as "unrequited gifts" and are difficult to maintain (M. Makintosh:2003).

A group of women working in the civil service, for instance, told me that even though they were regular members of the social security system and members of Philhealth (the local public health insurance system), they sought to augment their family's needs by attempting to tap the benefits outlined in the "Solo Parents Act," but failed due to inconsistent standards in implementation across local governments. The law extends additional benefits to single parents or single heads of households, but has only seen implementation in less than five key cities in Metro Manila.

The other down side of a market oriented health system scheme has often been the portrayed conflict between active users and members of social security who are either blue collar or civil service employees, and the indigents.

All too often, bona fide members of the system who aren't exactly well off themselves are portrayed as scheming and making claims which supposedly "bleed the system dry." Still, in a setting like ours, what forces (and powers) are actually able to bleed the system dry is highly debatable and a whole other story altogether.

Caption: Gino Menguito, 29 is one of few Filipino men who have undergone vasectomy after attending information and educational campaigns about family planning targeting men's involvement. (File Photo from Social Acceptability Project, Technical Notes:2003)

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