9  FAIR ACCESS TO HOSPITAL FACILITIES
In an archipelagic country composed of 17 regions across more than 7,000 islands, healthcare facilities are unevenly distributed. In 2018, around two thirds of hospital beds in the Philippines were in one area, the National Capital Region.126 Dayrit, et al., op. cit., note 69.
The problem of physical location has been complicated by the suspension of public transportation during the quarantine. The quarantine period started in March 17, 2020.127 Medialdea, S.C. (2020, March 16). Community Quarantine over the Entire Luzon and Further Guidelines for the Management of the Coronavirus Disease 2019 (COVID‐19) Situation. Office of the President of the Philippines Malacañang Memorandum from the Executive Secretary. Retrieved July 6, 2020, from https://www.officialgazette.gov.ph/downloads/2020/03mar/20200316‐MEMORANDUM‐FROM‐ES‐RRD.pdf
Since then, public transportation has not been fully restored. Various problems have ensued with largely ineffective government support for safe mass conveyances. A bone cancer patient with only one leg had to walk to her healthcare facility for her monthly check‐up.128 KBK. (2020, March 18). One‐Legged Cancer Patient Walks from Masinag to Checkpoint to Get to PGH. GMA News Online. Retrieved April 27, 2020, from https://www.gmanetwork.com/news/news/regions/730172/one‐legged‐cancer‐patient‐walks‐from‐masinag‐to‐checkpoint‐to‐get‐to‐pgh/story/
A leukemia patient had to walk in excess of five kilometers to get his chemotherapy medication.129 dela Peña, K. (2020, March 18). Last updated 2020, March 18. ‘Walang Choice’: Man with Leukemia Walks to Get Chemo Meds amid Luzon Lockdown. Rappler. Retrieved April 27, 2020, from https://www.rappler.com/move‐ph/254995‐man‐leukemia‐walks‐get‐chemotherapy‐medicine‐luzon‐lockdown
As with other countries, the Philippines has a healthcare infrastructure that was not adequately prepared for the magnitude of this pandemic. Hospital facilities and opportunities for safe medical confinement are not well distributed. People have variable access to good quality facilities. Access is largely dependent on two factors: location and financial capability. Access in relation to location was taken up in an earlier section. This section focuses on financial capability as well as infrastructure and equipment availability. While universal healthcare funding is not fully in place, financial capability is a huge factor affecting access to hospital facilities.
A survey done in March 2020 showed that there were only 2,335 beds in all intensive care units (ICUs) in the Philippines, accounting for 3.1% of the total approved bed capacity of Levels 2 and 3 hospitals in the country.130 Tantuco, V. (2020, March 28). In Numbers: what Hospitals Need to Treat COVID‐19 Patients. Rappler. Retrieved May 1, 2020, from: https://www.rappler.com/newsbreak/in‐depth/256133‐numbers‐what‐hospitals‐need‐treat‐coronavirus‐patients
Therefore, there were not enough beds in ICUs to cater to the projected 8,800 to 19,800 critical COVID‐19 cases if the number of additional cases did not go down.131 UP COVID‐19 Response Team. (2020, April 20). Estimating Local Healthcare Capacity to Deal with COVID‐19 Case Surge: Analysis and Recommendations. University of the Philippines. Retrieved May 1, 2020, from https://www.up.edu.ph/estimating‐local‐healthcare‐capacity‐to‐deal‐with‐covid‐19‐case‐surge‐analysis‐and‐recommendations/
Earlier on, a number of private hospitals had announced that they were temporarily not accepting suspected or confirmed COVID‐19 patients due to unavailable facilities and equipment.132 CNN Philippines Staff. (2020, March 24). Hospitals Close Doors to COVID‐19 Patient after Reaching Capacity. CNN Philippines. Retrieved May 1, 2020, from https://cnnphilippines.com/news/2020/3/24/st‐lukes‐coronavirus‐patients.html?fbclid=IwAR0gXkJvLT6woPwp_‐3C32uy9c2‐vEP8_iSo8RxnJCZbxjI‐7spAVxRa6CI
Philippine hospitals are classified into 3 levels. Level 2 and Level 3 hospitals, which have ICUs, can admit COVID‐19 patients. There are 456 of these hospitals nationwide with a combined total number of 67,119 beds, and 41% are in government owned hospitals while the remaining 59% are owned by private hospitals.133 UP COVID‐19 Response Team, op. cit. note 131.
As public hospitals become congested, some patients have been forced to consider confinement in private hospitals. But this is a privilege that very few could afford. One patient’s bill for a 16‐day stay at a private hospital totaled PHP 3 million or around USD 59,000, which is about equivalent to a middle‐class Filipino worker’s salary for 3 years.134 Garcia, M.A. (2020, April 15). COVID‐19 Patient’s Hospital Bill Reaches P3M. GMA News Online. Retrieved April 27, 2020, from https://www.gmanetwork.com/news/news/nation/734202/covid‐19‐patient‐s‐hospital‐bill‐reaches‐p3m/story/
An estimate for a private hospital bill for a moderate COVID‐19 case amounts to at least PHP 1 million or a little under USD 20,000.135 Punzalan, J. (2020, April 9). How Much to Be Treated for COVID‐19 in a Metro Manila Private Hospital? for a Moderate Case, Prepare at Least P1M. PEP.ph. Retrieved April 27, 2020, from https://www.pep.ph/lifestyle/health‐and‐fitness/150720/covid‐19‐treatment‐cost‐a3830‐20200409‐lfrm
To address these financial concerns, the Philippine Health Insurance Corporation (PhilHealth) has come out with new policies for at least partial coverage of COVID‐19 cases.136 Garcia, op. cit. note 134.
The problem with PhilHealth is not everyone is able to use it. In 2018, 53.9 % of Current Health Expenditures came from household‐out‐of‐pocket payment instead of medical insurance.137 Mapa, C.D.S. (2019, October 17). Total Health Expenditure Grew by 8.3 Percent in 2018. Philippine Statistics Authority. Retrieved April 27, 2020, from https://psa.gov.ph/pnha‐press‐release/node/144466
Both public and private healthcare sectors have been overloaded to the point that inequities have often surfaced. Infected patients have been sent home to ease the burden on hospital facilities. For example, in Quezon City, reports of 3 COVID‐19 positive patients being sent home were followed by reports of another 14 patients being sent home for the same reason of patient overload.138 Chaves, C. (2020, March 22). Belmonte ‘Shocked’ 3 Patients who Tested Positive for COVID‐19 in QC Sent Home. Manila Bulletin. Retrieved April 27, 2020, from https://news.mb.com.ph/2020/03/22/belmonte‐shocked‐3‐patients‐who‐tested‐positive‐for‐covid‐19‐in‐qc‐sent‐home/
Many more mildly symptomatic patients were subsequently refused admission, not being made aware earlier of the policy that only those who were likely to need ventilators were being admitted. Some of those who required admission could only be accommodated in tents set up on hospital grounds.
The stress on the healthcare system brought about by COVID‐19 has reverberated in the management of other diseases. A 56‐year‐old man died from cardiac arrest in a tent outside a hospital after calls to more than 30 hospitals were met with rejection citing the lack of ventilators.139 Canoy, J. (2020, April 2). Her 56‐Year Old Father Had a Heart Attack and No Hospital Would Take him in. ANCX. Retrieved April 27, 2020, from https://news.abs‐cbn.com/ancx/culture/spotlight/04/02/20/her‐56‐year‐old‐father‐had‐a‐heart‐attack‐and‐no‐hospital‐would‐take‐him‐in
A woman who needed an immediate operation to remove her placenta after giving birth died due to blood loss after being refused by six hospitals in Metro Manila because their hospital rooms were fully occupied by COVID‐19 patients.140 Cayabyab, M. (2020, April 26). Woman Dies after Being Refused by 6 Hospitals. Retrieved April 27, 2020, from https://www.philstar.com/nation/2020/04/26/2009815/woman‐dies‐after‐being‐refused‐6‐hospitals.
Another patient died after spending 11 hours in a tent outside the Lung Center of the Philippines, prompting the Department of Health to remind hospitals that COVID‐19 is not the only disease that has to be accommodated.141 Sabillo, K. (2020, April 3). After Man Dies in Tent, DOH Reminds Hospitals to Take in Patients Ill with COVID‐19, Other Illnesses. ABS‐CBN News. Retrieved April 27, 2020, from https://news.abs‐cbn.com/news/04/03/20/after‐man‐dies‐in‐tent‐doh‐reminds‐hospitals‐to‐take‐in‐patients‐ill‐with‐covid‐19‐other‐illnesses
The problems have been exacerbated by the lack of safety equipment for doctors. Public institutions like the Philippine General Hospital, the national university hospital, have had to call for donations of alcohol and masks.142 Baticulon, R.E. (2020, March 20). Last updated 2020, March 20. Opinion: the Philippine Health Care System Was Never Ready for a Pandemic. CNN Philippines. Retrieved April 29, 2020, from https://cnnphilippines.com/life/culture/2020/3/20/healthcare‐pandemic‐opinion.html?fbcid%3Ffbclid%3Ffbclid%3Ffbclid
At one point, the National Centre for Mental Health was operating with 100 PPEs instead of its requirement of a minimum of 250 in a day.143 Dancel, R. (2020, April 8). Last updated 2020, April 8. Struck down by COVID‐19, Philippine Doctor Returns to Front Line to Rally Troops. The Straits Times. Retrieved April 29, 2020, from https://www.straitstimes.com/asia/se‐asia/struck‐down‐by‐covid‐19‐doctor‐returns‐to‐frontline‐to‐rally‐troops
The situation in hospitals is further complicated by issues whose underlying roots are not so easy to explain. A person under investigation for having COVID‐19 escaped from a private hospital where he or she was being observed.144 KBK. (2020, February 6). Person under Investigation Dahil sa nCoV sa Cavite, Tumakas sa Ospital. GMA News. Retrieved May 22, 2020, from https://www.gmanetwork.com/news/balitambayan/promdi/725055/person‐under‐investigation‐dahil‐sa‐ncov‐sa‐cavite‐tumakas‐sa‐ospital/story/
An overseas Filipino worker with COVID‐19 symptoms also escaped from a hospital to probably go back to work abroad.145 FRJ. (2020, March 13). OFW na Nakitaan ng Sintomas ng COVID‐19 sa Sarangani, Tumakas Umano sa Ospital. GMA News. Retrieved May 22, 2020, from https://www.gmanetwork.com/news/balitambayan/pinoyabroad/729486/ofw‐na‐nakitaan‐ng‐sintomas‐ng‐covid‐19‐sa‐sarangani‐tumakas‐umano‐sa‐ospital/story/
Another patient who tested positive for the SARS‐CoV‐2 virus escaped by jumping from a hospital window after she was not given permission to go home.146 Estrada‐Larino, J. (2020, May 12). Babaeng Positibo sa COVID‐19 Tumakas sa Ospital sa Davao City. DWIZ 882 AM. Retrieved May 22, 2020, from http://www.dwiz882am.com/index.php/babaeng‐positibo‐sa‐covid‐19‐tumakas‐sa‐ospital‐sa‐davao‐city/
Expenses or space limitations are possible explanations but the exact reasons why these quarantined patients have tried to escape need to be probed further. Of course, the reasons may have to do with things that are not unique to hospitals. For instance, socio‐economic conditions characterized by inequity and a lack of safety nets for the worst off may compel patients to ignore their health and avoid long hospitalizations so they can continue to try to make a living for themselves and their families.
As earlier noted, the fair allocation of critical care resources is a concern that arises way before the need to prioritize patients arises in the triage context within hospital premises. Many people affected – or suspected to be affected – by COVID‐19 do not have full information about their options for consultation, treatment, or confinement. Access to the relevant services or facilities can easily be denied if pertinent information is not properly disseminated. People need to know about confinement options, contact procedures, costs, prerequisites for admission, etc., in order to gain fair access. Knowledge about these factors helps one decide which treatment alternatives suit one’s financial capability. To be able to fully understand these factors, people need to be functionally literate and to have a minimum level of health literacy. As we address these issues during the pandemic, it should be clear to us that these are also long‐standing concerns that have been waiting for durable solutions. Only durable solutions can help us maintain emergency readiness over the long term. In the meantime, during the COVID‐19 pandemic, guaranteeing fair access is necessary. One way for authorities to do this is to uphold fair allocation principles in the various areas taken up so far, as well as in emergency critical care.