Why Federalism Means Improved Healthcare

“Healthcare is a harmonious orchestra of people delivering care with various instruments playing in one harmony.”

Why Federalism Means Improved Healthcare
When everyone flocks to Manila for healthcare, quality suffers

By Ryan Torres

This article was originally published in the Philippine Panorama last January 15, 2017

Imagine you have colon cancer, non-functioning kidneys, a history of heart attack or probably any combination of complex medical conditions. You will need more than a simple chest x-ray or the common blood tests. You would need different doctors to be effectively treated. Notwithstanding the role of a general practitioner, the first doctor who should assess any patient, your condition needs doctors of different specialties.

With the vast breadth of medical knowledge today, five years of medical education and internship are not sufficient to have a full grasp of treating complex medical conditions. Hence, some doctors undergo further training, residency, and fellowship. These doctors are then usually found in Metro Manila. Why?

The rule of thumb in the healthcare system of the current unitary Philippines is“as one goes farther from Metro Manila, the quality of care you may receive usually deteriorates.” Most provincial hospitals are understaffed, underequipped, and understocked.

Medical care is a symphony of doctors, nurses, pharmacists, and other health care workers in one hospital. Aside from the members of the hospital orchestra, they need instruments such as medicines, diagnostic machines, sufficient rooms, etc. More often than not, hospitals in the provinces do not have enough of these instruments or they even lack members of the orchestra. The professions mentioned also have families and would need to make a living. Wages are usually higher in the urban centers which attract these professionals.

Economies of scale also demand that these professionals would stay where there are more people. For years, many doctors to the barrios and rural doctors have had lower salaries; their practice is an act of heroism. It’s not unheard of to receive wages in the form of chicken, eggs, and vegetables. Although their salaries have now been increased, difficulties still arise especially in the accessibility of some healthcare facilities that even some urban areas don’t have, only Manila has.




Have you heard the tales of Philippine General Hospital, East Avenue Medical Center, and other DOH-affiliated hospitals in Metro Manila congested with people not just from their vicinity but also from people from far-flung provinces? Most provincial facilities don’t have the necessary medicine and advanced diagnostic machines, not to mention that most tertiary hospitals are found in Metro Manila. Did you know that even Calabarzon with a population of almost fifteen million only has one DOH hospital? Hence, patients rush to the DOH hospitals of Metro Manila. There’s even a running joke to rename the Philippine General Hospital as Cavite General Hospital.


Oh sure, if you have the means to pay, you can go to the private medical hospitals in Metro Manila in the form of St. Luke’s Medical Center, Makati Medical Center, Medical City and others but these facilities are still mostly in Manila. For those who don’t have the means to pay, they are left with public hospitals. However, going to Manila already drains the patient’s finances not only for transportation but also for food, lodging, and the other basic necessities the patients and their relatives have to take care of while in Manila.



The centralization of health care in Manila also affects the quality of care that patients receive. Imagine a doctor attending to boatloads of patients from all over the country. One does not even need to imagine for it has been going on for decades in different public hospitals. It is even considered an integral part of doctors’ and nurses’ training to handle more patients than they are required to.


Unfortunately, not only complex cases are being referred to Manila.



Picture a Filipino suffering from dengue fever. As a tropical country, the Philippines has lots of dengue cases. Dengue fever typically lasts for two to seven days, characterized by fever, headache, nausea and vomiting, joint pains, and rashes. It is important to note the not all dengue cases should be admitted to a hospital. Dengue fever without warning signs can be treated at home. A patient should see a physician first to determine if a hospital admission is needed especially when warning signs have already appeared. These warning signs include abdominal pain, persistent vomiting, bleeding, and low platelet count as seen through a blood test. Moreover, dengue presents potential complications where one can literally bleed to death; thus, severe cases should be monitored hourly and there may be a need for blood transfusion.

Dengue fever, per se, does not have a cure and is basically managed with intravenous fluids or commonly misnamed as dextrose. It is a simple case that any doctor should be able to manage if treated early but why are some cases still referred to Manila? Imagine a patient, feverish, weak and in pain, but who still needs to board a bus for hours just to go to Manila. Imagine how it pains the patient and his relatives to see his dire state. We don’t need to imagine. We have seen patients referred to Manila for simple cases either due to unavailability of rooms, lack of staff or lack of medical supplies.

How can we prevent this scenario?

Under Federalism, there is a national government and a state government. The responsibilities of each are clearly delineated. The national government is concerned with national interests like defense and international relations while state governments are concerned with the state interests such as the economy, education and health. In a federal set-up, states are given more autonomy in their own development. They get to keep most of their earnings (such as taxes) to develop their state. Instead of Imperial Manila dictating what each region should do, they decide for themselves how to develop their own region.

In terms of health, we are in a devolved system where most of the responsibilities rest on local government units instead of the Department of Health. However, in the current unitary system, local government units remit majority of their earnings to the national coffers. The budget is then dispersed to local government units based on their population or as decided upon by the national government which is usually determined by political alliances.


Devolution gave local government units more responsibilities in terms of health without giving them a higher budget or even more freedom in developing their area. With fewer responsibilities in the over-all development of their area, they are molded to be short-sighted and think of projects which would keep them elected. They are not enthusiastic in thinking of long term projects since the budget they will receive will not grow even if their area is more developed, even if they are doing a better job. Their idea of catering to the health needs of their constituents are medical missions, paying medical bills and ambulances with their names on it; these are things which are easily noticed by the electorate.



Remember, healthcare is a harmonious orchestra of people delivering care with various instruments playing in one harmony. For the members of the orchestra, understand that they are also people. They also need decent living wages enough to start a family. For the instruments, they need to be sufficient and well-maintained. The health system is complicated which is the reason why it was devolved in the first place. A country of a hundred million has different needs which require different leaders. We believed that local leaders are more knowledgeable in determining the issues of their area but why don’t we have the conviction that they can also handle their economies and finances as well? Why give them added responsibilities without giving them added command and access to resources?

Federalism is the missing piece in the devolution of the health care system. By giving state governments more autonomy in development, a push to develop their area, they are molded to become visionaries and to take into account the overall health and development of the Filipino people within their areas.

(Ryan Torres is a med-student on his final internship year who will be graduating from the St. Luke’s College of Medicine – William H. Quasha Memorial this 2017. He finished his pre-med education in BS Biology at the Ateneo de Manila University and is a passionate advocate of constitutional reform with the CoRRECT™ Movement.)

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