Philippines

Original Editor - Mary Ramos.

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Patient Access to Physiotherapy or Physical Therapy Services / Entry Point

Residents of the Philippines can access Physical Therapy services through referral by their primary care physician if they are not hospital in patients. The out patient clinics are mostly affiliated to a major hospital that employs physiatrists (doctors of rehabilitation medicine). They evaluate the patient and prescribe both medical and physical therapy prescriptions. Further medical testing such as imaging, lab tests and medication prescriptions are accomplished during the initial visits. Physical therapy prescriptions include the modalities, tx frequency, and duration. The patients then bring the prescription to the physical therapist who performs the evaluation and the prescribed treatment.

The second method of access is for the hospital in patients. Following surgery or any other medical illness, the patient will be referred to the Rehab department. The physiatrist will be the first responder performing evaluation and writing rehab prescription. The acute care physical therapist will then conduct the PT evaluation and the prescribed treatment regimen.
The last method of PT access is through private care. Through private pay negotiation, the patient gets to be seen at home without the need for primary care or physiatrist prescription. There are small out patient clinics run and operated by the physical therapists.

In Philippines direct access to physiotherapy is not permitted, but it is allowed for physiotherapists to act as first contact/autonomous practitioners.

Therapist Preparation

Degree/Credentialing

The Commission on Higher Education (CHED) issues memoranda and guiding instruments for all formal college education, including physical therapy. Its Technical Panel on PT Education monitors compliance of colleges and universities with physical therapy programs to educational standards.
As of January 2011, there are ninety-four (94) local higher education institutions with a Bachelor of Science in Physical Therapy program.
As of June 2011, three (3) higher education institutions are known to offer master’s degrees in physical therapy.

In the Philippines, the physical therapy program is 5 years in length awarding the Bachelor of Science in Physical Therapy. Students undergo 10 months of rotating internship in relevant institutions such as hospitals and clinics to complete the required clinical internship program of 2,000 hours. A graduate of BS in Physical Therapy needs to pass the Physical Therapist Licensure Examination in order to practice as a registered physical therapist in the Philippines. The examination is given by the Board of Physical and Occupational Therapy under the supervision of the Professional Regulation Commission (PRC).

Specialization

Special interest groups recognized by Philippine Physical Therapy Association:

• Educators in physical therapy.
• Orthopaedics/manual therapy
• Older people
• Paediatrics
• Sports Physiotherapy
• Neurology

Licensed clinicians get to specialize in certain areas of care depending on where they get to be employed. For example, physical therapists who work at the Lung Center of the Philippines get to be more adept with pulmonary rehabilitation. While others who get to work at the Heart Center of the Philippines become experts in cardiac rehabilitation. Philippine General Hospital for example becomes the training center for everything. As of this date there are no credentialing institutions or specialty schools/training centers that grants certification for some type of specialization. PT graduates however can pursue Master of Science in Physical therapy from two accredited universities.

Professional Associations

 The Philippine Physical Therapy Association, Inc. (PPTA) is a local professional organization of Filipino physical therapists recognized by the  Philippine Professional Regulation Commission. PPTA, in its Mission-Vision-Goals 2010, envisions Physical Therapy to become a legally mandated autonomous profession with established areas of specialization, the value of excellence in service upheld in its practice, and at the same time being recognized by clients, colleagues and the community. The Association strives to be the visible and accessible organization of Filipino physical therapists, advancing the welfare of the members of the Association, and physical therapists in general. It will be comprised of active members in pursuit of competent and ethical practice towards the provision of effective and efficient services for the Filipino people. PPTA is a member organization of the World Physiotherapy and the World Physiotherapy Asia Western Pacific Region.

Information about the Patient Community

The country’s projected population for 2010 was 94 013 200. It is predominantly young, with the 0-14 years age group representing 33.8% and those aged 65 years and above comprising only 4.4%. There are almost equal numbers of males and females. The crude birth rate is 19.7 per 1000 midyear population and the crude death rate is 5.0 per 1000 midyear population. Life expectancy for both sexes was 70 years in 2009: 67 for males and 73 for females.
Noncommunicable diseases (NCD) are considered a major public health concern in the Philippines, accounting for six of the top 10 causes of death. Diseases of the heart and vascular system are the leading causes of mortality, comprising nearly one-third (31%) of all deaths. Other NCD topping the list include malignant neoplasms, chronic obstructive pulmonary disease (COPD), diabetes mellitus, and kidney disease.
Accidents of all types, including road traffic crashes, rank 10th among the causes of mortality for all age groups. Road traffic accidents constitute the fifth leading cause of injury death, with a mortality rate of 39.1/100 000.
Among children aged 0-17 years, it is the second leading cause of injury death (mortality rate of 5.85/100 000),  next to drowning.
Seven of the 10 leading causes of morbidity in 2009 are caused by infections. They are: acute respiratory infection; pneumonia; bronchitis/bronchiolitis; acute watery diarrhoea; influenza; urinary tract infection and tuberculosis. Among these communicable diseases, pneumonia and tuberculosis continue to be among the 10 leading causes of mortality, causing a significant number of deaths across the country.
At the same time as deaths due to preventable diseases have been in a decline, lifestyle-related diseases have begun to dominate in the leading causes of death, particularly heart diseases, diseases of the vascular system, malignant neoplasms, diabetes mellitus, and chronic lower respiratory diseases. However, certain conditions originating in the perinatal period are also among the 10 leading causes of mortality, illustrating the vulnerability of the newborn child.

Social/Cultural Influences

The strong feeling for family, a quality derived from Chinese influence, is manifested by old fashioned patterns imposed by the family patriarch or equally authoritative matriarch. Respect and deference are always given to one’s elders, whose words and decisions gets the most weight. The younger family members are unconditionally under protection and responsibility of their elders. The implications for health care are important. Filipino patients always have their families hovering over them, perhaps to the irritation of the medical staff. The sick Filipino child feels lost without his mother constantly at his bedside. When grandparents are ill, sons, daughters and even grandchildren take turns keeping them company and doing everything for them. This would require patient and family education on rehabilitation goals set by the therapists promoting functional independence. A daughter who just had a baby may follow a traditional customs related to activity, food and hygiene which may be contrary to what the doctor or nurse prescribes.

Delivery of Care

In the public sector the Department of Health (DOH) delivers tertiary services, rehabilitative services and specialized healthcare, while the local government units (LGUs) deliver health promotion, disease
prevention, primary, secondary, and long-term care. Primary health services are delivered in barangay (village) health stations, health centers, and at hospitals.

In total, there are approximately 1800 hospitals in the Philippines, of which 721 (40%) are public hospitals and 70 are DOH hospitals. In 2010, there were a total of 98,155 hospital beds; 50 percent or
49,372 were in government hospitals. Of the 17 regions, only 4 have sufficient numbers of beds per 1000 population.
The DOH has existing policy to provide services under the National Mental Health Policy, the National Policy on Oral Health, including the Minimum Essential Oral Health Package of the DOH for children 2-6 years, and to overseas Filipino workers. However there is also a very limited dental and rehabilitative services in the public sector. The 7.76 million overseas Filipino workers face a wide range of occupational, mental, reproductive and sexual health-related problems, but currently receive almost no education or information and variable levels of insurance and support.
Public facilities from both national and local governments provide free services including medicines and laboratory work up during outbreaks and other public health related events.
In 2012 the DOH released a new classification system of hospitals and other health facilities with specific guidelines for scope of services and functional capacity for each classification, and overall operating 
standards. There is also an ongoing effort to upgrade government health facilities in line with the goal to achieve universal coverage.

Type of Health System

The Department of Health (DOH) is responsible for developing health policies and programmes, regulation, performance monitoring and standards for public and private sectors, as well as provision of
specialized and tertiary level care. The DOH Centres for Health and Development (CHDs) are the implementing agencies in provinces, cities and municipalities, and link national programs to Local
government units (LGUs). The CHDs are the DOH offices at the regional level. They assist the LGUs in the development of ordinances and localization of national policies, provide guidelines on the
implementation of national programs at the LGU levels, monitor program implementation, and develop support system for the delivery of services by LGUs.
Health service delivery has evolved into dual delivery systems of public and private provision, covering the entire range of interventions with varying degrees of emphasis at different health care levels. Public
services are mostly used by the poor and near-poor, including communities in isolated and deprived areas. Private services are used by approximately 30 % of the population that can afford fee-for-service payments. The service package that is supported by the government is outlined by PhilHealth. Coverage is reported by PhilHealth to be 74 million or 82% of the population at end December 2011. However, the services covered are not comprehensive, copayments are high and reimbursement procedures are difficult.
The dominant private sector is made up of large health corporations and smaller providers. Health maintenance organisations are also present. Professional organizations contribute to continuing
education, clinical practice guidelines development, advocacy, and influence policy and regulation. Opportunities for community participation in health are through the barangay health workers who come
from the local community, and representatives from civil society and the private sector who participate in LGU policy-making local health boards.

Payment System

In the Philippines, health financing is fragmented with insufficient government investment, inappropriate incentives for providers, weak social protection and high inequity. Figures on coverage by PhilHealth
vary, compounded by an inadequate information system on membership. In 2008 the Demographic Household Survey indicates a PhilHealth coverage rate of 38%. In 2007 expenditures on health services were paid for by the government (33%) and out-of-pocket payments (57.00%) and total health expenditure per capita was US$68. Government funding is a share from general taxation. Several earmarked taxes are also directed to PhilHealth; these include: value added tax, sin tax, stamp tax and excise tax. A small proportion of funding comes from private insurance, HMOs, employment-based plans and private schools. Foreign assisted projects comprise only 1.7% of health finances. Both public and private facilities operate on a fee-for-service basis, although public services receive greater subsidy from PhilHealth. The PhilHealth benefits scheme pays for a defined set of services at predetermined rates, beyond which patients pay out-of-pocket. PhilHealth reimbursements are paid directly to service providers. Public hospital professional fees and stays are free of charge, but the cost of medicines, supplies, and diagnostics while in hospital are covered by PhilHealth within the predetermined rate. Public hospitals have private rooms and pay-wards that can be partly covered by PhilHealth. A few government agencies and charity organizations offer further subsidies or discounts for the poor and indigent, but no standard policy exists. Senior citizens and the disabled also have additional discounts. PhilHealth subsidizes direct medical costs up to a certain level in private hospitals through direct reimbursement to providers. Patients make out-of-pocket co-payments. Outpatient consultations and ongoing requirements for drugs are not yet included in the benefits package although additional benefits that include outpatient TB DOTS, outpatient care for sponsored program (SP) members, and maternity care are now provided. PhilHealth contributions are compulsory for formally employed individuals, but there are difficulties in enrolling the informal sector. Poor households are progressively being enrolled and paid for through earmarked taxes. PhilHealth premium levels continue to be regressive since their low ceiling means that those in the upper salary brackets contribute proportionately less compared to those with lower income. The limited population and service coverage means that the high out-of-pocket payments is a major barrier to accessing health services. In general, the health financing system does not provide a safety net from the financial consequences of illness. People who get sick can easily slide into poverty since PhilHealth cannot provide full insurance coverage.

Resources

World Physiotherapy Country Profile for Philippine