We are averse to giving long introductory bios for our interviewees. Credentials, especially long ones, are more of a bother than helpful in getting to the crux of the personality and views of the subject. But with Dr. Ernesto Domingo, National Scientist, we are obliged to take a portion from the Ramon Magsaysay Awards website introduction: “A well-respected but unprepossessing specialist in hepatology and gastroenterology, Domingo has always valued the social side of his profession, devoting over four decades to the University of the Philippines-Manila (UPM) as researcher, teacher, chancellor, and university professor emeritus. Passionate about science, he organized the UPM Liver Study Group and led in groundbreaking studies of viral hepatitis and liver disease which established the causative connection between chronic hepatitis-B and liver cancer. By determining as well the preventive solution to liver cancer—the immunization of newborns against hepatitis-B within twenty-four hours from birth reduces the probability of acquiring hepatitis by 95 percent—his research has saved millions of people from the danger of life-threatening illness, and reduced health care costs. Deeply concerned about the poor’s access to health care, he has pushed for hepatitis vaccination to be mandatory and available to all. Working closely with legislators, he has also successfully lobbied for a law that ensures annual budgetary support for neonatal hepatitis immunization.”
Sunfu Solutions, Inc. advocates for financially viable local government hospitals partly because we think citizens are primarily responsible for their health, and largely because fiscal responsibility means more money for local governments to improve health care, basic education, local government employee salaries (especially of health workers, which includes medical doctors); equally important, we hope public hospitals are not seen as unnecessary economic and political burdens best ignored, or at most attended to only during elections season. But our discussion with Dr. Domingo has opened up the important fact of social stratification, or his group’s great advocacy, that universal health care for Filipinos is a simple and serious answer to the social inequity in Philippine society. Health care as an important avenue towards solving the problems of the Philippine economic pyramid must be acknowledged, studied carefully, and in the long run, supported, implemented, and we in Sunfu Solutions, Inc. certainly want to be a part of that future.
What is exciting you in your field right now?
If you are talking about medicine, or the science of medicine, and my medical specialization in particular: I am no longer interested, so there is no excitement. I no longer give talks or accept invitations to be a reactor to scientific papers. It doesn’t interest me anymore. I keep up-to-date with what is new, because I still practice medicine, so it is my personal responsibility to know what is happening in my field. But what is exciting me right now, what is getting the bulk of my time is public health advocacy. I am trying to help in the efforts for a comprehensive universal health care system for the Philippines. The efforts to improve the system, make it more efficient, to have the funding for it; the sincerity of the Aquino administration in setting up this system, they are all helping me get out of bed every day. More than excitement, maybe I should say there is really a need to do this, and that keeps me occupied every day. This leadership in government, starting 2010, is serious about health care, and the health policy adapted by the bureaucracy is very progressive. We are actually late compared to our neighbors in this area of health policy. Kalusugan Pangkalahatan is the idea: health care for everyone, rich or poor, by virtue of just being a Filipino.
I have had too much of the science part of my profession: after training abroad, in 1967, I already started working in the University of the Philippines. There is very little I want to do in the science part of medicine.
Is Philhealth the universal health care that you are talking about?
No, Philhealth is only a part of this. To put it simply, by virtue of your citizenship, as a Filipino, if you get sick, you will be able to get the best health care provided by the country without dipping into your pocket.
Are we capable of this? Do we have the money?
Thailand has had it since the late 1970s.
Japan and Korea did it before they became First World countries. England declared universal health care after the 2nd World War, when the government was down, it had no money. They were able to do it. Why can’t we?
Philhealth is just a mechanism of paying, but it is only one of the many possible mechanisms. It is not the only model or mechanism. In England, there is a tax for health. In contrast, Philhealth is supposed to be a social health insurance. This is a development of Medicare, so Philhealth is a move forward, and we now have to co-opt it to move it towards universal health care. 12 million families are supposed to be covered by Philhealth, with no balance billing for certain health problems already. The only condition is the patient goes to a government hospital. If fully developed, a day will come when there will be no distinction between private and public hospitals. This is developing: it will attain maturity much later. It will not be immediate.
Ospital ng Maynila was mostly free at one time. It almost ruined the whole hospital system of Manila, maybe even of some surrounding government hospitals not under the City of Manila. Is it wise to have everything free?
You cannot have everything free immediately, for sure: if we have very rich local and national governments, maybe. But as I keep emphasizing, universal health care is not about just one mechanism, it will look for various sources of funds to answer the health needs of the public. England is via taxes, Germany is via the guild system, which means the employer shoulders it; in Canada, a province negotiates with central government and both contribute to make it possible for hospitals to be paid a fee for services rendered; Thaksin has his 30-Baht system, which means once say a farmer pays 30 Baht to a hospital, all is taken cared of to help him solve his health concern or problem.
Do we have the money for a universal health care system?
That is the eternal question. And the answer is certainly we can do it. If we can’t do it, we should abandon all our efforts towards achieving it. Only the United States and the Philippines are the two so-called free and capitalists countries that do not have universal health care. Look around the world, they are doing it. Go to Canada. England started in 1945. Germany started even before the war, at the time of Bismarck.
Costing studies have been done. It is not a question of money being available for the public to use them. It is a question of getting money from various sources and mechanisms, pooling them, having a national program aligned to the local programs, of doing a detailed cost study, and having an educated public use the pool of funds wisely. The implementation of the initial structures and various serious studies are happening now.
This is not a very good example, but P600,000 for example is allocated in Philhealth for kidney transplant: why is Philhealth doing this? Because some of those who need it are very poor and they cannot wait for the perfect system. They already have to allocate money for this; the way they allocate a budget for appendectomy, dengue, and so on. We want to support the coming of a time when we are able to cover fully catastrophic diseases that will wipe out an average Filipino’s financial resources if there is no support from the government. We cannot do it totally immediately, but we have to start somewhere, and Philhealth is doing that already because many people who are sick cannot wait for the perfect system and the perfect budget to come. The thrust of Philhealth is just the primary needs right now. This is just the beginning, but we are going already for the preventive and promotive, aside from curative.
Are these realistic goals?
This is not a walk in the park. We are all realists in the Universal Health Care Study Group. We did not enter this dreaming. The experience of other countries tells us we can do it; we see this is as a way to partially solve the problems of inequity in society. If health care and medicine are seen as commodities to be sold and bought, purely as commodities to be traded in the market, what happens to 60 percent of Filipinos who do not have money?
There are now local government hospitals registering an income because of Philhealth. As a result, they are able to give better services. Their staff, the nurses and doctors, also get to add to their income. Is this bad?
They are earning because of Philhealth, yes. Of course to earn is not bad, but maybe the bigger problem is the planning, as Manila I know has built so many hospitals, it is just not sustainable. I think the debate of devolution or reverting local government hospitals back to the Department of Health is not a healthy debate: it is already devolved and we work from there. But planning and coordination are important, projecting budgetary requirements is important. This is why I think Navotas City is unique in that they really went out of their way to consult many people and sectors outside Navotas on how they can set up a hospital and run it well. Some other local government hospitals have done it too, I am sure, but I am not aware of them.
To go back to your question: No, of course it is not bad if local government hospitals are earning money because of Philhealth. City hospitals are slightly different in that they have their needs and responsibilities that are outside the purview of the national government. They do not remit earnings to the national government and they do not rely on the national government for funding. They have to do their planning carefully and judiciously.
How did this involvement with Navotas come about? Are you paid by the national government or Navotas?
I was not initially involved with the Navotas project. It was actually a product of discussions between Dr. Quasi Romualdez and the Tiangco brothers, the Congressman and the Mayor. I only got involved later on, when the Universal HeaIth Care Study Group got fully involved. I have no official involvement with the government now, although the health secretary asked for my help to set up a research mechanism to evaluate, measure, and assess national health programs. DOH needs it for policy and program planning and implementation. They have the money for this. 2 percent of the DoH budget can legally be used for research. The question is can we absorb such a large budget? Can we use the budget well? At the moment, we are trying to put the system in place so we can do good research using this money. One thing I can tell you, dealing with the DOH has made me realize they have many very good people working there. All they need is support and the proper mechanisms to do good work. I have a very high regard for DOH, and not just at the level of the secretary and undersecretaries. I am talking about the bureau directors, the doctors, the staff.
So all the time you have invested in say Navotas is gratis?
Yes, the group doesn’t get any financial considerations from Navotas. We do not ask for anything financial, nor do we expect anything financial in return. It is enough that they give us a chance to exchange ideas, and they take our suggestions into serious consideration. Of course some of the members of the Universal Health Care Study Group teach in U.P., so in a way they are paid by government, but there is no direct link between the Study Group as a group to any government body.
I read some of the recommendations of the study group. Although we are a selling company, we have our advocacies as well. We find tie-ups and Public Private Partnership arrangements generally disadvantageous to the government, most especially to patients; like when it comes to running laboratories inside government hospitals. In effect, the government loses control over laboratories and pharmacies in the name of efficiency. We have strong disagreements with this, even though as a company in a capitalist system, this could work to our great advantage.
Well I do not think we have any recommendation on tie-ups or things of that nature that is definite or firm. It is all in flux at the moment. We are also still studying the options and possibilities.
You mentioned helping in the area of research for DOH, which is very functional in nature, meaning research in aid of program implementation. Don’t we need more science research?
Yes, but we will only have so much science research as we have serious science researchers. We also do not have enough people to create that research atmosphere. Of course there is a problem that those in U.P. who show themselves to be good in either teaching or research end up working or being promoted to administration, and that eventually hinders the research and teaching of these very good scientists and doctors.
I know Professor Edgardo Gomez of the UP Marine Science Institute is very much against the promotion of top-rank researchers to administrative positions.
Yes, like Dr. Gomez, I am also against that. In our department in PGH, when I was given the opportunity to head it, I broke from that. I designated as researchers those inclined towards research and had shown talent in doing the work. I did not saddle them with teaching unless they wanted to teach in the classroom, and promotions were based on their output, not teaching load or student evaluation. I remember many names: Augusto Lingao, Agbayani, Flora Pascasio. We produced many productive researchers because of that. It is a departmental decision what we did: it was not university wide. In the University, you must teach no matter what, at that time. That is not bad, but the ideal is to just leave it to the guy to decide if he wants to pursue a purely research track.
Yes, definitely it is a problem in our country: if you become a good researcher and teacher, you become administrator. Look at Eva Cutiongco, Menchit Padilla, and Dr. Bellisario. They get curtailed in their research. Many good research people also get attracted to administrative work, because it is a way of contributing to the profession in an immediate and practical way, and additionally, it is a sure way to promotion, of moving up in the academic hierarchy.
You seem to have done it all: teach, research, administration. And you seem to have done well in all.
There is a cost to that. It takes a lot. I did not become rich, as you can see. (Laughter) You have to make basic decisions on what you want and you set your priorities on the basis of those decisions. I love teaching. I love research. Two faces of the same thing as far as I am concerned: a teacher is more effective if you can share original research. But that is a personal inclination: the two do not have to go together. Yes, like Dr. Gomez, I am very much against the promotion of good researchers to administrative positions. In the end, it is likely counter-productive for everyone.
Going back to Navotas: you sound excited. Why?
Yes, because the leadership of Navotas is, like the leadership of the national government, very serious: they ask us for guidance. And we are trying our best. They ask many groups and people. They consult many people before they do anything, and when I refer to people, I mean they consult “neutral” people, people who only have the best of health care for the poor in their agenda.
We gave suggestions on size, what services, relationship with the barangay health centers, and we are even part of the process of choosing who will head the hospital. We give inputs. It is very exciting.
You seem to be quite familiar with the area.
I grew up in the Navotas-Malabon area. I left in 1976. The population of Malabon then was around 60,000. Malabon at that time had no squatting problem, as it was sparsely populated.
Did it already flood the way it does today?
No, not at all. Flooding only started when the spillways and rivers were covered and converted into Imelda Marcos’ Dagat Dagatan. I did a paper on that. Rivers and rivulets, water from storms went through those channels. It was fun, as kids we played with paper boats in the rivers.
My mother is from Navotas. My father is from Malabon. I grew up in Malabon. My siblings are all still in Malabon. I consider myself from Malabon, even if Quezon City is the place of my residency now. I am still attached to the area.
I went to the National Teacher’s College in Malabon for high school. I went to the Malabon Elementary School for grade school. I am a product of the public school system.
You also sound excited about the current leadership in the national government.
We never thought any government would ever take this issue of universal health care seriously. At the level of the President, he himself, when he gives a talk, I know he understands the problem and the concept of universal health care. President Benigno Aquino has a firm grasp of the issues and what it takes to solve the problems, and his marching orders to the Department of Health are very specific. This is not necessarily true of the other candidates during the 2010 elections. We are very lucky with this President. We are very happy.
Thaksin is loved by a good segment of the population: why? Because of universal health care. In some places, they are willing to die for him. The universal health care of Thailand appears difficult to reverse. If a universal health system works and works well in the Philippines, we hope it will be irreversible as well.
What is a good doctor for you?
A good doctor takes care of his or her patients, obviously. His primary business is taking care of those who seek him: he should be competent, that’s a given, he knows his science, his medicine. He has the interest of his patient, including the material well-being of the patient, at heart: meaning he must worry about the patient’s material resources. Note that I use the word worry. A good doctor must protect the resources of his patients. If a laboratory exam is not necessary, he must not require it, because you want to protect his resources. There must be a personal touch; it cannot be all science: after all, we literally do not cure, we just facilitate it. Curing is really beyond us. It is really about caring. It goes beyond a medical and professional relationship. While you are in practice, a medical doctor should participate in the social aspect of medicine, one must not just spend time doing your medical job or duties, but you should do your best to get involved in the social, political, economic issues of medicine.
How old are you?
How do you keep strong and healthy?
I love work. I work very hard physically. Food I have likes and dislikes, but I am not faddish in what I eat. I do not choose this or that food because it is supposed to make me healthier.
We are constantly looking for good and cheap medical equipment. We feel expensive brands simply suck resources of Third World countries and we need plenty of resources to improve health care. We are somehow involved with the ventilator innovation of Dr. Abundio Balgos, hoping we could help in the manufacturing and dissemination of local medical equipment and devices. Do you think we have a chance still in manufacturing? Manufacturing of course means creativity and jobs, two issues we are also greatly attached to.
Dr. Abundio Balgos I have known him since his days as a medical student. I am not sure about the details of this project, but whatever he decides to do, he will do a good job. Since residency, once he accepts a task, he will do it, and he will do it well to the utmost of his abilities. Just on the basis of who is involved, I would say there is a good chance.
We always end our interviews by asking if there are books or authors you want to share with our readers.
I am more of a people person rather than a books person: I have been privileged in that I have met many good people, like Antonio Sison, Chuchi Herrera. By observing how they do things, without words exchanged, I learned about honesty, efficiency, focus. I don’t see all these in one person, but I see bits of it in many people, and I learn from seeing. For example, Dr.Oscar Liboro, I am not related to him, but he took me under his wing, he looked for opportunities for me to study abroad. When I came back, I had no money, and he said come work with me and when you are ready to go on your own, just tell me. Imagine that. After 11 months, I did that: I went to him and said I am ready to go on my own. And that was it, no problem, immediately it was okay, and immediately I started my own practice. From him, I learned about generosity. The doctor who contributed much to my professional growth was National Scientist Paulo C. Campos. It was he who enabled me to do many academic projects that turned out to be crucial to the kind of work I have pursued. And of course, without a good family life, especially a supportive wife, I will probably feel less fulfilled.