Out-of-pocket spending hounds dementia care in the Philippines
15 May 2024
byDr. Issa Rufina Señga-Tang
What is the status of dementia in the Philippines? What are the challenges and gaps in care? Dr Anlacan and team recently endeavored, in their research, “Current Status and Challenges in Dementia Care in the Philippines: A Scoping Review,” to answer these questions by looking into the available data and research in Filipinos living in the country.
They observed that 60 percent of people with dementia live in low- and middle-income countries such as the Philippines. Despite this, comprehensive Filipino data on dementia is lacking. For the study, the researchers were able to include 75 articles for review, which were topical on dementia epidemiology, research, health service delivery and financing, diagnostics, management, manpower resources, and caregiver support. [J. Alzheimer’s Dis. 2024;97(4):1533-1543]
Local prevalence and research output
From the 2015 data, it was estimated that more than 726,000 people in the Philippines suffered from dementia, the researchers reported. The prevalence at the time, they said, was 10.6 percent for those aged 60 and above, while as of 2021, incidence of dementia in the Philippines was about 16 per 1,000. The numbers were reported to expectedly increase to more than 1.4 million in 2030, and to more than 2.5 million by 2050. In the Philippines, the most common type of dementia noted is Alzheimer’s Disease. Despite many Filipinos having dementia, the investigators said that local research output on this disease was low. They reported that only 1.1 percent (11 out of 1,006) articles in a systematic search of published articles on dementia in Southeast Asia came from the Philippines.
Costs of care
Out-of-pocket spending has been the leading source of health expenditure in the Philippines for the past decades. In 2020, government schemes and compulsory contributory healthcare financing schemes reportedly contributed the largest percentage to health expenditure (45.7 percent), with out-of-pocket payments following at a close second place (44.7 percent). PhilHealth, the national health insurance system, automatically covers senior citizens, as well as inpatient diseases including dementia. Anlacan et al. said that the case rates for dementia ranges from USD141 to 180, but utilization is low. The researchers attributed this to poor awareness and maldistribution of health services and facilities. In addition, PhilHealth only covers inpatient admissions, while dementia is usually diagnosed and treated on an outpatient basis, they noted, but If patients have private health maintenance organizations (HMOs) or insurance, outpatient diagnostics and treatment can be covered (depending on the terms of the HMO).
All senior citizens can avail of the provisions of the Expanded Senior Citizen Act of 2003 and 2010, which entitle them to a 20 percent discount and exemption from the value-added tax (VAT) in the purchases of goods and services, including medicines and diagnostic fees. They can also avail of free medical, dental, and diagnostic services in all government facilities. Although this helps the elderly financially, the authors noted that this act doesn’t cover young-onset dementia, in addition to dementia that requires costly higher levels of care.
Treatment challenges
Dementia care is collaborative, with pharmacologic and nonpharmacologic approaches going hand in hand, according to Andacan et al. Drugs used for treatment include acetylcholinesterase inhibitors (eg, donepezil, galantamine, and rivastigmine) and N-methyl-D-aspartate antagonists (eg, memantine).
These drugs, the review reported, cost more in low- to middle-income than high-income countries. The latter also happen to subsidize the cost of care, whereas it is usually out-of-pocket in low-income countries. The Philippine National Formulary reportedly includes only the lower doses of donepezil and rivastigmine.
In addition to medicine-related costs, other medical costs, they said, are incurred by laboratory tests, neuroimaging studies, consultation and hospitalization fees; non-medical costs, on the other hand, include nursing home fees, transportation, and home safety modifications. Consultation fees of private specialists, they said, can cost two to six times the minimum wage.
The authors reported that in a study in 2016, the median direct medical cost was USD237.40, direct non-medical cost amounted to USD6.57, with the total median indirect cost at USD229.03. The median direct cost was USD3,650, making the total annual per capita cost at USD3,916.47.
Manpower
Primary care is usually the first point of contact when symptoms first appear, but, according to Andacan et al., more than half of doctors at this level are not confident in diagnosing dementia and 92 percent prefer referral to specialists.
The ratio of neurologists in the country, they said, is about one per 164,000 Filipinos, and there are only 11 dementia specialists practicing, mostly in the National Capital Region, and only three NCR institutions offering dementia fellowship training.
Only a few facilities offer specialized dementia services, they noted, with most memory centers being privately-owned, while only one center being funded by the Department of Health.
They also noted that Filipino healthcare professionals, mainly nurses, opt to migrate to high-income countries. However, the most common source of manpower that they noted are the patients’ families, which often have not received training in dementia care.
All in all, the various above-mentioned factors contribute to the lack of properly trained healthcare providers that cater to patients with dementia.
From their scoping review, the authors have shown that while the country has a high dementia prevalence, there is still a lack of local research output. They observed cost as one of the major barriers to high quality care, with government coverage being inadequate to defray comprehensive dementia diagnosis and care. Families primarily spend out-of-pocket for health expenses.
Andacan emphasized the big disparity among “availability, accessibility and affordability of services between public and private health systems.” There is a shortage of healthcare manpower, with primary physicians lacking confidence in dementia diagnosis and care, and specialists being few and concentrated in the National Capital Region.
Although the scoping review has some limitations, including the lack of critical appraisals of articles, the authors were able to show the current status and gaps in dementia care in the Philippines. They recommended a multi-pronged approach to enhance research and programs that improve dementia diagnosis and care in the country.
It is clear from the review that there is a lot to improve on, in local dementia care. The cooperation of all those involved is required to give the best quality services to patients. Hopefully, we will see a future when all dementia patients receive the best support and care.
They observed that 60 percent of people with dementia live in low- and middle-income countries such as the Philippines. Despite this, comprehensive Filipino data on dementia is lacking. For the study, the researchers were able to include 75 articles for review, which were topical on dementia epidemiology, research, health service delivery and financing, diagnostics, management, manpower resources, and caregiver support. [J. Alzheimer’s Dis. 2024;97(4):1533-1543]
Local prevalence and research output
From the 2015 data, it was estimated that more than 726,000 people in the Philippines suffered from dementia, the researchers reported. The prevalence at the time, they said, was 10.6 percent for those aged 60 and above, while as of 2021, incidence of dementia in the Philippines was about 16 per 1,000. The numbers were reported to expectedly increase to more than 1.4 million in 2030, and to more than 2.5 million by 2050. In the Philippines, the most common type of dementia noted is Alzheimer’s Disease. Despite many Filipinos having dementia, the investigators said that local research output on this disease was low. They reported that only 1.1 percent (11 out of 1,006) articles in a systematic search of published articles on dementia in Southeast Asia came from the Philippines.
Costs of care
Out-of-pocket spending has been the leading source of health expenditure in the Philippines for the past decades. In 2020, government schemes and compulsory contributory healthcare financing schemes reportedly contributed the largest percentage to health expenditure (45.7 percent), with out-of-pocket payments following at a close second place (44.7 percent). PhilHealth, the national health insurance system, automatically covers senior citizens, as well as inpatient diseases including dementia. Anlacan et al. said that the case rates for dementia ranges from USD141 to 180, but utilization is low. The researchers attributed this to poor awareness and maldistribution of health services and facilities. In addition, PhilHealth only covers inpatient admissions, while dementia is usually diagnosed and treated on an outpatient basis, they noted, but If patients have private health maintenance organizations (HMOs) or insurance, outpatient diagnostics and treatment can be covered (depending on the terms of the HMO).
All senior citizens can avail of the provisions of the Expanded Senior Citizen Act of 2003 and 2010, which entitle them to a 20 percent discount and exemption from the value-added tax (VAT) in the purchases of goods and services, including medicines and diagnostic fees. They can also avail of free medical, dental, and diagnostic services in all government facilities. Although this helps the elderly financially, the authors noted that this act doesn’t cover young-onset dementia, in addition to dementia that requires costly higher levels of care.
Treatment challenges
Dementia care is collaborative, with pharmacologic and nonpharmacologic approaches going hand in hand, according to Andacan et al. Drugs used for treatment include acetylcholinesterase inhibitors (eg, donepezil, galantamine, and rivastigmine) and N-methyl-D-aspartate antagonists (eg, memantine).
These drugs, the review reported, cost more in low- to middle-income than high-income countries. The latter also happen to subsidize the cost of care, whereas it is usually out-of-pocket in low-income countries. The Philippine National Formulary reportedly includes only the lower doses of donepezil and rivastigmine.
In addition to medicine-related costs, other medical costs, they said, are incurred by laboratory tests, neuroimaging studies, consultation and hospitalization fees; non-medical costs, on the other hand, include nursing home fees, transportation, and home safety modifications. Consultation fees of private specialists, they said, can cost two to six times the minimum wage.
The authors reported that in a study in 2016, the median direct medical cost was USD237.40, direct non-medical cost amounted to USD6.57, with the total median indirect cost at USD229.03. The median direct cost was USD3,650, making the total annual per capita cost at USD3,916.47.
Manpower
Primary care is usually the first point of contact when symptoms first appear, but, according to Andacan et al., more than half of doctors at this level are not confident in diagnosing dementia and 92 percent prefer referral to specialists.
The ratio of neurologists in the country, they said, is about one per 164,000 Filipinos, and there are only 11 dementia specialists practicing, mostly in the National Capital Region, and only three NCR institutions offering dementia fellowship training.
Only a few facilities offer specialized dementia services, they noted, with most memory centers being privately-owned, while only one center being funded by the Department of Health.
They also noted that Filipino healthcare professionals, mainly nurses, opt to migrate to high-income countries. However, the most common source of manpower that they noted are the patients’ families, which often have not received training in dementia care.
All in all, the various above-mentioned factors contribute to the lack of properly trained healthcare providers that cater to patients with dementia.
From their scoping review, the authors have shown that while the country has a high dementia prevalence, there is still a lack of local research output. They observed cost as one of the major barriers to high quality care, with government coverage being inadequate to defray comprehensive dementia diagnosis and care. Families primarily spend out-of-pocket for health expenses.
Andacan emphasized the big disparity among “availability, accessibility and affordability of services between public and private health systems.” There is a shortage of healthcare manpower, with primary physicians lacking confidence in dementia diagnosis and care, and specialists being few and concentrated in the National Capital Region.
Although the scoping review has some limitations, including the lack of critical appraisals of articles, the authors were able to show the current status and gaps in dementia care in the Philippines. They recommended a multi-pronged approach to enhance research and programs that improve dementia diagnosis and care in the country.
It is clear from the review that there is a lot to improve on, in local dementia care. The cooperation of all those involved is required to give the best quality services to patients. Hopefully, we will see a future when all dementia patients receive the best support and care.