From Coverage, To Care, To Whose Care:

A REACTION PAPER

Presented by: Leizel P. Lagrada, MD, MPH, PhD

4th Stephen Zuellig Annual Public Health Lecture

Admiral Hotel, Manila, Philippines

August 6, 2026

Your title is From Coverage to Care. I want to add one word: from coverage, to care, to whose care.

Let me say my position plainly, because everything after this comes from it.

The Philippines has not achieved universal health care until we can demonstrate health equity—in access, financial protection, and health outcomes. We need to see this not only in national figures, but in the experience of Filipino families.

And today, the evidence and our experience do not yet show that UHC is reaching everyone. It is not because nothing is working. It is because national measures can still miss the people who are being left behind.

In Photo: Excerpt of Dr. Carlo Panelo's lecture entitled "From Coverage to Care: Reimagining Universal Health Care" at the 4th Stephen Zuellig Annual Public Health Lecture

Let me illustrate this with three examples.

FIRST, ON MONEY.

The national picture is improving, but not every family is benefiting equitably.

Let me acknowledge the progress we can see. Out of every peso spent on health in this country, families now pay 41 centavos from their own pockets, down from 44 just two years ago. This is an improvement in financial protection, and it is important to acknowledge it.

But the national figure does not tell us which families continue to experience financial hardship.

We therefore looked more closely at the distribution of this burden using the 2023 Family Income and Expenditure Survey. Our analysis is still under review, so let me focus on the pattern rather than the detailed estimates.

First, health spending can be more than a large expense for poor families. It can push a household to the poverty line or below it, after accounting for basic household needs.

Second, the burden is concentrated among the poorest two-fifths of households and declines substantially as household resources increase.

Third, the burden is also higher among rural households, at more than twice the rate observed among urban households. For these households, medicines are a major source of health spending.

So, Dr. Panelo, when you say that YAKAP and GAMOT are urgent, our findings support that direction. But they also point to a larger issue. For the poorest families, reducing the cost may not be enough. We need to reduce or remove the financial barrier at the point of care.

SECOND, ON ACCESS.

Some access gaps have narrowed, but others remain.

We looked at two decades of National Demographic and Health Survey data, from 2003 to 2022, and asked a simple question: Did the poorest households catch up?

For some services, yes. The gap has narrowed for prenatal care, iron supplementation, and childhood immunization. Poorer mothers now receive these services at rates much closer to those of better-off mothers. This shows that sustained investment can reduce inequities in access.

But the pattern is different for skilled birth attendance. Better-off families continue to have higher coverage than poorer families. The socioeconomic gap was present in 2003 and remained in 2022. There was also a setback during the pandemic, after some improvement in the mid-2010s.

The pattern suggests that we have been more successful in closing gaps that can be addressed through community and primary care services. The gaps are harder to close when access depends on a functioning facility that is staffed, supplied, and available when care is needed.

That is exactly your point about supply, Dr. Panelo, backed by twenty years of evidence. PhilHealth financing cannot by itself address a service that is not available in the facility.

THIRD, AND THIS IS THE POINT I MOST WANT YOU TO REMEMBER.

The people we most need to reach are often the least visible in the data.

In some provinces, deaths may be substantially under-recorded, including provinces with poor health outcomes.

Consider the GIDA list—our official list of communities that are hard to reach and left behind. The Department of Health validated it in 2023. They visited 121 barangays and compared reported information with conditions observed on the ground. The reported information was consistent with the observed situation only about half the time.

Information on whether a community was more than an hour from a health center was accurate only about half the time. Information on the number of families enrolled in 4Ps was accurate only about one-third of the time.

This means that we are trying to identify underserved communities using information that is not consistently accurate.

What these findings have in common is that the places that are harder to reach may also be the places where our information is weakest. This is not simply a technical problem. If we cannot identify where the need is, it becomes harder to direct resources to where they are most needed.

So, the Program for Health Equity is taking this analysis down to the local level. The Philippine Health Atlas, which we are co-publishing with IHME and the DOH Epidemiology Bureau, helps us see how the burden of disease varies across provinces. The proposed Equity Data Hub takes the next step by connecting information on socioeconomic conditions with information on health and service use. In Noveleta, we are working with Dr. Bucu to examine differences between barangays within the same municipality, including differences in immunization, nutrition, and access to safe water.

See PHA Pocket Guide

THREE ASKS.

These findings point to three practical actions.

First, remove financial barriers to care for the poorest households.

In public hospitals, there are already provisions intended to protect patients from co-payments in the ward. Yet patients can still incur costs. One reason is that medicines may not be available in the facility, requiring patients to purchase them elsewhere. Strengthening the supply chain can therefore reduce an important source of out-of-pocket spending.

For private providers, the issue is transparency and predictability. When a private provider is contracted to serve a low-income population, families should know before admission what costs, if any, they will still have to pay.

Second, develop and maintain one validated national list of unserved and underserved communities.

It must include the urban poor, not only geographically remote communities. A family may live close to a hospital and still face barriers to using its services because of cost or other constraints.

We need validated information so that our maps and resource-allocation decisions reflect actual conditions on the ground.

Third, let equity guide where additional resources and support are directed.

Some places need additional resources. Others may have resources but need support to use them more effectively. The challenge is that we do not yet have sufficiently granular information to distinguish between these situations. As a result, interventions can end up being applied in much the same way across places with very different needs. We are testing an approach in Noveleta, Cavite. We are mapping barangays using an equity-efficiency matrix to distinguish where additional resources may be needed from where capacity support may be more appropriate. From this work, we hope to develop a diagnostic tool that can support more evidence-informed resource allocation. The goal is to provide decision-makers with that level of clarity at the barangay level.

Governor Miraflores, Governor Edduba, Director Legaspi, and Director Tan, none of this can be done without you. We would rather build this with you than study you from Manila.

Before I worked on these issues from the perspective of policy and research, I was a municipal health officer in Palawan. I learned then that a social contract is not measured only by what we offer at the RHU. It is measured by what actually reaches people—at the last house, on the last mountain trail.

Until we can demonstrate that UHC reaches people—in access to care, financial protection, and health outcomes—we cannot say that universal health care is reaching everyone.