Access to Surgical Treatment for Breast Cancer in the Philippines

Abstract

Female breast cancer is the most commonly diagnosed cancer worldwide; however, while high-income countries have the highest incidence rates, lower-middle income countries have the highest mortality rates. In this article, we describe the landscape of disparities in access to surgical care for patients with breast cancer in the Philippines, a lower-middle income country in Southeast Asia. We describe the payment landscape that allows access to care for patients with non-metastatic disease, and draw attention to the fact that despite some degree of insurance for most Filipinos, great barriers to access remain in the form of a low number of surgical providers, geographic disparities, and persistent socioeconomic barriers. Lastly, we suggest steps forward to improve equity in access to surgical care for Filipino patients with breast cancer.

Female breast cancer is the most commonly diagnosed cancer worldwide;¹ however, while high-income countries have the highest incidence rates, lower-middle income countries (LMIC) have the highest mortality rates. In the Philippines, a lower-middle income country in Southeast Asia (SEA), this inequity has been magnified during the coronavirus disease 2019 (COVID-19) pandemic where access to and willingness to seek treatment have been reduced due to fear of being infected, lockdowns preventing patients from traveling to healthcare facilities, and unemployment reducing purchasing power and demand for healthcare.²

Under the Z Benefit Package of the country’s national health insurance system, Filipinos diagnosed with stage 0–IIIA breast cancer are entitled to coverage of all necessary materials and services needed for the entire course of their treatment.³ This includes payment for hospital room fees, drugs and laboratory examinations, operating room and professional fees, and other services. However, despite this coverage provided by the government, access to surgical management is limited in rural and geographically isolated areas due to the lack of and unequal distribution of health facilities and providers across the country. The Philippines has 0.9 surgeons per 100,000 people, far below the recommended number of 20 specialist surgical, anesthetic, and obstetric (SAO) physicians supported by the Lancet Commission on Global Surgery.⁴ In addition, patients residing in Luzon, where the capital Manila is located, have greater access to surgical facilities, as 58% of the country’s equipped government hospitals are located there, compared with Mindanao (24%) and Visayas (18%).⁵

Improving health financing is critical. A study conducted on countries in SEA showed that over 30% of patients with cancer are at risk of financial catastrophe, with women being at greatest risk.⁶ Although the Z Benefit Package covers all costs for patients with non-metastatic breast cancer, patients with metastatic cancer, who are likely to incur higher out-of-pocket costs, are not covered. Non-medical costs, including childcare, transportation, accommodation, and loss of income and productivity during and after treatment, must also be taken into consideration as they impact health-seeking behavior and willingness to undergo treatment. Therefore, it is important to expand national health insurance coverage and increase funding for patients with cancer. This will require a substantial increase in the national health budget; currently, the Philippine government has allotted only 1.2% of the country's gross domestic product (GDP) for health, far below the WHO-recommended 5%. Indeed, Duggan et al.⁷ found that the degree of universal health coverage and access to care such as having public cancer centers are predictors of a country’s capacity to reduce breast cancer mortality. Therefore, breast cancer mortality in the Philippines is not likely to change until these two areas are addressed through the public healthcare system.

Capacity-building and development of public health facilities across all regions of the country must be prioritized, as countries with a higher number of public cancer centers have improved breast cancer mortality.⁸ Efforts are underway to create cancer centers in the country; however, access especially for geographically isolated patients is critical. Furthermore, the referral system from primary to specialized health care units requires efforts to further streamline organization. A nationwide telemedicine system and electronic medical record system may help facilitate these improvements. Additionally, adherence to breast cancer screening, diagnosis, and treatment may be poor among Filipino women due to cultural barriers.⁹ This may be mitigated through culturally appropriate community education and public health campaigns to help patients understand the importance of early detection and treatment to improve breast cancer outcomes.

The surgical workforce must also be increased and equitably distributed. Using the projected Philippine population, the Philippines will need to increase its SAO workforce to 25,200 to satisfy the recommended density of 20 per 100,000 people. This should also be supported by increasing the density and distribution of allied health providers such as nurses, operational managers, and radiology, pathology, and laboratory technicians.⁴

Financial incentives are needed to encourage specialists to practice in underserved areas. A multifaceted approach is needed to increase the rural medical workforce in Asia-Pacific LMICs through increasing publicly-funded universities, promoting education access in rural communities, developing scholarships for trainees from rural and underrepresented regions, and ensuring having a supportive and well-financed rural health system.¹⁰ In addition, collaboration with other oncology disciplines may aid in enacting other needed changes, such as government procurement and local production of essential drugs, as well as increasing coverage for treatment in private facilities. Therefore, government legislation is crucial to making treatment equitable regardless of a patient's socioeconomic standing and geographic location.

Disclosures

Edward Christopher Dee and Christian Daniel U. Ang are funded in part through the Cancer Center Support Grant from the National Cancer Institute (P30 CA008748). Luis Miguel B. Co, Michelle Ann B. Eala, and Samuel D. Ang have no disclosures to declare.