Concepts of Health
HEALTH Is a state of complete physical, mental and social
well-being, and not merely the absence of disease or infirmity.
(WORLD HEALTH ORGANIZATION, 1948)
What are people's concepts of health?
 Most individuals define health as the following:
o being free of symptoms of disease and pain as much as
possible
o being able to be active and able to do what they want or
must do
o being in good spirits most of the time
COMPONENTS
Physical
 ability to carry out daily tasks
 achieve fitness maintain nutrition and proper body fat
 avoid abusing drugs, alcohol, or using tobacco products
Social
 ability to interact successfully with people and within the
environment of which each person is a part
 develop and maintain intimacy with significant others
 develop respect and tolerance for those with different
opinions and beliefs
Emotional
 ability to manage stress and express emotions appropriately
 ability to recognize, accept, and express feelings
 ability to accept one's limitations
Intellectual
 ability to use information effectively for personal, family, and
career development
 striving for continued growth and learning to deal with new
challenges effectively
Spiritual
 belief in some force (nature, science, religion, or a "higher
power") that serves to unite human beings and provide
meaning and purpose to life
 includes a person's morals, values, and ethics
Occupational
 ability to achieve a balance between work and leisure time
 beliefs about education, employment and home influence,
personal satisfaction and relationships with others
Environmental
 ability to promote health measures that
 promote the standard of living and quality of life in the
community
 influences include: food, water, air
Smith's Models of Health and Illness
Clinical Model
 narrowest interpretation
 medically-oriented model
 Health is seen as freedom from disease
 Illness is seen as the presence of disease
Role Performance Model
 ability to perform work, that is fulfill societal roles, essential
to the model
 assumption of the model is that a person's most important
role is their work role
 Health is seen as the ability to fulfill societal roles
 Illness is seen as the inability to fulfill societal roles
Adaptive Model
 ability to adapt to the environment and interact with it to
maximum advantage essential to the model
 health is seen as adaptation
 illness is seen as a failure of adaptation / maladaptation
Eudaemonistic Model
 most comprehensive, holistic, view of health
 ability to become self-actualized essential to the model
 Health is actualization or realization of one’s potential
 Illness is seen as the failure to actualize or realize one’s
potential
Summary of Sociological Studies of Lay Health Beliefs
(Crinson:2007)
6 Constructs:
1. Health as functional capacity
 this broad notion would also include the notions of
o "health as the absence of disease" (as not ill)
o "health despite disease" (Blaxter, 1990)
 largely a working class conception, but also held by the
elderly, particularly those in poor health, were less likely to
define health in terms of illness
 Indicators
o The ability to fulfill social & work roles as main criterion of
healthiness
 "never having a day's illness" was found to be used as a
(positive) moral characteristic of individuals
o Conceiving health as coping or overcoming
disease/misfortune
 related to this is the idea of health as "reserve"
 Cornwall (1984) in her study of a working class community in
Bethnal Green, found that the way people thought about
their health was a kind of "cheerful stoicism," even when
physically ill.
2. Health as emotional well-being (MacInnes & Milburn,
1994)
 closely linked to health as energy / vitality (Blaxter, 1990)
 essentially a middle class concept (d'Houtaud & Field, 1986)
 Indicators
o A positive approach to life, do not "worry all the time."
o Illness as resulting from negative attitudes - "moaners."
o A holistic and multidimensional view of health and illness.
3. Health as reflecting lifestyle, including a moral
dimension (MacInnes & Milburn, 1994)
 Closely linked to health as "healthy" behavior, the "healthy
life" (Blaxter, 1990)
 Indicators
o Healthy behavior as not smoking, good diet, exercising, and
not drinking alcohol to excess.
o Moral evaluations of individuals, role of "bad habits" in
causative explanations.
4. The notion of 'candidacy'
 utilized in lay explanations of relative risk of disease and
efficacy of preventive health behaviors
 constructed from appearance or circumstances surrounding
an event, i.e., the onset of illness
 can support or challenge biomedical etiology (Davison,
Davey Smith & Frankel, 1991)
 Indicators
o Identification of those who become ill / "disease
candidates," retrospectively and/or predictively.
o Teleological explanations of illness 'there was a meaning /
purpose in their becoming ill'
5. Conceptual duality of health
 Endogenous health / exogenous illness (Herzlich, 1973)
 Indicators
o Illness as external, arising from a conflict between the
individual and society - lifestyle in its widest sense.
o Health as coming from within; requiring a struggle against
"unhealthy lifestyles."
 The basic logic of health and illness consists of prevention
(avoiding inappropriate behavior that leads to imbalance)
and curing (restoring balance); it is a system oriented to
moderation. Parallel to this holistic belief system is the
understanding of modern medicine with its own basic logic
and principles that treats certain types of diseases. These
two systems co-exist, and Filipino elders use a dual system
of health care (Anderson, 1983; McBride, et al., 1996;
Miranda, McBride, and Spangler, 1998).
6. Theorizing the body as physical capital or the
"commoditization of the body" (Bourdieu, 1977)
 Working class having an instrumental relation to body
 middle class seeing the body as a "personal project"
 Indicators
o Working class ideology: body as a "means to an end" /
as machine, which may require servicing from medical
experts to run efficiently
o Middle class ideology: body as under personal control,
choices can be made about "appropriate lifestyle"
Measuring Health, the Cost of Health, and Health
Outcomes
Measuring Health and Diseases
 Different measures of health and disease are widely used to
describe the health of populations.
 One of the principal roles of epidemiology is to measure the
health of the community.
 Although we are mainly interested in "health," in reality we
usually measure "ill-health" or "disease" as it is easier to
measure.
 The measurement of health proceeds by assigning numbers
to health states and manipulating these numbers
 Indicators of health status define quantities that describe
aspects of health.
 These indicators are considered to be either "negative" or
"positive" measures.
Measures of Mortality
 mortality rates are defined as estimates of the portion of a
population that dies during a specified period
 rates are
o crude death rate
 deaths per 1000
o infant mortality rate
 deaths of infants under 1 per 1000 live births
o maternal mortality rate
 deaths of women from childbearing per 100,000 live
births
o age-specific death rate
 deaths in an age group
o cause-specific death rate
 deaths from a cause
o proportion dying of a specific cause
 deaths from specific cause
o leading causes of mortality
Measures of Morbidity
 is any departure, subjective or objective, from a state of
physiological or psychological wellbeing
 in this sense, sickness and illness are synonyms for
morbidity
 WHO Expert Committee on Health Statistics says that
morbidity can be measured in terms of three units:
o people who were ill
o the illnesses the people experienced
o the duration of the illnesses
Incidence
 the incidence rate of a disease tells us how
 quickly people are newly getting the disease
 differs from prevalence as incidence rate only considers new
cases of the disease that occurred in a given time period
Prevalence
 the prevalence of a disease tells us what proportion of the
population has the disease
 often expressed per 100 people (%)
Leading Causes of Morbidity causes of disease
Leading Causes of Mortality causes of death
Measure of Life Expectancy
the average number of years a group of people born in the
same year can be expected to live if mortality at each age
remains constant in the future
Measuring Health Costs
 The costs of health intervention are the expenses in trying to
produce better health.
 Costs are what society, governments, or individuals incur to
run a program, or to produce something that desire, like
better health.
What makes health goods and services different from
other commodities?
 Health care services are sought or utilized not as an
endpoint but as an intermediate to achieve something else,
that is, better health.
o the demand is "derived demand"
 Although most healthcare goods and services are bought,
paid for, and consumed by the buyer, decisions are made by
individuals other than the buyer/consumer of goods.
o individuals rely on health professionals
 Healthcare goods and services are both consumption goods
and investment goods.
o utilizing healthcare goods and services make people feel
better (consumption good) and more productive with a
better earning capability or enjoyment of life (investment
good)
 Costs are monetary value of producing a good or service,
while prices are usually cost plus markup which is largely
driven by market forces.
 Unlike most markets for consumer services, the health care
market generally lacks transparent market-based pricing.
o patients are typically not able to compare for medical
services based on price, as medical service providers do
not typically disclose prices prior to service
What is the cost of Health?
 There is no single price/cost for a health care service.
 The amount paid for a health care service will vary based on
who performs the service, where it is performed, and who
pays the bill.
 In addition, the amount paid for a particular service will differ
depending on which hospital or physician is performing the
services.
According to the Behavior of Costs
Total Cost
 example, in a vaccination program, total costs will be
comprised of
o all the vaccines given
o all syringes and other medical supplies
o training and salaries of personnel
o equipment
o transportation expenses utilities, and
o all other expenses incurred
Average Cost
 is the measure of the total cost of production associated with
each unit of output
 example, if the total cost of the vaccination program is
P1,000,000.00, and the program was able to vaccinate
10,000 children, then the average cost would be
o average of 100 pesos each child
Marginal Cost
 is the measure of the resources associated with a small
incremental change in output
o if vaccination is extended to another village distant
barangay, no further training, equipment and new
transportation will be needed
o only extra vaccines, syringes, medical supplies and
personnel salary will be included as marginal posts
Opportunity Cost
 is the cost of 'sacrificing' other outputs/outcomes in favor of a
chosen program
 assumes that due to limited resources, one program or
intervention will be given priority over another
 also assumes that to do an activity, other activities are
sacrificed
According to the Frequency of Incurring Costs
Capital Cost
 this is the cost for items with life expectancy of more than a
year
 example, if the total cost of the DMSFI Hospital is P160M,
which has a usable life of 25 years, the monthly cost of the
building can be estimated as
Recurrent Costs
 these are costs necessarily incurred each year or each
month
 examples
o salaries and wages of personnel
o medical supplies
o utilities like water, electricity, fuel
 incurred commonly, on a monthly basis
Capital Cost + Recurrent Cost = TOTAL COST
According to the Relationship of Costs to the Product or
Service Produced
Direct Medical Costs
these are costs which individuals pay for in exchange for
goods and services they consume
Direct Non-Medical Costs
these are costs which individuals incur, other than payments
made for health goods and services
Indirect-Opportunity Costs
 these are potential earnings that should have been gained
from "missed opportunities" as a result of seeking healthcare
 can be a missed earning potential or lost productivity
Intangible Costs
 these can be summarized as the cost of pain and suffering
when one is ill
 very difficult to measure objectively since the severity differs
from person to person
Dental Health Costs
 compared to the cost of medical care, dental is a major
healthcare bargain
o cheaper and more economical
o the major reason is that dental care is usually not
catastrophic
 good dental care can offset potential major health care
problems, such as heart disease and stroke
Estimates of the economic cost of poor dental health
 Direct cost of dental services
o $6.72 billion, expenditure on dental services in 2008-09
(AIHW 2010)
o $6 billion annually, direct treatment costs and additional
care costs exceeding $1 billion (Rogers 2011)
 Indirect cost: time lost
o 600,000 days lost from school (Spenser & Lewis 1988)
o million days lost from work (Spenser & Lewis 1988)
o 1 million lost days of work per annum (Leeder & Russell
2007)
o US estimate of 148 lost work hours per 100 employed
persons (Gift, Reisine et al 1992)
 Direct and indirect costs
o $2 billion, total direct costs and lost productivity in Australia
(Leeder & Russell 2007)
o US estimate of 148 lost work hours per 100 employed
persons (Gift, Reisine et al 1992)
 The Costs of Untreated Oral Health Problems
o US Surgeon General Report (2000) - students missed 51
million school-hours employed adults missed 164 million
work- hours
o 2009 - 504,000 children, age 5-17 missed at least a day of
school in California alone
 40.36 million hours lost from school or work or normal
activities in one year due to check-ups or problems with
teeth
o 2.26 million school-days
o 4.15 million working days
Measuring Health Outcomes
How do we measure health outcomes?
Health Outcomes are a change in the health status of an
individual, group or population which is attributable to a
planned intervention or series of interventions, regardless of
whether such an intervention was intended to change health
status.
 Outcomes are the effects of the health intervention for which
the costs were incurred.
 "benefits" that individuals and society get in return for
undertaking certain activity
 Examples
o improvement of health - life years gained as a result of
intervention
o improvement of quality of life - better, more active life
o increased economic output - less work days lost
because of "better" health
o monetary saving - less expenses
 Measuring health outcome is a process in which a
standardized attempt is made to observe an often complex
clinical picture.
 Health measurement is essentially evaluative or subjective
rather than objective.
Some Health Outcome Instruments (Indices) 1. the individual's symptom experience, including pain,
emotion, and recognition of experience as symptomatic of
Happy Planet Index (HPI)
illness
 This is an index of human well-being and environmental
2. the individual's assumption of a sick role - during this
impact.
second stage, the individual also explores his/her lay
 The index is designed to challenge well-established indices
referral system for validation of the sick role and for
of countries' development, such as GDP and the HDI, which exploration of treatment options;
are seen as not taking sustainability into account. 3. medical care contact - during this stage the individual
Satisfaction with Life Index seeks a health care professional
 This is an index that attempts to show life satisfaction in a. the pace at which a person enters this stage is
different nations. determined by their membership within parochial and
 In this calculation, subjective well being correlates most cosmopolitan social networks
strongly with health, wealth and access to basic education. b. if parochial (limited/narrow outlook), they will tend to
delay medical care contact by continuing the first two
Health Care Utilization stages for longer than a person who is a member of a
HEALTH CARE UTILIZATION is the extent to which an cosmopolitan (diverse) network
individual, family or group use a health care service. 4. the assumption of a dependent-patient role via
 A Theory is a considering decision point or stage of health acceptance of professional health care treatment - it is
care seeking. possible for this stage to be disrupted if the individual and
 A Model can be regarded as containing a set of interacting the professional health care provider have differing
variables. opinions of the illness;
5. the individual's recovery from illness - the individual
THEORIES recovers upon relinquishing their role as patient
The Sick Role Theory (Parson, 1951)
 When an individual is sick, they adopt a role of being ill.
 The 4 Main Components:
o the individual is not responsible for his/her state of illness
and is not expected to be able to heal without assistance  If an illness is not curable, a person may assume a
o the individual is excused from performing normal roles and chronically ill role (Wolinsky, 1988).
tasks Theory of Planned Behavior
o there is general recognition that being sick is an the Theory of Planned Behavior from Ajzen (1991) is one of
undesirable state the most researched and validated models in social
o to facilitate recovery, the individual is expected to seek psychology that explain the factors that influence behavior
medical assistance and to comply with medical treatment
 Parsons' theory attempts to identify typically seen behavior
in individuals who are ill.
Theory of Help Seeking (Mechanic, 1978)
 takes a psychological approach to health care utilization
 the theory incorporates ten decision points which determine
illness behavior
 The 10 Points:
o the salience of deviant signs and symptoms
 signs are what we physically see like the inflammation of
the eye
 symptoms are what can be felt or more on physiology
like coughing
o the individual's perception of symptom severity
o the disruption of the individual's daily life as caused by the
illness
o the frequency of symptoms and their persistence
o the individual's tolerance of symptoms
o the individual's knowledge and cultural assumptions of the
illness
o denial of illness as a result of basic needs
o whether or not response to the illness disrupts needs
o alternative interpretations of symptom expression
o treatment availability via location, economic cost,
psychological cost (stigma, humility, etc.), and treatment
resources
 Beyond these ten points, Mechanic's theory allows for illness
response to be influenced by either the individual or a
person who makes decisions for the individual (Wolinsky,
1988).
 Thus, as expressed in the illness behavior theory, autonomy
and heteronomy influence health care utilization. Models of Health Care Utilization

Stages of Illness and Medical Care (Suchman, 1965) Health Belief Model
 indicates five stages of the individual's decision process in  the Health Belief Model (HBM) is a psychological model that
determining whether or not to utilize health care attempts to explain and predict health behaviors
 The 5 Stages:  done by focusing on the attitudes and beliefs of individuals
 was first developed in the 1950s by social psychologists o the individual's cues to action - media, friends, family, or
Hochbaum, Rosenstock and Kegels working in the U.S. well-known citizens can provide an impetus for prevention
Public Health Services  the absence of cues to action will reduce the likelihood
 the model was developed in response to the failure of a free of prevention
tuberculosis (TB) health screening program
 since then, the HBM has been adapted to explore a variety
of long- and short-term health behaviors, including sexual
risk behaviors and the transmission of HIV/AIDS
 The HBM is based on the understanding that a person will
take a health-related action (i.e., the use of condom) if that
person:
o feels that a negative health condition (i.e., HIV) can be
avoided,
o has a positive expectation that by taking a recommended
action, he/she will avoid a negative health condition (i.e.,
using condoms will be effective at preventing HIV), and
o believes that he/she can successfully take a
recommended health action (i.e., he/she can use condoms
comfortably and with confidence).
 the Health Belief Model constructed by Rosenstock (1966),
was based on four constructs of the core beliefs of
individuals based on their perceptions
 The 4 Constructs:
o Perceived susceptibility - an individual's assessment of
their risk of getting the condition
o Perceived severity - an individual's assessment of the
seriousness of the condition, and its potential
consequences
o Perceived barriers - an individual's assessment of the
influences that facilitate or discourage adoption of the
promoted behavior
o Perceived benefits - an individual's assessment of the
positive consequences of adopting the behavior
 Thus, the individual's choice to utilize health services is
contextually dependent (Wolinsky, 1988).

Andersen's Health Care Utilization Model (1968)

 looks at three categories of determinants
 predisposing characteristics
 Rosenstock, Strecher, & Becker, 1994)- discusses the
individual's actions to treat and prevent disease via
consideration of four central variables
 The 4 Central Variables:
o the individual's perceived susceptibility to disease - an
individual will seek preventive health services if he/she
believes that he/she is susceptible to disease;
o the individual s perception of illness severity - if a
person does not perceive the illness as serious, he/she will
not seek treatment or prevention
o the individual's rational perception of benefits versus
costs - an individual will not take action unless the
treatment or prevention is perceived as having greater
benefits than costs
o this category represents the proclivity to utilize health care
services
o according to Andersen, an individual is more or less likely
to use health services based on demographics, position
within the social structure, and beliefs of health services
benefits
o an individual who believes health services are useful for
treatment will likely utilize those services
o Has three types
o Demographic variables
 The Health Interview Survey of 1978 demonstrated that
both sex and age influenced utilization of dental service
 women made more visits than did men
 age has less of an effect, although it was found that
those 65 years of age and over made fewer visits
o Social variables
 Dunning also suggested occupation (as presentability)
o Health beliefs
 The Health Interview Survey of 1978 demonstrated that
factors such as how susceptible to diseases the person
believes himself/herself to be or how serious one
believes a particular dental condition to be
 dental care being symptom-oriented one's health beliefs
are related to one's culture, in such aspects as value of
beauty - definition of attractive teeth (for example, having
teeth extracted rather than undergoing long-term
restorative work)
 Filipino Oral Health Beliefs and Practices:
  teeth brushing cannot be done without toothpaste  incorporates four components that are most essential to the
 toothbrushes do not need to be replaced individual's health service choice
 some Filipino families share toothbrushes  The 4 Components:
 milk teeth need no brushing since these will be
replaced by permanent teeth o Perceptions Of Gravity
 permanent teeth need no extra care since dentures  this category includes both the individual's perception
will replace them anyway and their social network's consideration of illness
 it's normal to wear dentures in old age severity
 dentures do not require any cleaning at all  gravity is based on the assumption that the culture
 some school-aged children have no clue what dentists classifies illnesses by level of severity
do o The Knowledge Of A Home Treatment
 some middle-aged adults have never been to a dentist  if a person knows of a home remedy that is efficacious,
they will be likely to utilize that treatment before utilizing
 enabling characteristics/resources
a professional health care system home remedy
o this category includes resources found within the family
knowledge is based on lay referral
and the community
o The Faith In Remedy
o family resources comprise economic status and the
 this component incorporates the individual's belief of
location of residence
efficacy of treatment for the present illness
o community resources incorporate access to health care
 an individual will not utilize the treatment if they do not
facilities and the availability of persons for assistance
believe the treatment is effective
o The most important family resource enabling people to use
o The Accessibility Of Treatment
services is income.
 accessibility incorporates the individuals' evaluation of
o Andersen and Newman found that the family's perception
the cost of health services and the availability of those
of its income was also important - that the family must not
services
only have the means to pay for care, it must also be aware
 according to Young, access may be the most important
that it has those means
influence on health care utilization (Wolinsky, 1988)
o Nikias and associates pointed out socioeconomic status
as a factor - those who were poor were less likely to seek
care, or, more specifically, preventive care
o Russo, Herrin, Pons (Household health care facility
utilization in the Philippines) - Households in the highest The Anderson Model of Health Care Utilization
income quartile are approximately twice as likely to utilize
private hospital services vis-à- vis households in the
lowest income quartile.
o community resources that enable a person to utilize
services have also been studied
 people with low incomes may live in areas with relatively
few services available, or if this not the case,
 low-income people may lack resources, such as time
and transportation necessary to utilize available services
o Muller, 1986 - Education and income usually result in Zola's Help-Seeking Model
higher use of health care, especially preventive visits and
clinic visits; however, educated persons experience less
acute.
o Holtmann and Olse found that both income and
waiting time influenced utilization - that if low-income
people are paid hourly wages rather than weekly salaries
paid to higher income groups, the time spent waiting in the
dental clinic can be very costly
o the major community resource is, of course, the dental
provider - that the demand for dental care is controlled by
the profession (Leverett)
 need-based characteristics
o this category includes the perception of need for health
services, whether individual, social, or clinically evaluated
perceptions of need (Wolinsky, 1988)

HEALTH SEEKING BEHAVIOR can be defined as personal

actions to promote optimal wellness, recovery, and
rehabilitation. (Nursing Outcomes Classification (NOC))
 One of the most important objectives of economics is to
make sure that we maximize the output, out of the inputs
that we process to produce goods and services.

Young's Choice-Making Model (1981)

 based on his ethnographic studies of health services
utilization in Mexico
 Types of Economic Evaluation
Cost-Benefit Analysis
 CBA
 values both costs and benefits in money terms and
compares them
 directly compares the benefits of a chosen option against the
costs incurred with the option
 Solution: Benefit/Cost
 evaluation criterion becomes a ratio
 the ratio shows "how many times the cost is earned by its
effect" through the monetary benefits of a certain option
o a ratio of one (1) means that the option simply had the
same monetary benefit compared to the cost attached to
the option
ECONOMIC EVALUATION refers to the systematic analysis in  to make a decision, if the program ratio is greater than one
(1), the project is worthwhile
an attempt to identify, measure, evaluate and compare the
cost (inputs) and benefits (outcomes) of two or more  as the ratio becomes higher than one (1), the project
alternative treatments or interventions. (Gabay, et. Al) becomes more worthwhile
 Example
Evaluating Health Programs o Assume that we are evaluating a project proposing to
Measuring Costs and Outcomes vaccinate 2,000 children for measles in a certain distant
 To assess whether the health resources are used optimally, barangay.
there must be a way to measure the costs of health o Assume also that the cost per child immunized is P300.00.
interventions (expenses in trying to produce better health), If we do not immunize these children for measles, there is
and the effects of these health interventions (the health good chance that they will contract it. Is it cost-beneficial to
effects of the costs spent) or its ability to produce better immunize all of these children?
health). o Assume further that all these parameters are true:
 90% of non-immunized children will contract measles
 Ideally, the effects of health programs, activities, or
interventions, should outweigh their costs.  of those who will contract it, 30% will have complications
 of those who develop complications, 30% will have
meningo-encephalitis and 70% will have
bronchopneumonia
o Costs are as follows:
Uncomplicated cases 500 pesos per case
Meningo-encephalitis 20,000 pesos per case
bronchopneumonia 15,000 pesos per case

Basic Principles of Economic Evaluation

 Decision Making economic evaluations are techniques
done to evaluate options which all promise to produce
"better health" - allows program planners to have an
objective basis for choosing a specific option from a list of
several
 Comparing Costs with Benefits costs attached to the
available options are measured against the health effects or
benefits that they produce

Cost Effectiveness Austral CEA

 compares effects and costs
 Total Cost / Total Health Effect
 more specifically, it evaluates which possible intervention will
 Bang" and "Buck" best achieve a given objective at the least cost
o buying and playing with firecrackers  when given a fixed budget, which intervention maximizes the
o economic evaluation techniques are essentially comparing effectiveness of the expenditure
"bucks" and "bangs"  it is a ratio that compares cost per health effect
 costs and outcomes are measured in non- comparable units
 generally used to either:
 o compare alternative programs with a common health
outcome, or
o assess the consequences of expanding an existing
program
 it is the most common approach and can tell which strategy
maximizes an objective, example, heart attacks prevented
with the lowest cost
Cost-Minimization Analysis CMA
 a derivation of CEA
 focuses on the costs of different alternative programs or
intervention options
 assumes that regardless of whichever option is taken, the
effects or the outcomes will be identical
 with the assumption that the outcomes of the interventions
are measurably identical, the least cost option is chosen
 the simplest form of economic evaluation
 advantages
o the measurement problem is reduced in examining
resource consequence
o analysis will consist of simply comparing costs alone, or
considering other resource consequences that are
measured in monetary terms in order to identify the least
cost alternative or the cheapest option
 disadvantages
o inappropriate to use if 2 treatments signal differences in
effectiveness, or the cheaper option may harm the patient
o needs a strong assumption that individual health effects
are the same between 2 alternative treatments
Cost-Utility Analysis CUA
 special form of the CEA
 estimates the ratio between the cost of a health-related
intervention and the benefit it produces (outcome)
 outcomes are measured in terms of utility (well-being); in
terms of the number of years lived in full health by the
beneficiaries
 the most well-known measure of health utility is the Quality
Adjusted Life Year (QALY)
o measures quality of life from 0 to 1 (where 0 denotes death
and 1 equates to perfect health)
o is the product of quality of life and length of life
 Sol: Cost/QALY gained
 for example, intervention A allows a patient to live for 3
additional years than if no intervention had taken place, but
only with a quality of life weight of 0.6, then the intervention
confers (3)(0.6) = 1.8 QALYs to the patient
 if intervention B confers 2 extra years oflife at a quality of life
weight of 0.75, then it confers 1.5 QALYs to the patient
[(2)(0.75)]
o the net benefit of intervention A over intervention B is
therefore, 1.8-1.50.3 QALYS
 in the UK, as of January 2005, the National Institute for
Health and Clinical Excellence (NICE) is believed to have a
threshold of about £30,000 per QALY
 in North America, US$50,000 per QALY is often suggested
as a threshold ICER for a cost-effective intervention
HEALTH CARE SYSTEM AND FINANCING
HEALTH CARE is the prevention, treatment, and
management of illness and the preservation of mental and
physical well- being through the services offered by the
medical and allied health professions.
HEALTH CARE DELIVERY is the provision of health care.
 is rendering health care services to the people. (Williams-
Tungpalan, 1981)
 is the network of health facilities and personnel which carries
out the task of rendering health care to the people.
(Williams-Tungpalan, 1981)
HEALTH SYSTEM (or HEALTH CARE SYSTEM) consists of
all organizations, people and actions whose primary intent is to
promote, restore or maintain health. (WHO)
Health System Goals (World Health Report 2000)
 overall health system outcome or goal: improving health
and health equity care, in ways that are responsive,
financially fair, and make the best, or most efficient, use of
available resources
 intermediate goal: the route from inputs to health outcomes
is through achieving greater access to and coverage for
effective health interventions, without compromising efforts
to ensure provider quality and safety

The 6 Building Blocks Of A Health System: Aims And
Desirable Attributes
1. Good health services are those which deliver effective,
safe, quality personal and non-personal health interventions
to those who need them, when and where needed, with
minimum waste of resources.
2. A well-performing health workforce is one which works in
ways that are responsive, fair and efficient to achieve the
best health outcomes possible, given available resources
and circumstances, i.e., there are sufficient numbers and
mix of staff, fairly distributed; they are competent,
responsive and productive.
3. A well-functioning health information system is one that
ensures the production, analysis, dissemination and use of
reliable and timely information on health determinants,
health systems performance and health status.
4. A well-functioning health system ensures equitable
access to essential medical products, vaccines and
technologies of assured quality, safety, efficacy and cost-
effectiveness, and their scientifically sound and cost-
effective use.
5. A good health financing system raises adequate funds
for health, in ways that ensure people can use needed
services, and are protected from financial catastrophe or
impoverishment associated with having to pay for them.
6. Leadership and governance involves ensuring strategic
policy frameworks exist and are combined with effective
oversight, coalition-building, the provision of appropriate
regulations and incentives, attention to system-design, and
accountability.
Health Care System Basic Models
The Beveridge Model
 named after William Beveridge, the daring social reformer
who designed Britain's National Health Service in 1948
 health care system in which the government provides
health care for all its citizens through income tax payments
 most hospitals and clinics are owned by the
government; some doctors and health care professionals
are government employees, but there are also private
institutions that collect their fees from the government
 With the government as the single-payer in this health
care system, it eliminates competition in the health care
market and helps to keep the costs low
 Using income tax as the main funding for health care
allows for services to be free at the point of service, and the
patients' contribution to taxes covers for their health care
expenses
 countries using the Beveridge plan or variations on it include
Great Britain, Spain, most of Scandinavia, New Zealand,
Hong Kong, Cuba
The Bismarck Model
 also referred as "Social Health Insurance Model"
 named for the Prussian Chancellor Otto von Bismarck, who
invented the welfare state as part of the unification of
Germany in the 19th century
 is a limited health care system, in which people pay a fee
to a fund that in turn pays health care activities
 health care activities are provided by State-owned
institutions, other Government body-owned institutions,
or a private institution
 Bismarck-type health insurance plans have to cover
everybody, and they don't make a profit
 found in Germany, France, Belgium, the Netherlands, Japan,
Switzerland, Latin America
The National Health Insurance Model
 has elements of both Beveridge and Bismarck
 uses private-sector providers, but payment comes from a
government-run insurance program that every citizen
pays into
 is a health care program administered by a government,
rather than by private insurance companies.
 since there's no need for marketing, no financial motive to
deny claims and no profit, these universal insurance
programs tend to be cheaper and much simpler
administratively than American-style for- profit insurance
 the single payer tends to have considerable market power to
negotiate for lower prices
 found in Canada, Taiwan, South Korea
 Types of NHI
o government pays private health care providers
o health care providers are direct government employees
The Out-of-Pocket Model
 health care is paid for by consumers to public and private
care providers
 Out-of-Pocket Payment - Fee paid by the consumer of
health services directly to the provider at the time of delivery.
(WHO Terminology Information System)
 little to no insurance coverage expenses
 used by most low- and middle-income countries
Methods of Funding Health Care Systems
 General taxation to the state, county or municipality
 Social health insurance
 Voluntary or private health insurance
 Out of pocket payments
PHILIPPINE HEALTH CARE SYSTEM
 is a complex set of organizations interacting to provide an
array of health services (Dizon, 1977)
 The Philippines has a dual health system:
o Public Sector - which is largely financed through a tax-
based budgeting system at national and local levels and
where health care is generally given free at the point of
service (although socialized user charges have been
introduced in recent years for certain types of services)
o Private Sector - consisting of for-profit and non-profit
providers, which is largely market- oriented and where
health care is paid through user fees at the point of service
certain types of services
 The Philippine Health System - under this health system,
the public sector consists of the DOH, LGUs and other
national government agencies providing health services
The Department of Health Kagawaran ng Kalusugan
 it is the executive department of the Philippine Government
responsible for ensuring access to basic public health
services to all Filipinos through the provision of quality health
care and the regulation of providers of health goods and
services
 It has a regional field office in every region and maintains
specialty hospitals, regional hospitals and medical centers.
 It also maintains provincial health teams made up of DOH
representatives to the local health boards and personnel
involved in communicable disease control.
Health Care Facilities
 Various health facilities serve the health needs of the
Filipinos
 6 facilities
o Barangay Health Units - managed by barangay/municipal
governments
 o Rural Health Units - managed by municipal governments
o City Health Offices - managed by city governments
o Municipal or 'district' hospitals - managed by provincial
governments
o Provincial hospitals - managed by provincial
governments
o Regional hospital and medical center levels - managed
by the DOH
Health Workforce
 various health professionals serve the health need of the
Filipinos
 physicians, dentists, nurses, pharmacists, midwives, sanitary
inspectors, community health workers
3 Levels of Health Care Workers
Barangay Health Workers (BHW) / Barangay Nutrition
Scholars (BNS)
 first contacts of the community and initial links of health care
 provide simple curative and preventive health care measures
promoting healthy environment
 participate in activities geared towards the improvement of
the socio-economic level of the community like food
production program
 community health worker, volunteers or traditional birth
attendants
Intermediate Level Health Workers
 represent the first source of professional health care
 attends to health problems beyond the competence of village
workers provide support to front-line health workers in terms
of supervision, training, supplies, and services
 physicians, nurses, midwives
First Line Hospital Personnel
 provide back up health services for cases that require
hospitalization establish close contact with intermediate level
health workers or Barangay Health Workers
 physicians with specialty, nurses, dentist, pharmacists, other
health professionals
Sources of Funds for Health
 Government - National / Local
 Social Insurance- Medicare/PhilHealth, Employees'
Compensation
 Private Sources- Out-of-pocket, Private Insurance, HMO's,
Employer-based Plans, Private schools
What is Health Care Financing?
 mobilization of funds for health care
 allocation of funds to the regions and population groups and
for specific types of health care
 mechanisms for paying health care (Hsaio, W and Liu, Y,
2001)
 refers to a system that pays health care costs on a collective
basis via employer or government funding
The Broad Approaches to Health Care Financing
Market-Based System - care is generally delivered by private
organizations and individuals and all parts of the system are
subject to some level of competition
Government Financed
 most government-financed systems tend to provide
everyone living in the country with coverage that offers
access to some basic level of care
 most people pay for these systems through taxes and other
charges
Methods of Funding Health Care Systems
 General taxation to the state, county or municipality
 Social health insurance
 Voluntary or private health insurance
 Out-of-pocket payments
 Donations
Social Insurance
 is any government-sponsored program with the following
four characteristics:
o the benefits, eligibility requirements and other aspects of
the program are defined by statute;
o explicit provision is made to account for the income and
expenses;
o funded by taxes or premiums paid by (or on behalf of)
participants (although additional sources of funding may
be provided as well); and
o the program serves a defined population, and participation
is either compulsory or the program is heavily enough
subsidized that most eligible individuals choose to
participate
Philippine Social Insurance
National Health Insurance Program
 NHIP
 Compulsory health insurance program of the government as
established in the National Health Insurance Act of 1995 (RA
No. 7875), which shall provide universal health insurance
coverage and ensure affordable, acceptable, available, and
accessible health care services for all Filipinos
 institutionalized social health insurance in the country
 aims to reduce out-of-pocket spending as well as the
inequities in health financing
 done by pooling funds from members who are healthy, and
can afford health payments, and subsidizing those who are
sickly and cannot afford medical care
 Benefits
o Inpatient coverage: subsidy for room and board, drugs
and medicines, laboratories, operating room and
professional fees for confinements of not less than 24
hours
o Outpatient coverage: day surgeries, dialysis and cancer
treatment procedures such as chemotheraphy and
radiotheraphy in accredited hospitals and free-standing
clinics
o Special benefit packages:
 Coverage for up to the fourth normal delivery
 Newborn Care Package
 TB treatment through DOTS
 SARS and Avian Influenza Package
 Influenza A (H1N1) Package
 RA 9241 (February 10, 2004) amended RA 7875
 RA 10606, National Health Insurance Act of 2013, amending
RA 7875
PhilHealth PHILIPPINE HEALTH INDURANCE
CORPORATION
 is a Government Owned and Controlled Corporation
(GOCC) that administers the NHIP
 funding sources:
o National and Local Government Units for the annual
premium of enrolled
o Sponsored Members
o Contribution of members into the Program
Employee’s Compensation Commission
 The Employee's Compensation Program is designed to
provide public and private sector employees and their
dependents with income and other benefits in the event of a
work-connected injury, sickness, disability or death.
 created under P.D. 626 and became effective on January
1975
 assures workers of total protection through the provision of a
comprehensive benefit package encompassing preventive
occupational safety and health aspects, curative or medical
and compensatory grant, and rehabilitation of occupational
disabled workers
Sources of Fund:
 Government
 Social Insurance
 Private Source
o Private Out-of-Pockets represents the share of the
expenses that the patient or the family pay directly to the
health care provider
 Out-of-Pocket Expenditure - In public health,
especially in relations to national health accounts, the
sum of all out-of-pocket payments made by individuals.
(WHO Terminology Information System)
o Private Insurance
 insurance plan brought by individuals for themselves or
their families
 insurance that is purchased by employers for their
employees and financed through employer or joint
employer-employee contributions
 Enrolment: an individual pays an annual premium to an
insurance company, and in return the company
guarantees to cover his/her hospital expenses up to a
certain limit for a period of one year the company says,
"Give me your money now, and I will pay your
hospitalization needs if you get seriously sick requiring
hospitalization, within a period of one year."
 Advantages: the individual pays a relatively small
amount to be assured of relatively big hospitalization
coverage within a period of one year
o Health Maintenance Organization
 HMO
 a form of health insurance combining a range of
coverage in a group basis
 is a type of managed care organization (MCO) that
provides a form of health care that is fulfilled through
hospitals, doctors, and other providers with which the
HMO has a contract
 Employer Based Plans - health packages that
companies administer for the medical benefits of their
employees (medical facility/clinic, hospital referral
system, hospital)
 Private School - private schools are required to put up
clinics and set budgets for the health care needs of their
students
o Foreign Assistance and Grants
 Bilateral donors – USAID, JICA, AusAID
 Multilateral donors – WHO, UNICEF
INTRODUCTION TO TAXATION
 Taxation is the imposition of compulsory levies on individuals
or entities by governments in almost every country of the
world
 14 Countries with No Income Tax: Antigua and Barbuda,
Bahamas, Monaco, Qatar, Bahrain, Somalia, Bermuda, St.
Kitts and Nevis, Brunei, United Arab Emirates, Cayman
Islands, Vanuatu, Kuwait, Western Sahara
 Tax is the lifeblood of the government
 Nature/primary purpose of the taxing power: To provide
funds or property with which to promote the general welfare
of its citizens and to enable it to finance its activities
7 ESSENTIAL CHARACTERISTICS OF TAX
IT IS AN ENFORCED CONTRIBUTION
A tax is not a voluntary payment or donation and its imposition
is in no way dependent upon the will or assent, open or implied
of the person taxed.
IT IS GENERALLY PAYABLE IN MONEY
Unless qualified by law, the term "taxes" or "tax" is usually
understood to be a pecuniary burden - an exaction to be
discharged alone in the form of money which must be in legal
tender.
IT IS PROPORTIONATE IN CHARACTER
A tax is laid by some rule of apportionment according which
persons share the public burden. It is ordinarily based on
ability to pay. Thus, in practice, some people pay very high
taxes; others, very small amounts or none at all.
 TRAIN LAW TRAIN (Tax Reform for Acceleration and
Inclusion) Law addresses several weaknesses of the
current tax system by lowering and simplifying personal
income taxes, simplifying estate and donor's taxes,
expanding the value-added tax (VAT) base, adjusting oil and
automobile excise taxes, and introducing excise tax on
sugar-sweetened beverages.
o Republic Act No. 10963
o DATE ENACTED BY CONGRESS December 14, 2017
o DATE ENACTED BY SENATE December 13, 2017
o DATE COMMENCED IN THE PHILIPPINES January 1,
2018
o The prominent features of the tax reform are lower
personal income tax and higher consumption tax Individual
taxpayers with taxable income not exceeding P250.000
annually are exempted from income tax. The exemption
for minimum wage earners is retained in the revised tax
system.
IT IS LEVIED IN PERSONS OR PROPERTY
A tax may also be imposed on acts, transactions, rights or
privileges. In each case, however, it is only a person who pays
the tax. The property is resorted to for the purpose of
ascertaining the amount of tax that must be paid and of
enforcing payment in case default of the taxpayer.
IT IS LEVIED BY THE LAW-MAKING BODY OF THE STATE
The power to tax is a legislative power which under the
Constitution Only Congress can exercise through the
enactment of tax statutes.
IT IS LEVIED FOR PUBLIC PURPOSES
Taxation involves, and a tax constitutes, a charge or burden
imposed to government, the administration of the law, or the
payment of public expenses.
IT IS COMMONLY EQUIRED TO BE PAID AT REGULAR
INTERVALS
TAX DISTINGUISHED FROM OTHER FEES
FROM TOLL
A toll is a demand of proprietorship, is paid for the use of
another's property and may be imposed by the government or
private individuals or entities, while a tax is a demand of
sovereignty, is paid for the support of the government and may
be imposed only by the State.
FROM PENALTY
A penalty is designed to regulate conduct and may be
imposed by the government or private individuals or entities.
Tax, on the other hand, is primarily aimed at raising revenue
and may be imposed only by the government.
FROM SPECIAL ASSESSMENT
Special Assessment is levied only on land, is not a personal
liability of the person assessed, is based wholly on benefits
and is exceptional both as to time and place. Tax is levied on
persons, property, or exercise of privilege, which may be made
a personal liability of the person assessed, is based on
necessity and is of general application.
FROM PERMIT OR LICENSE FEE
License fee is imposed for regulation and involves the
exercise of police power while tax is levied for revenue and
involves the exercise of the taxing power. Failure to pay a
license gee makes an act or a business illegal. while failure to
pay a tax does not necessarily make an act or a business
illegal.
FROM DEBT
Debt is generally based on contract, is assignable and may be
paid in kind while a tax is based on law, cannot generally be
assigned and is generally payable in money. A person cannot
be imprisoned for non-payment of debt while he can be for
non-payment of tax except poll tax.
FROM REVENUE
Revenue is broader that tax since it refers to all funds or
income derived by the government taxes included. Other
sources of revenues are government services, income from
public enterprises and foreign loans.
AGRARIAN REFORM
Agrarian
 Relating to cultivated land of the cultivation of land
Reform
 Make changes in (something, typically a social,
political, or economic institution or practice) in order to
improve it
Land reform VS agrarian reform
LAND REFORM
 refers to a full range of measures that may be taken to
improve or remedy defects in the relations among men
with respect to their rights in land;
 the transfer of land ownership from large holders to
small or from non- tillers to tillers. In order to sustain
itself and to achieve these values, land reform must be
accompanied by agrarian reform (Overholt 1976)
AGRARIAN REFORM
 defined as the creation of the physical and institutional
infrastructure necessary for smallholders to maintain
themselves (Overholt 1976);
 could be in the form of policies and programs aimed at
redistributing land from wealthy landowners to poor
and marginalized farmers. It aims to promote social
justice and reduce poverty in rural areas by providing
land for cultivation, improving land productivity, and
increasing the income of farmers
Sec. 3(a), R.A. 6657 Comprehensive Agrarian Reform
Law
 Agrarian reform means the redistribution of lands,
regardless of crops or fruits produced to farmers and
regular farmworkers who are landless, irrespective of
tenurial arrangement, to include the totality of factors
and support services designed to lift the economic
status of the beneficiaries and all other arrangements
alternative to the physical redistribution of lands, such
as production or profit-sharing, labor administration,
and the distribution of shares of stocks, which will allow
beneficiaries to receive a just share of the fruits of the
lands they work.
Brief History of CARP
 Spanish-introduced the concept of encomiendia (Royal
Land Grants), which soon became land rents to a few
powerful landlords
 American-instituted Torrens system for the registration
of lands, but did not solve the problem completely
 The New Republic-problems of land tenure remained
and pushed for the revision of the tenancy law
 Agricultural Land Reform Code of 1963 (RA 3844)
(under Diosdado Macapagal) aimed to distribute public
and private agricultural lands to tenant farmers by
setting a retention limit at 75 hectares and abolishing
the share tenancy
 Under dictator Ferdinand Marcos, PD No.27 was
implemented, restricting land reform scope to tenanted
rice and corn lands and set the retention limit at 7
hectares
 Enactment of RA 6657 or otherwise known as the
Comprehensive Agrarian Reform Law (CARL) under
the administration of Corazon Aquino
Comprehensive Agrarian Reform Program (CARP)
 It is one of the flagship programs of the government
aimed at reducing poverty, promoting equitable
distribution of land resources and social justice, and
industrialization
 The program's implementation has gone through
several phases, including under the Comprehensive
Agrarian Reform Law (CARL) of 1988 and its
subsequent amendments
Components of CARP
 Land acquisition and distribution
 Provision of support services
 Promotion of social justice
Declaration of Principles and Policies (Sec. 2, A
6657)
The welfare of the landless farmers and farmworkers
will receive the highest consideration to:
 Promote social justice
o "right of farmers and regul farmworkers who are
landless, to own directly or collectively the lands they
till or to receive a just share of the fruits"
o "encourage and undertake he just distribution of all
agricultural lands"
 Move the nation toward sound rural development
and industrialization
o "farmers to participate in the planning organization,
and management of the program, and shall provide
support to agriculture
 Establish owner cultivatorship of economic-size
farms as the basis of Philippine agriculture
o "formation and maintenance of economic-size family
farm
o "apply the principles of agristian reform in the
disposition or utilization of other natural resources
suitable for agriculture"
 Land has a social function and land ownership has
social responsibilities
o the State may lease undeveloped lands of the public
domain to qualified entities for the development of
capital-intensive farms
 Basically, agrarian reform is seen as vital in reducing
poverty and promoting social justice in rural areas. By
providing land to farmers, they can cultivate and own
their land, which leads to increased agricultural
productivity and Improved income. This, in turn,
promotes rural development and economic growth
Why the need for agrarian reform?
 Agrarian reform could be justified for 2 reasons
(Lonzana 2019)
o Introduce greater efficiency in agricultural production
in terms of land size; and
o Need for a redistributive policy
Scope (Sec. 4)
Covers all public and private agricultural lands
including other lands of the public domain suitable
for agriculture. Specifically,
 alienable and disposable lands of the public domain
devoted to, or suitable for agriculture;
 all lands of the public domain in excess of the specific
limits as determined by Congress
 all other lands owned by the Government devoted to or
suitable for agriculture
 all private lands devoted to or suitable for agriculture
 All lands of the public domain leased, held, or
possessed by multinational corporations on
associations, devoted to existing and operational agri-
business or agro-industrial enterprises, shall be
programmed for acquisition and distribution (Sec. 8)
o implementation to be completed within three (3)
years
o in case it is not economically feasible to divide the
land, workers shall form a workers' cooperative or
association for production and income-sharing (see
Sec 32)
 The rights of each indigenous cultural community (ICC)
of their ancestral land shall be protected to ensure their
economic, social, and cultural well-being
Priorities (Sec 7)
Ten (10)-Year Period of implementation (acquisition
and distribution of all agricultural lands)
 Phase One (effectivity up to not more than 4 years)
includes all rice and corn lands; all idle or abandoned
lends; all private lands voluntarily offered by the
owners for agrarian reform; all lands foreclosed by
government financial institutions; all lands acquired by
the Presidential Commission on Good Government
(PCGG); and all other lands owned by the government
devoted to or suitable for agriculture
 Phase Two (immediately and up to not more than 4
years)
all alienable and disposable public agricultural lands,
all arable public agricultural lands under agro-forest,
pasture and agricultural leases already cultivated and
planted to crops; all public agricultural lands which are
to be opened for new development and resettlement,
and all private agricultural lands in excess of fifty (50)
hectares
 Phase Three-large landholdings and proceeding to
medium and small landholdings
24 to 50 hectares on the 4th year upon the effectivity of
the Act and to be completed within 3 years
- Retention to 24 hectares on the 6th year and
completed in 4 years
Modes of acquisition
 Compulsory acquisition (Sec. 16)
 Voluntary offer to sell (Sec. 19
 Voluntary land transfer (Sec. 20)
 Landowner will be compensated in such amounts as
may be agreed upon by the landowner and the DAR
and the LBP. Modes of payment include cash, shares
of stock in government-owned or controlled
corporations, tax credits, LBP bonds
Retention limits (Sec. 6)
 retention by landowners shall not exceed five (5)
hectares
 three (3) hectares may be awarded to each child of the
landowner.
o at least 15 years old
o actually tilling or directly managing the land
o all rights previously acquired by the tenant farmers
under PD 27; and
o the security of tenure of farmers/farm workers prior to
the approval of RA 6657 shall be respected
 Landowner has the right to choose the area to be
retained
o shall be compact and contiguous
o in case the selected area is tenanted, the tenant has
the option to choose whether to remain or be
beneficiary in another agricultural land
o must signify this intention within one (1) year their
choice of the selected retention area
o failure to do so shall constitute authorize the Agrarian
Reform Office to choose what to retain
 Any sale, disposition, lease or transfer of private land
by the original landowner in violation of R.A.6657 shall
be null and void
 Landowner has an obligation to cultivate the land
directly or thru labor administration
Land distribution
 Qualified beneficiaries (Sec. 22);
o Agricultural lessees and share tenants;
o Regular farmworkers,
o Seasonal farmworkers:
o Other farmworkers,
o Actual tillers or occupants of public lands;
o Collectives or cooperatives of the above
beneficiaries; and
o Others directly working on the land
o Individual willingness, aptitude and ability to cultivate
and make the land as productive as possible
 Beneficiaries shall be awarded an area not exceeding
three hectares. Beneficiaries may opt for collective
ownership, such as co-ownership, farmer’s
cooperative, or some other form of collective
organization
 Lands acquired by beneficiaries under this Act may not
be sold, transferred or conveyed for period of ten (10)
years (Sec. 27)
 Lands awarded shall be paid for by the beneficiaries in
thirty 100ml amortizations at six percent interest per
annum (Sec. 201
Support services (Sec. 35)
 Infrastructure development and public works projects;
irrigation facilities
 Government subsidies; price support and guarantee for
all agricultural produce
 Financial assistance; credit
 Development of cooperative management skills
through intensive training
 Research, development, and dissemination of
information on agrarian reform and low-cost and
ecologically sound farm inputs and technologies
 Marketing
 Land Acquisition and Distribution (LAD) program
 Agrarian Production Credit Program (APCP)
 Credit Assistance Program for Program Beneficiaries
(CAP-PB)
 Socialized Credit Program (SCP)
 Farm Support Services Program (FSSP)
 Program Beneficiaries Development (PBD)
Comprehensive Agrarian Reform Program Extension
with Reforms
 In 2008, there still remained 1.2 million hectares of
agricultural land waiting to be acquired and distributed
to farmers
 CARPER or CARPer (Republic Act 9700) is the
amendatory law that extends the deadline for
distributing agricultural lands to farmers for five years
 Signed by Gloria Arroyo in 2009 and set to expire in
2014
Salient Provisions and Amendments of RA 9700
It amends other provisions stated in CARL but does
not supersede it. They include:
 Categorical policy against land conversion -
amended Sec 73 (c), RA 6657 (see Sec 24)
Under Prohibited Acts and Omissions, "any conversion
by any landowner of his/her agricultural land into any
non-agricultural use with intent to avoid the application
of this Act to his/her landholdings and to dispossess
his/her bonafide tenant farmers."
 Gender-sensitive Agrarian Reform (Sec 1)
"[...] recognize and enforce, consistent with existing
laws, the rights of rural women to own and control land,
taking into consideration the substantive equality
between men and women as qualified beneficiaries, to
receive a just share of the fruits thereof, and to be
represented in advisory or appropriate decision-making
bodies." Additional funding of Php150,000,000,000.00
for the acquisition and distribution of lands for 5 years
extension (Sec 21)
 Creation of a Congressional Oversight Committee
(Sec 26)
composed of the Chairpersons of the Committee on
Agrarian Reform of the Congress poth Upper and
Lower House); three Members of the House off
Representatives; and three Members of the Senate of
the Philippines
 CARPER as a continuing program (Sec 30)
"[...] any pending case and/or proceeding involving
CARP implementation shall be allowed to proceed to
its finality and be executed even beyond such date."
 Others:
o covered all private and public agricultural lands
o streamlined mode of acquisition and distribution of
lands
o expanded the provision of support services
Agrarian reform outcomes
 In 2016, 4.742 million hectares of land of the total
5.425 million hectares of land marked for CARP were
already distributed to 2.807 million landless farmers
since its inception
 In 2020, the government has given out 4.9 million
hectares of land, distributing 90 percent of its farget
 Productivity in coconut and sugar has fallen drastically,
and poverty incidence among beneficiaries in agrarian-
reform communities is even higher than among farmers
la general (Fabella 2017)
 generating a high degree of environmental stress
 created a new social class: the landed poor
 increasing agrarian distress for farmers with small- and
marginal-sized holdings
Controversies
 "For 26 years, the bogus CARP has been guilty of the
bloodshed and human rights violations against the
Filipino peasants." - Rafael Mariano, KMP
 a total of 664 farmers were victims of agrarian-related
extra-judicial killings (Mariano 2014) - Mendiola
Massacre (1987) and Hacienda Luisita Massacre
(2004)
 more than 120 peasant political prisoners in the
country and counting (SENTRA) with 494,945 agrarian
law implementation cases (KMP) - Mamburao 6
Challenges in the agrarian reform
 Favors organized farmers; regular farm workers are
prioritized while seasonal farm workers are treated as
lesser priority
 Limited budget faced challenges in funding with limited
resources allocated for the program's implementation
 Resistance of landowners - lead to delays and legal
challenges in land acquisition and distribution
 Government's lack of political will and commitment
 while the law may provide farmworkers de jure political
power, the current institutional framework may run
contrary to credible commitments and provide
landowners or the political elite de facto political power
(Acemoglu & Robinson 2006)."
 "despite the enormous power given by the law to the
farmers, there seems to be greater leeway given to the
landowners offered by the institutions in terms of area
cover and compliance. The elite have somehow
maintained their control over the ownership of these
assets (Lanzona 2009)."
Ways forward
 If there is a need to continue the agrarian reform, a
total overhaul of the Program is needed. This may
include but is not limited to
 offer the remaining qualified landless farmers a grant or
a subsidized loan to buy land
 give farmers a choice between owning land or using
the subsidy for other household needs vs. bureaucratic
processes
 Government must create an environment where the
landowner and farmworkers can negotiate and bargain
for each other's rights; enforce and strengthen the rule
of law by improving the justice system
o accelerate the administrative and systematic
adjudication of property rights beginning in areas of
high agricultural potential
o streamlining of titling and registration
o harmonize or unify the various legal framework for
land use and management to reduce overlaps
o a progressive land tax should be enforced
 removal of land monopolies should be a high priority