The Healthcare System in The Philippines: Hilippines Pecial Eport

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PHILIPPINES SPECIAL REPORT

Date: December 2001
The Healthcare System in the Philippines

Overview................................ ................................ ................................ .......................... 1 Age Distribution & Life Expectancy.................................................................................... 2 Mortality Rates ................................................................................................................ 4 Causes of Death ................................ ................................ ................................ .............. 4 Nutritional Intake................................ ................................ ................................ .............. 6 Access to Medical Facilities ............................................................................................. 7 Related Industries ............................................................................................................ 8 Healthcare Expenditure..................................................................................................... 8 The High Price of Medicines................................ ................................ ............................ 10 Appendix 1: Health Agencies and Associations in the Philippines ....................................... 11 Appendix 2: Priority Programs of the Department of Health ................................ ................ 12 Appendix 3: Major HealthCare Indicators .......................................................................... 13
Overview Despite the presence of a few modern medical establishments in Metro Manila, health conditions in the Philippines remain among the poorest in East Asia. The figures speak for themselves. There are an estimated 76.5 million Filipinos today, 40 percent of whom are struggling against poverty.
Number of Persons per Physician (ADB Statistics 1999) 12000 10000 8000 6000 4000 2000 0 China
Hong Kong
December 01
Philippines
Singapore
Cambodia
Viet Nam
Thailand
Indonesia
Malaysia
Korea
Myanmar
Taiwan
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The Asian Development Bank (ADB) has estimated that there is only one doctor for every 9,689 Filipinos and one hospital bed in 909 Filipinos. Other Asian countries that are widely believed to be less developed than the Philippines and including Indonesia, Vietnam and Myanmar are way ahead of the Philippines in terms of health indicators. The Philippines ratio of one doctor per 9,689 persons is only slightly better than Cambodias one doctor per 9,997 but poorer than Indonesias one doctor per 6,195; Thailands 3,670; Myanmars 3,291; Vietnams 2,122; Malaysias 1,465; Taiwans 749; Singapores 731; Koreas 710; Hong Kongs 689; and Chinas 500. In 1998, the Asian Development Bank (ADB) said there were 909 Filipinos per hospital bed in the country, lower than Indonesias 1,429 people per bed or Myanmars 1,603, but higher than Thailands or Malaysias 500, Cambodias 476, Vietnams 391, Chinas 345, Singapores 278, Hong Kongs 215, Koreas 208, or Taiwans 179. The health conditions in the Philippines would have improved a lot, had all Filipino doctors opted to stay in the country. Many Filipino physicians, nurses and medical personnel opted to go to the US, Europe and the Middle East where they could earn ten times as much as their salaries in the Philippines, leaving only a few doctors attending to the needs of the large population in the country. This in part explains the h igh cost of medication in the country, forcing some Filipinos to consult faith healers, witch doctors or self-declared physicians who charge less. Others treat themselves with herbal medicine.
Number of Persons Per Hospital Bed (ADB Statistics, 1998) 1800 1600 1400 1200 1000 800 600 400 200 0
Hong Kong
Philippines
Cambodia
Indonesia
Singapore
Thailand
Myanmar
Selected Asian Countries
With a low budget allocation for health and social services, the Philippine government has to confront perennial problems such as the outbreak of dengue fever, cholera and water-borne diseases every year. Limited access to potable water and sanitation among the poor aggravate the problem. Unplanned urbanization and industrialization are also contributory factors to the adverse health conditions. No Philippine city has a modern sewerage system. Age Distribution & Life Expectancy The Philippine population is relatively young. Of the 76.5 million Filipinos, about 43 percent or 32.9 million are aged 17 years old and younger. Some 10.1 million children, accounting for 13.8 percent of the population are aged four years old and younger; 9.3 million or 12.7 percent are five to nine years old; 8.5 million or 11.6 percent are ten to 14 years old; and 4.9 million or 6.7 percent are 15 to 17 years old. The average Filipino male has a life expectancy at birth of 66.6 years, while the Filipino female has 71.8 years. Crude birth rate is about 2.6 percent of the population while crude death rate is 0.58 percent. The population is growing between 2 and 2.3 percent annually. In 1996, the National Statistics Office (NSO) reported that about 1.6 million infants were born in the Philippines, while some 344,000 Filipinos or 0.5 percent of the population died. Over half a million marriages were also recorded during the period.
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Viet Nam
Korea
Malaysia
Taiwan
China
Live Births and Deaths in the Philippines, 1970-1996 Live Births 1,800,000 1,600,000 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996
Rate of Births and Deaths in the Philippines, 1970-1996 Births 3.5 3 (In Percent) 2.5 2 1.5 1 0.5 0 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996
Mortality by Age Group and Sex, 1996 Male 35,000 30,000 25,000 20,000 15,000 10,000 5,000 Under 1 year 0 85 and over 15 - 19 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 11 - 14. 80 - 84 1 - 4. 5 - 9. Female Age Group
Deaths
Deaths
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Mortality Rates In terms of mortality rate, the age group of 85 years old and above accounted for 9.2 percent of all deaths in 1996. It was followed by the age group one year old and less, with 8.9 percent; 80 to 84, 8.2 percent; 75 to 79, 8.0 percent; 70 to 74, 8.0 percent; 65 to 69, 7.6 percent; 60 to 63, 7.3 percent; 5 to 59, 6.1 percent; and 50 to 54, 5.2 percent. The age group with the lowest mortality 5 rate of 1.5 percent was 11 to 15 years olds. While gross infant mortality rates dropped by 40 percent between 1970 and 1993, the figure for the Philippines is lower than the regional average. Across Asia the decline in mortality rate during this period averaged 55 percent. In 1997, mortality rate among infants was 17 per 1,000 live births. Maternal mortality rate was 0.9 per 1,000 live births. The Department of Health recorded 1,557 maternal deaths, 30,550 infant deaths and 9,693 fetal deaths in 1996. The ten leading causes of infant deaths were respiratory conditions of the fetus and newborn, pneumonias, congenital anomalies, diarrhea diseases, birth injury and difficult labor, septicemia, measles, meningitis, other diseases of respiratory system and avitaminoses and other nutritional deficiency. About 28 percent of Filipino children aged five years old and below are severely or moderately underweight based on international standards while 49 percent of Filipino infants and 26 percent of children aged one to six years old have anemia. Primary complex of tuberculosis is prevalent among infants and young children. As industries have replaced traditional agricultural pursuits in many provinces, the lifestyle of the Filipinos has also changed. As a result, hypertension and heart disease, which are the leading causes of death in industrialized countries, so it is in the Philippines too. Causes of Death Among the causes of death, diseases of the heart topped the list, claiming the lives of 53,865 people out of 61,139 cases in 1996. About 33,319 people died out of 679,172 cases of pneumonia. Out of 165,453 victims of tuberculosis, some 27,368 people died. In terms of prevalence, diarrhea topped the list of notifiable diseases, with 997,914 cases, leading to 4,979 deaths. Other prevalent diseases were influenza, with 560,168 cases; and bronchitis, 602,708.
Causes of Mortality, 1997 (Per 100,000) Causes 1. Diseases of the Heart 2. Diseases of the Vascular System 3. Pneumonia 4. Accidents 5. Malignant Neoplasm 6. Tuberculosis, All Forms 7. Chronic Obstructive Pulmonary Diseases and Allied Condition 8. Other Diseases of the Respiratory System 9. Diabetes Mellitus 10. Nephritis, Nephritic Syndrome and Nephrosis Source: Philippine Health Statistics 1997 Number 49,962 38,693 30,811 28,563 26,842 23,056 11,807 6,961 6,749 6,704 Rate 69.8 54.1 43.1 39.9 37.5 32.2 16.5 9.7 9.4 9.4
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In 1997, the Philippine Health Statistics data showed that diseases of the heart claimed the lives of 69.8 persons out of every 100,000 people in the Philippines; diseases of the vascular system, 54.1; pneumonia, 43.1; accidents, 39.9; malignant neoplasm, 37.5; tuberculosis, 32.2; chronic obstructive pulmonary diseases and allied condition, 16.5; other diseases of the respiratory system, 9.7; diabetes mellitus, 9.4; nephritis, nephritic syndrome and nephrosis, 9.4.
Ten Leading Causes of Morbidity (Per 100,000) Cause 1. Diarrheas 2. Bronchitis/Bronchiolitis 3. Pneumonias 4. Influenza 5. Hypertension 6. T.B. Respiratory 7. Malaria 8. Diseases of the Heart 9. Ch ickenpox 10. Typhoid and Paratyphoid Fever Number 908,454 717,214 693,334 514,198 208,248 144,932 68,155 63,167 35,699 17,675 Rate 1189.9 939.4 908.1 673.5 272.8 189.8 89.3 82.7 46.8 23.1
Source: Philippine Health Statistics 1999
In terms of morbidity, the leading cause was diarrhea, 908,454 cases of which were reported in 1999. The Philippine Health Statistics data showed that there were 1,189.9 cases of diarrhea in every 100,000 persons. This was followed by bronchitis/bronchiolitis, which was responsible for 717,214 cases or 939.4 out of every 100,000 persons during the same period. Other leading causes of morbidity were pneumonia, which led to 908.1 cases of every 100,000 persons; influenza, 673.5; hypertension, 272.8; tuberculosis, 189.8; malaria, 89.3; diseases of the heart, 82.7; chickenpox, 46.8; and typhoid and paratyphoid fever, 23.1.
Diseases and Deaths by Cause, 1996 Cases Diseases of the Heart Pneumonia Malignant Neoplasms Tuberculosis Diarrhea Measles H-Fever Infectious Hepatitis Typhoid & Paratyphoid fever Tetanus Malaria Influenza Schistosomiasis Bronchitis Cholera December 01 61,139 679,172 2,715 165,453 997,914 35,390 15,571 6,686 12,817 1,197 68,056 560,168 9,069 602,708 710 Deaths 53,865 33,319 30,339 27,368 4,979 1,376 1,376 1,084 1,052 758 536 340 267 218 157 Page 5
Leprosy Varicella Acute Poliomyelitis Diphtheria AIDS Syphilis Whooping Cough Filariasis Gonococcal Infections
1,788 34,344 8 108 22 271 2,554 401 2,443
96 78 43 29 19 10 9 6 1
Source: Department of Health
Nutritional Intake Although most Filipinos can be considered poor, they can become extravagant in terms of food, come fiesta or Christmas season. Here, they take respite from the tiring days of work and put their attention on food like roasted suckling pig. Filipinos are not known for watching their diet, and only the high price of meat prevents them from partaking of meat regularly. Come ordinary days, the average Filipino familys diet includes rice, fresh or dried fish and vegetables. Among middle income Filipinos , obesity is growing. In a detailed report issued in 1993, the Department of Health said the average per capita food and nutrient consumption in the Philippines involved the following:
Daily Per Capita Food Consumption, 1993 In Grams (Raw) Cereals and cereal products Starchy roots and tubes Sugars and syrups Fats and oils Fish, meat and poultry Eggs Milk and milk products Dried beans, nuts and seeds Vegetables Fruits Miscellaneous 340.0 17.0 19.0 12.0 47.0 12.0 44.0 10.0 106.0 77.0 19.0
Source: Food and Nutrition Research Institute
For a more complete summary of the Philippines Food Balance Sheet you can download the latest available statistical data in graph and spreadsheet form from the Virtual-asia.com website at: http://www.virtual-asia.com/ph/bizpak/statistics/food.htm
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Mean Daily Per Capita Nutrient Intake Nutrient Energy (kcal) Protein (g) Iron (mg) Calcium (g) Thiamine (mg) Riboflavin (mg) Niacin (mg) Ascorbic Acid (mg) Fat (g) Carbohydrates (g) Retinol Equivalent (mcg) 1993 1,684.0 49.9 10.1 0.4 0.7 0.6 16.1 46.7 28.0 302.0 391.9
Source: Food and Nutrition Research Institute
Access to Medical Facilities About 92 percent of Filipinos in urban areas and 80 percent in rural areas have access to potable water while 92 percent in urban areas and 71 percent in rural areas have sanitation facilities at home. The Department of Health reported that the country had 1,794 hospitals with 83,491 beds nationwide in 1999. Only 648 or 36 percent of these hospitals are government-owned while the remaining 1,146 hospitals or 64 percent are privately owned. For every 10,000 Filipinos, there were only 11.2 hospital beds. Apart from hospitals though, there were other medical establishments in the country. The Department of Health said that in 1998, there were about 2,405 rural health units and 14,267 barangay health stations in the whole country. There are over 42,000 barangays or villages in the Philippines. Doctors and nurses would visit these rural health units while midwives or nurses would visit the barangay health units at least once a week. The government health department had in its payroll some 2,848 doctors, 1,713 dentists, 4,389 nurses, and 14,962 midwives as of 1998.
Number of Hospitals in the Philippines Government 2,000 1,800 1,600 1,400 1,200 1,000 800 600 400 200 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Private
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Health Facilities and Worke rs Item Hospitals Government Private Government Health Manpower Doctors Dentists Nurses Mid wives Barangay Health Stations Rural Health Units 2,029 1,071 2,694 10,898 11,646 2,335 3,119 1,668 5,653 13,750 17,090 2,856 2,582 1,370 4,096 13,275 13,096 2,405 2,848 1,713 4,389 14,962 14,267 ... 1995 1,700 589 1,111 1996 1,738 600 1,138 1997 1,817 645 1,172 1998 1,713 616 1,097
Source: National Statistics Office
Related Industries The Philippines had 12,218 establishments involved in food and drug production in 1999. Most of these establishments were involved in food production - numbering about 10,914. The Bureau of Food and Drug Administration reported that year that there were 239 drugs manufacturers in the country, 146 of which were in Metro M anila, the nations capital. There were also 197 cosmetic manufacturers, 41 medical device manufacturers, 414 drug traders, 117 cosmetic traders, 10 medical device traders and 296 traders of household/hazardous substances.
Number of Establishments in Food and Drug Production, 1999 Classification Drug Manufacturer Cosmetic Manufacturer Medical Device Manufacturer Drug Trader Cosmetic Trader Medical Device Trader Household/Hazardous Substances Food Establishments All Establishments Metro Manila Outside MM 146 125 21 362 109 10 192 2099 3064 93 72 20 52 8 0 104 8805 9154 Philippines 239 197 41 414 117 10 296 10904 12218
Source: Bureau of Food and Drug Administration
Healthcare Expenditure Healthcare spending constituted 3.4 percent of the gross national product (GNP) in 1999, below the 5 percent standard set by the World Health Organization (WHO) for developing countries. While there exists a national health insurance program, pension funds and private insurance plans, personal expenses still account for about 57 percent of all health expenditures. Total annual health expenditure in the Philippines amounted to P108.3 billion in 1999 from P35.9 billion in 1991, growing at an annual rate of 6.4 percent at constant 1985 prices. In 1999, the per
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capita health expenditure was estimated at P1, 449. Of this figure, the government contributed P549 or 38 percent; social insurance, P70 or 5 percent; and private individuals, P829 or 57 percent. The governments goal is to increase the share in expenses of social insurance from 5 percent of the total health expenditures to 30 percent. At present, the social insurance is the responsibility of the Philippine Health Insurance Corporation (PhilHealth). PhilHealth was created to assume the administration of the former Medicare program from the Government Service Insurance System (GSIS), the pension fund for government workers and the Social Security System (SSS), the pension fund for private employees. The transfer of the health insurance funds, amounting to only a little over P14 billion from the two state pension funds to PhilHealth began only in 1998. All Filipino citizens, whether self-employed, employed or indigent are required to become members of PhilHealth. Under the program, members are to make regular contributions before they can avail of the benefits or reimbursement of expenses for medical services. This is done through automatic salary deductions or direct payments to PhilHealth. The average monthly deduction on salaries for Philhealth contribution is P100, although those who are self-employed can pay the amount quarterly, semi-annually or annually. Overseas Filipino Workers (OFWs) who have registered with PhilHealth have to shell out premium contributions amounting to P225 per quarter. The following is a more detailed list of monthly contributions to PhilHealth.
Monthly Contribution to PhilHealth (In Pesos) Monthly Salary Range Salary Base From Below 3,500.00 4,000.00 4,500.00 5,000.00 5,500.00 6,000.00 6,500.00 7,000.00 7,500.00 To 3,499.99 3,999.99 4,499.99 4,999.99 5,499.99 5,999.99 6,499.99 6,999.99 7,499.99 Up 3,000.00 3,500.00 4,000.00 4,500.00 5,000.00 5,500.00 6,000.00 6,500.00 7,000.00 7,500.00 Monthly Employer Employee Contribution Share Share 75 87.5 100 112.5 125 137.5 150 162.5 175 187.5 37.5 43.75 50 56.25 62.5 68.75 75 81.25 87.5 93.75 37.5 43.75 50 56.25 62.5 68.75 75 81.25 87.5 93.75
Aside from the PhilHealth, Filipinos have the choice to become members of life insurance companies. However, the Insurance Commission (IC), the country's regulatory body for life and nonlife insurance companies, said only 13.5 percent of the 76.5 million Filipinos had insurance coverage in 2000, way below its target of 20 percent. Also in 2000, premium income in the life sector amounted to P25.56 billion, according to the Philippine Life Insurance Association (PLIA). Total insured assets reached P1.016 trillion; admitted assets, P144.62 billion; cash and investment assets, P137.78 billion; legal reserves, P67 billion; and net worth, P50.55 billion. The number of licensed insurance agents was placed at 29,223 while the number of employees was put at 6,862. Foreign companies dominated the life insurance market, with the top three foreign insurers accounting for more than 55 percent of the P25.56 billion premium. As of December last year, there were 42 foreign and local insurance companies in the life sector.
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In general, health conditions in the Philippines call for improvement. While the public health system was decentralized to local governments, this only led to inequitable distribution of health services. Poor municipalities could hardly deliver health services as efficiently as urban cities do. It must be noted that the national government is showing efforts to make efficient health services available to as many Filipinos. The Department of Health in coordination with the Department of Trade and Industry has been importing much cheaper medicine from India, in an attempt to lower the prices of locally manufactured medicines. The High Price of Medicines According to the Department of Health (DoH), the prices of medicine in the Philippines are among the highest in the region. The Health Department claims in its statements that medicine sold by multinational pharmaceutical firms are highly overpriced, some of which are selling at fives times their price in India. The Pharmaceutical and Healthcare Association of the Philippines (PHAP), however denies this and wants the health department to stop its generic drug importation program. At present, the Department of Health imports the following drugs from India: Adalat Retard or Nifedine 20 mg tablet, P5.74 (savings of P28.40); Tenormin (Atenolol) 50 mg tablet, P9.05 (savings of P9.65); Ventolin (Salbutamol) 100 mcg inhaler, P197.60 (savings of P97.15); Becoride or Bectomethasone 250 mcg inhaler, P532.50 (savings of P298.50); Bactrim DS or Cotrimoxazole 800 mg/160 mg tablet, P5.10 (savings of P18.90); Bactrim adult 400 mg/80 mg tablet, P2.80 (savings of P10.70); Septran or Cotrimoxazole 200 mg/40 mg, 50 ml suspension, P67.60 (savings of P15.10); and Daonil or Glibenclamide 5 mg tablet, P3.10 or a saving of P4.65 per tablet.
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Appendix 1: Health Agencie s and Associations in the Philippines The following is a list of the main agencies involved in the delivery of health care and related services in the Philippines: Department of Health San Lazaro Compound, Rizal Ave. Ext. cor. Tayman, Sta Cruz, Manila, NCR Tel: 743-8301~23 / 781-7086 / 742-3945 Website: http://www.doh.gov.ph Insurance Commission Insurance Commission Bldg., 1071 United Nations Ave., 1004, Manila Tel: 525-2015 / 524-4784 Fax: 522-1434 Philippine Medical Association Secretariat, PMA Bldg., North Ave., Quezon City P.O. 4039, Manila, Philippines Tel: 929-3514 / 929-6951 / 928-2132 / 929-6366 / 929-7361 / 926-2447 Fax: 929-4974 Website: http://www.pmasite.org.ph Pharmaceutical and Healthcare Association of the Philippines (PHAP) Unite 502, One Corporate Plaza Condominium, 845 Pasay Road, Makati City P.O. Box 2248 MCPO, 1299, Makati Tel: 815-0325 / 816-7334 / 816-0618 / 816-7373 Fax: 819-2702 Philippine Life Insurance Association (PLIA) Suite 54, 5th Fl, Legaspi Suites, 178 Salcedo St., Legazpi Village, Makati City Tel: 893-0311 Fax: 812-1552 Website: http://wwwplia.com.ph
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Appendix 2: Priority Programs of the Department of Health Expanded Program on Immunization against killer diseases in childhood such as measles, polio, tuberculosis, diphtheria and tetanus. The targets of this program are areas in the country where children have not been immunized. When infected, the children can infect others resulting in possible epidemic breakouts. National Family Planni ng Program focuses on family welfare and health, through education and choice; it aims to provide basic family planning services and information. Prevention and Control of Cardiovascular Diseases and Cancer is the government's response to the increasing incidence of hypertension and its complications; and cancer of the lungs, breast, liver, cervix and stomach. The program aims to provide basic knowledge and skills on the prevention and detection of these diseases. Environmental Health Program addresses health problems related to air, water, and soil pollution. Hospitals as Centers of Wellness seeks to make the hospital a place where programs for the prevention of diseases are also being implemented. It seeks to make basic health services, family counseling and health education available in the hospital setting. Control of Tuberculosis and Other Communicable Diseases remains to be a major program of the government. Tuberculosis, schistosomiasis and malaria are still common causes of sickness and death in the country. National AIDS Program answers the problem of increasing number of PWAs or persons with Acquired Immune Deficiency Syndrome (AIDS). Tests to detect infection in high-risk groups are made available. Public Health Education is also undertaken. Herbal and Philippine Traditional Medicine promotes the use of herbal medicine and traditional healing practices. Backyard gardening, community projects ad putting up of herbal plants are among the major activities under this program. National Drug Policy Progra m seeks to make essential drugs available, affordable and accessible to the people. It also actively supports the development of the local drug industry. Nutrition Program addresses the problem of malnutrition among mothers and children. It focuses on deficiencies in iron, iodine and vitamin A. Health stations serve as distribution centers where the micronutrients can be given. Safe Water and Sanitation are major thrusts of the government because diseases due to poor environmental sanitation still abound. Among the activities under this program are the construction of community-made toilets and provision of safe water. Araw ng Sangkap Pinoy The program aims to help end hidden hunger or micronutrient malnutrition problem particularly Vitamin A deficiency, iron deficiency anemia and iron deficiency disorders. Three-pronged strategy includes: micronutrient supplementation, education on proper dietary practices and eating habits and food fortification.
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Appendix 3: Major HealthCare Indicators
Health Indicators, Philippines Male Female Total Population Life Expectancy at Birth, 2001 Male Female Contraceptive Prevalence Rate Total Fertility Rate Crude Birth Rate Crude Death Rate Infant Mortality Rate, 1997 Number Rate (per 1000 live births) Maternal Mortality Rate, 1997 Number Rate (per 1000 live births) Health Expenditure 1999, In Billion Pesos Percent to GNP Per Capita Health Expenditure 1999, In Pesos Government Allocation Social Insurance Private Spending Insurance Coverage - Population 2000, (%) Persons Per Hospital Bed, 1998 Persons Per Physician, 1999 Per Capita energy intake (in kilocalories) Moderately and severely underweight (%) Pre-school children Schoolchildren Percent of underweight adults 6.4 5.3 8.3 1,521 0.9 108.3 3.4 1,449 549 70 829 13.5 909 9,689 1,956 28,061 17 66.63 71.88 42.3 3.6 2.62 0.58 38,681,843 38,137,354 76,819,197
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Prevalence of Anemia Infants Pre-school Elderly Pregnant Women Lactating Mother Vitamin A deficiency among preschool children Prevalence of Iodine Deficiency/Goiter Access to Safe Water, In Percent Urban Rural Access to Sanitation, In Percent Urban Rural Estimates Based on Department of Health Survey, 1995 and ADB Statistics, 1998 92 71 92 80 43.6 23.5 40.4 38.6 38.1 0.05 3
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PHILIPPINES SPECIAL REPORT

PHILIPPINES SPECIAL REPORT