What, exactly, is the RH Bill intended to accomplish, and how does it improve on the existing conditions of the country? Disagreement with the RH Bill takes two basic forms. The first and most obvious is the moral objection of the Catholic Church. The second is an objection on practical grounds, that the RH Bill, despite its good intentions, is poorly-conceived: it fails to clearly define a problem to be solved and then offer effective solutions to that problem.
Making a judgment about any real or perceived moral hazard from the point of view of the Catholic or any other church is beyond my purview, but I will offer this observation: the RH Bill’s advocates have fallen into a fairly well-designed trap set for them by the Church leadership, and as a consequence are at serious risk of losing the debate in a moral context, if they haven’t already.
Moral positions are intractable and are impossible to change. Rather than demonstrating how the intent and provisions of the RH Bill do not present a moral hazard to Catholic tenets – which it does not – the most vocal of the RH advocates have chosen instead to make the debate one of whether or not the moral position of the Church is right or wrong, which is irrelevant and futile. What the Church thinks of the RH Bill has nothing to do with whether or not the RH Bill is good or bad for the country. To be fair, there are many RH advocates who do respond to the Church’s objection in a rational way, by pointing out that the bill does not force anyone to compromise their personal beliefs; unfortunately, these voices of reason have long been drowned out by “the Church’s teachings are wrong” argument.
A disturbing knock-on effect of the debate taking on moral overtones thanks to the efforts of the Church is that the RH advocacy is now tending to respond to the objections against the bill on practical grounds with the moralistic, straw-man position that “one who is against the RH Bill is against reproductive health.” That rather hysterical approach is perhaps the result of the RH advocacy’s lacking substantial and objective answers to the question presented at the beginning of this article:
What is the RH Bill intended to accomplish, and how does it improve on the existing conditions of the country?
And the reason the advocacy lacks those answers is because they are not actually provided by the proposed legislation. The statement of policy of the RH Bill begins with the eminently noble assertion that:
“The State recognizes and guarantees the exercise of the universal basic human right to reproductive health by all persons, particularly of parents, couples and women, consistent with their religious convictions, cultural beliefs and the demands of responsible parenthood. Toward this end, there shall be no discrimination against any person on grounds such as sex, age, religion, sexual orientation, disabilities, political affiliation and ethnicity.”
That implies that the problem to be addressed by the RH Bill is a lack or deficiency of the protection “of the universal basic human right to reproductive health by all persons”. That begs two further questions:
1. Is there indeed a lack or deficiency in the protection of reproductive health rights, and the provision of adequate services to allow the Filipino people to exercise those rights, and
2. Is the protection of reproductive health rights an end in itself, or is it intended to have some additional positive result for the country?
As I explained in a previous article, the ‘conventional wisdom’ is that over-population and/or a high rate of population growth contributes to increased poverty, but empirical data seems to indicate that this might not necessarily be the case and that the relationship between poverty and population is at the very least more complicated than it first appears. Inconvenient facts notwithstanding, both the RH advocates and at least most of their detractors are willing to accept the basic assumptions that:
- The population is too large for the country’s present capacity to support it,
- The population is growing at too fast a rate, and
- The population is badly-distributed, with over-concentration in urban areas, particularly in and around Metro Manila.
The root problems of the first assumption are ‘excess population’ and ‘insufficient capacity’. Actually reducing the population is not an option any humane person would want to consider, so the only potential solutions are those that address capacity. The second assumption requires a solution that reduces the rate of population growth, and the third calls for a solution to redistribute the population to a state in which the concentration of people in a defined area does not require more resources than that area can sustainably provide.
Of the three assumptions, the third is beyond the scope of the RH Bill; uneven population distribution is a critical problem that needs to be addressed, but issues of reproductive health are if anything coincidental to that problem. However, the RH Bill, particularly considering the effort being put into advocating its passage and the attention it is diverting from other, equally-important objectives, can reasonably be expected to provide positive solutions to the first two problems; and if you ask the RH advocacy, they are quite confident that the bill in fact does provide those positive solutions. This is a confidence that may very well be misplaced.
For starters, the framers of the RH Bill cannot decide whether the bill should address the problem of overpopulation or not. Among the bill’s 15 “Guiding Principles” are these entirely contradictory assertions:
“k. There shall be no demographic or population targets and the mitigation of the population growth rate is incidental to the promotion of reproductive health and sustainable human development;
“m. The limited resources of the country cannot be suffered to be spread so thinly to service a burgeoning multitude that makes the allocations grossly inadequate and effectively meaningless;”
So in effect, the RH Bill specifically eschews any sort of population goal and simply assumes its subsequent provisions for “the promotion of reproductive health and sustainable human development” (the latter term being completely undefined by the bill, and in fact not referred to again anywhere within the bill’s 8,000-plus words) will mitigate the population growth rate. By the same token, the bill also recognizes that the pressure on national resources is at a critical stage, and by saying that they “cannot be suffered to be spread so thinly” acknowledges that the population problem needs to be directly addressed. The bill’s “hope for the best” approach assumes a response by the population that the RH advocacy cannot support with objective evidence, and essentially asks the country to make an investment on faith in its return.
The consolidated current version of the RH Bill comprises 20 legislative provisions in addition to the normal provisions concerning prohibited acts, penalties, implementing rules, funding, and separability. Despite the apparent good intentions of the RH Bill’s authors and its advocates, the scope and intent of many of the provisions are poorly defined, and the bill potentially creates a number of opportunities for mismanagement, either outright corruption or in reducing existing standards of public health management:
LGU’s must employ a pre-determined number of skilled birth attendants: The Local Government Units (LGUs) with the assistance of the Department of Health (DOH), shall employ an adequate number of midwives to achieve a minimum ratio of one (1) fulltime skilled birth attendant for every one hundred fifty (150) deliveries per year, to be based on the annual number of actual deliveries or live births for the past two years.
The established national standard for public health coverage as it relates to “skilled birth attendants” is one midwife per 5,000 population; the national birth rate is 25.68 per 1,000 population, so the existing standard calls for a ratio of one midwife for every 128 annual births. The RH Bill will actually allow LGUs to reduce their staff in some cases. For example, in Cavite there are 334 midwives in the public health service, a ratio of one to each 8,946 population. This has been a matter of some concern to the provincial leadership, since the ratio is far short of the prescribed standard of 1:5,000. The midwife-to-birth ratio, however, is positive; 40,133 births results in a ratio of 1:120, well above the proposed ratio of the RH Bill. Province-wide, Cavite could eliminate 66 midwife positions and still be in compliance with the new standard under the RH Bill – something provincial officials have said they would have no problem considering if necessary to shift funding to meet other requirements of the RH Bill. Certainly, the situation in Cavite is not necessarily the same as in other places in the country, but it does highlight the problem of the blanket prescription of standards represented by the bill.
Provision for emergency and advanced obstetric care: Each province and city will have to provide at least one hospital with comprehensive emergency obstetric care (Level 3 hospital), and four other hospitals or health facilities with basic emergency obstetric care (Level 2 facilities) for every 500,000 population.
The enormity of the investment required to meet this provision of the RH Bill cannot be overstated. Again using Cavite (with a population of approximately 3.3 million) as an example, seven Level 3 and 27 Level 2 facilities would be required; the implication is that these should all be government-run facilities, although that is not clearly explained one way or the other in the text of the RH Bill. At present, the entire province has one Level 4 public hospital (Aguinaldo Memorial in Trece Martires City), and only three Level 2 public hospitals, all in District I (two in Cavite City and one in nearby Kawit).
If private hospitals are included in the census of facilities, then the requirement can be met – public and private hospitals counted together give Cavite 11 facilities of Level 3 or higher and 25 Level 2 facilities. Then the problem becomes a matter of enabling access to these additional, ordinarily pay-as-you-go private facilities for indigent or low-income patients, an issue that the RH Bill in its current form avoids. Either way, the problem is one of funding – either build at least 30 public hospitals in Cavite, or underwrite the costs incurred by some as-yet uncalculated number of births per year at private hospitals. And this is the circumstance of one province (albeit a large one) of 79 across the country. The Php 700 million in funding for the RH Bill approved by the House Appropriations committee so far will not even begin to make a dent in what the initiative will actually cost.
Family planning supplies to be included in the National Drug Formulary and Procurement and distribution to be managed by DOH: These will be included in the regular purchasing by all government health units. Supply and budget levels will be based on current data and projections of the following (among other things):
a) number of women of reproductive age and couples who want to space or limit their children;
b) contraceptive prevalence rate, by type of method used; and
c) Cost of family planning supplies.
In an AP article last week entitled “Revisiting the RH Bill: A Trojan Horse for Increased Wasteful Public Spending?” BongV pointed out some of the obvious potential pitfalls of placing another program into the government procurement basket. While the RH advocacy might bristle at being accused of enabling ‘irregularity’ in government procurement, the blame for inspiring that suspicion falls squarely on the bill’s authors. No details are provided on how “current data” and “projections” of the specified factors are to be gathered and audited, not to mention what “other things” may be included in the determination of supply and budget levels. Here again, the RH advocacy is asking the Filipino taxpayer to take it on faith that his investment will be productively used – an assumption for which there is very little positive precedent in the country’s recent history.
The State will encourage an ideal family size of two children: However, this will not be compulsory, nor will any penalties be imposed on those having more than two children.
On the one hand, this makes some sense; how the “ideal family size” was determined to be two children is not explained, but the figure is below the fertility rate so it is a step in the right direction in terms of slowing the population growth rate. However, making the “ideal” completely optional seems pointless; there is no incentive presented to encourage couples to limit their number of children to two, and as a matter of fact, if the State’s “encouragement” is truly effective, some couples who would have otherwise had only one child or none at all might feel somehow obliged to have more. True, it’s mostly a semantic argument – but when it comes to a bill that proponents intend should be a law of the land, fuzzy language is not only sloppy, it risks unintended consequences.
Responsibilities of employers: Consistent with the intent of Article 134 of the Labor Code, employers with more than 200 employees shall provide reproductive health services to all employees in their own respective health facilities. Those with less than 200 workers shall enter into partnerships with hospitals, health facilities, and/or health professionals in their areas for the delivery of reproductive health services.
This is what Article 134 of the Labor Code says:
ARTICLE 134. Family planning services; incentives for family planning. – (a) Establishments which are required by law to maintain a clinic or infirmary shall provide free family planning services to their employees which shall include, but not be limited to, the application or use of contraceptive pills and intrauterine devices.
(b) In coordination with other agencies of the government engaged in the promotion of family planning, the Department of Labor and Employment shall develop and prescribe incentive bonus schemes to encourage family planning among female workers in any establishment or enterprise.
Rather than enact a redundant law, perhaps the RH advocacy could direct some effort to enforcing the existing part of the Labor Code that has the exact same intent as their bill.
Is there any good in the RH Bill? Indeed there is. Among the bill’s provisions are the stipulations that “all accredited hospitals shall provide a full range of modern family planning methods” (although specialized facilities are exempted from this requirement), that each LGU and the various crisis response agencies prepare sufficient resources in a “Minimum Initial Service Package” to address obstetric, maternal, and reproductive health matters during times of crisis, that family planning be integrated into other anti-poverty programs, that private health care practitioners provide a minimum required amount of “pro bono” reproductive health care services, and that reproductive health and sexuality education be made a formal, mandatory part of the education curriculum. What is most unfortunate is that these relatively sensible ideas are tossed into the same legislative basket as so many questionable ones; because of the enormous expense and potential for harm represented by the rest of the RH Bill, it must fail, and with it these good ideas. Perhaps that is just as well: If the RH Bill does pass, one could rightly wonder how much attention and funding can be given to the parts of the bill that do have some promise.
Access to adequate and appropriate reproductive health care – and for that matter, all forms of health care – is a noble end in itself, because it is a basic human right; the State has a duty to ensure that care is provided to all citizens. Poverty alleviation is a noble end as well, and it can be considered a human right that all citizens of the State have a fair opportunity to prosper; along those lines, population management is relevant, since too many people competing for a shrinking amount of resources tends to work against any notion of prosperity. The RH Bill in its present form does not accomplish any of those things, and in fact presents very real risks that some of the problems of inequitable access to health care and irregularity in the delivery of government services will be seriously aggravated.
Dropping the RH Bill certainly won’t solve any of the country’s problems, either, but at least that would put a stop to the politicized, moral debate that has virtually crippled the current initiative – clearing the stage, so to speak, to give all concerned a chance to regain the plot. The country needs an improved public health system, the country needs to develop a culture in which reproductive health issues are handled intelligently as a matter of informed choice, and the country needs to improve the economic lot of the population it already has, as well as those who will be added to the population in the future. By attempting to rush the RH Bill through the Legislature and trying to convince themselves and the rest of the country through the sheer volume of their strident wishes that they are actually achieving those goals, about the only thing the RH advocacy is accomplishing is wasting everyone’s time. Stopping the RH Bill now will at least limit the cost to that alone, and save the hard resources for something a little more practical and effective.