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IN PHILIPPINE SETTING:
A CRITIQUE ON CAMBRIS POSITION PAPER OPPOSING HOUSE BILL 5347,
DISCUSSION OF PHILIPPINE HEALTH INSURANCE COVERAGE AND OTHER
COMMENTS AFFECTING MENTAL HEALTH
Authored by
Naomi Therese F. Corpuz
TABLE OF CONTENTS
To this day, the Philippines is one of the remaining "30%" States which
still have no mental health law.1 This is why until now, patients can languish in
psychiatric hospitals because there are no rules nor oversight mechanisms to
review their cases.2 By recognition of these facts, a House Bill known as HB
5347 was drafted through the sponsorship of legislators such as Rep. Leni
** Cite as Naomi Therese F. Corpuz, LAWS AFFECTING MENTAL HEALTH IN PHILIPPINE
SETTING: A critique on Cambris Position Paper Opposing House Bill 5347, Discussion of
Philippine Health Insurance Coverage And Other Comments Affecting Mental Health.
**** J.D., University of the Philippines College of Law (2015); A.B. Psychology, cum laude,
University of the Philippines (2013).
1 Interview with Dr. June Pagaduan-Lopez, practicing psychiatrist at Cardinal Santos Medical
Center, March 23, 2016.
2 Supra.
2
Robredo and Sen. Pia Cayetano during the Sixth Congress of 2015. The
drafted law in HB 5347 is entitled, The Philippine Mental Health Act of 2015. 3
Although this bill was made, it has received criticisms such that it is allegedly
non-compliant with International Human Rights Conventions. The question is,
Are International Human Rights Conventions absolute? For if they are not
absolute, HB 5347 does not need to comply to these International Conventions
especially if such Conventions have loopholes and have received criticisms
themselves.
3 Interview with Dr. Eduardo Tolentino, Past President of Philippine Psychiatric Association
To reiterate the last sentence which states, The Philippines signed, adopted
and/or acceded to all these treties, is misleading for it is non sequitur that the
Philippines will absolutely without exceptions will accede to all these treaties.
Cambri tends to forget that there are Philippine Jurisprudence where the
Supreme Court provides, among others, Lim v. Executive Secretary6 which
states:
From the perspective of public international law, a treaty is favored over
a municipal law pursuant to the principle of pacta sunt servanda.
Hence, [e]very treay in force is binding upon the parties to it and must
be performed by them in good faith. Further, a party to a treaty is not
allowed to invoke the provisions of its internal law as justification of its
failure to perform a treaty.
Our Constitution espouses the opposing view.
jurisdiction as stated in section 5 of Article VIII:
Witness our
xxx
xxx
This means that if a mentally ill person will hurt himself or others due to
his condition, the State has the power to restrict his liberty - that is for the
interest of the general welfare.
Cambri further criticizes mental health bills in her position paper which
she describes to even manipulate the laws to justify forced treatments during
psychiatric emergency which they define as:
Psychiatric emergencies are conditions which may present a serious
threat to the persons wellbeing and/or that of others requiring
immediate psychiatric interventions such as in cases of attempted
suicide, acute intoxication, severe depression, acute psychosis, or
violent behavior.
10 Melvyn Colyn Freeman et.al., Reversing hard won victories in the name of human rights: a
critique of the General Comment on Article 12 of the UN Convention on the Rights of Persons
with Disabilities (Lancet Psychiatry 2015 Journal), Published Online on July 6, 2015.
Available at http://dx.doi.org/10.1016/ S2215-0366(15)00218-7 (Last visited: March 23,
2016).
Our own law in special proceedings for instance, particularly Rule 101 of
the Rules of Court establishes the procedure for having a person allegedly
insane committed to an institution.11 Cambri, however, cites Rule 101 of the
Rules of Court entitled Proceedings for Hospitalization of Insane Persons that
allows for involuntary institutionalization as non-compliant with Articles 12
and 14 of the UNCRPD12 but she did not discuss the contents and substance of
such Rule.
Under Rule 101 a petition for the commitment of a person to a hospital
or other place for the insane may be filed with the Court of First Instance (now
Regional Trial Court) of the province where the person alleged to be insane is
found.13 The petition shall be filed by the Director of Health (now Secretary of
Health) in all cases where, in his opinion, such commitment is for the public
11 Antonio Bautista, BASIC SPECIAL PROCEEDINGS (2004).
12 Cambri, Supra Npte 5
13 RULES OF COURT, Rule 101, Sec. 1.
7
welfare, or for the welfare of said person who, in his judgment, is insane
and such person or the one having charge of him is opposed to his being taken
to a hospital or other place for the insane. 14 Upon satisfactory proof, in open
court on the date fixed in the order, that the commitment applied for is for the
public welfare or for the welfare of the insane person, and that his
relatives are unable for any reason to take proper custody and care of
him, the court shall order his commitment to such hospital or other
place for the insane as may be recommended by the Director of Health. 15
When the lawmakers crafted this law, they reiterated in the provision that
institution of the insane individual is for the common welfare and for the
welfare of said person, and not violate the latters right in any manner. More
importantly it is the exercise of the police power of the State to protect the
person from harming himself and others. Cambri must know that no matter
how numerous her citations are in her position paper criticizing national laws
that restrict liberty of the insane, supported, among others, by Interim Report
of the Special Rapporteur on torture and other cruel, inhuman, inhuman or
degrading treatment or punishment (2008) and Report of the Special Rapporteur
on torture and other cruel, inhuman or degrading treatment or punishment (2013)
of the UN General Assembly, such reports can never supersede the police
power of the State.
Police power cannot be contested according to
jurisprudence. The case of Lao H. Inchong vs. Jaime Hernandez et al.,16
emphasized that police power may not be curtailed or surrendered by any
treaty or any other conventional agreement.
The CRPD says that the existence of a disability shall in no case justify
a deprivation of liberty. Freeman and colleagues 17 say that this is an
important principle that deserves support, particularly as mental disability has
historically been used as justification to remove people from their communities
and restrict them to institutions. They explain:
However, application of an absolute rule of not admitting a
person because of mental disability could in some circumstances
result in the long-term deprivation of libertypossibly in a prison
rather than a potentially much short(er)-term deprivation in a
14 Id.
15 Id., Rule 101, Sec. 3.
16 101 Phil.,1155 (1957)
17 Freeman, Supra Note 10
8
11
the exercise of full agency to the point of self-harm or the right to veto
necessary decisions when periculam in mora.
Several States Parties also submitted statements in support of
substituted
decision-making
in
limited
circumstances
for
consideration by the Committee in finalising the General Comment,
including Norway, Germany, Denmark, and France. Norways
statement reflected back to the interpretive declarations made by the
country at the time of ratification, reserving the right to withdraw legal
capacity and allow for compulsory care or treatment in limited
circumstances. Speaking of their initial declarations, Norway stated:
The existence of several declarations similar to the Norwegian
declarations, the state reports submitted to the Committee and recent
national legislation intended to implement the Convention, indicate a
general understanding among the States Parties that the Convention
allows for substitute decision-making, provided that such provisions
meet certain criteria and are subject to legal safeguards.
Germany reported in its statement, It seems therefore that the
Committees interpretation is not shared by the State Parties in
general; not even by a substantial minority.
Germany continued, While sharing the view that the provision of
support for persons with disabilities is the best possible way to help
them exercise their rights, Germany remains convinced that there are
situations in which persons with disabilities simply are not able to
make decisions even with the best support available. Therefore, while
representing a shift in focus from substitute decision-making to
supported decision- making, the Convention could not and in
Germanys view does not rule out the possibility of substitute decisionmaking in some cases.
14
http://science.education.nih.gov/supplements/nih5/mental/guide/info-mental-b.htm (Last
visited: November 26, 2012).
30Id.
31Id.
32Id.
33Id.
34Id.
15
factors,35 such factors that can be attributed to mental disorders. Dr. Jercyl
Leilani Demeterio says that mental disorders are as debilitating as any form of
illness affecting the persons ordinary daily activities, even relationships and
even results to, if not correlated with, physical illnesses such as heart diseases,
thyroidism, stroke, cancer and many others.36
Psychopharmacology on the other hand only proves further that mental
disorders have a connection with the brain. Psychopharmacology is the
scientific study of the actions of drugs and their effects on mood, sensation,
thinking, and behavior; this field studies a wide range of substances with
various types of psychoactive properties, focusing primarily on the chemical
interactions with the brain. 37 It is also defined as, the study of drug-induced
changes in mood, thinking, and behavior. These drugs may originate from
natural sources such as plants and animals, or from artificial sources such as
chemical syntheses in the laboratory. These drugs interact with particular
target sites or receptors found in the nervous system to induce widespread
changes in physiological or psychological functions.38
However, as aptly explained by Dr. Jercyl Leilani Demetetrio 39, it is a sad
state that despite studies and evidence that mental disorders are attributed to
brain function there are still many who do not believe that there is a
connection of emotions and feelings to the brain.
However the debate over this issue presented above by Cambri is already moot
and academic as this survey by the author of this paper was conducted in
2011 when since 2014, the Philippine Psychological Association (PPA) paved
the way in crafting a bill known as House Bill 5347. It is also incorrect for
Cambri to say that HB 5347, among others, is bereft of any genuine and
participatory agreement with organic and primary stakeholders who are the
users/survivors of psychiatry and persons with psychosocial disabilities. 42 The
Bill before it was finalized for submission to the legislators was subjected to two
conferences- a pre summit in September 2014 and the Healthy Mind Summit 2
of October 2014.43 The two were attended by various stakeholders - from
patients and family, to MH institutions, civil society organizations, media, the
PMHA, the PAP, the DOH, the CHR and interested private citizens.44 A WHO
representative was present and even praised the initiative as well as the draft
bill.45 There were 495 attendees (18 as individuals and rest represented
organizations) in the summit proper and over 100 in the pre summit. 46 Thus, it
cannot be said that the primary lobbyists are only psychiatrists as Cambri in
her position paper states.
Furthermore, Cambri criticizes further the psychiatrists of PPA by stating in
her position paper:
"It is safe to assume that legislators and even government employees
working at the CHR simply took the word of the psychiatrists who
peddled these bills to them. As evidence, when questioned as to why
the filing of the bill, a Chief of Staff of one of the bills coauthors,
admitted finding nothing wrong with the bill when the doctors led by
Dr. June Lopez presented the draft, did not conduct any further study
or consultation with the sector at all, and simply signed. Former
Gabriela Rep. Liza Maza also confirmed that the latter talked to the
41 Corpuz, Naomi Therese, Mentally Disabled but not crazy, Youngblood Article Published on
47 Id.
48 Freeman, Supra Note 10
18
Committee.
The involvement of service users in drafting the CRPD and the General
Comment was prioritised and we fully agree with this principle. We
acknowledge that many mental health service users and organisations
advocating on their behalf feel strongly that involuntary admission and
treatment should be done away with and many such organisations
submitted statements to the Committee for consideration in finalising
the General Comment. (Emphases mine)
Freeman and colleagues thus suggested that the service user input was not
broad enough to represent a range of different service user views. Thus,
they further explained in their research that there are countries who are infact
in favor of involuntary admission and treatment:
In responding to a request from the South African Department of
Health on whether there should be involuntary admission and
treatment, the Gauteng Consumer Advocacy Movement (GCAM), a
large user group, said The GCAM is in favour of involuntary
admission...We acknowledge that there are times when we as mental
health care users relapse and become mentally unstable and therefore
not capable of acting in our own best interest, especially when it comes
to treatment and the various ways of obtaining the necessary
treatment, which may include involuntary admission. We also
acknowledge that at times some of us might become verbally or
physically abusive or threatening, and it is then the responsibility of
the State to protect those around us and protecting us from harming
ourselves (personal communication). The GCAM did a survey of
their members in 2013 and found that 99% felt that psychiatric
medication has resulted in improved mental health and improved
quality of life (personal communication).
19
INSURANCE SYSTEM (eds. Ma. Luz Querubin & Sonia Rodriguez, BEYOND THE PHYSICAL:
THE STATE OF THE NATIONS MENTAL HEALTH REPORT) (2002).
51Meeting of Minds, available at http://www.medobserver.com/article.php?ArticleID=440 (last
visited May 17, 2012).
20
7875.
RA 7875 gave birth to Philhealth which became the driver in
implementing the first and only social based insurance in the Philippines.
In a benefit package of R.A. 7875 of 1995 which states:
SEC. 10. Benefit Package. - Subject to the limitations
specified in this Act and as may be determined by the
Corporation, the following categories of personal
health services granted to the member or his
dependents as medically necessary or appropriate,
shall include:
a) Inpatient hospital care:
1) room and board;
2) services of health care professionals;
3)
diagnostic,
laboratory,
and
other
medical
examination services;
4) use of surgical or medical equipment and facilities;
5) prescription drugs and biologicals; subject to the
limitations stated in Section 37 of this Act;
6) inpatient education packages;
b) Outpatient care:
1) services of health care professionals;
2)
diagnostic,
laboratory,
and
other
medical
examination services;
3) personal preventive services; and
4) prescription drugs and biologicals, subject to the
limitations described in Section 37 of this Act;
c) Emergency and transfer services; and
d) Such other health care services that the
Corporation shall determine to be appropriate and costeffective: Provided, That the Program, during its initial
phase of implementation, which shall not be more than
five (5) years, shall provide a basic minimum package of
benefits xxx. (Emphasis Supplied)
21
SEC.
11.
Excluded
Personal
Health
Services The benefits
granted under this Act
shall not cover expenses
for
the
services
enumErated hereunder
except
when
the
Corporation,
after
actuarial
studies,
recommends
their
inclusion subject to the
approval of the Board:
a)
non-prescription
drugs
and devices;
b) alcohol abuse or
dependency treatment;
d) cosmetic surgery;
e) optometric services;
f) fifth and subsequent
normal
obstetrical
deliveries; and
Coverage
Rules
of
Psychiatric Conditions
Requiring Admission
In order to facilitate
reimbursement
of
claims
on
confinements
for
psychiatric conditions,
the following rules are
hereby issued:
1. Claims for mental
and
behavioral
disorder shall be
compensable only
for patients with
acute attacks or
episodes
admitted for any
of
the
following
reasons:
a. When
22
e)
home
and
rehabilitation services;
f) optometric services;
g) normal obstetrical
delivery; and
h)
cost-ineffective
procedures which shall
be defined by the
Corporation.
xxx
(emphasis supplied)
g)
cost-ineffective
procedures which shall
be defined by the
Corporation.
aggressive
of
assaultive
behavior
presents
danger to self
or others;
b. When
patient
the
is
suicidal;
c. When
the
patient
becomes
manic
or
depressed and
there is gross
impairment in
judgement and
reality testing;
d. When
medication
side
effects
became
disabling
or
potentially life
threatening
(e.g.
severe
parkinsonism,
severe tardive
dyskinesia,
23
neuroleptic
malignant
syndrome);
e. For
special
medical
procedures
such
as
electric
convulsive
therapy. xxx
24
(emphasis
supplied)
Above are the provisions and the circular implemented and issued respectively
by the PhilHealth affecting mental illness in chronological order. The lack of
insurance coverage prior PhilHealth Circular No. 09-2010 was made categorical
under sec. 11 of the National Health Insurance Act of 1995 (RA 7875):
SEC. 11. Excluded Personal Health Services The
benefits granted under this Act shall not cover
expenses for the services enumerated hereunder
except when the Corporation, after actuarial studies,
recommends their inclusion subject to the approval of
the Board: xxx
b) out-patient psychotherapy and counselling for
mental disorders;
RA 9241, The Act Amending the National Health Insurance in 2003
amended RA 7875, particularly the benefit b) out-patient psychotherapy and
counselling for mental disorders of section 11 as shown in the first column of
Figure 1 above. This benefit was removed (as shown in the second column of
Figure 1) as one of those excluded for personal benefits thus making it vague if
mental disorders are now covered by PhilHealth.
Although the present psychiatric conditions covered was made clear after
8 years when PhilHealth Circular No. 09-2010 was issued ,52 it is surprising
to know that out of 94 respondent- psychiatrists in a survey done by
random sampling nationwide in 2011, 51 of them (54.26% of the
respondents) did not know that such health insurance coverage for their
patients exists.53
This only goes to show that there is poor dissemination of information
by the PhilHealth to the people, especially psychiatrists the most important
health provider for the mentally disabled.
52Philhealth Circ. No. 09-2010. This is the Coverage Rules of Psychiatric Conditions Requiring
Admission (hereinafter PH Circular 09-10).
53Survey conducted by Naomi Therese F. Corpuz on Psychiatrist-Respondents of Philippine
Psychiatric Association, Inc. (PPA), at Dusit Thani Manila, Makati City (July 28-30, 2011).
25
26
it can be gleaned that the PhilHealth insurance coverage for mental disorders
as issued in its PH Circular 09-10 is limited only to acute inpatient care (as
shown in the third column of Figure 1 above).54
Apart from being limited, PhilHealth did not operationally define what acute
is and how different it is from chronic. Thus, it can only be assumed that the
terms acute and chronic are understood in their laymans terms: acute for
short period attacks55 and chronic for persistent and long-lasting attacks.56
It is important to distinguish the two because it is only inpatients with
acute attacks or episodes are covered in the PH Circular 09-10. The Circular
merely gave five reasons where this acute inpatient care is limited to, which
are:
(a) when aggressive of assaultive
presents danger to self or others;
behavior
disorder
shall
be
27
57Interview with Dr. Israel Francis Pargas, Senior Manager for Benefits Development and
Research of PhilHealth, Pasig City (July 22, 2011).
28
is income and lack of health insurance coverage. 58 Less well known is the fact
that those with severe mental illness (SMI) are less likely to have health
insurance coverage of any kind.59 There have been reports that chronic
illnesses such as mental health problems, including depression and
schizophrenia, are among the 10 leading causes of disability worldwide. 60
According to a World Bank study, depression will become the second leading
cause of disability in 2010.61Clinical depression is a common mental disorder
that affects about 121 million people across the globe. 62 It is estimated that by
2020, clinical depression will be the second most leading cause of disability
worldwide second only to cardiovascular illness.63 If these are the cases, and
at the same time confinement of such chronic mental illnesses are not covered
by Philhealth, mentally-ill adults are more likely to be unemployed relative to
other adults.64 Multivariate studies of labor force outcomes have generally
found unemployment levels to be lower among persons with mental illness. 65
If they are unemployed, this would also result to non-eligibility for employer
sponsored insurance, the primary source of health care for elderly adults. 66
They also become ineligible to insurance disability benefits from GSIS or SSS if
they stop working for the government or a private employer respectively.
Although the basis of Philhealth in all its insurance coverage are
actuarial studies, it can be of help to widen the scope given to mentally-ill
patients if there are psychiatrists who can explain that early intervention
in treatment of mental illness lessens its reccurrence or even with greater
probability to be completely cured. Onset of mental illness occurs during
late adolescence or young adulthood especially the aged 25-34 years. 67 This
is the same age group that has the highest level of uninsurance; in part
because mental illness often begins during late adolescence or young
58Catherine Mclaughlin, Delays in Treatment in Mental Disorders and Health Insurance
Coverage, 39 Health Serv. Res. 221-224 (2004).
59Id.
60 Sol Jose Vanzi, Mental Health Problems: Psychiatrists Tap Social Science, available at
http://www.newsflash.org/2004/02/si/si001922.htm (last visited October 25, 2004).
61 Id.
62Cara Davis, 7 Ways to Ward off Clinical Depression, 3, at http://halogentv.com/articles/7ways-to-ward-off-clinical-depression/ (last visited: June 20, 2011).
63 Id.
64Catherine Mclaughlin, Delays in Treatment in Mental Disorders and Health Insurance
Coverage, 39 Health Serv. Res. 221-224 (2004).
65Id.
66Id.
67Id.
29
Psychiatry of U.P. College of Medicine and current private practioner at Cardinal Medical
Santos Center, Mandaluyong City (August 6, 2011).
71Reuters, Mental health disorders common in young adults: survey, at http://www.abscbnnews.com/lifestyle/12/14/08/mental-health-disorders-common-young-adults-survey (last
visted May 19, 2012).
30
31
32
33
Figure 2.78
75Interview with Mr. Nelson Mendoza, National Program Coordinator, National Mental Health
Program and Degenerative Disease Office, Department of Health, Philippines (March 30, 2012).
76Id.
77Id.
78Id.
35
The Philippine Government only gave 5% of its DOH budget to the National
Mental Health Program where only 5% of which are for health care
expenditures by the government health department directed towards mental
health. Of all expenditures on mental health, 95% are spent on the
operation, maintenance and salary of the personnel of mental hospitals.
The percentage of the population that has free access to psychotropic
medication is unknown.79 For those that pay out of pocket, the cost of
antipsychotic medication is 0.46% and antidepressant medication is 11.4% of
the minimum daily wage.80
There is also a scarce resource of Mental Health Workers.
conducted by World Health Organization in 2007:
Figure 3.
# of Mental
Health Workers per 100,000 pop
Psychiatrists*
412
0.42
Nurses
769
Psychologists
119
0.14
Social Workers
74
0.08
Occupational Therapists
72
0.08
Others
1,372
In a study
0.91
1.62
39
During the term of former President Gloria Macapagal Arroyo, Republic Act No.
9422 was enacted entitled as, An Act Amending Republic Act No. 7277,
Otherwise known as the Magna Carta for Persons with Disability as Amended,
and For Other Purposes Granting Additional Privileges and Incentives and
Prohibitions on Verbal, Non-Verbal Ridicule and Vilification Against Persons
with Disability. It is the objective of Republic Act No. 9442 to provide persons
with disability, the opportunity to participate fully into the mainstream of
society by granting them at least twenty percent (20%) discount in all basic
services. Section 1 of R.A. 9422 states:
with disability must present his//her identification card issued by the National
Council on Disability Affairs (NCDA) or by the Local Government Units (LGUs)
where he/she resides.88 In addition, a purchase booklet issued by the LGUs to
persons with disabilities for free shall be presented every time a purchase of
medicine is made.89 Hence, although a mentally ill person can avail of a
discount in in public railways, skyways and bus fare or in purchasing
medicines there is an undeniable fact that there is a stigma attached to
persons with mental disorder while there is none to those who are suffering
from other illnesses. If an illness of a patient is not apparent, it is inevitable
that one of the assumptions of the persons seeing a PWD identification card is
that the patient who owns the card has a mental illness which he can possibly
identify as sirang ulo. Infact a mother of an autistic child said that she does
not want to avail of the PWD identification card because she doesnt want
anybody to identify that her daughter is, sirang ulo,90 though a mentally ill
patient with a PWD identification card is not insane or sirang ulo per se.
It is best if the legislators of R.A. 9422 and NCDA have thought of a different
term instead of Person With Disability (PWD) that will not identify the
patient, with non- apparent illness, in any way to be suffering from mental
illness. Persons With Discounts, Persons With Special Discounts are terms
that can be used for instance that will not identify the patient to be suffering
with any form of mental illness.
Also, in the experience of Perlas Reodica, when she bought the generic
medicine Clonazepam, a sedative for her anxiety disorder with her PWD
identification card in a known drugstore in Sta. Mesa, Manila, three of the
pharmacists told her, Drug addict ka ano? (You are a drug addict arent
you?).91 This experience only shows the discrimination and ridicule that the
PWD identification card can cause to a mentally ill patient. This also shows
that there is a need for a wider dissemination of information of R.A. 9422
particularly Prohibitions on Verbal, Non-verbal Ridicule and Vilification
Against Persons With Disability92 and its penal clause93.
88 National Council for Disability Affairs, Administrative Order No. 1, Series of 2008.
89Id.
90Interview with Mrs. Gene Lesaca, mother of a a 10 year old autistic child (October 7, 2012).
91 Interview with Perlas Reodica, patient with anxiety disorder (November 12, 2012).
92Rep. Act. No. 9244 2 (2007). This is known as the Amendment to R.A. 7277 otherwise
known as the Magna Carta for Disabled Persons of 2007 (hereinafter R.A. No. 9422)
933.
42
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44
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