The Search for Best Practices of Universal Health Coverage Policies: Health Insurance for the Poor in the Philippines

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1 The Search for Best Practices of Universal Health Coverage Policies: Health Insurance for the Poor in the Philippines Briefer on the Universal Health Care Program Page 1

2 Briefer on the Universal Health Care Program in the Philippines Prepared by Laurice Yasmin V. Ramos-Mejia For the Office of Rep. Sharon S. Garin AAMBIS-Owa Party-list 07 June 2014, Quezon City Briefer on the Universal Health Care Program Page 2

3 The Search for Best Practices of Universal Health Coverage Policies: Health Insurance for the Poor in the Philippines Cong. Sharon Garin, AAMBIS-OWA Party-list I regard universal health coverage as the single most powerful concept that public health has to offer. It is inclusive. It unifies services and delivers them in a comprehensive and integrated way, based on primary health care. Dr. Margaret Chan, WHO Director-General (from the WHO website) Abstract: This policy review is a partial review of the Philippines Universal Health Coverage (UHC) policy for the poor and indigent, and the issues concerning the health sector. Included are the recommendations on how we can plug the loopholes and concerns regarding the issue thru legislative measures especially in the eventual campaign to put the UHC as one of the MDG goals post There are various definitions of Universal Health Coverage. (Bump,2010) Universal Coverage is taken to mean that everyone should have health insurance and that all medical services should be made available at a low or no cost at all. A broader view presents an implementation system of delivering health care and benefits for all, regardless of age, gender and race. In the Philippines, the health sector remains problematic in terms of ensuring universal coverage especially among the vulnerable and indigent. The present Universal Health Coverage program of the Aquino administration is mostly centered on the parallel efforts of including the poor in the National Health Insurance Program thru the Philippine Health Insurance Corporation or Philhealth sponsored membership and better resources for health care and facilities. Issues and concerns regarding the health sector are also considered such as the lack of health services in some areas in the country and the underutilization of Philhealth. Methodology: There are voluminous materials on Philippines Health Care issues and on Universal Health Care, sifting through all these was an arduous process especially in determining which is the most relevant for this study. The big scope of the issue and the need to choose specific areas also presented a problem more so because of the time constraints. Various policy and research papers were used in doing this research, most of which can be downloaded through the internet. The various legal and administrative issuances regarding UHC in the Philippines were also perused. Briefer on the Universal Health Care Program Page 3

4 Introduction: Long lines, overflowing charity wards, and the lack of facilities- describe the state of many public hospitals in the country. The lack of access to affordable and most current medical services affects the most vulnerable, especially poor women and children. In the Philippines, the attempt to provide Universal Health Care especially for the poor mostly centers on the provisions of accessible and affordable health services and health insurance through Philippine Health Insurance Corporation (PHIC) or PhilHealth. The poor and indigent Filipinos are covered by the PhilHealth s Sponsored Program and the government. The DOH and LGUs have undertaken the payment of premiums for the 14.7 million targeted households identified under the DSWD s National Household Targeting System Program or Listahanan i. Still, despite the various attempts to improve health care as a whole in the country, many concerns and issues regarding health care remain. Philippine National Health Accounts show that health care expenditures, despite being subsidized by the national and local government through social health insurance for the poor, health spending has increased. Unfortunately, for the poor, this meant that food and education expenses for the family suffered in exchange for expenses incurred during sickness. Other issues include the burgeoning health sector expenditures, the corporatization or privatization of many government hospitals and the concomitant increase of rates in the services of supposedly public hospitals. Various studies have shown that underutilization of PhilHealth benefits by the poor highlights the need for comprehensive and inclusive health coverage for the marginalized and most vulnerable Filipinos. I. Health Sector Situation: a. Health Sector Expenditures From the time of former President Cory Aquino, no administration has given a marked increase on the budget for health services. The only exception is the 2014 DOH budget which increased due to the announced PhilHealth contributions of poor Filipinos (to be paid from excise tax collections from 2013), targeted thru the DSWD s Listahanan program. Traditionally, low spending on social services such as health and education marked the spending priorities of previous administrations. Last 2013 for example, the DOH budget incurred a Php 2.5 billion decrease in budgetary allocation, with the total health service allocation a measly 0.8% of the country s GDP. A far cry Briefer on the Universal Health Care Program Page 4

5 from the WHO s suggested minimum of 5% of the GDP as health budget for 3 rd world countries. The 2014 budget fared much better with an increase of more than Php 30 Billion, mostly due to the allocation from the amended excise tax collections of The Php 83.7 Billion 2014 budget of the DOH benefited from the more than Php 90 Billion excise tax collections from These incremental increases received by the DOH from the more popularly known Sin Tax law collections, will be used for the following purposes: 1. Fund PhilHealth premiums for poor and non-poor beneficiaries; 2. Fund the facilities enhancement of government hospitals and other health facilities; 3. Expand public health programs such as immunization; 4. Hire health workers to support the implementation of the Universal Health Care program. Php 35.3 Billion of the DOH budget will be used for subsidizing the PhilHealth contributions of the 14.7 million poorest families in the Listahanan. b. The Corporatization of Government Hospitals in the Philippines: A bigger concern in the situation of the health sector, especially in the context of this paper s discussion on UHC and health insurance, is the prevailing policy of corporatizing government owned hospitals. It is necessary to discuss the phenomena of corporatizing many public hospitals especially in the context of increasing hospital fees and the underutilization of PhilHealth by some members due to large out of pocket expenses. The Philippine government defines privatization as a policy of disengagement in activities that are not inherent functions of the government. This may involve the complete turnover to private sector of certain public corporations, and the contracting of services to private firms that have the necessary resources, or turning over particular services to the private sector, but with the accompanying government incentives and/or measures. (Ibon, 2003) Corporatization is the process of transforming state assets, government agencies or municipal organizations into corporations. It refers to a restructuring of government and public organizations into joint-stock publicly listed companies in order to introduce corporate and business management techniques to their administration. Hospital corporatization meanwhile, is the middle ground between budgetary hospitals Briefer on the Universal Health Care Program Page 5

6 and private hospitals. Similar to private hospital, a corporatized hospital will have a board of directors. This could mean that the corporatized hospital will hire several experts like a finance manager to manage hospital operations. This hospital will now be accountable for its financial status. They cannot always operate at a loss. A corporatized hospital should ideally be exposed to competition and market forces which will drive quality of care upwards. In the Philippine context, the moves toward corporatization has resulted into government hospitals having to raise prices to address subsidy shortages and to also entice investors under the public-private partnership program - showing that they will earn a substantial amount from hospital services. In 2011, the Philippine Orthopedic Center (POC) ordered the increase of laboratory fees "as part of the revenue enhancement program" of the hospital. Many procedures were subjected to a % increase, including chest (108%, from P120 to P250), leg (233%, from P105 to P350) and knee x-ray (171%, from P240 to P650). The San Lazaro Hospital and Tondo Medical Center increased the fees for laboratory and diagnostic procedures. Also, based on experiences in GOCC hospitals, procedures and diagnostic procedures in PHC, Lung Center of the Philippines, Philippine Children s Medical Center (PCMC) and National Kidney and Transplant Institute (NKTI), are more expensive compared to other public hospitals and even compared to private hospitals. Materials by the Alliance of Health Workers give a comprehensive look at the moves to corporatize government hospitals in the Philippines. c. Universal Health Care in the Philippines and PhilHealth In the Philippines, the Department of Health (DOH) defines Universal Health Care as the "provision to every Filipino of the highest possible quality of health care that is accessible, efficient, distributed adequately funding, fairly financed, and appropriately used by an informed and empowered public." Currently, it is packaged by the Aquino administration as the Kalusugan Pangkalahatan or the "availability and accessibility of health services and necessities for all Filipinos." UHC is therefore a government mandate aiming to ensure that every Filipino shall receive affordable and quality health benefits and services such as human resources, health facilities, and health financing. It is part of the Philippine Development Plan for and is guaranteed in the fundamental law of the land and international laws recognized by our country. Section 15 of Article II of the 1987 Philippine Constitution states that: "The State shall protect and promote the right to health of the people and instill Briefer on the Universal Health Care Program Page 6

7 health consciousness among them." The UHC/KP was launched to move health sector reforms and focus the efforts towards the poor and ensure that nobody is left behind. A presentation by DOH Secretary Dr. Enrique Ona gives a clear glimpse of what are the elements of the Aquino administration s Kalusugang Pangkalahatan. This includes: 1. Achieving public health MDGs through primary prevention and health promotion; 2. Providing financial risk protection through interventions of care (secondary and primary); 3. Securing access to quality care at facilities through curative health care. For the purpose of this paper, focus will be on UHC s number 2, or the provision of health insurance to ensure improved health especially for the poor and vulnerable. (Ona, 2013) UHC in the country is under the purview of the National Health Insurance Act, most recently amended under Republic Act and signed by the President last June 2013(the other time this law was also amended was in 2004). RA include among its provisions, placing the country s most vulnerable citizens under the umbrella of the government s national health insurance program or Philhealth. The basic premise of the NHIP is the pooling of funds from members who are healthy and can afford health payments and subsidizing the sick and poor. (SEPO, 2009) The Philippine Health Insurance Corporation or Philhealth was created in 1995 as a social health insurance measure in the National Health Insurance Program or NHIP. Guided by the principles of universality, equity and care for the indigent, it was mandated to establish a sponsored Indigent Program sponsored by the LGUs and National Government. It also called for the mandatory enrolment of the Employed sector (private and government employees), Voluntary individually paying and Overseas Filipino Workers. Senior Citizens or Non-Paying are automatically covered. It assumed the former Medicare program for government private and public employees from the GSIS in 1997, SSS in 1998 and the OWWA in The benefits and contributions of the various types of memberships are available at the Philhealth website. For the purpose of this series, focus will be on the Sponsored Program which covers the poor and indigent or the individuals whose income is insufficient for the subsistence of their families. (Manasan, 2011) The various key features of the Philhealth, including the payment of premiums and benefits coverage are widely Briefer on the Universal Health Care Program Page 7

8 available online and include the newest benefits packages such as enrollment at point of care, No Balance Billing and 23 case rates packages. Almost 20 years after its implementation, the NHIP was once again amended and this new law puts universal health coverage within the reach of 95 million Filipinos. RA supports a socialized health insurance program offering free health care services to indigents and prioritizing the needs of the underprivileged, elderly, persons with disabilities, women and children under PhilHealth, the government s national health insurance scheme. The funds for the payment of Philhealth contributions were the aforementioned excise tax collections, or the so-called sin tax revenues from cigarette and alcohol sales. According to the Philhealth, the coverage as of July 2013 is 81 % of the population or about 74 million Filipinos based on the estimated count of members and dependents. Among the UHC targets by 2016 is the enrolment and coverage of all the targeted poor Filipinos in the Listahanan, or 100% coverage. Despite the claims on nearing the 100% coverage of the poor and indigent, accessibility and affordability remains as an issue as claims on the underutilization or non-availment of philhealth benefits abound. It seems that more than the payment of premiums of Philhealth, other reform measures such as affordability and accessibility to premium health facilities and relevant information on benefits are needed to ensure that a systematic effort for the health protection of the poor is achieved. The DOH, through its various policies, seems to also recognize this, but it remains to be seen as to how successful they are in implementing all the policies. II. Issues and Concerns 1. PhilHealth is plagued with operational and administrative issues which directly affects the utilization and delivery rate of benefits for poor members. First, there are disparities on membership figures between official Philhealth and DOH reports and other independent studies. What is true figure or statistic of current Philhealth coverage? In 2004, PhilHealth claimed 84% coverage. In 2011, PhilHealth claimed 81% membership of the country s total population. During the 2013 SONA, it was still 81% according to the President. But PhilHealth figures do not match information on the ground. Results of the 2008 National Demographic Health Survey showed that only 38 % of respondents were aware of at least one household member Briefer on the Universal Health Care Program Page 8

9 being enrolled in PhilHealth. A 2010 Social Weather Station survey on health care services and financing showed only 36% of respondents having PhilHealth coverage. The Philhealth officers themselves agree that the database needs to be cleaned and assessed to determine the exact coverage of Philhealth beneficiaries especially on the sponsored program. One of the problems regarding the discrepancy is that PhilHealth, it seems, considers the payment of premiums as the data for membership instead of the number of PhilHealth IDs released. Some of the identified problems on the confusion regarding the number of covered Filipinos are the distribution of PhilHealth cards with short-term coverage or good only for one year most especially prior to the elections of This has added to the confusion on the exact number of members, since many of those who received the cards were not able to pay the insurance premium after the government subsidy expired. Local government officials have also taken to distributing PhilHealth cards to their constituents during election campaigns or special occasions. The PhilHealth Sponsored Program appeared to have attained universal coverage over the targeted poor population at the national level for the year However, universal coverage was not true in all regions or provinces. Majority of provinces experienced mild to extreme leakages in the program. As of March 7, 2013, the total sponsored Philhealth members (members + dependents) totaled 38,187, ,900,729 of these members were sponsored due to NHTS targeting. (Silfverberg, 2014) There is a need for PhilHealth to ensure an updated database system of members and dependents for a more detailed analysis of data. Add to this is the administrative problem of late issuances of IDs for sponsored members. The PhilHealth ID is the primary requirement to avail of benefits in all health facilities as the Philhealth and hospitals have no centralized online database of members. Without a PhilHealth ID, sponsored members face the difficulty of availing their benefits. There are reports that the IDs of sponsored members are usually released in the latter part of the sponsored year, making the months they can avail of PhilHealth, shorter. 2. Targeting has been susceptible to a long history of political intervention, leading to leakages and non-coverage of some poor families. Still, there are high hopes for the success of the Listahanan as the main database for separating the poor and non-poor in the country. ii Briefer on the Universal Health Care Program Page 9

10 The political nature of PhilHealth sponsored premiums especially during election period (as mentioned above) directly affects the utilization of benefits. Studies have pointed out that the indigent beneficiaries whose premiums were paid from public subsidy were not always aware of their membership and accompanying benefits. (Quimbo et. al, 2008) Targeting systems in the country has been extremely poor prior to the creation of the DSWD s Listahanan. There had been different targeting regimes for different programs (some central and some are local government targeting) which showed different and inconclusive results e.g. there are findings that only 38% of food-forschool program estimated to go to the poor. (Ramos,et al. 2014) By 2013, the Listahanan has successfully targeted the 14.7 M poor families which is to be included in the list of those to be subsidized for Philhealth but concerns remain regarding those who would fall through the cracks of political patronage involved on the process of listing and enrollment to the sponsored programs. There are poor households who are enrolled previously but will be removed due to non-inclusion on the Listahanan but who still cannot afford the Philhealth premiums. Perhaps, aside from the specific targeting of the Listahanan, another reform measure on the payment methods of poor but not sponsored families can be instituted. It is a telling reminder to note that only 21% of the households which are included under the Listahanan are covered under the Sponsored Program in In fact, only 15% of the households enrolled under the sponsored program in 2010 are considered poor under the Listahanan. (Manasan, 2011) The 5.1 million households which lost its Philhealth sponsorship under better targeting cannot be ignored. It is positive to note that the DSWD is not blind to the gaps and leakages problem. There is a strong commitment of the DSWD leadership and capacity to manage the entire nationwide implementation and regular assessments are done before the program s start and after it has been implemented nationwide. 3. The need to address the various factors affecting Philhealth underutilization iii Data have shown that in the Philippines, underutilization is associated with the type of Philhealth membership and it is more prevalent among sponsored members. (Faraon, et.al 2013) Various reasons have been cited as to why despite the high percentage of PhilHealth coverage, many members opted to not avail of the benefits Briefer on the Universal Health Care Program Page 10

11 packages or to even utilize their Philhealth membership. Some of the most common reasons or variables are: The availability and accessibility of Philhealth accredited facilities including public and private hospitals, Rural Health Units and Private clinics and other health professionals. It has been said that only three out of ten Filipinos get to see a doctor when they are sick. Another problem is the lack of equipment, medicines and services in some hospitals and members are forced to buy these outside from their own funds. Lack of knowledge and information on insurance benefits and coverage. Due to the sponsored program s political nature in the past, some households enrolled may not be cognizant of their memberships and the concomitant benefits. This is one of the highest ranked in the underutilization variable in the UP study of Poverty or the lack of money for payment of premiums and other out of pocket expenses. Schneider (2004) considers this the choice against paying premiums for future health insurance versus the need for present consumption and necessities. When faced with the choice between food, education and health, education and health takes a backseat for a family who has scant financial resources. Although a World Bank report presents an alternative view, citing that there are families who may choose to have a higher value for future protection than current consumption. (Silfverberg, 2014) Out of pocket (OOP) expenses continue to rise due to lack of services in public hospitals and expensive services in private hospitals. National health accounts in 2011 computed OOP for health to be around 52.7% of total health expenditures. Supposedly, the policy of No Balance Billing or NBB is undertaken for sponsored members, but the UP School of Economics has computed that Philhealth has not helped Filipinos in coping with health shocks or in the event of sudden and expensive sickness. A 2008 study by the UP econ s Health Policy Development Program introduced a way of computing the true financial risk protection were able to present the true value of Philhealth benefits via the Benefit Delivery Rate or BDR. The BDR is a summary measure of social health insurance performance that reflects the capacity of social health insurance to cover the target population (coverage rate), the accessibility of social health insurance Briefer on the Universal Health Care Program Page 11

12 benefits to beneficiaries (claim rate) and the magnitude of social health insurance benefits relative to medical expenditure (reimbursement rate). The financial protection provided by the PhilHealth was pegged at a low 9.05% at the average since 2008, affecting the poor and the OFWs the most. In simpler terms, Prof. Quimbo of the UP School of Economics has explained the BDR as the value or amount Philhealth covers for each 100% health expenditure of a member. The perceived administrative and operational problems of the PhilHalth go hand in hand with the factors affecting utilization. Aside from lack of information about their benefits, the cumbersome claims process and costly transaction costs are sometimes less than the potential benefit claims that some members opt not to utilize their PhilHealth. 4. The sustainability and financial viability of funding premiums versus allotting these funds to public hospitals. This is a common observation by advocates of public hospitals and public health providers. The argument of using the funds for Philhealth premiums for upgrading and improving the capacity of public hospitals to provide services to the poor versus funding health insurance so the poor can avail of services in private hospitals is an often repeated. This is also related to the out of pocket expenses variable to the underutilization of Philhelath benefits. If public hospitals can provide services and medicines free of charge, out of pocket expenses cease to be a problem. Philhealth reported a benefit payment of Billion from the private sector, almost twice the amount they paid to public hospitals. III. Recommendations: 1. There are bills on Health Insurance filed in Congress. Perhaps, even if the concerned committee is yet to take up this matter, it would be beneficial to review these bills for reference. 2. A resolution calling for the Committee on Health s oversight function to investigate the various administrative and operational lapses and problems of the PhilHealth administration especially in light of the big amount of premium subsidies from public funds which are being paid to PhilHealth for the sponsored programs. The reports regarding late issuances of member IDs, and more recently, the threat by private hospitals not to accept PhilHealth Briefer on the Universal Health Care Program Page 12

13 beneficiaries because of PhilHealth s delay in remitting payments to hospitals should be investigated. 3. Same resolution or a different one via the Committee on Health can also help in determining the impact of the Sponsored program (since it has been in effect for a while), its benefits and coverage and the extent of financial protections it has given the targets before more funds are allotted for the program. This can be through a resolution calling for review of the excise tax funds allotted for the payment of Philhealth premiums (on whether the funds have been released) and the exact number of poor families who benefited from the payment of these premiums as of the current date. 4. Another concern is the big amount of PhilHealth funds held in reserve. It must be discovered whether the PhilHealth administration has a utilization plan for its reserve funds which will ultimately benefit its members. The pertinent information from PhilHealth should be acquired including its financial utilization plan. 5. The resolution previously mentioned is very important especially in determining the financial viability and sustainability of funding Philhealth premiums versus allotting these funds for the facilities enhancement of public hospitals and making all services free of charge to the poor, negating the great need for health insurance. 6. Because lack of knowledge regarding the benefits and coverage ranked highest among the reasons for underutilization of Philhealth, a concerted effort between Philhealth, DOH and LGUs must be launched to bridge this gap. Membership to Philhealth is useless if indigent members are not aware of the benefits of the program. Ideally, it is the most poor who should benefit most from Philhealth memberhsip but they show the highest rate of underutilization. IV. Conclusion: Considering the importance of health services in the protection of the most vulnerable and poor, it is a positive to note that it is now being prioritized by the government. Whereas the previous years have shown the prioritization of MDG goals on the allotment of the health budget, health insurance has slowly gained traction as an important aspect of Universal Health Coverage. Hopefully, the concomitant health sector reforms such as facilities enhancement, hiring of more health workers and Briefer on the Universal Health Care Program Page 13

14 professionals will continue in line with better health insurance. There is still a need to campaign for the inclusion of UHC insurance in the MDG post This is a campaign which the Philippines can help initiate and lead the way. But first, there is a challenge to enhance our current social health insurance that is PhilHealth. i The National Household Targeting System for Poverty Reduction (NHTS-PR) or Listahanan is an information management system that identifies who and where the poor are in the country. The system makes available to national government agencies and other social protection stakeholders a database of poor families as reference in identifying potential beneficiaries of social protection programs. It is also aimed at reducing leakage or inclusion of non-poor and under coverage or exclusion of the deserving poor using a proxy means testing or PMT model. (Ramos,et.al. 2014) ii Leakages refer to families and households who should not be included in the program (non-poor as per targeting data), while under coverage refer to families that should have been in the program but were not included. (Silfverberg,2014) iii Underutilization is defined as the inability to file insurance claims despite one s eligibility to do so. A study in 2008 cited factors such as transaction costs and level of education as factors. These factors were expanded in the 2013 paper by Faraon, et. al of the College of Public Health, UP Manila. References: Planning for the local implementation of Universal Health Care/Kalusugang Pangkalahatan, MDG breakthrough strategy guide. USAID, RTI, DOC Center for Health Development-Zamboanga Peninsual. (2012) Ona, Enrique. Universal Health care in the Philippines: Gains and Challenges. (2013) Ramos-Mejia, Laurice. The Corporatization of Government Hospitals in the Philippines. PA 241 Policy paper. (2013) Ramos-Mejia, et. al. The National Household Targeting System for Poverty Reduction: Ensuring the Success of the DSWD s Poverty Alleviation Programs. PA 243 Paper. (2014) Senate Economic Planning Office. PhilHealth at a Glance. (2009) Manasan, Rosario. Expanding Social Health Coverage: New Issues and Challenges. PIDS discussion paper series no Silfverberg, Raymunda. The Sponsored Program of the Philippine National Health Insurance- Analyses of the Actual Coverage and Variations across Regions and Provinces. PIDS discussion paper series Faraon, et al. Significant Predictors of Underutilization of Inpatient Benefits among Philhealth Members in selected Barangays in Manila. ACTA MEDICA PHILIPPINA. Vol.47, No. 3. (2013) Briefer on the Universal Health Care Program Page 14

15 Quimbo S, Florentino J, Peabody JW, Shimkhada R, Panelo C, et al. Underutilization of Social Insurance among the Poor: Evidence from the Philippines. PLos ONE 3(10):e3379.doi: /journal.pone (2008) Quimbo S, et.al. How Much Protection does PhilHealth provide Filipinos against health shocks? Powerpoint Presentation for the Joint Forum of NEDA, PCED and UPSE, April Briefer on the Universal Health Care Program Page 15

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