วารสารการเม องการปกครอง ป ท 5 ฉบ บท 2 ม นาคม ส งหาคม 2558 การจ ดการบ านเม องท ด /นโยบาย (Good Governance / Policy)

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1 Financing Universal Healthcare and the ASEAN: Focus on the Philippine Sin Tax Law * Abstract Abigail A. Modino ** This paper looks at the possible impact of the ASEAN integration in the region as well as the challenges it brings especially on the goal of financing health care. This study analyzes how a reform measure, the sin tax law, imposing tax on cigarettes and alcohol, was passed into law considering its conflicting role of being a revenue measure but at the same time a regulatory and health measure. The new law which supports the goal of achieving universal health care coverage is actually a revenue raising measure considering its nature as a tax law. However, under the present administration s drive to institute reforms in governance, this policy reform deviates from this nature and seeks to fulfill a social goal of improving not only universal health coverage but also lower tobacco and liquor related health problems among the youth. Data from other countries was also used in the analysis to see how the present law compares with current and past prices of alcohol, liquor and cigarettes and how international organizations affected the passage of the measure. Keywords: Universal Healthcare/ Sin Tax/ Philippines Introduction The ASEAN comprised of ten-member states with its combined GDP at almost US$ 3T ( org) and tremendous economic potential will make the region a major economic group especially once the goals of ASEAN Economic Community are achieved. By 2015 the full impact of ASEAN integration will be felt in the region, the ASEAN s vision of a single market and production base with five core elements of free flow of goods, services, investment, capital and skilled labor necessitate necessary adjustments within each member nation and state. Greater connectivity and trading within the region is expected. In the course of the attainment of these goals however lie the vital changes in the domestic policies and approaches of each member state. Concept of development and development policies will definitely be redefined and adjusted to allow for the envisioned objectives of an organization that lies outside the nation and state. Among the identified sectors of the ASEAN economic blueprint is the health * Paper presented at the 3 rd International Conference on ASEAN Connectivity: Current Issues and prospects towards ASEAN Community held on 17 November 2014 at the Mahasarakham University, Thailand.. Bilnd Peer Reviewers of this Journal. ** DPA Candidate, Nation College of Politic Administration and Governance (NCPG), University of the Philippines, Diliman. 351

2 sector. Efforts of each member in the attainment of universal health care within its territorial jurisdiction will be placed in focus, as the economic integration conceived of does not only contemplate of economic success for the region but also health for a most precious resource the people. This paper looks at health being identified as a right under the Philippine constitution is endeavored to be attained with the passage of a universal health care law and a concomitant financing measure, the sin tax law. In the course of the discussion of the passage of the sin tax law, its significance to health is related as well as the implications of ASEAN integration. Health as a right The objectives sought to be attained of creating an ASEAN economic community may at first glance be mistaken to mean purely an economic move but with health as one of the targeted priority sectors, the human capital approach is evident. By focusing on health as vital to accelerating economic growth in the region, health as paramount interest of member states is reinforced. Standards have been developed and set for countries around the world to follow as in the case of the World Health Organization, and on the local and domestic scene by the governments. However, this cannot be attained by focusing on health policy and implementation alone. Accessibility is important. In the case of the Philippines, health is a right as stated in the Philippine Constitution with the mandate given to the state of protecting and promoting this right. Accessibility to health services and facilities is always an issue especially in a country with a big population like the Philippines. To promote access, various policies have been passed and implemented through the years including providing financial support from the national government. Under the 2015 National budget, social services allocation rose from 841.8B to 967.9B with P37.2 for health insurance intended to cover 15.5 million beneficiaries. As far back as the 1970s there was the Primary Health Care which provides for the delivery of eight essential elements of health care, including the prevention and control of prevalent health problems; the promotion of adequate food supply and proper nutrition; basic sanitation and adequate supply of water; maternal and child care; immunization; prevention and control of endemic diseases; appropriate treatment and control of common diseases; and provision of essential drugs. Executive Order 851 in 1982 sought to integrate the preventive, curative and rehabilitative components of health care delivery in the country and reorganized the Ministry of Health for this purpose. It likewise mandates the regional health offices to be responsible for the field operations of the Ministry of Health in the region utilizing the Primary Health Care approach providing for health and medical services 352

3 responsive to the prioritized needs of the community. In 1987, Executive Order 119 provided for the reorganization of the Ministry of Health and its attached agencies, with the former given the power to define the national health policy and formulate and implement a national health plan. To help lower prices and promote drugs accessibility, RA 6675 The Generics Act of 1988 was passed. It mandates the use of generic terminology in the manufacture, importation and dispensing of drugs, and ensure adequate supply of drugs with generic names at the lowest possible cost. It also seeks to increase awareness among the public and health professionals on drugs with generic names as alternative with equal efficacy to the more expensive branded drugs. Department guidelines were also issued by the Department of Health in 2004 for the exclusive use of generic terminology in all prescriptions and orders in DOH hospitals. A landmark law which was passed in RA 7160 Local Government Code of 1991 provides for the devolution of health services to local government units. It specifically provides for the duties and functions of local health officers and created the local health board in every province, city or municipality which shall propose to the sanggunian concerned annual budgetary allocations for the operation and maintenance of health facilities and services within the local unit and serve as an advisory committee on health matters. For better access to health services, RA 7875 or the National Health Insurance Act was passed in 1995 which seeks to provide all Filipinos with the mechanism to gain financial access to health services.. By creating the National Health Insurance Program, the government is supposed to provide health insurance coverage and ensure affordable and acceptable health care services for all Filipinos. The law likewise created the Philippine Health Insurance Corporation, a tax-exempt entity, which administers the NHIP. Few years after this was the Health Sector Reform Agenda which was anchored on the five pillars of health financing, public health, local health system development, hospital development and regulations seeks to improve health care delivery, financing and regulation. To promote access to vital drugs,ra 9502 or the Universally Accessible Cheaper and Quality Medicines Act was passed. It seeks to provide access to affordable and quality medicines and provides among others, power to the President to impose maximum retail prices over certain drugs. In 2010, there was the Aquino Health Agenda (AHA) which streamlined and scaled up interventions introduced in the 1999 Health Sector Reform Agenda (HSRA) and provided for the objectives, thrusts and framework for implementing the Universal Health Care (UHC). 353

4 In 2013, the National Health Insurance Act was signed into law providing for a mandatory health insurance coverage for all even the indigent, sponsored and abandoned. The law makes the Program compulsory in all provinces, cities and municipalities despite existence of LGU-based health insurance programs. ASEAN Integration More than a decade after the initial efforts towards regional economic integration as embodied in the ASEAN Free Trade Area (AFTA), the creation of an ASEAN Economic Community (AEC) was recommended by heads of state in the region (CPBRD 2013, Haw 2003). AFTA promotes free trade within a 15-year period through the elimination of tariff and non-tariff barriers. The AEC envisions freer flow of goods, services and trade, capital and economic development within the region. Based on the 2007 Blueprint, the AEC is supposed to narrow development gap and accelerate economic community by Among the priority sectors identified in the blueprint is the health sector. The AEC envisions a free flow of services and remove restrictions on trade in services for air transport, e-asean, healthcare and tourism and logistics services. Among the ASEAN member state is the Philippines which have made preparations in time for the 2015 target. Among its priorities is to provide universal health care coverage. Embodied in the present administration s efforts towards good governance is the passage of reform measures that seek to provide better, efficient and accessible services to all Filipinos. Various Philippine health policies have been instituted even prior to the enactment of RA in 2013 An Act Amending Republic Act No. 7875, otherwise known as the National Health Insurance Act of Under the existing Universal Health Care program of the DOH launched in 2010 also known as the Kalusugan Pangkalahatan is the goal of providing every Filipino that is accessible, efficient, equitably distributed, adequately funded, fairly financed and appropriately used by an informed and empowered public. ( Its three thrusts are: 1) Financial risk protection through expansion in enrollment and benefit delivery of the National Health Insurance Program (NHIP); 2) Improved access to quality hospitals and health care facilities; and 3) Attainment of health-related Millennium Development Goals (MDGs). Aside from the Philippines, Indonesia and Vietnam have also made major strides in decentralization efforts and local governments have become major implementers in policies issued by the national governments. However, just like the Philippines, will decentralization and financing mechanism enable the realization of universal health care coverage? Section 4 Article X of the 1987 Philippine Constitution clearly enunciates the general supervision of the President over local governments and for provinces to 354

5 ensure that the acts of their component units are within the scope of their prescribed powers and functions. It basically embodies the implied broader powers of the local government units and allows greater participation in national development. This policy pronouncement was further enabled by the Local Government Code, a landmark measure passed in The Code devolves to local governments the responsibilities for basic services delivery which used to be reposed with the national government such as: health, social services, public works and education, among others. Their financial resources capabilities were also increased which includes: broadening of taxing powers; share from use of national wealth exploited in their areas and share in national taxes as in the case of Internal Revenue Allotment. Given this landscape and the tangible effects of impending ASEAN integration scenario, the new law necessarily, as well as its implementation has to be viewed also in light of the capacity of the local government units. On top of that is the concomitant effort of the national government to finance its implementation and achieve universal health care coverage for all Filipinos. One such move is the new sin tax law, a revenue generating measure also intended to provide reforms in the taxing regime which was passed in Tax as an economic intervention tool Tax is vital to sustain vital programs of the government and in ensuring the efficient and effective delivery of services to the people. Thus, it is inevitable that it has always been viewed as an economic measure with direct impact on property, profession and businesses of taxpayers. Oftentimes, it is seen as an inevitable mode for the government to intervene within the framework of a free market society to deliver if not to preserve merit goods and control externalities. The new sin tax law, on its face, presents its nature as more than a fiscal tool. In this study it is viewed as a reform measure, other than a revenue generation move of the administration and looks at how a typical government economic intervention also becomes a health measure considering its goal of achieving the government s bid for universal health care coverage. The Need to Amend After more than a decade of efforts to reform the tax structure imposing excise tax on tobacco and alcohol products, Republic Act 10351, a certified urgent measure, was passed. Its passage would amend the existing law and impose rates that will increase revenues for the government considering the current law failed to generate much-needed revenues despite increases in the tax rates. Several weaknesses of the existing system have been pointed out. The mandated increases in the existing law did not effectively reduce consumption of tobacco and alcohol products. In fact, data showing Family Income and Expenditure reveals that those in the bottom 30% foster higher consumption of tobacco and alcohol than those in the upper 70% in

6 Expenditure Items All Bottom Upper All Income 30% 70% Income Groups Groups Bottom 30% Upper 70% Alcoholic Beverages Tobacco Source: National Statistics Office, 2006 and 2009 Family Income and Expenditure Survey Final Results Neither does the share in government revenues of excise taxes for the past years go to the credit of the existing system. Its share of 8.2% in year 2010 to total revenue is negated by the general decline of excise tax on goods ( From year 2002 or in a span of eight years, the decline is more than 5%. The share from alcohol products went down from 3.1 to 2.5 in year 2006 while that from tobacco products went down from 4.1 to 3.3 in It was also noted that there was decelerated rate of revenue increase from cigarettes shows the downshifting of consumption and production from high to low priced products. The current multi-tiered structure is viewed as complicated with its various categories for classification creating too much room for discretion on the taxing authority. It is open to downshifting of high-priced to low-priced brands. The system is eroded by inflation due to lack of automatic tax rate adjustment and a classification freeze of some brands makes the system non-buoyant ( Health statistics showing seven out of ten leading causes of mortality in the country is smoking-related also necessitate consideration in the need to amend the existing system. The passage of an amendatory law is considered favorable since this would generate revenue and serve as deterrent for people to smoke. The move to increase tax rates on sin products will affect the country s ranking which is at the third lowest among countries with specific rate. Country Specific Duty Per Capita GDP (PPP) (in thousands) Australia 6.16 Brunei 1.24 Fiji 8.04 Hongkong 3.08 India 5.33 Japan 2.49 Laos 2.49 Macao

7 Maldives 3.02 Mongolia 2.76 New Zealand 8.24 Philippines.47 Singapore 8.11 Taiwan 1.19 Source: DOF position paper citing Emil Sunley, Tobacco Excise Taxation in Asia: Recent Trends and Development The international community also counts as a factor especially as the country complies with its commitment under the Framework Convention on Tobacco Control where each Party adopts measures including tax and price policies on tobacco products to reduce tobacco consumption. Likewise, a Party should prohibit the sale and/or importation by international travelers of tax and duty-free tobacco products. The Sin Tax Law Excise taxes which are taxes on the sale of specific good andservices such as alcohol (Hines 2007) are imposed for revenue generation, benefit principle application, control of externalities and to discourage consumption of potentially harmful substances. Curbing negative externalities preoccupy governments considering these cannot be delegated and performed effectively by the private sector while still maintaining desired profits and return on their investments. In the same way, providing health insurance and services to all would better be addressed by the government. Based on various studies, intervention by the government directly affect the price of sin products while price on the other hand is supposed to influence consumption pattern. Basic of course in a free market is also the idea that price affects demand. There is an inverse relation between price and demand. As price increases, quantity demanded for a product decreases. Among the salient features of the new law is the move towards a simplified tax administration and lesser discretion on classification. Mandated Tax Increase Sin Products RA 9334 RA Cigarettes 3.6 % + P.16 4% every year effective Jan Distilled Spirits 8% 4% every year effective Jan Fermented Liquor 8% 4% every year effective Jan Source: NTRC 2011 and RA

8 The new law points towards the direction of a uniform rate of 4% and the shift from the old multi-tiered and different rates. Perception of the government imposing unfair taxation scheme will be eliminated under the new law. Prior to the passage of RA 10351, tax tiers are according to net retail price (NRP) or the manufacturer s or importer s price less the amount of excise and VAT ( It distinguishes old brands of alcohol and tobacco for the new ones. Old brands are taxed on the basis of their tax classification determined according to the Oct 1,1996 NRP. The law also provides for an increase of the rates by four percent (4%) every year thereafter effective on January 1, For distilled spirits, the law imposes this schedule effective January 1, 2013: (1) An ad valorem tax equivalent to fifteen percent (15%) of the net retail price (excluding the excise tax and the value-added tax) per proof; and (2) In addition to the ad valorem tax herein imposed a specific tax of Twenty pesos (P20.00) per proof liter. Effective January 1, 2015, the law provides an ad valorem tax equivalent to twenty percent (20%) of the net retail price (excluding the excise tax and the valueadded tax) per proof; and a specific tax of Twenty pesos (P20.00) per proof liter. Similar with tobacco products, the law provides for the rates to be increased by four percent (4%) every year thereafter effective on January 1, 2016, through revenue regulations issued by the Secretary of Finance. RA aside from generating additional revenues for the government also allocates 15% of the incremental revenue collected from the excise tax on tobacco products under R. A. No to and divided among the provinces producing burley and native tobacco in accordance with the volume of tobacco leaf production. The law also requires that the fund be exclusively utilized for viable alternatives programs for tobacco farmers and workers such as: inputs, training, and other support for tobacco farmers who shift to production of agricultural products other than tobacco including, high-value crops, spices, rice, corn, sugarcane, coconut, livestock and fisheries; and programs that will provide financial support for tobacco farmers who cease to produce tobacco; livelihood and cooperative programs. The New Sin Tax and Health Laws RA aside from generating additional revenues for the government also allocates 15% of the incremental revenue collected from the excise tax on tobacco products under R. A. No to and divided among the provinces producing burley and native tobacco in accordance with the volume of tobacco leaf production. The law also requires that the fund be exclusively utilized for viable alternatives programs for tobacco farmers and workers such as: inputs, training, and other support for tobacco farmers who shift to production of agricultural products other than tobacco including, high-value crops, spices, rice, corn, sugarcane, coconut, livestock and fisheries; and programs that will provide financial support for tobacco farmers who cease to produce tobacco; livelihood and cooperative programs. 358

9 The passage of the new sin tax law becomes more significant in the policy pronouncement of providing universal and holistic health care for Filipinos. It makes vice more expensive while raising more money for health law (SONA 2012). It is expected to generate P B additional revenues ( from cigarettes, distilled spirits and fermented liquor just on the first year of its implementation. Aside from generating these projected revenues for the government, 80% of incremental revenue is allocated for the universal health care under the National Health Insurance Program, the attainment of the millennium development goals and health awareness programs. The law also provides that 20% shall be allocated for medical assistance and health enhancement facilities program. In the course of this study, several issues have been identified which, more or less, might pose as challenges in the effective implementation of the goal of providing universal health care coverage in the ASEAN region as illustrated in the case of the Philippines. Among these challenges are decentralization and financing issues. More needs to be done to ensure access to health services for the poor in the region despite efforts towards greater health care access and coverage. The region although geologically proximate each other shows a region of diverse culture, historical and political development. It is therefore not a surprise that policy approaches as in the health care systems in the region vary. It was noted that health and systems approaches range from dominantly tax-based financing to social insurance and high out of pocket payments (Chongsoviratwong, 2011). Greater access to health services for the poor is an issue. Efforts towards universal health care coverage should further be strengthened. This same diverse culture, history and approaches is seen to have an effect on industries in the region (Sackman 2013). This is where the ASEAN and AEC can come in to synchronize efforts among member states and the region to further improve costs and accessibility to health care, medicines and services. Needless to say, governments role is important in providing universal health care coverage. Among the health issues that affect the Southeast Asian region are: (Chonsoviratwong, 2011) maternal and child health, infectious diseases, health workforce challenges and health care financing reforms. Human and financial resources are among the constraints that might affect ASEAN integration scenario which are present in regulation guidelines and actual enforcements in the region (Sackman 2013). Health care spending in the Philippines may have increased between 1990 and 1997 but still places the country below average category for countries of similar wealth (Hindle 2001). Revenues from members contribution and out of pocket is the largest single source of health care expenditure which accounted for 4.6% of the total in 1997 and comprise a majority of the National Health Insurance Program. With the passage of RA 9502 or the Universally Accessible Cheaper and Quality Medicines Act of 2008" the government sought to ensure access to affordable and quality drugs and medicines for all. 359

10 Comparing the Philippines with other countries, patterns have been identified. These moves toward universal insurance coverage show either: the use of tax revenues to subsidize target populations, steps towards broader risk pools, and emphasis on purchasing services through demand-side financing mechanisms. The progress attained by these countries include: increasing enrolment in government health insurance, a movement towards expanded benefits packages, and decreasing out-ofpocket spending accompanied by increasing government share of spending on health (Lagomarsino, et al, 2012) Decentralization is also a factor identified that pose a challenge to the development of health sector in the region (Chongsuviratwong 2011). In the case of the Philippines, decentralization led to the increased role of LGUs which demands more capacity for lgus to implement crucial policy reforms devolved and decentralized. Decentralization is a process that intends to hasten decision making by decongesting central government and decreasing red tape (Brillantes, 1986). It is intended to increase citizen s participation, empower them and the local units. Conclusion In an era where governance encompasses government and society as well as the delivery of public goods, various reforms have been instituted. On top of the list always would be institutional reforms. This paper, however, preferred to look at a tax measure by focusing on the reasons for its passage, the objectives sought to be achieved and its role as government intervenes. It looks at the interplay of various factors and areas of concern which the government encounter and must dealt with to carry out initiatives such as the sin tax without compromising the needs of the public as well as that of the government. On one end is the need to generate revenues to enable the government to carry out its programs and projects. On the other end is to fund health care coverage to Filipinos and deter consumption of sin products by the vulnerable groups. Another significant factor is the effect on the group of tobacco producing provinces and farmers by any increases in tax rates on tobacco products. The passage of the law does not only need an analysis of the law of supply and demand, price and demand or factors of production. Needs and interest of crucial key players and sectors of society also came to fore. In summary, the policy measure was intended to address pressing needs of the society specifically, as additional revenue source and to finance universal health care coverage. In addition to this health aspect is the law s objective of providing additional funding support for tobacco farmers who will be affected by the new increase in rates. The new system is hoped to increase government revenues as well as discourage consumption of tobacco and alcohol especially among the vulnerable sectors such as the youth and the poor. It is also in synch with the drive of the present administration against graft and corruption and transparency as the new system is believed to eliminate discretion as perceived under the old one. The Sin tax law can be viewed as a means by which the government intervened in the existing set-up and in the market. The need for a government to intervene cannot 360

11 be denied especially in addressing externalities and delivery of public goods that a normally functioning free market society cannot efficiently produce. Providing health care coverage for the people is one of the reasons merit goods that prods any government to intervene. Letting the free market s invisible hand alone to correct any excesses or externalities is not enough for it is blind even to the inequalities within an economy (Hockley, 1992). Viewed within the country s role as a member of the region, the law is a concomitant measure to the state s mandate with respect to health and the enabling laws. A country s objective and resolve of providing basic services to its people can best be determined by the accompanying or existing economic policies and revenue support measures. In trying to attain a strong health sector, aside from financing and revenue measures, existing factors such as decentralization and role of private sector should also be addressed. Given the demands and effects of liberalized and removal of trade restrictions, the state should address healthcare policy issues especially financing, a development social issue and a public good. Even with the increasing role of institutions like the ASEAN and the international community on the traditional mandates of states and nation states, the role of providing health and welfare services and public goods reinforces the role of states. As shown in this paper, even with the growth of private sector participation in health care services, the issue of providing universal health care as well as the issue of financing remains a concern of the state and the government. Hence, the demands posed on ASEAN member states with the envisioned goal of an integrated ASEAN economic community leading to liberalization or removal of trade barriers as well as a competitive private sector, the issue of health financing remains strong. References ASEAN. (2007). ASEAN Economic Community Blueprint. Asian Development Bank. (2013). The Road to ASEAN Financial Integration. ADB Balboa, Jenny, Medalla, Erlinda and Yap, Josef. (2007). Closer Trade and Financial Co-operation in ASEAN: Issues at the Regional and National Level with Focus on the Philippines. ASEAN Economic Bulletin April 2007: Bird, Rirchard and de Jantcher Milka Casanega ed. (1992). Imrproving Tax Administration in Developing Countries Brillantes, Alex Jr. (1980). The Regional Development Council as a Mechanism for Coordination and Effective Performance: Focus on Region III at PJPA Vol XXIV. Brillantes, Alex Jr. (1996). Decentralization, Devolution and Democratization. Old Concepts, Contemporary Applications. Kasarinlan vol 12 No. 1 3 rd Quarter 1996 Brillantes, Alex Jr. and Moscare, Donna. (2002). Decentralization and Federalism in the Philippines: Lessons from Global Community, a paper presented at the International Conference of the East West Center Kuala Lumpur, Malaysia 361

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