Successes and Successes and Failures in Failures in
expanding and expanding and deepening deepening
coverage of health coverage of health protectionprotection
-- the Philippine the Philippine experienceexperience
Eduardo P. Banzon, MD, MScSenior Health Specialist
World Bank
Health ProtectionHealth Protection
““CHARITYCHARITY”” BEDS IN GOVERNMENT HOSPITALSBEDS IN GOVERNMENT HOSPITALS
FREEFREE PUBLIC HEALTH/ PREVENTIVE HEALTH PUBLIC HEALTH/ PREVENTIVE HEALTH SERVICES and PRIMARY MEDICAL CARE SERVICES SERVICES and PRIMARY MEDICAL CARE SERVICES in GOVERNMENT HEALTH FACILITIESin GOVERNMENT HEALTH FACILITIES
SOCIAL HEALTH INSURANCESOCIAL HEALTH INSURANCEHOSPITAL SERVICES in PUBLIC and PRIVATE HOSPITAL SERVICES in PUBLIC and PRIVATE HOSPITALSHOSPITALSSELECT OUTPATIENT SERVICESSELECT OUTPATIENT SERVICES
HOSPITALS
HEALTH UNITS/ CENTERS/
OPD DEPARMTENTS of PUBLIC HOSPITALS
““CHARITYCHARITY”” HOSPITAL BEDSHOSPITAL BEDS
NationalGovernment
Budgets
Local Government
(LGU) Budgets
DoH Hospitals
AFP, PNP & VeteransHospitals
University Hospitals
Private Hospitals
LGU Hospitals
Household Out of Pocket
Payments
90%
10%
90%
90% charity bedsby a 1947 Law
10% charity bedsby DoH administrative order
““CHARITYCHARITY”” HOSPITAL BEDSHOSPITAL BEDS
Government budgets not enough to provide all “necessary” medicines/ diagnostics
• Budget for DoH hospitals have decreased in real terms in the last five years
IN RESPONSE, a patient classification scheme (Class A to D)• “Class D” patients – 100% subsidy• Class C1 C3 A – increasing share in underwriting the cost of
hospital care with Class A expected to pay full costs• HOWEVER, Class D patients are still being made to pay from
out-of-pocket unavailable medicines and diagnostics
10% CHARITY BEDS in PRIVATE HOSPITALS • No clear funding source
Poor monitoring and NO DATA on compliance
HOSPITALS
““PHILHEALTHPHILHEALTH”” BEDS/ WARDSBEDS/ WARDS
NationalGovernment
Budgets
Local Government
Budgets
PhilHealth (SHI)Coverage
DoH Hospitals
AFP, PNP & VeteransHospitals
University Hospitals
Private Hospitals
LGU Hospitals
Household Out of Pocket
Payments
PRIVATE ROOMS or BEDS
PHILHEALTHBEDS or WARD
PRIVATEHEALTH
INSURANCE
Source: PhilHealth internal databases
FREEFREE PRIMARY CARE SERVICESPRIMARY CARE SERVICES
Public health and preventive health Public health and preventive health Devolved to local governmentsDevolved to local governments
•• Dependent on local government budget financing Dependent on local government budget financing •• BUT, national government still finances vaccines and drugs for BUT, national government still finances vaccines and drugs for
key public health programs such as tuberculosis and key public health programs such as tuberculosis and schistosomiasisschistosomiasis
Primary medical care servicesPrimary medical care servicesHealth center or OPD of public hospitalsHealth center or OPD of public hospitals
•• ALSO dependent on available budgetsALSO dependent on available budgets
NO national policy/program committing toNO national policy/program committing toensure ACCESS to essential outpatient medicinesensure ACCESS to essential outpatient medicines
PhilHealthPhilHealth finances professional health care with finances professional health care with diagnostics for indigentsdiagnostics for indigents
Preventive and Promotive Services Outpatient Consultation and Diagnostic Benefit Package thru Accredited Rural
Health Units, Health Centers and Authorized Hospitals
•Primary consults•Laboratory fees for:
Chest X-rayCBCFecalysisUrinalysis Sputum Microscopy
•Preventive ServicesVisual acetic acid screeningRegular BP measurementsDigital rectal examBody measurementsClinical breast examCounseling for smoking cessationLifestyle modification counseling
(Private workers, Self-employed& retirees)
(Govt. workers & retirees)
(Overseas Workers)
SPONSORED PROGRAM(Indigent Families)
MEDICARE(since 1971)
YearYear
CityCityMunicipalityMunicipality
(4(4thth –– 66thth class)class)MunicipalityMunicipality(1(1stst –– 33rdrd class)class)
NGNGShareShare
LGULGUShareShare
NG ShareNG Share LGU ShareLGU Share
%% AmountAmount %% AmountAmount
1st1st P600P600 P600P600 90%90% P1,080P1,080 10%10% P120P120
2nd2nd P600P600 P600P600 90%90% P1,080P1,080 10%10% P120P120
3rd3rd P600P600 P600P600 85%85% P1,020P1,020 15%15% P180P180
4th4th P600P600 P600P600 80%80% P960P960 20%20% P240P240
5th5th P600P600 P600P600 75%75% P900P900 25%25% P300P300
6th6th P600P600 P600P600 70%70% P840P840 30%30% P360P360
7th7th P600P600 P600P600 65%65% P780P780 35%35% P420P420
8th8th P600P600 P600P600 60%60% P720P720 40%40% P480P480
9th 9th onwardsonwards P600P600 P600P600 55%55% P660P660 45%45% P540P540
NG- national govt.LG- local govt.
Meanstesting
Legal Spouse/s
Children below 21 yrs old
Parents 60 yrs old & above
Primary Member
PRO XI PRO XII PRO-CARAGA PRO ARMMPRO XPRO IX
0%10%
24%
13%
147%
107%102%
145%
134%
26%20%
15%1%
43%
9%3%
23%
12%
69%
26%
36%35%
35%
1% 0% 1% 6% 5% 8%
0%
20%
40%
60%
80%
100%
120%
140%
160%
100%
9,118 (2007 Enrollment)8,551 (2010 Target)
172,060 (2007 Enrollment)
116,982 (2010 Target)
63,929 (2007 Enrollment)43,997 (2010 Target)
124,517 (2007 Enrollment)92,930 (2010 Target)
88,932 (2007 Enrollment)87,156 (2010 Target)
• Maternity Care Package
• Day Surgery Benefit
• Outpatient TB Package
Unified Inpatient Packages Other Packages
• Dialysis, Chemotherapy & Radiation Therapy
• Outpatient benefits for the poor
90% claims made by hospital to PhilHealth. predominantly fee-for-
service
Source: PhilHealth
PhilHealth does not negotiate prices
with hospitals for its members
Illustrative
Illustrative
Illustrative
Source: PhilHealth internal databases
Source: PhilHealth internal databases
SUPPORT VALUE in PRIVATE HOSPITALS is quite POOR
Source: Department of Health, GoP
PhilHealthcreated
Source: World Health Report 2006
Source: Philippine National Health Accounts
Source: Philippine National Health Accounts
ConclusionConclusion
No explicit policy to expanding and deepen health protectionNo explicit policy to expanding and deepen health protection
Need to clarify role of public hospitals and definition of chariNeed to clarify role of public hospitals and definition of charity bedsty beds
N0 clear policy on the N0 clear policy on the ““payorpayor”” roles of government and roles of government and PhilHealthPhilHealth
SHI has probably increased public spending on health in absoluteSHI has probably increased public spending on health in absolute terms, terms, but has made no difference to % total spending from public sourcbut has made no difference to % total spending from public sourceses
Heavy reliance on outHeavy reliance on out--ofof--pocket remains unchangedpocket remains unchanged
Growth in real per capita spending coming more from private thanGrowth in real per capita spending coming more from private thanpublic sources with a slow shift of public spending towards the public sources with a slow shift of public spending towards the demanddemand--sideside
SHI does not seem to have triggered an expansion/improvement of SHI does not seem to have triggered an expansion/improvement of hospitals/health facilitieshospitals/health facilities
ConclusionConclusion
Current design of benefits fuels inflation with the traditional Current design of benefits fuels inflation with the traditional action of increasing benefit ceilings possibly leading to no, oaction of increasing benefit ceilings possibly leading to no, or r minimal, improvements in financial protectionminimal, improvements in financial protection
The poor are being enrolled into the SHI but The poor are being enrolled into the SHI but PhilHealthPhilHealth provides provides very limited financial protection for patients with serious illvery limited financial protection for patients with serious illness, ness, and fails to break the link between illness and povertyand fails to break the link between illness and poverty
BUT, BUT, PhilHealthPhilHealth recently launched LEAPING recently launched LEAPING FourWARDFourWARD towards towards FINANCIAL PROTECTIONFINANCIAL PROTECTION
PROVIDER PAYMENTPROVIDER PAYMENTCONTRACTING with HOSPITALSCONTRACTING with HOSPITALSPREFERENTIAL TREATMENT of PUBLIC HOSPITALS and PHYSICIANSPREFERENTIAL TREATMENT of PUBLIC HOSPITALS and PHYSICIANSEXPANDED OUTEXPANDED OUT--PATIENT/ OP MEDICINE BENEFITPATIENT/ OP MEDICINE BENEFIT