Phil Health Indigent Progam for Filipinos

8/3/2019 Phil Health Indigent Progam for Filipinos

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UNIVERSITY OF THE PHILIPPINES

VISAYAS TACLOBAN COLLEGE

TACLOBAN CITY

PHILIPPINES HEALTH IN PHILHEALTH:

EXTENDING HEALTH INSURANCE TO INDIGENT FILIPINOS

MANAGEMENT 243

PROGRAM DEVELOPMENT

APURILLO, SHERYL Y.

GAYAS, IMELDA M.

HURTADO, ADOR L.


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CHAPTER I

INTRODUCTION

The struggle against disease has progressed considerably over the years. Health

conditions in the Philippines in 1990 approximated to those in other Southeast Asian countries

but lagged behind those in the West. Life expectancy, for instance, increased from 51.2 years in

1960 to 69 years for women and 63 years for men in 1990. Infant mortality was 101 per 1,000 in

1950 and had dropped to 51.6 per 1,000 in 1989. In 1923 approximately 76 percent of deaths

were caused by communicable diseases. By 1980 deaths from communicable diseases had

declined to about 26 percent.

In 1989 the ratio of physicians and hospitals to the total population was similar to that in

a number of other Southeast Asian countries, but considerably below that in Europe and North

America. Most health care personnel and facilities were concentrated in urban areas. There was

substantial migration of physicians and nurses to the United States in the 1970s and 1980s, but

there are no reliable figures to indicate what effect this had on the Philippines. Hospital

equipment often did not function because there were insufficient technicians capable of

maintaining it, but the 1990 report of the Department of Health said that centers for the repair

and maintenance of hospital equipment expected to alleviate this problem.

In 1987 a little more than one-half of the infants and children received a complete series

of immunization shots, a major step in preventive medicine, but obviously far short of a desirable

goal. The problem was especially difficult in rural areas. The Department of Health had made


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efforts to provide every barangay with at least minimum health care, but doing so was both

difficult and expensive, and the more remote areas inevitably received less attention.

A. RATIONALE

The Philippines has a dual health care system consisting of modern (Western) and

traditional medicine. The modern system is based on the germ theory of disease and has

scientifically trained practitioners. The traditional approach assumes that illness is caused by a

breach of taboos set by supernatural forces. It is not unusual for an individual to alternate

between the two forms of medicine. If the benefits of modern medicine are immediately obvious-

-eyeglasses, for instance--then there is little argument. If there is no immediate cure, the impulse

to turn to the traditional healer is often strong.

The Philippines had a social security system including medicare with wide coverage of

the regularly employed urban workers. It offered a partial shield against disaster, but was limited

both by the generally low level of incomes, which reduced benefits, and by the exclusion of most

workers in agriculture. In April 1989, out of more than 22 million employed individuals, a little

more than 10.5 million were covered by social security. In health care and social security, as

with other services, the Philippines entered the 1990s as a modernizing society struggling with

limited success against heavy odds to apply scarce financial resources to provide its people with

a better life.


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B. PHILHEALTHS HISTORY

The basic right to health is mandated by the International Covenant for Economic, Social

and Cultural Rights promulgated by the United Nations. In the Philippines, the Philippine Health

Insurance Corporation (PhilHealth) has pushed for the coverage of the largely under- and un-

employed persons in the poorest of communities through a partnership with the local government

units (LGUs). At the core of that partnership is an arrangement that encourages LGUs to enroll

heads of indigent families to the PhilHealth system. Ten years after its institution, some four

million indigents have been enrolled under PhilHealth, mostly heads of families, thus effectively

covering about 20 million individuals.

The PhilHealth Indigent Program was established in the context of the countrys

worsening poverty situation, decentralization and the establishment of the Philippine Health

Insurance Corporation (PhilHealth) to take the lead in implementing the countrys National

Health Insurance Program.

In 1969, the Philippine Medical Care Act (Republic Act No. 6111), known more widely

by its acronym, Medicare, provided for increased medical care benefits mostly to the regularly

employed, particularly those also covered by the Government Service Insurance System (GSIS)

for public employees and the Social Security System (SSS) for private sector employees. It failed

to cover the larger sections of the population who were unemployed, underemployed or

employed by the so-called informal sector: essentially the poor. The Medicare law was replaced

by the National Health Insurance Act (NHIA) of 1995, which modified the Medicare system


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with the creation of the Philippine Health Insurance Corporation (PhilHealth) to administer a

new setup designed to expand coverage to previously un-served sectors. The NHIA also

established the National Health Insurance Program, to be implemented by the PhilHealth, with

the mandate to provide all citizens with the mechanism to gain access to health services in

combination with other government health programs

In 1995, the Philippine Health Insurance Corporation or PHIC was created to administer

a National Health Insurance Programme which aims to provide all citizens of the Philippines

with the mechanism to gain financial access to health services and to serve as the means to

help people pay for health care services.

First among the guiding principles declared in the National Health Insurance Act is the

state policy to provide free medical care to paupers (Article I Section 2). It is therefore

explicit from the law that the National Health Insurance Programme aims to achieve coverage of

the entire population with at least a basic minimum package of health insurance benefits - and

with the priority of the underprivileged explicitly recognised. The word entire population

needs to be emphasised at this point, if only to remind us that when the law was crafted, the

framers of the law clearly had in their minds from the very start the intention to cover the entire

population from the highest to the lowest rungs of the society.

PhilHealth had been given 15 years to attain universal coverage with utmost priority

given to the poor as they are the ones who need health insurance coverage the most. This is the


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central theme of this paper how PHIC has progressed in making available to the indigents the

benefits of social health insurance financed through premium subsidies.

C. PROGRAM FOR INDIGENT FILIPINOS

Access to health is the most pressing concern of most households. During adverse

changes in economic conditions, it is not the lack of food, but access to health services and

medicines that figures prominently among households concerns, especially among the poor.

Faced with a serious debt problem, the government can account for only 38 percent of

expenditures in health services. Most health expenses are shouldered by the private households

(55 percent). Private and state health insurance cover only 2 percent and 5 percent, respectively.

With the poor, especially the unemployed and under employed among the most

vulnerable to adverse situations, better ways of making health services accessible to them

became, and even now remains, a major challenge. With public health service delivery functions

now devolved, that challenge falls squarely on LGUs. Unfortunately many are as hard put as the

national government, with devolved funds not quite matching the cost of devolved (especially

health) functions. It is this situation that the PhilHealths Indigent Program, with its component

capitation scheme, was designed to address. The government saw the health insurance system,

particularly the public health insurance system as its main tool for ensuring the poors access to

quality health services. However, fully cognizant of the LGUs financial and health service

delivery limitations, a scheme had to be devised to encourage local governments to use the health

insurance system for its poorest constituencies.


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At the time the PhilHealths Indigent Program was conceptualized in 1997, less than 26

percent of the population (about 22 million) was covered by health insurance, of which the

PhilHealth accounted for close to 90 to 95 percent. The overwhelming majority of those covered,

estimated at more than 95 percent were regularly employed personnel from the government and

private sectors, and their beneficiaries. Some 34,000 cooperative societies also provide insurance

services to the poor. A study conducted by the International Labor Organization estimated that

only 1.25 million were beneficiaries of some 935,600 documented micro insurance schemes in

the Philippines. Of these schemes, only a handful involves the provision of health insurance

services. Considering that members of poor families number close to 20 million, much needed to

be done in terms of health insurance coverage.

The NHIA was conceived in the light of frustration over the earlier Medicare system and

the need to expand the health care insurance system to cover those who are not regularly

employed. An expanded system, coupled with decentralized government was thought to be an

effective way of delivering health services to those who needed the services the most. This was

the germ of the idea communicated to members of Congress who eventually enacted the NHIA

law. The support of the LGUs through their Leagues had to be mobilized, to make the intent of

the law a reality. There was need for LGUs to invest in improvements in local health facilities

and services. For lack of funds, devolved facilities had not been properly maintained and

managed.


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In its initial stages, PhilHealths Indigent Program had to ride on the implementation of

President Ramos Social Reform Agenda which listed twenty poorest provinces, dubbed as

Club 20 as priority sites for implementation. In this manner, the Indigent Program gained the

support of the highest office of the country. At the start, only two provincial LGUs actively

patronized the program although all twenty had entered into Memoranda of Agreement with the

PhilHealth. Initial successes however led to more buy-ins from LGUs, especially as the

Capitation Scheme went into full implementation. The Program had (and continues to have) the

support of various levels of government as well as of a growing number of private entities.

Support from the legislative branch eventually translated into the passage of the NHIA of 1995,

including provision for a Capitation Scheme which comprises an important component of the

incentives package to entice LGUs to invest in health. The Congress and Senate have

continuously supported the program as evidenced by growing appropriations from an initial P500

million (US$10million) to the current P3.5 billion (US$70 million). In addition, legislators from

both the Senate and Congress set aside amounts from their Countrywide Development Funds to

support the Indigent Program.

The Department of Health (DOH) has been at the forefront of the advocacy work for the

PhilHealth Indigent Program, especially among LGUs. Its regional offices provide various kinds

of training in the field of effective health care and public health management. The strongest

support however has been from the LGUs: the provincial governments with their provincial and

district hospitals; the city and municipal governments with their Rural Health Units (RHU) and

City Health Centers (CHC); the barangay (village) which actively assist in seeking out indigent

families, The LGUs provide the funds to pay for the insurance premiums of indigent families.


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From the original two provinces that initially joined the program, today there are close to 200

provinces, municipalities and cities participating. Besides the premiums, LGUs have taken

advantage of the Capitation Scheme to improve their health facilities, many bringing these to par

with accredited private health service providers much to the advantage of the poor who can often

fully afford only the services of public facilities even with their insurance coverage. LGUs have

adopted central administrative and operating systems in which funds are managed in such a way

that revenues from health operations are earmarked for more health service delivery for the poor.

Within the private sector, hospitals have supported the indigent program by ensuring high quality

service for indigents, upgrading their overall capabilities, systems and equipment, and enrolling

and properly participating in the system. Certain civic organizations and foundations, especially

corporate foundations, have been mobilizing funds to augment the counterparts either of

PhilHealth or of the LGUs. Some of these private sector sponsoring entities assume the role of

LGUs in sponsoring indigent families for the latters enrollment in the system.

D. DEFINITION OF TERMS

The following terms have been used in this paper:

Beneficiary Any person, who benefits from the program and is used interchangeably as to the

member himself/herself or any of his/her dependents.

Corporation The term is used interchangeably with PhilHealth or Philippine Health Insurance

Corporation


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Indigent - An indigent or sponsored member refers to a member with no visible means of income

or whose income is insufficient for the subsistence of the family, as identified based on the

specific criteria set by the Corporation.

Healthcare Providers Refers to entities or institutions such as rural health units, hospitals, and

clinics accredited to deliver services to PhilHealth members and may also refer to the actual

individuals providing healthcare services.

Household Refers to a family, with parents and children and is used as a collective identity.

Member Person actually enrolled in the Program, whose name appears in the identification

card issued by PhilHealth.

Program Refers to the actual PhilHealth Indigent Program and is used synonymously with

Sponsored Indigent Program.


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CHAPTER II

INTO DEEP: PHILHEALTHS INDIGENT PROGRAM

The NHIA that created the PhilHealth states among its guiding principles, that the

government shall be responsible for providing a basic package of needed personal health services

to indigents through premium subsidy, or through direct service provision until such time that the

program is fully implemented. Created to operationalize this mandate, the PhilHealth Indigent

Program seeks to cover more indigents of the country to ensure access to quality health care

services, and to eventually wean them from dependence on the program by helping them raise

themselves from their very status of indigence.

A. GOALS

The PhilHealth Indigent Programs goals are:

First, to sustainably provide increasing access to health care systems, both

preventive and curative, through health care financing for all indigents, specifically for

the most vulnerable sectors, like the women, children, senior citizens and the physically

infirm among the indigents. Second, to enable indigents to save what they would

otherwise be spending for health care and use these savings as new capital for small-scale

entrepreneurship that would create for them the opportunity for upward social mobility.


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The program seeks to provide necessary assistance to the LGUs for their indigent

constituents effective accessibility of such basic services while these LGUs capability

for full self-reliance for upgraded health care services has yet to be attained. Helping the

LGUs perform well on the devolved mandate for health care service provision has been

this Programs distinct service and contribution to the historic decentralization and

localization process spearheaded by the enactment of the Local Government Code. The

timeframe for the full implementation of the Indigent Program is 15 years after which the

country should have achieved universal health coverage of the countrys indigent

population.

B. PROGRAM KEY ELEMENTS

Certain attributes make up the key components of the PhilHealth Indigent

Program. First and foremost, the program is sharply focused on serving and uplifting the

poorest of the poor through provision of quality health service. Secondly, it seeks to

achieve this through a strong partnership with LGUs. Third, the program provides an

effective incentive scheme to encourage LGUs to invest in health facilities and service

delivery. Finally, as mentioned earlier, the program endeavors to eventually wean the

indigent enrollees from dependence on the system by enabling them to attain upward

social mobility. In this connection, the program has started building partnerships with

cooperatives and other enterprise-oriented organized groups to take over assisting their

members to move from indigence to stable income status within the informal sector.


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1. Target Beneficiaries

Households whose members have a per capita income of P11, 500 (US$250)

per annum or lower, are eligible for coverage. These households are identified by

the LGU through their social welfare officers and barangay (village) officials. The

PhilHealth assists in the selection process. The program is open to all provinces,

cities and municipalities willing to shoulder premiums and improve the level of

health service delivery to their poorer constituents.

2. Two Modes of Paying for Health Services

The Capitation Scheme

Briefly, the Indigent Program keeps a list of enrolled indigents per locality

per year, and serves these enrollees in two ways. One way is through free out-

patient treatment of indigents at the municipal RHU or the city CHC. These

RHUs and CHCs however, need to be accredited as a PhilHealth facility to insure

that the service and supplies delivered are of acceptable quality. The Indigent

Program uses the Capitation Scheme to fund out-patient services of RHU/CHC

facilities and for other purposes as the recipient LGU may decide. Under this

scheme, the PhilHealth pays the sponsoring LGU P 300 per year of indigent

enrollment. The amount is released by the LGU to the RHU/CHC where the

enrolled families are listed. The said RHU/CHC may use the fund to buy essential


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drugs, acquire supplies and materials critical to effect delivery of primary health

care services and pay for referral fees. This result in improved capabilities and

quality of service of the health care facilities. Some LGUs have been able to

purchase critical medical equipment or completely re-furbished medical facilities

using capitation funds received and accumulated. The key to this Scheme

however is that the LGU is enticed to improve its facility and service delivery

system to a level where it becomes eligible for accreditation by PhilHealth. As an

accredited health service provider, the RHU/CHC may then serve individuals

(including non-indigents) who have PhilHealth coverage. Otherwise, the indigent

family has to be served by an accredited private health service provider.

Reimbursement of Hospital Expenses

The second way is through reimbursement by PhilHealth of

hospitalization expenses of the enrolled indigents. As in the case of the RHUs and

CHCs, the hospital used must be an accredited facility. Indigents needing tertiary

level care are referred to an accredited hospital by the RHU or CHC as the case

may be. The PhilHealth reimburses a substantial portion of enrolled indigents

hospital bills, professional fees and medicine expenses. This usually ranges from

50% to 80% on ward rates.

3. Inter-LGU Cooperation in Health Realized Through the PhilHealth Indigent

Program


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LGUs have the primary responsibility of providing health care services for

their constituents. The municipal and city governments, with their RHUs and

CHCs are officially responsible only for primary health care, but enrolment in the

National Health Care Insurance System allows them to send their constituents to

hospitals which are primarily the responsibility of provincial/district/city

hospitals. The referral system has improved coordination in the delivery of health

services, especially between provinces, municipalities and cities.

4. Project Activities

a. Advocacy

The program conducts regular orientation visits to LGUs. For non-

participants to the Indigent Program, the orientation serves as a tool to entice them

to join the program. For existing program participants, the orientation serves as a

venue for updating new products and services of the Indigent Program. Updates

include new items in the list eligible for reimbursement or systems and procedures

governing the program. An orientation to new LGUs includes discussions on the

moral/ethical and legal responsibilities of local governments and its officials as

well as incentives for meritorious performance. Added to this are full explanations

on the workings and benefits that may be derived from the capitation scheme.

Samples of documents to be signed by the LGU officials are presented. Generally,


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the capitation scheme generates the most interest among LGUs. Prior to the

introduction of the Capitation Scheme, PhilHealth focused on the reimbursement

of hospital bills of policy holders, an arrangement which benefited principally the

provincial and city governments. There was no provision for covering outpatient

services which involved mainly the municipal RHUs as well as the CHCs.

Furthermore, at the time the Indigent Program was introduced, LGUs were faced

with financial problems spawned by inadequate funding to maintain and operate

local health facilities. It was no surprise then that LGUs, especially the

municipalities whose support the provincial leadership needed, were tepid to the

offers of partnership (via a Memorandum of Agreement or MOA modality) to

address the health problems of the poor.

b. Process of LGU Enlistment to the Indigent Program

The process of enlistment to the Indigent Program is as follows:

1. The local legislature passes a resolution adopting the program and

authorizing the LCE to enter into an agreement with PhilHealth;

2. The same body enacts an ordinance adopting the capitation fund on

indigent programs Out-Patient Benefit package;

c. Enrolment of Eligible Beneficiaries


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The following process summarizes the enrolment of eligible beneficiaries

to the Indigent Program:

1. The local social welfare officer, in cooperation with the barangay

(Village) chairperson, draws up list of enrollees, using PhilHealth guidelines for

proving indigence. At present, the guidelines are income-based, but this is being

phased out in favor of minimum basis needs (MBN) and community-based

monitoring information system (CBMIS);

2. The list is submitted to the Provincial Health Board for approval;

3. The approved list is then submitted to the PhilHealth Indigent Program,

which proceeds to enlist the LGUs enrollees into its master data base, computes

the requisite amounts of premiums that need to be paid, computes the capitation

fund due the LGU;

4. PhilHealth issues the enrollees service availment cards. The LGUs

share to the premium payments of indigents (amounting to P 1,188 or US$26.40

per family) depends on its classification: first to third class municipalities have to

shoulder bigger amounts per beneficiary than fourth to sixth class municipalities.

Specifically, first- to third-class cities and municipalities are given counterpart

funds equivalent to 50 percent of the total premium payments they have to make.

Fourth- to sixth class municipalities receive PhilHealth counterparts of up to 90

percent of the premium until such time that they can be upgraded to 3rd class.

d. Release of Capitation Fund


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The capitation fund, computed by multiplying the number of indigent

enrollees by the current fixed per capita amount of P300, is released in quarterly

tranches. This fund is used in the operation and upgrading of RHUs or CHCs or

for other health-care related uses. It has been used to purchase medicines (62

percent) and equipment/supplies (average of about 20 percent). The use of the

capitation fund for administrative expenses is limited to not more than 12 percent

of the capitation amount. Of the amount used for administrative expenses, half

must be paid to the RHU/CHC physician and the other half to be shared by the

centers staff members. This guideline has encouraged many health personnel to

stay on, a welcome respite from the current exodus of health personnel to Europe

and the Americas. LGUs have also used the capitation fund to purchase direly

needed equipment including ambulances, x-ray machines and laboratory

materials.

e. Availment of Health Services

The current indigent program features an outpatient benefit package that

covers: primary consultations with a physician, diagnostic and laboratory tests

and chest x-ray. This package is provided through RHUs and CHCs. These

facilities are paid a fixed fee of 300 per indigent household per year. As

administrators over these RHUs, local government units (LGUs) receive this

amount that is specifically designated to be used to complement health center


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funds, under well-defined guidelines for fund spending. Members are also entitled

to a basic inpatient package similar to the package offered for employed and

individually paying members. Members needing hospitalization can avail

themselves of the services of 1,512 PhilHealth accredited facilities, public and

private, found all over the country. Providers are reimbursed for services rendered

subject to maximum caps or ceilings for specific items (e.g. room and boards,

diagnostics, etc). Professional fees are paid subject to a relative unit value system

based on a classification for procedures made. Using the cards issued to them,

policy-holders go to RHUs and CHCs either for routine or symptoms-induced

check-ups. Depending on the results of these checkups, the RHU/CHC decides on

the kind of treatment: an outpatient treatment or hospitalization. For outpatient

treatments, the card entitles the policy holder to free services and medicines. If

hospitalization is needed, the RHU/CHC officer-in-charge writes a referral letter

which the indigent presents to the accredited hospital. The LGU handles all the

administrative requirements needed to reimburse services, facilities and supplies it

advanced to meet the needs of policy holders, including the collection of

capitation funds due the RHUs and CHCs. LGUs issue local guidelines to

translate Phil-Health policies and rules. These include guidelines for the use and

allocation of capitation funds as well as reimbursement of advances made by

LGU hospitals to policy holders.

f. Accreditation of Health Facilities


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The PhilHealth regularly inspects and accredits health care facilities

operated by both public and private health service providers who apply for

accreditation. The Department of Health and the Phil-Health are guided by rules

and regulations setting the standards for accreditation. Many LGUs have used

accumulated Capitation Funds to refurbish, re-equip or modernize their health

facilities to ensure that they obtain PhilHealth accreditation.

g. Training in Health Service Delivery

Technical inputs and training services for LGU health units are facilitated

by the regional offices of DOH. These services are provided on a case-to-case

basis mostly through customized courses. Support from external donors has

helped expand the capacity of the regional DOH offices to respond to the LGUs

training needs.

h. Implementing Agency

The National Health Insurance Act mandates the PhilHealth to implement

and manage the National Health Insurance Program, including its component

Indigent Program. More specifically, the PhilHealth Indigent Program is

implemented and managed by the PhilHealths Program Management Group for

Membership and Marketing. This group coordinates all partner organizations

especially the LGUs and the latters health care facilities. It also works closely


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with the relevant national government instrumentalities including the Congress

and the Senate. PhilHealth also is responsible for monitoring the program.

i. Program Cost

The programs cost item consists essentially of premiums paid for jointly

by the PhilHealth and the LGUs. Each enrolment incurs a cost of P1,188 (US$

26.40). As of April, 2007, the program has cost the government about P4.7 billion

a year (US$104 million). This cost is shared between the national governments

National Health Insurance Program and the LGUs. The LGUs share however

depends upon its classification, as discussed earlier. It must be noted however that

of the amount, P1.18 billion (US$26 million) or roughly 25 percent is plowed

back to LGUs in the form of capitation funds to help them improve their health

facilities and maintain appropriate stocks of medical supplies.

C. OUTCOMES

In addition to increased revenues to PhilHealth (growth rates as high as 166

percent in high enrolment sites), undoubtedly, the Indigent Program, particularly through

the Capitation Fund scheme, has led to the upgrading of the capability of many LGUs,

through improved facilities and management, to deliver high quality health-care services

to their constituents. A fine example would be the province of Bukidnon in Mindanao,

where the provincial government financed the establishment of well-manned and well-


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supplied health stations in all towns to augment the capabilities of the RHUs in providing

primary health care. With the flexibility offered by insurance financing, the Indigent

Program has inspired local officials to develop and employ creative solutions to their

health problems. In some places, local public health facilities are improved so much as to

pose serious competition to private health service providers. Whether this is good or bad

news remains to be seen. Whatever the case, some observers have noted that in some

places, the competition has resulted in lower hospital rates.

The Indigent Program has expanded the coverage of local health service delivery

to unprecedented levels. Previously, hospital services were provided directly by LGU

hospitals. Under this old mode a provision of P500,000 (US$ 9,000) for hospitalization

expenses could cover only 75 patients, based on an average value of P6,600 (US$128)

per claim. Under the insurance system, that same amount can cover 4,000 families, or up

to about 20,000 beneficiaries. The incentives provided by the Capitation Fund have

encouraged LGUs to enroll the poorer constituents, effectively increasing the poors

access to quality primary health services and facilities.

Participation in the program increased the use of primary health care facilities.

There is anecdotal evidence to support the observation that such an increase is

significantly attributable to renewed interest of women in pre- and post natal care and

even childbirth, these services being accessible to indigent policy holders. One indication

of success in this regard is the number of days of drug stock outs in RHUs and CHCs. In

high (PhilHealth) enrolment areas, the average was 35 days compared to 180 days in


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areas with low enrolment rates. Studies conducted by the Department of Health also

showed that local health facilities in high enrolment areas were well-stocked and well-

equipped compared to those in low enrolment sites. Likewise utilization rates, measured

in terms of per capita visit rates per year, of RHUs and CHCs were higher (equivalent to

4.9 per 100 person days of listed members) in high enrolment sites compared to those in

low enrolment sites (2.5 per 100person days of listed members).

Health insurance has changed the way local public health provision is financed

(albeit partially). One is through the capitation fund and another through direct

reimbursement of advanced services, supplies and facilities. This has created a strong

motivation for LGUs to provide services to the poor at levels unheard of even in the

recent past.

There is at least one anecdote indicating that the program has positively impacted

on local politics by reducing patronage. A Mayor explained that he expected to reduce

the number of people approaching him for assistance once the health insurance program

is implemented in his municipality. He has so far been unsatisfied with the result but is

hopeful that it will change for the better.


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CHAPTER III

CONCLUSION

The PhilHealths Indigent Program has been evaluation in terms of coverage, quality

benefit availment, sustainability, and in terms of poverty alleviation.

A. COVERAGE

PhilHealth is definitely ahead of its deadline when it comes to membership coverage.

Table 1 shows the segregation of members to PhilHealth in terms of sectors, which the

Sponsored/Indigent Program ranks second in term of membership.


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Mass enrolment has proven to be an effective strategy in meeting PhilHealths mandate

of achieving universal coverage on its fifteenth year. However, it must be ensured that all

enrolled indigent members are really indigents. Though PhilHealth has a well-defined criteria in

choosing qualified indigent enrollees, politics will always intervene. Indigents who are known as

supporters of the existing LCEs are favored to those who are non-supporters.

Figure 1 shows the number of families actively enrolled in the Sponsored Program from

2000 2009:

The criterion based on whether the program was effective was in comparison to

PhilHealth set goals. Since the program was able to register more than the target set, therefore

the program can be considered effective in terms of coverage.


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B. QUALITY BENEFIT AVAILMENT

In terms of quantity, PhilHealth certainly achieved its goals, the question now lies on the

availment of benefits, whether these number of new members were able to avail quality

healthcare, and on the side of the sponsors, if they were also benefited in return of their

investment.

Comparing the number of members enrolled as to the actual member or beneficiaries

availing the program, Table 2 describes the percentage of members availing PhilHealth benefits

in the past 12 months:

In 2005, Philhealth contributed 11.0 percent or PhP 19.2 billion to the countrys total

health expenditure which amounted to PhP 180.8 billion. The burden of financing health


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care was still heaviest on individual families with 48.4 percent or PhP 87.5 coming

from households outofpocket spending. The NG contributed 16 percent or PhP 26.0 billion

while local governments gave 13 percent or PhP 24.7 billion. One of the targets

of the National Objectives for Health is to have 15 percent of financed by PhilHealth by 2010.

In terms of the amount of paid claims, figures show that PhilHealth was able to meet its

targets and have continuously paid more filed claims since it has been created. This can be

bserved in the figure below:

But first hand testimonies have spoken that not all can testify quality benefit availment.

For one, the tedious process of filing for a benefit claim. Healthcare providers lack the


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uniformity of their requirements and processes in filing for a claim. Members who are supposed

to be indigents are thus burdened of the expenses just to be able to retrieve all the documentary

requirements. This happens when the healthcare provider requires attachments that are yet to be

retrieved in PhilHealths service offices which often located far from the hospital where most

indigent members are admitted. More often than not, cardholders choose to knock on the

doorsteps of their Mayors than consume themselves processing their filing of claims. This is not

an uncommon situation especially when most of the indigent members are not well informed of

the nature of PhilHealths programs and process flow in benefit availment.

On the side of the sponsors, their benefit from the program lies at the release of the

PhilHealth Capitation Fund (PCF), which is released as a trust fund to finance for medical

supplies and improvements on medical facilities on sponsoring LGUs or Provinces. This

mechanism has also proven to be an attractive package that enticed almost all municipalities and

provinces nationwide to enter into a memorandum of agreement in implementing the Indigent

Program.

But there are requirements needed in order to receive the PCF, namely, implementation

of the Indigent Program, timely payment of the premium, and a PhilHealth accredited healthcare

provider (this may refer to a rural health unit or a hospital). Thus the LGU is again required to

invest in improving their respective RHUs in order to meet the accreditation standards set by

PhilHealth. But this did not hinder enrolment even in 4th-6th class LGUs since they often get the

lions share of the benefits. They are able to provide health insurance to their indigent

population, they get to improve their local health facilities, they pay the lesser counterpart of the


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premium (sharing it with the national government in incrementing levels based on the year of

implementation of the program), plus they usually receive a much higher amount of PCF than the

actual premium that they have paid.

C. SUSTAINABILITY

How long can PhilHealth sustain this Program? Moneywise, PhilHealth is releasing too

much of its money in implementing the Indigent Program. But fifteen years after its initial

implementation, PhilHealth claims to be in a financially stable state. With its current assets

reaching up to P91 billion as of July 31, 2009, President Rey B. Aquino firmly asserts that

PhilHealth is on solid ground and counting. In fact, earnings from investments have allowed

PhilHealth to expand the numbers of its beneficiaries and increase hospitalization by 35% as of

April 2009.

D. POVERTY ALLEVIATION

Created in the context of the worsening poverty, the Indigent Program initially was

tasked to extend health insurance to the needy. Since poverty is caused by a multitude of

elements, it is but improper to treat health insurance as the only solution. Although provision of

health insurance can somehow alleviate poverty in terms of availment of health services, the

program can be considered effective in such area.


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E. SLOGAN

Created to improve the Medicare system, PhilHealth extended health insurance coverage

to the unserved sectors, more importantly the poorest in the society. The PhilHealth Indigent

Program is also known as Medicare Para Sa Masa, was aimed at ensuring that all sectors in the

society benefits from the National Health Insurance. It is a practice of social equity wherein

healthcare is made available to every Filipino citizen.


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CHAPTER IV

RECOMMENDATION

Initially, LGUs did not respond positively to invitations to participate in the program for

a number of reasons: (a) the initial design benefited principally provinces and cities which were

responsible for the operation of hospitals; (b) the program was viewed as a cost center

requiring the usual counterpart funds; and (c) there was general discontent among the LGUs over

the inadequacy of funding for health operations vis--vis the magnitude of the responsibility. The

introduction of the capitation funding scheme and the cost sharing scheme between national and

local governments to cover premium payments changed the minds of LGU officials. Further,

many officials also saw participation as a concrete way of gaining electoral advantage.

A second major challenge was the selection of enrollees. Political patronage figured

prominently in the selection of enrollees. This had to be overcome by ensuring that official

guidelines were followed. In some instances, non-government groups were asked to assist in the

selection. This challenge continues to be an on-going concern and only the vigilance and

dedication of the concerned local officers, specifically the social worker and the village leaders,

PhilHealth officials and civil society groups, can minimize the influence of political patronage in

the selection process.

A third challenge is changing the way local officials view the capitation fund. PhilHealth

officials are leery of the view that the capitation fund is a return on investment. This was and

still is being overcome by painstaking education work among LGUs to make them realize that


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the fund is provided as a means to improve health service delivery and reduce health service

delivery cost.

Information on the entitlements that come with being insured has been confusing and in

certain cases, conflicting. This includes poor information on the obligations of the insured

particularly on the matter of what is and is not covered by the insurance. Often this has led to

confusion over what the insured needs to pay for. This has inconvenienced both the indigents as

well as both the local private and public service providers. Information dissemination on such

entitlements was and continues to be inadequate. The PhilHealth, together with the DOH and the

LGUs has agreed to address this information need. Inequality of coverage among regions is

conspicuous. The programs management believes however that LGUs now lagging behind the

others in terms of enrollment would be catching up as soon as they realize the advantages of

increasing their indigent enrollees.


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REFERENCES

Publications

PhilHealth at a Glance, November 2009, Senate Economic Planning Office

Priming the Health Insurance Programme for the Indigents, 2002, Philippine Health Insurance

Corporation

Republic Act No. 7875, National Health Insurance Act of 1995 Instituting a National Health

Insurance Program and Establishing the Philippine Health Insurance Corporation

The Revised Implementing Rules and Regulations of the National Health Insurance Act of 1995,

First Edition, July 2000

1996 2002 PHIC Annual Report

Best Practices in Health Financing, Department of Health

Online References

Philippine Health Insurance Corporation Website, Accessed at ,

Accessed on January 04, 2010

U.S. Library of Congress Website, Accessed at ,


Health Care in the Philippines, Accessed at ExpatForum Website at

,


World Health Organization Website, Accessed at ,


Phil Health Indigent Progam for Filipinos

Documents

Transcript of Phil Health Indigent Progam for Filipinos