successes and failures in expanding and deepening...

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)




• 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


SUPPORT VALUE in PRIVATE HOSPITALS is quite POOR

Source: Department of Health, GoP

PhilHealthcreated

Source: World Health Report 2006

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

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