LianJumilD.Rivera

WhyPoorMothersFailtoEnjoyPhilHealthBene�its

published by the National Anti-Poverty Commission Issue # 8

To the poor, health care had simply meant accessing whatever free services were available at the nearest health facilities. Very few had been able to complete treatments because the costs of diagnostic tests and medicines came out of their own pockets. Health insurance was practically unheard of.

But change had come. Significant reforms introduced under the Aquino government saw Philhealth, the national health insurance program, increasing its coverage to 92% of the population, the highest since it started in 1995. Half of those now covered are poor families enrolled under the Indigent Program, their premiums fully subsidized by the national government using additional revenues from the Sin Tax.

Expanding the benefit packages to cover more illnesses, including catastrophic ones that require expensive and long-term treatments, has increased PhilHealth's total benefit payout by three-fold: from P31 billion in 2010 to P97 billion in 2015. Several policies were put in place to facilitate the access of vulnerable groups—especially poor families and women about to give birth—to quality healthcare.

However, it appears that health insurance coverage is still no guarantee that those who need it most will seek medical care. Even the benefits that they are supposed to receive from the health insurance company are not deemed adequate.

The National Anti-Poverty Commission (NAPC) conducted a series of surveys in 2015 to determine the barriers that indigent PhilHealth beneficiaries—particularly pregnant mothers—face when seeking healthcare. The findings showed that seven in ten indigent mothers went to a health facility to give birth, but only four in ten used their PhilHealth card for maternal care services.

The survey was conducted among 1,130 indigent mothers in 12 cities and municipalities nationwide. The ages of participating mothers were between 15 to 49 years old. They are either members or dependents of members under PhilHealth's Indigent or Sponsored Program. Except for some respondents in three survey areas who gave birth between 2010 to the present, the interviewees delivered their babies in the past 12 months prior to the survey period.

Households enlisted as poor in the National Household Targeting System for Poverty Reduction are automatically enrolled under PhilHealth's Indigent Program as mandated by Republic Act (RA) No. 10606 or the National Health Insurance Act of 2013. Their premiums are sourced from the Sin Tax revenues based on RA 10351; Source: PhilHealth Stats & Charts, 2015

PhilHealth Stats & Charts, various years

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Delivery at home and the lack of accredited facilities

As of 2015, only 752 public hospitals and infirmaries had been accredited by PhilHealth; eight in 10 cities and municipalities nationwide had at least one accredited outpatient clinic for maternal care services.

The survey among the mothers found that many of them gave birth at home despite the heightened campaign for facility-based delivery. Many of them went to health care facilities but were not able to avail themselves of the benefits because the facilities were not accredited by PhilHealth.

Health facilities were also usually inaccessible to families living in remote areas. The only option was the barangay health station (BHS), which was not PhilHealth accredited because it did not comply with the accreditation standards of PhilHealth.

This highlights the importance of investing on the quality of services of the BHS. It is the most feasible point of care for the poorest population in faraway places.

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Lack of access to right information

The PhilHealth Alaga Ka campaign and the Family Development Sessions for beneficiaries of Pantawid Pamilyang Pilipino Program (4Ps) were attempts to inform the poor. However, the impact of these efforts are yet to be seen.

The survey found that four in every ten respondents were not aware of the PhilHealth benefits for pregnant mothers and their infants. Still, those who knew of their benefits were discouraged from using their PhilHealth card. They either lacked documentary requirements or thought that there was a limit to the number of birth deliveries covered by PhilHealth.

As far back as 2014, PhilHealth had already relaxed its birth parity rule, which had set coverage only up to the fourth childbirth, to include all childbirths of a mother-beneficiary. Crucial details such as this should be emphasized during information dissemination and posted in strategic areas in hospitals and healthcare facilities.

More families could have used their PhilHealth card had they known about their membership, benefits, and availment process. Currently, PhilHealth only requires indigent beneficiaries to present either their PhilHealth ID or their Member Data Record to access benefits.

Out-of-pocket costs of health care

The indirect cost of health care is another reason why poor families forego their PhilHealth benefits. This includes the perceived out-of-pocket expenses, transportation costs, and lost wages.

Survey findings showed that mothers who used their PhilHealth card for childbirth still spent an average amount of P2,275 from

their own pocket to pay for medicines and supplies bought outside the health facility.Assuming that the pregnant mother was employed, she also lost P481 of her wage for the day and spent P69 for transportation. The total out-of-pocket expenses was P2,825, onerous for a poor family that can only spare 2% of its total annual expenses to healthcare.

But these mothers should not have spent their own resources in the first place because PhilHealth has a No Balance Billing (NBB) policy. It is supposed to ensure that beneficiaries will not pay any amount for healthcare services in public health facilities.

In 2015, only half of indigent PhilHealth beneficiaries was able to avail themselves of the NBB. Clearly, there are still gaps in the policy implementation that need to be addressed.

Reducing the indirect costs spares the family from worrying about the expenses of seeking healthcare. Essential services should be available at the BHS and rural health units, and ensure that these facilities get PhilHealth accreditation.

The people will get the most of the benefits of the NBB policy if healthcare providers have complete diagnostic and treatment facilities, and medical supplies for indigents. To this end, NAPC has been advocating for the proper implementation of income retention, a provision in the Republic Act No. 7875, as amended, mandating local government units to allow their local health service providers to retain all PhilHealth reimbursements.

PhilHealth Circular No. 22, series of 2014 Similar findings by Villaverde, 2012 and Wang et al., 2012P481 is the minimum wage rate for workers in the non-agriculture sector in the National Capital Region as of April 2015; P69 is the average cost of transportation to any facility in 2013, according to the 2013 NDHSFamily Income and Expenditure Survey, 2012PhilHealth Stats & Charts, 2015

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The said income should be used to defray operating costs, maintain or upgrade facilities and equipment, and improve service quality.

In support of NAPC's advocacy, the Department of Health made income retention a mandatory requirement in the 2016 Health Facility Enhancement Program (HFEP) Availment Guidelines. With income retention as HFEP conditionality, the local health service providers can further enhance their capabilities and provide incentives to their health personnel as they gain more flexibility and independence with their revenues.

Local evidence-based strategies

Most of the barriers to benefit utilization were common across all the surveyed localities. However, in a highly urbanized city where there are more accredited facilities than the other areas, childbirths were facility-based and the utilization rate was relatively high. Mothers in these areas incurred the highest out-of-pocket payment for medicines compared to other areas.

Meanwhile, in rural areas where access to facilities are limited, more mothers delivered at home or at the BHS. In Palimbang, Sultan Kudarat for example, 69% of the surveyed mothers gave birth at home and another 16% gave birth in a barangay health station. As of December 2015, there were still no PhilHealth-accredited hospitals, infirmaries, and outpatient lying-in clinics there. Consequently, it has the lowest PhilHealth utilization rate at 8%.

Some barriers are better addressed by local action rather than national policy and program enhancements.For instance, the LGU's utilization of their hospitals' income from PhilHealth can help build more facilities serving the remote areas. The information campaign about getting access to healthcare through PhilHealth should be held at the barangay level.

Looking through a local lens in understanding the problem and proposing solutions was deemed more effective given the country's devolved healthcare system. Thus, NAPC proposes that the survey instrument be further enhanced into a standard tool that the LGUs can use to analyze the factors affecting the underutilization of PhilHealth benefits in their locality. Insights from the survey should be integrated in the local health plans, with clear arrangements on accountability among the various stakeholders.

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Income retention is based on Article VIII Section 34-A of Republic Act No. 7875, as amended by RA 9241 and RA 10606 or the “National Health Insurance Act of 2013”N=64Note though that the survey in this area includes some respondents who had given birth more than 12 months prior to the survey period but between 2010 to present.

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There are gains in the reforms, and we have national-level figures to support this. Yet, if we look closer, we find that there are still gaps in the mechanisms that are supposed to deliver these reforms to the smallest communities. NAPC will continue to push for local evidence-based strategies to ensure that the vulnerable sectors fully benefit from the financial risk protection that PhilHealth provides.

ReferencesPhilippine Health Insurance Corporation. 2010-2015. [Tables and graph illustrations on PhilHealth

membership and benefits]. PhilHealth Stats & Charts. Accessed at http://www.philhealth.gov.ph/about_us/statsncharts/

Philippine Health Insurance Corporation. 2014. PhilHealth Circular No. 22 Series of 2014.Philippine Statistics Authority. 2013. [Tables]. 2012 FIES (Statistical Tables). Accessed at

https://psa.gov.ph/content/2012-fies-statistical-tablesPhilippine Statistics Authority & ICF International. 2014. Philippines National Demographic and Health

Survey 2013. Manila, Philippines, and Rockville, Maryland, USA: PSA and ICF International.Quimbo, S., Florentino, J., Peabody, J. W., Shimkhada, R., Panelo, C., & Solon, O. 2008. Underutilization of

social insurance among the poor: Evidence from the Philippines. Plos ONE, 3(10), e3379. doi:10.1371/journal.pone.0003379

Shaikh, B. T. & Hatcher, J. 2005. Health seeking behaviour and health service utilization in Pakistan: Challenging the policy makers. Journal of Public Health, 27(1), 49-54.

Soeung, S. C., Grundy, J., Sokhom, H., Blanc, D. C., & Thor, R. 2012. The social determinants of health and health service access: An in depth study in four communities in Phnom Penh Cambodia. International Journal for Equity in Health, 11(46), 1-10.

Villaverde, M. C., Vergeire, M. & de los Santos, M. 2012. Health Promotion and Non-communicable Diseases in the Philippines: Current Status and Priority Policy Interventions and Actions. Quezon City, Philippines: Ateneo de Manila University & Health Justice Philippines.

Wang, H., Liu, Y., Zhu, Y., Xue, L. Dale, M., Sipsma, H., & Bradley, E. 2012. Health insurance benefit design and healthcare utilization in northern rural China. Plos ONE, 7(11), 1-7.

About the Author:

Lian Jumil D. Rivera is a staff of the Policy, Monitoring and Social Technology Service Unit (PMSTS) of NAPC. She is a graduate of Psychology at the University of the Philippines, Diliman and is pursuing a Master's degree in the same field, also in UP. Her professional interests are advocacies on public health and social protection. Her doodles, cartoons and drawings delight her colleagues.

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