Professional Documents
Culture Documents
(HPAd 201)
PHILIPPINES
3.9
34.7
7.7
54.7
INDONESIA
2.2
54.4
8.7
30.1
VIETNAM
7.1
39.3
12.7
54.8
Philippines 2005 GNI - $108 B 2005 GNI / capita $ 1,300.00 Population below $ 1.00 / day 15.5% Population below $ 2.00 / day 47.5%
Malaysia 2005 GNI - $ 125.8 B 2005 GNI / capita - $ 4,960.00 Population below $ 1.00 / day NA Population below $ 2.00 / day 9.3%
MALAYSIA
Govt 58.2% of of funding in public health sector Private sector 41.8% of funding in public health sector Out-of-pocket 73.8% of private health expenditure Private insurance 13.7% of private health expenditure Employee Provident Fund (EPF) Social Security Organization (SOCSO)
PHILIPPINES
(1) PhilHealth > Formal Sector (GSIS, SSS) > Informal Sector (selfemployed; individual paying program) > Sponsored (unemployed, underemployed, indigent, retirees, pensioners) (2) Private health insurance (2) HMOs (3) Community Schemes
Govt 58.2% of public health expenditure Out-of-pocket - 73.8% of private health expenditures
4,960.00
1,300.00
4.8%
3.8%
44.8%
35.3%
care outcomes are not very sensitive to variations in health care expenditures Life expectancy and infant mortality measures are similar in OECD countries but the variations in total health care expenditures are very large
8 OECD countries: little difference in health status; large differences in health care expenditure, resource allocation, and use of services Ratio of MD to population range of 1.4 to 3.1 / 1,000 Average number of MD visits / person / year range of 2.8 11.5
Evidence of Allocative Inefficiency Number of hospital beds range of 4.7 to 12.4 / 1,000 Annual number of hospital days / person range of 1.2 to 3.7 Number of MRI scanners / 1,000,000 population ranges from 1 in Canada to 11.3 in USA Total health care expenditure as a % of Gross Domestic Product range of 6.5% in Denmark to 14% in USA
1/5 live in absolute poverty; globalization skewed income distribution & accelerated destitution
wealth & income are among the most important determinants of health
Poverty as Disability
poor peoples coping mechanisms to rising cost of medical care reduce their consumption of poor in Uganda decrease spending on meals distress sales Kenya: of land sales; Vietnam: sale of buffalo household borrowing Manila shifting spending e.g., children stop schooling delaying / reducing care
Developed
US$ 9 B
US$ 82 B
Developing
US$ 80 B
US$ 10 B
In rich countries, government pays for health; in poor countries, people pay out-of-pocket Industrial Countries: Private Spending as % of Total USA 55 Germany 15 Britain 5 Poor Countries: Latin America East Asia South Asia Sub-Saharan Africa
Private Spending as % of Total
58 52 75 60
30,021 beds), 6 special medical institutions (with 4,740 beds), 809 health clinics, 1,919 rural clinics, 89 maternal and child health clinics, and 146 mobile clinics
open-door policy in regard to general outpatient services and hospital admissions has been practiced by the public health sector. Access to specialist services is nonetheless controlled through a national system of referral.
Philippine Trends of Per Capita Health Spending at Current and Constant (1985) Prices, 1993 - 2007
Private
Private Clinic Other Private
Other
Alternative Medical Nonmedical
Lowest
2.3
Second
6.0
Middle
7.1
Fourth
8.3
Highest
4.0
66.9
(2008)
30.1
34
(2008)
25.5
25
(2008)
17
Baseline
162
(2006)
Target (2016)
50
34
(2008)
51
(2008)
63
(2015)
62
(2008)
90
44
(2008)
90
Baseline
Less than 1% (2009) 22 (2009) 0.03 (2009) 486 (2008) 41 (2007) 73 (2008) 79 (2008)
Target (2016)
Less than 1% 4 Less than 0.03 387 33 (2015) 85 85
Proportion of population with access to safe water, Households (%) Proportion of population with access to sanitary toilet facilities, Households (%) Population with access to affordable essential drugs (%)
82.3
(FHSIS 2008)
88
76.8
(FHSIS 2008)
88
73
(2009)
95
Baseline
2.04 (2000-2007) 3.3 (2008) 54.3 (2007)
Target (2016)
1.48-1.82 (2015) 2.4-2.96 (2015) 35
Percentage of out of pocket payment from total health care expenditure Benefit Delivery Rate (National Health Insurance Program)
7.7 (2008)
30
53 (2008)
74 (2010)
100
100
Baseline
90 (2010)
Target (2016)
95
26.3 (2008)
22.4
MDG
Prevalence of underweight children under 5 years of age Percent of household with per capita energy less than 100% adequacy Under-5 mortality rate (per 1,000 live births) Infant mortality rate (per 1,000 live births) Proportion of yearold children immunized against measles
TARGET By 2015
CURRENT LEVEL
17.3
Medium
Medium
69.4
34.7
80
26.7
33.5 (2008)
High
57
19
High Low
77.9
100
MDG
Maternal mortality ratio (based on 7-12 PMDF* range) Proportion of births attended by skilled health personnel
TARGET By 2015
CURRENT LEVEL
121-207
30.3-51.8
95-163 (2006)
Low
58.8
100
74.0 (2008)
Medium
40.3
118.7
100
0
50.7 (2008)
13.3 (2008) 0.2 (2005)
Low
High High
1.4
MDG
Prevalence associated with tuberculosis Death rate associated with tuberculosis AIDS
TARGET By 2015
CURRENT LEVEL
246.0
Medium
Low Low High High
39.1
<1% 73.0
<1% 86.5
Proportion of population with access to safe water supply Proportion of households with sanitary toilet facility
67.6
83.8
89.0 (2008)
Reference of Subsequent Slides: Prof. Orville Solon, PhD, UP School of Economics, Series of Health Sector Reform Agenda Reports Focusing on Health Care Financing
1. Epidemiological context: rising chronic and degenerative diseases will mean increasing pressure in the market place as well as in public health budget to reallocate resources away from the delivery of services for infectious and communicable diseases
2. Demographic context: the size, structure and rate of growth of the population determines over the long term the capacity of the health sector, the mix of services produced, and the rate at which such capacity will have to increase.
3. Macroeconomic context: the prospects for GNP growth, the creation of new jobs, and price stability determine how much households, from which all finances are generated, can spend on health care.
3. Many households lack accessible and affordable transport facilities that would allow them better access to health care facilities 4. Many households find their work and social time schedules incompatible with the service hours especially of public health care providers
Philippine Households Face Barriers to Health Care Other than Financing 5. Many households hold on to socio-cultural values and belief systems that prevent them from receiving appropriate and effective health care services.
The Impact of Financial Barriers is Reflected in the Way Income, Prices, and Insurance Coverage Influence Household HealthSeeking Behavior in the Philippines
1. With higher incomes, utilization of facility-based services increase, and the services of more expensive (perhaps better quality) providers are sought. 2. With price increases, poorer households reduce health care utilization; others switch to less expensive (perhaps lower quality) providers. 3. Regardless of income and prices, insured households tend to have higher utilization rates for facility-based care and prefer more expensive health care providers.
However, Because Insurance Reduces the Cost-Consciousness of Households, Adverse Health-Seeking Patterns may Result.
1. The likelihood that facility-based care will be sought for mild conditions will increase. 2. Referral systems are likely to be by-passed as services of more expensive providers are sought. 3. The tendency to substitute equally effective home-based preventive and promotive care with facility-based care is induced.
The Institutions which Assist the Filipino Household in Financing Health Care Expenditures include:
1. Extended family networks (i.e., remittances, gifts, and transfers) 2. Informal community social networks (i.e., paluwagan)
3. Organized community schemes (i.e., health cooperatives)
The Institutions which Assist the Filipino Household in Financing Health Care Expenditures include:
4. Social networks (i.e., church, charitable institutions) 5. Sectoral networks (i.e., labor unions, employers) 6. Private voluntary insurance
The Institutions which Assist the Filipino Household in Financing Health Care Expenditures include:
Reference of most of the subsequent slides: Ramon P. Paterno, MD, MPH, Universal Health Care Financing, Acta Medica Philippines, Vol. 44, No. 4, 2010, pages 58 70.
1. Tax-based funded U.K. National Health Service model or the Cuban model 2. Social Health Insurance funded German Bismarckian model
3. Government-subsidized National
Health Insurance paying for services provided by private providers 4. Out-of-pocket system including private insurance paid out-of-pocket; US model is a combination of the different means of financing health care
4. Out-of-pocket system (continued) government insurance subsidized with Medicare for the elderly & Medicaid for the poor, a tax-funded Veterans health service & private health insurance or out-of-pocket payments for the rest US model has one of the highest national health expenditures (16% of GDP in 2007) but with a large number of the population uninsured (49 million) and with health outcomes ranked only as number 37th in the world
WHO Western Pacific Region Health Financing Strategy for the Asia-Pacific Region 2010 - 2015
1. Chronic underfunding 2. Inequitable sourcing of funding (low public spending leading to high out-of-pocket spending)
Underfunding Most developing countries in the Asia-Pacific Region spent (in terms of total health expenditure or T.H.E.) less than 5% of GDP based on National Health Accounts for 2007. Country T.H.E. as % of GDP Vietnam 7% Korea ) Mongolia ) > 5% Cambodia ) Nepal ) Philippines 3.9% (3.8% in 2009)
Philippines
4.8
3.8
44.8
35.3
55.2
0.9
64.7
19.7
73.2
83.5
Other
Donations, grants, loans Employers funds Collected by various agencies
Premiums
Households, individuals Collected by private insurance funds
Out-of-pocket payments
Households, individuals Collected by providers
Allocative Efficiency
80% of essential care and 70% of desirable health interventions can be delivered at the primary level but an average of only 10% of health resources are used for primary care in Asia
Allocative Efficiency
Six (6) countries in the Asia-Pacific Region spent less than 20% on primary health care; Philippines spent 11% on public health care About half of total health spending in Cambodia, China, Lao PDR & Vietnam went to pharmaceuticals & diagnostic services
Payment Mechanisms
More common methods: (1) Fee-for-service (2) Salaries (3) Case payments (4) Capitation (5) Global budget
Payment Mechanisms
Main provider payment mechanism in AsiaPacific Region: (1) Budget allocations (2) Salaries (3) Fee-for-service regulations regarding fees and balance billing tend to be weak; when the provider is paid for every service provided, usually at the time of service; usually strong in terms of quality but drives cost up & encourages over-provision of services
Path to Universal Coverage Key Health Financing Options at Different Stages of the Evolution towards Universal Coverage Universal Coverage
Tax-based financing Social health insurance Mix of tax-based and social health insurance
Personal care expenditures 73 - 78% of national health expenditures Public health expenditures 11-14% of national health expenditures
Fee-for-service payment mechanism remains the dominant form of the reimbursement mechanism of PhilHealth 90% of reimbursement for hospital claims
Stakeholders of government health spending: 1. DOH finances retained hospitals & national health programs 2. LGUs (provincial governors, municipal & city mayors) 81 provinces, 136 cities, 1,495 municipalities; use IRA to finance health facilities & services; provinces finance provincial and district hospitals; municipalities are in charge mainly of public health & primary health care 3. PhilHealth pays for services of DOH, LGUs, & private health facilities
PhilHealths Quality Improvement Study patients in secondary hospitals in the Visayas had outside of hospital purchases amounting to 30% of their hospitalization needs
2007
6,647
2011
9,018
2013
10,549
2015
12,341
Setting up a National Health Development Fund with at least an additional PhP 50B to the present Department of Health budget; will provide the following:
1. PhP 14 B for the Philippine Health Insurance Corporation premium of the poorest 60% of the population
2. PhP 10 B for health infrastructure
3. PhP 10 B for improving personnel salaries of the governments health human resources
4. PhP 15 B to ensure adequate supply of 100 essential medicines 5. PhP 1 B for disaster preparedness
Implementation can begin with the poor families in the regions with the worst health status: ARMM, MIMAROPA, Samar-Leyte, Bicol, Zamboanga Peninsula, West Visayas, Davao Peninsula, urban poor areas of Metro Manila, metro Cebu, Davao.
Source
PhilHealth Reserve Fund Removal of PHIC Salary Cap Anti-Corruption Drive Road Users Tax PAGCOR
Revenue (PhP)
110 B
280 B 10 B 30 B
100 B 5B 7B
22.6 B
6.8 B
Possible Sources of Revenue for Universal Health Care Table 3. Potential Sources of Funds for Universal Health Care (UHC) Source Revenue (PhP) Potential for UHC (PhP)
Sin taxes Amendment: 1st Year 2nd Year 3rd Year
20 B 30 40 B 40 50 B
10 B
4th Year
Debt for Equity Swap TOTAL
70 B
40% of National Budget
100 B
Allocative Efficiency
Essential Health Package: Defined by a Filipino Technical Working Group under the sponsorship of WHO Philippines Country office Costing was modeled on a working rural Inter-Local Health Zone consisting of 5 municipalities (and RHUs) Centered around a functional district hospital with the necessary health facilities, equipment, essential medicines, & staffed by the health human resource needed to provide the defined services
Allocative Efficiency
Essential Health Package: Consists of eight (8) services with supporting diagnostic lab services and an adequate supply of prioritized essential medicines Eight (8) services build on existing RHU health services & were expanded to include community mental health & oral health & rehabilitative services connected with noncommunicable diseases
Allocative Efficiency
Cost of the Essential Health Package =
PhP 1,400.00 per Filipino 2007: With Total Health Expenditure = PhP 235 Billion, the per capita health expenditure = PhP 2,640.00
Allocative Efficiency
Costing of Essential Health Package gives us a scientific basis for health budget formulation To provide all Filipinos basic health services, need at least a health budget of:
PhP 1,400.00 x 94 million Filipinos in 2010 = PhP 135 Billion vs. the 2011 Department of Health budget of PhP 33 B.
Global Budgeting
Provision of Essential Health Package can be sub-contracted to interested inter-local health zones (ILHZs) using a global budget based on the capitation amount of PhP 1,400.00
Might be a financial incentive for district hospitals & surrounding municipalities to work together This would incentivize promotive & preventive health services to lessen the need for the more expensive curative services & medicine
Improvements in the health sector only account for about 20% of the improvement in health status Improvements in the social (i.e., socio-economic-politicalenvironmental) conditions account for the larger 80%
Governments anti-poverty strategy focus on agriculture & rural development thru asset reforms (e.g., agrarian reform, urban land reform, ancestral domain reform); reforms in the agricultural sector investments in productivity improvements & supporting infrastructure
?
High % of rural population Self employed, high illiteracy