DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

CEBU INSTITUTE OF MEDICINE-COMMUNITY MEDICO-SOCIAL SERVICES

Brgy. Paknaan, Mandaue City
Tel No.: 344-3642

THE PHILIPPINES NATIONAL HEALTH

INSURANCE PROGRAM AND UNIVERSAL
HEALTH CARE

Submitted by:
Sophia Vivien L. Verallo
Applied Nutrition Coordinator
FAMED Clinical Clerk
Submitted to:
Annely Jane R. Celocia, MD
CIM-CMSS Chief

I. History of Philippine Health Care

August 1969: Medicare
- provided health care to employed citizens

- benefits only involved hospitalization

- limited in scope
September 1987: National Health Insurance Program
- enshrined health as a right of the Filipino people
- formed by the 1987 Constitution
- moved that all people should have affordable and
available health care
- established the Filipino family as the foundation of the
nation
- aimed to provided health care for all Filipinos

II. R.A. 7875: National Health Insurance Law

- established the National Health Insurance Program (NHIP)
>> Guiding principles relevant to Family Medicine:
1. Universality coverage for the entire population
2. Equity universal access to health care based on need
and not on ability to pay
3. Responsiveness meeting the needs of the people at
various stages of life
4. Effectiveness striking the balance between economic
use of resources and quality of care
5. Innovation adapting to changing epidemiologies,
popuation distributions, etc.
6. Compulsory coverage to avoid adverse selection and
social inequity
7. Profession responsibility providers of health care are
held accountable in all their dealings
8. Quality of services institutionalization of a quality
assurance program where satisfaction with the service
will be the determinant
9. Care for the indigent the government will provide basic
packages of personal health services
- Philippine Health Insurance Corporation (PhilHealth)
>> formed as the working arm of NHIP
III.Medicare Para Sa Masa
- government move to minimize over-utilization of hospital
facilities and avoid unnecessary confinement
- government empowered local government units (LGUs) and
strengthened partnership between LGU and PhilHealth
- upgraded facilities and available services at primary care
levels
- integration of local health systems through out-patient
referral
- provided out-patient packages available under PhilHealth
benefits

>> includes: ambulatory surgeries, hemodialysis, ambulatory

cataract extraction, chemotherapy, mother and child package
with newborn screening, directly-observed tuberculosis short
course (DOTS) programs
>> later expanded to include treatment for HIV/AIDS,
malaria, leptospirosis, and others
Case Rate Payment Scheme
>> disease entities were assigned certain amounts available
to cover for expenses at PhilHealth- accredited facilities
>> packaged fees for health interventions for most common
conditions and procedures
>> faster turn around of claims
>> fixed rate for hospitalizations, diagnostics, and
medications

IV.Kalusugan Pangkalahatan
- health agenda by the Aquino administration
- provide financial risk protection to families
- provide sustainable access to modern facilities and services
- aimed to attain health-related Millennium Development Goals
(MDG)
- partnered government with poverty-alleviation programs (e.g.
4Ps)
- goal: all Filipino families registered with primary care facilities
for primary care needs
V. Primary Care Benefits (PCB), Gate Keeping, Family Registration
A. Providers of PCB Packages
- any government facility that meets prescribed standards
- facility should have resources and man-power enough to
cater to the needs of the people
- includes: regional health units (RHU), health centers, outpatient departments of hospitals
- tasks:
1. enlistment of families
2. performance and updating of individual health profiles
3. performing obligated services
4. submission of reports
B. Primary Care Benefits 1
- Objectives:
1. expand the number of available services
2. increase utilization rate of services
3. enhance incentives for PCB providers
4. ensure complete and timely reporting of health data
- Primary preventive services and obligated services:
1. consultations

2. visual inspection with acetic acid

3. regular BP measurements
4. breastfeeding program education
5. periodic clinical breast examination
6. counceling of lifestyle modification
7. body measurements
8. digital rectal measurements
Diagnostic examinations:
1. complete blood count
2. urinalysis
3. fecalysis
4. sputum microscopy
5. fasting blood sugar
6. lipid profile
7. chest x-ray
Drugs and medications for:
1. asthma
2. acute gastroenteritis (with no or mild dehydration)
3. upper respiratory tract infection
4. pneumonia (minimal and low-risk)
5. urinary tract infection
Referral mechanism:
>> services can be referred to another capable and
accredited health facility
>> transfer is coordinated and facilitated by PCB provider

C. Primary Care Benefits 2

- covers medications for diabetes and hypertension (most
common chronic conditions)
- improved access to medications
- Php 400.00 allocated to each family with a member who is
either hypertensive or diabetic
- compliance packs available at accredited pharmacies
D. Capitation Payment
- Per Family Payment Rate (PFPR)
- allocates Php 500.00 per family
- 80% to cover for drugs and operational expenses
20% as honoraria of staff
- money given to center quarterly
- requirements to avail of installment:
1. submission of updated master list
2. clientele health profile
3. summary of services provided
E. Accreditation of Health Care Providers
- for physicians:

>> regular paying of premiums

>> pay accreditation fees for 3 years
>> attend continuing medical education activities
submission of electronic reports