Universal Health Care

OUTLINE
Universal Health Care
1. What is UHC for Juan and Juana?

2. Key components of the UHC Act

3. What is a UHC Integration Site

4. Expectations for Strategic Planning

Department of Health, Philippines

What is UHC for
Juan and Juana?

3
Department of Health, Philippines
Department of Health, Philippines
 BARANGAY
RURAL HEALTH UNIT HEALTH
STATION

DIAGNOSTICS SPECIALIST CLINICS

HOSPITAL
LABORATORIES

PHARMACIES APEX HOSPITAL

Department of Health, Philippines

Department of Health, Philippines
Department of Health, Philippines
Department of Health, Philippines
 DIAGNOSIS:

PNEUMONIA

Department of Health, Philippines

Department of Health, Philippines
Department of Health, Philippines
 LAB

Department of Health, Philippines

 50% 50%
patient PCP
SPECIALIST

Department of Health, Philippines

Department of Health, Philippines
 Key Components of the
Universal Health Care Act

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 RA 11223: Universal Health Care Act
GENERAL OBJECTIVES

To ensure equitable access to quality and affordable health

care and protection against financial risk.

Department of Health, Philippines

 RA 11223: Universal Health Care Act
GENERAL OBJECTIVES

To progressively realize universal health care through

systemic approach and clear role delineation

Coordinated, not Know our role to

piecemeal “band-aid” play our part well

Department of Health, Philippines

 RA 11223: Universal Health Care Act
DECLARATION OF PRINCIPLES
Integrated and
Everyone is actively
Comprehensive People at the Center
participating
Approach

Ensure health literacy, healthy living,
and protection from hazards and
risks.
Whole-of-system Whole-of- People-oriented approach centered
government, Whole-of-society
on people’s needs and well-being
approach in the development of health
policies

Department of Health, Philippines

 What will UHC be for you?
UHC ensures that EVERYONE
will be receiving OPTIMAL HEALTH SERVICES.

Every Filipino family is matched to a primary care team, who

ensures that they get the appropriate services they need in the
appropriate facility.

Department of Health, Philippines

 What will UHC be for you?
UHC ensures that NO PATIENT
WILL BE LEFT ALONE.

Creation of health networks that will navigate the patients throughout

the process of their Health Care Needs. From BHS to Higher Health
Facilities back to the BHS.

Department of Health, Philippines

 What will UHC be for you?
UHC ensures that PRIMARY CARE / COMMUNITY HEALTH
will be STRENGTHENED.

Primary Care Services and Community Health will be strengthened.

Prevention is always better than Cure.

Department of Health, Philippines

 What will UHC be for you?
LGUs will be provided with additional funding for Health Services.

Health Services in the LGU will be funded through a pooled fund. Health
Workers will be incentivized and compensated properly (Additional health
workers may be employed). Pooled fund will remain and be reflected as LGU
Income.
Department of Health, Philippines
 What will UHC be for you?
LOCAL CHIEF EXECUTIVES as CHAMPIONS OF HEALTH

LGUs will be empowered to lead on Public Health in their areas. Health Governance
is key to a Healthy Community. (RA 11223 did not explicitly repeal LGC)

Department of Health, Philippines

 Universal Health Care means…

✔ healthy living, schooling ✔ primary care provider ✔ health spending is

& working environments team for every family predictable, not “lahat libre”

✔ care is provided for by providers organized as

INTEGRATED NETWORKS

Department of Health, Philippines

 Universal Health Care
does not mean...

“A Cure All Reform”: Prescribed “Lahat Libre:”

reforms need to have careful Basic health services will be
execution to ensure success. FREE, but for fees beyond the
basics, every Filipino family’s health
spending will be predictable.

Department of Health, Philippines

 It means everyone wins!
Payers (private insurers, governments, or self-pay
Filipinos/Patients are health literate,
individuals) able to shape provider
practice healthy lifestyle, live in low-
behavior towards quality and efficiency
risk environments, receive effective
care without financial hardship

Health Care Workers earn decent Providers earn a positive margin for
predictable income and able to producing good outcomes at low cost
pursue career paths

Suppliers of drugs, devices, and diagnostic tests that improve outcomes and/or lower
total costs find their products incorporated into treatment protocols used and reimbursed

Department of Health, Philippines

 What is a
UHC Integration Site?

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 Scope of the UHC Integration Sites (UIS)

Philippines
UHC Reforms for Immediate Implementation to the Whole Country

UIS
Simplifying Pooling National Regulating
Eliminating PhilHealth Funds HRH Coverage Transparent
Redundancies Membership to PhilHealth Master Plan Co-payment Pricing

SHF
Integration-specific reforms
Technical Integration
Health Health
Managerial Integration
Licensing
Setting and Health Impact Data Technology Financial Integration
Standards Registries Promotion Assessment Management Assessment

Department of Health, Philippines

 UHC Integration Sites

UHC Integration Sites (UIS) are provinces

and/or cities that will be supported and
contracted by DOH & PhilHealth to
demonstrate various approaches and
mechanisms to achieve:
TECHNICAL INTEGRATION
MANAGERIAL INTEGRATION by 2022
FINANCIAL INTEGRATION by 2025
as prescribed by the UHC Law.

Department of Health, Philippines

 UHC Integration Sites

The lessons and experience generated

from these sites will serve as basis for
the development of national policies on
the integration of local health systems to
attain Universal Health Coverage.

Department of Health, Philippines

 FOR GOVERNMENT
TECHNICAL INTEGRATION
Health system outcomes
EXISTING Responsiveness
PUBLIC AND Efficient resource
PRIVATE management
RESOURCES
Human FOR PATIENTS
Effective access
Finances MANAGERIAL INTEGRATION
Trust
Facilities Quality care
Equipment Financial risk protection
Information
Standards FOR PROVIDERS
Policies Job security
Work-life balance
FINANCIAL INTEGRATION Career productivity
 Integrating Local
Health Systems Dimensions of Integration
A. Technical Integration
Encompasses the clinical and
public health functions to deliver
seamless, coordinated,
comprehensive primary health care
with intersectoral participation
Department of Health, Philippines
B. Managerial Integration
Consolidated administration and
management of public resources at
the province-wide/city-wide level:
Human resources for health, health
facilities and equipment, health
information system, health
technologies and medicines
C. Financial Integration
Consolidating all financial resources
within a province-wide/city-wide
health system in a Special Health
Fund, exclusively and strategically
used for health and health-related
needs.
 FOR GOVERNMENT
Health system outcomes
EXISTING Responsiveness
PUBLIC AND Efficient resource
PRIVATE management
RESOURCES
Human FOR PATIENTS
Effective access
Finances Trust
Facilities Quality care
Equipment Financial risk protection
Information
Standards FOR PROVIDERS
Policies Job security
Work-life balance
Career productivity
 PATIENT 1. Patients receive zero co-pay or are subject to regulated
OUTCOMES co-pay ceilings where relevant
2. Patients have access to the health personnel and
services they need in a timely manner
3. Patients have access to the medicines and devices they
need in a timely manner
4. Patients trust the HCPN in their city or province
5. Patients benefit from comprehensive, responsive and
effective public health services to the entire
province/city

Department of Health, Philippines

 FOR GOVERNMENT
Health system outcomes
EXISTING Responsiveness
PUBLIC AND Efficient resource
PRIVATE management
RESOURCES
Human FOR PATIENTS
Effective access
Finances Trust
Facilities Quality care
Equipment Financial risk protection
Information
Standards FOR PROVIDERS
Policies Job security
Work-life balance
Career productivity
Technical Integration
1. Population catchment enumerated and needs
estimated
2. All families matched to PCP teams and PCP acts
as coordinator and navigator
3. Care coordination operational (dual referral system
- from primary to apex, then back to primary)

4. Public health functions fulfilled (disaster risk

reduction and management for health,
epidemiologic surveillance)

Department of Health, Philippines

Managerial Integration
5. Unified governance and management systems
6. Sufficient, competent clinical and management staff
aligned to the network vision-mission
7. Network-wide results-based performance monitoring
and evaluation implemented
8. User-friendly health information systems informing
performance of each unit, and the network as a whole

Department of Health, Philippines

Financial Integration

9. Network-wide pooling and accounting of funds

10. Network-wide investment and resource
allocation

Department of Health, Philippines

 FOR THE NATIONAL
GOVERNMENT
EXISTING Health system outcomes
Responsiveness
PUBLIC AND
Efficient resource
PRIVATE management
RESOURCES
Human FOR PATIENTS
Finances Effective access
Facilities Trust
Equipment Quality care
Information Financial risk protection
Standards FOR PROVIDERS
Policies Job security
Work-life balance
Career productivity
 Capacity Building & Health Systems
Scholarships for LCEs
Health Worker
Development
Development

Information Systems Procurement

and EMR Process and Systems

DOH Intervention
Packages
Health Emergency & Health Education and
Management Services Promotion

Department of Health, Philippines

 PhilHealth Intervention Packages
New financial mechanism that will support the local health systems in
delivering accessible quality and affordable health services.

Particularly for PhilHealth:

● Demonstrate network
contracting
● Introduce global budget
● Improve primary care benefit
package (higher capitation,
disease-agnostic)

Department of Health, Philippines

 Universal Health Care is all about...

Service Coverage
- immediate eligibility
Population Coverage Financial Coverage
and access
- automatic inclusion - Zero co-payment
- comprehensive
of every Filipino citizen - Fixed, predictable
outpatient benefit
into the NHIP co-payment
- provision of primary
care provider

Department of Health, Philippines

 If LGUs that commit to
integrate request technical and
financial assistance
1. LCEs must signify commitment to managerial
integration by 2022 and financial integration by
2025
2. Agree to and fulfill the terms of partnership that
will enable the optimal performance of the
integrated local health system through the
provision of needs-based support by the
National Government

Department of Health, Philippines

 The Aspiration

Assurance through
Holistic and Comprehensive Coordination
Services at Point of Care Unavailable but needed
All services eligible services of the client are
to a client are given. ensured by the provider
through other providers

Department of Health, Philippines

 Committing to be a UIS means

SHF

Families are linked Health services are Facilities in a The Special Health Eligible networks
to a primary care streamlined network are linked Fund pools are financed thru a
provider to an apex hospital resources for health Global Budget

Department of Health, Philippines

 INTEGRATING
LOCAL HEALTH Province- and City-wide Health Systems
SYSTEMS
• Provincial/City Health Board shall:
• oversee integration of health services
• manage the special health fund
• exercise administrative and technical supervision
over health facilities and HRH within their
jurisdiction
• Municipalities and cities shall be represented in
the Board

Department of Health, Philippines

 INTEGRATING
LOCAL HEALTH Province- and City-wide Health Systems
SYSTEMS
• National Government to provide technical and financial
support to LGUs that commit to province-wide
integration in the first 6 years
■ Managerial integration of province-wide and
city-wide systems within the first 3 years;
■ Financial integration within the next 3 years
• Upon positive recommendation by an independent
study and by the Secretary of Health, all local health
systems shall be integrated through the issuance of an
E.O. by the President

Department of Health, Philippines

MODULE

X WHAT CAN LOCAL

HEALTH SYSTEMS DO?

Department of Health, Philippines

 As an LGU, what can you do?

FOR FAMILIES/ IN YOUR BARANGAYS... IN YOUR GOVERNMENT

HOUSEHOLDS UNDER
● Ensure good HCW ● Improve facility OFFICE...
YOUR PURVIEW... ratio in all BHS equipment and ● Make sure that a Local
● Create healthy settings infrastructure Health Board is functional
and healthy environment ● Assure that your
in your communities HCWs actively ● Ensure no stock-out of ● Capacitate health through
coordinate and medicines and sound budgeting
● Make sure that all navigate care for supplies
families are profiled and patients seeking ● Create Ordinances and
with up-to-date civil consultation ● Bank on good data for Resolutions supporting
registration sound decision-making UHC and other health
● Make sure all in health programs
● Be responsible in essential health
disseminating the services prescribed ● Make sure doctor visits ● Engage DOH, PhilHealth,
message of UHC by UHC are available every barangay at least and Development Partners
24/7 2x a year for programs and initiatives

Department of Health, Philippines

 As an LGU, what can you do?

IN YOUR HEALTH UNITS... IN DISTRICT

● Encourage your
physicians to actively
coordinate and navigate
care for patients seeking
consultation
● Make sure all essential
health services prescribed
by UHC are available 24/7.
If not available, make sure
that transport vehicles are
available in care there is a
need to refer
● Ascertain that the
facility/ies is are PhilHealth
accredited
HOSPITALS WITHIN IN APEX HOSPITALS
● Improve facility WITHIN YOUR
equipment and YOUR NETWORK...
infrastructure NETWORK...
● Make sure outpatient and
community services are ● Strengthen
● Ensure no stock-out of
medicines and supplies available in case these partnership and
commitment thru
services cannot be
● Bank on good data for creation of MOAs
sound decision-making
availed by patients in
in health your health units
● Make sure a two-way ● Ascertain that the referral
referral system is in system is in place and is
place smoothly functioning
● Ascertain that your unit
has a MESU

Department of Health, Philippines

 Remember that in UHC,
There is a need for
You will become Good Health =
better Resource
Health Innovators Good Politics
Management

=
You are the first to
implement UHC Good Health Policies and Better management of
nationwide. Management translates to resources may pave way for
Healthier Constituents. more revenues.

Department of Health, Philippines

 Remember that in UHC,

Hard Work There is value in Multi- Services must

is essential Sectoral Cooperation focus on the Patient

The UHC reform is a paradigm We cannot work in “Silos” LGUs should push for accessible,
shift. It will entail a lot of hard anymore. All stakeholders need comprehensive, continuous,
work. to contribute for UHC’s success. and coordinated care for every
individual.

Department of Health, Philippines

 Expecatations for
Strategic Planning of UIS

60
GUIDING PRINCIPLES
1. Health shall be a shared accountability among
the State, communities and individuals.
a. Taking ownership of health in the individual and community level
shall be made possible by investing in improving overall health
literacy.
b. Protection from financial risk shall be achieved thru a mechanism
to pool / share risks, such that those who can pay more are able
to support those who can pay less, that those who are well can
support those who are sick.
c. Basic health benefits shall be covered by the State while non-
basic or fringe benefits shall be shouldered by the individual.

Department of Health, Philippines

GUIDING PRINCIPLES
2. Equity and fairness shall guide the path towards
universality.
a. All Filipinos, regardless of socio-economic standing,
ethnicity, religious belief, political affiliation, source of
payment of premiums shall receive the same benefits
package under UHC.
b. Recognizing limited resources, universality shall be
progressively realized by prioritizing the needs of the
unserved, underserved, and marginalized through
evidence-based health technology assessment, and
fair and transparent priority setting.

Department of Health, Philippines

GUIDING PRINCIPLES
3. Primary health care shall be the ethos of the health
system; primary care providers shall be the bedrock of
healthcare delivery system.
a. Individual and community health and wellbeing does
NOT not depend solely on healthcare services. Multi-
sectoral action shall be fostered to address the broader
social determinants of health.
b. Investments shall be directed to shifting from a hospital-
centric, curative-focused fragmented system, towards a
people-centered, primary care-led integrated health
system.

Department of Health, Philippines

GUIDING PRINCIPLES
4. Healthcare delivery shall be patient-centric.
a. Patients shall be guaranteed access to, and
availability of, all services and commodities
deemed necessary and essential by the State.
b. Patients shall be provided necessary care
from any provider of choice.
c. In the event of any conflict of rules or
guidelines, the safety and need of the patient
shall prevail.

Department of Health, Philippines

GUIDING PRINCIPLES
5. Information shall guide decision-making at the
institutional and individual level.

a. With due respect to privacy, information on health

transactions shall be collected and processed.
Maximum disclosure of depersonalized data shall
be exercised by healthcare providers and
institutions.
b. Information and power asymmetry between
various stakeholders in health shall be minimized.

Department of Health, Philippines

GUIDING PRINCIPLES
6. There shall be equal pay for equal work; better
pay for better (more efficient, higher quality) work.
a. Licensed, accredited and contracted health service providers and suppliers
shall receive remuneration commensurate to the level of effort and quality of
service they provide, regardless of ownership or affiliation (agnostic).
b. The system shall incentivize health service providers and suppliers that add
value to the system and those which facilitate demonstrable improvements in
quality and efficiency, including embedding new technology, among others.
c. PhilHealth shall seek to cover the costs of all the services provided (improved
support value), taking into consideration all sources of financing.

Department of Health, Philippines

 Outputs of the Strategic Planning Process
Network Network Network
Vision Analysis Arrangements

Allocation of catchment areas to

potential HCPNs
Legal personality
Vision Stakeholder analysis
Management structure
Strategies Facility mapping
Decision making structure
Milestones and Timeline Service capability mapping
Facility network formation
Strategic Planning Timeline and HRH mapping
Patient flow processes
Processes Health status of population
HRH plan
Integrated investment plans
Monitoring and Evaluation

Department of Health, Philippines

 Contracting by
Network Pathway of Patient Enlisted in a Network

HOSPITAL
HOSPITAL
Charge to
Charge
network
to network
(PUBLIC/PRIVATE)
(PUBLIC/PRIVATE)

SPECIALIZED
APEX
TERTIARY CARE
END REFERRAL
PRIMARY
PRIMARY
CARE CARE SPECIALIST
+ ANCILLARY
+ ANCILLARY SPECIALIST
OUTPATIENT
+ PHARMACY
+ PHARMACY OUTPATIENT
(P250 – P300)
+/- Population-based
+/- Population-based
services services

HEALTHY SICK
NON-EMERGENCY HEALTHY
SICK NON-EMERGENCY
SICK EMERGENCY

SICK EMERGENCY
Additional ENLISTED IN NETWORK
reimbursement from
PHIC using DRG
CONTRACTING
BY NETWORK Healthcare Provider Networks
• Philhealth to contract public, private or mixed
health care provider networks
• geographically-defined catchment area
• service quality
• co-payment/co-insurance
• data submission
• PhilHealth and DOH to incentivize health care
providers that form networks

Department of Health, Philippines

 Draft
Standards
Network Facility
Structure

APEX HOSPITAL

HEALTH CARE
PROVIDER
NETWORK (HCPN)
TRANSITION CARE
L1-L2 HOSPITAL FACILITIES

PRIMARY CARE
PROVIDER OUTPOSTS
NETWORK (PCPN) and
ANCILLARY
HEALTH
PROVIDERS
PRIMARY CARE (To complete
FAMILY FACILITY network service
70
(Comprehensive and Basic) capability)
 Sample Access Maps: RHU and Private

Travel time

Department of Health, Philippines

 Sample Access Maps: L3 Hospitals

Travel time

Department of Health, Philippines

 Draft
Standards Apex Hospital
To be assigned per
network by DOH based on
the Philippine Health
Within L3; Highest level comprehensive Facility Development Plan
Facility medical care in region

Within
Gatekeeping to national specialty centers, other specialty centers (including
Specialty
private), with reimbursement implications
Network APEX SPECIALTY
HOSPITAL SERVICES

REFERRAL M&E

Within
Network
Oversees referral mechanism of primary Creates referral mechanism to Teaching, training, and Monitors performance of health
care facilities to apex hospital other specialty centers, research hub of region care provider networks attached
wholesale procurement,
distribution hub for networks
with CHD 73
 Draft
Standards Network Referral Mechanisms

Outpost
Comprehensive L1-L2 hospital Apex hospital
PC Facility

Ancillary Services Transition

Care Facility

74
 Draft
Standards Network Referral Components

Medical Monitoring and

M&E

Transportation Evaluation

Information and
Communication Resources
Technology Sharing and
Procurement

Referral
Mechanism Public Health
Roles
 SOURCING
RESOURCES Special Health Fund
• Province-wide and City-wide Health System shall
pool and manage all resources in order to finance
population-based and individual-based health
services
• DOH, in consultation with DBM and LGUs, shall
develop guidelines for Special Health Fund
• PhilHealth payments shall accrue to the Special
Health Fund and credited as Annual Regular
Income (ARI) of the LGU

Department of Health, Philippines

D Sourcing
Resources Proposed Special Health Fund

Provincial /
LIPH
City Budget Population-based Individual-based
services services Apex Hospital

DOH Financial PhilHealth Pooled Individual-based

Grants Funds services

Appropriation Private
MOA
Ordinance Providers

Provincial / City SHF MOA

Budget for Health Non-Network

ODA, NGO, FBO Providers
Population-based services, human Financial Grants/
resources fees, and operating costs WFP, Allocation guidelines Donations

Operations and Remuneration for

Population-based
Maintenance of Health Additional Health Workers Health Systems
and Individual-based Health Research
Offices, Facilities and and Incentives for All Operating Costs
Health Services
Services Health Workers

Department of Health, Philippines

 Outputs of the Strategic Planning Process
Network Network Network
Vision Analysis Arrangements

Catchment
Vision* Management structure
Strategies* Legal personality
Stakeholder analysis*
Milestones and Timeline* Decision making structure
Facility mapping
Strategic Planning Timeline and Facility network formation
Service capability mapping
Processes* Patient flow processes
HRH mapping
HRH plan
*First activity outputs Integrated investment plans
Monitoring and Evaluation

Department of Health, Philippines