UPecon Foundation - Health Equity and Financial Protection in Asia Project Presented by: Aleli D.

Kraft

Asian Development Bank Conference in Impact Evaluation Manila, July 11, 2012

One of main thrusts of the DOH’s Kalusugang Pangkalahatan (Universal Health Coverage) is to provide financial risk protection through the enrollment of about 5 million poorest families with PhilHealth towards universal health insurance coverage by 2015  Main vehicle is the Sponsored Program where national and local government share in premiums for enrolled poor families, and lately the NG covering the premium for the poorest quintile  About 34.27% percent of total members are SP members (as of Dec. 2011)  However, coverage of the near-poor and informal sector is still low  Only about 52-55 percent of the informal sector who are less educated, live in urban areas and have low incomes, are covered (Quimbo, et al, 2011)  From 1.77 million in 2003 to 3.95 million in early 2011, the number of IPP members account for around only 18% of the total PhilHealth members.  Vehicle for PHIC coverage is the Individually Paying Program  Voluntary enrollment with the full premium shouldered by the member.  Financial risk protection still a problem as the near poor are equally vulnerable to health shocks  Experience of health shocks slightly higher for the second income quintile (24.3%) compared with the first (20.3%) (Baseline HEFPA Household Survey)

3P Study - an analysis of the effect of the PhilHealth Prepaid Premium (3P) certificate on the enrollment, health care utilization and health care payments of those eligible to be Individually Paying Program (IPP) members who are randomly selected to receive the certificates. Partnership between PhilHealth and UPecon Foundation to provide policy inputs to improve the coverage, sustainability, and financial protection aspects of the Individually Paying Program.
Part of the Health Equity and Financial Protection in Asia (HEFPA) Project, a four-year, EU-funded research project of a consortium of ten research institutions in East Asia and Europe.

Will a reduction in the financial and informational barriers increase the voluntary enrollment of the informal sector in the IPP?

243 municipalities nationwide (except 2 regions) randomly assigned to be treatment and control sites
2950 households = 2220 in treatment sites + 730 in control sites Treatment sites include 1187 with PhilHealth (expanded sample for vulnerability module) Cluster = barangay or precinct (5 - 10 households)

TREATMENT AND CONTROL SITES

TREATMENT AND CONTROL UNITS

Control sites Total Percent Willingness to pay Below 50 pesos 50 pesos and above Household income First quintile Second quintile Third quintile Fourth quintile Fifth quintile SAHS (household head) Poor Fair Good Very good Excellent Adverse health outcome 685 6.00 94.00 723 20.50 22.50 19.90 18.30 18.80 730 2.70 10.3 40.8 27.3 18.9 37.30

Treatment sites Total Percent 2037 7.00 93.00 2192 20.02 20.02 18.70 20.60 20.40 2220 2.80 10.5 39.6 26.7 20.4 34.90

Test of proportions (p-value) 0.203 0.203 0.859 0.180 0.454 0.177 0.356 0.889 0.892 0.572 0.772 0.393 0.259

2220

730

Selected potential informal sector IPP members
 Must be residing in a treatment site

 Excluded those employed in the formal sectors
 Household head, spouse or respondent in

surveyed household in treatment site  Household head, spouse or respondent is neither an active PhilHealth member nor a dependent of a PhilHealth member

Head is a member or dependent?

Yes. Head is not retired and last premium payment was more than 6 months ago? No. ELIGIBLE HEAD

Yes. ELIGIBLE HEAD

No. Spouse is a member or dependent?

No. Respondent a member or dependent?

Yes. ELIGIBLE SPOUSE

Yes. No. ELIGIBLE RESPONDENT Respondent is not retired and last premium payment was more than 6 months ago?

No. NOT ELIGIBLE

Yes. ELIGIBLE RESPONDENT

PhilHealth Prepaid Premium Certificate worth Php 600 + Information Kit + SMS reminders
 Offered to all eligible at baseline (February 2011):

 Original take-up period: March 2011 to February

2012

100 percent subsidy for the first 6 months of coverage, or 50 percent subsidy for 12 months of coverage

“Why didn’t you reply earlier, the boat has passed and I no longer have a ride going to town. Sender from Rizal

“I haven’t filed the philhealth form yet because we don’t have money right now. Maybe in June.” Sender from Leyte

“Ok we will just finish harvesting rice and we will register. Thanks for the reminder.” Sender from Quezon

“Good am regarding your philhealth promo, we showed it to the dumaguete philhealth ofc , they said they will first chek because they don’t know about the upecon hefpa team that did a survey here..they want to check with the head office first if it is true.” Sender from Negros Oriental

“(Name Concealed) already Enrolled yesterday at the PhiHealth CAINTA BRANCH,april 28 using your UPECON HEFPA PROJECT. Thank you very much for the favor you gave me to become a member of PHiHealth. Sender from Rizal

“What will happen if my child has his father’s surname but we are not married? Can he still be my dependent? “ Sender from South Cotabato


In addition… Pre-accomplished PhilHealth Membership Record Forms (PMRF) + Pick-up of Forms by enumerators
 Offered to randomly selected un-enrolled voucher

recipients as of December 2011  Period of take-up extended to February to March 2012 to all treatment households

100 percent subsidy for the first 6 months of coverage, or 50 percent subsidy for 12 months of coverage

2,950 total sample households FebApr 2011
Enrolled (IPP) = 8

Treatment sites = 2220

Control sites = 730 ~ eligible = 1183 decline = 131

eligible = 1037

accept = 906

Feb – Dec 2011

~ enrolled = 834

enrolled = 72

Take up = 7.9% (as of 30 Dec 2011)

Pre-accomplished PMRFs+ pick up = 418

Blank PMRFs =417

Feb Mar 2012

enrolled
w/o pick up =9 w/ pick up =118

~enrolled = 290

RTS = 10

Enrolled = 10

~enrolled = 368

RTS = 39

Overall take up = 30.4% (1 Feb-30 May 2012)

Overall take up = 23%
(as of 30 May 2012)

Intent-to-treat - 1
 Sample : All eligible households in both treatment

Intent-to-treat - 1

and control sites Ei = 0 + 1T+X’ +i  T = treatment site (offered vouchers)
 Sub-sample : All un-enrolled, voucher recipients

Ei =0 + 1P+X’ +i  P = pick-up households (sent filled out PMRFs and picked up by enumerators)

Table 1. Marginal effects of probit estimation, All eligibles Marginal Std. Err. Effect 0.295 0.037 1.9E-07 4.2E-07 -0.023 0.080 -0.001 0.001 0.046 0.035 0.028 0.036 -0.037 0.034 0.053 0.049 -0.023 0.073 0.038 0.022 -0.007 0.006 0.054 0.061 0.043 0.026 -0.003 0.022 0.016 0.025 0.011 0.030 0.046 0.035 0.030 0.040 1242 0.098 p-value 0.000 *** 0.653 0.776 0.134 0.189 0.432 0.283 0.275 0.752 0.085 * 0.239 0.369 0.098 * 0.910 0.512 0.710 0.192 0.444

Treatment Ave. per capita household expenditures Head is female Age of head Head has some college education Head is working Household belongs to a non-religious group OFW in the household Head has poor health Experienced health shock in last three years Number of children below 21 Household has other insurance Presence of formal health facility 15 minutes away Presence of alternative healing facility 15 minutes away Urban Luzon excluding NCR Visayas Mindanao Observations Pseudo R-squared

Table 2. Marginal effects of probit estimation, added intervention sample Marginal Std. Err. Effect With pick-up 0.260 0.025 Ave. per capita household expenditure -2.3E-07 4.7E-07 Head is female 0.006 0.099 Age of head -0.002 0.001 Head has some college education 0.004 0.050 Head is working 0.014 0.045 Household belongs to a non-religious group -0.017 0.042 OFW in the household 0.039 0.071 Head has poor health 0.004 0.097 Experienced health shock in the last three years 0.010 0.028 Number of children below 21 -0.009 0.008 Household has other insurance 0.102 0.083 Presence of formal health facility 15 minutes away 0.022 0.032 Presence of alternative healing facility 15 minutes away 0.032 0.027 Urban 0.016 0.031 Luzon excluding NCR 0.007 0.037 Visayas 0.091 0.045 Mindanao 0.106 0.052 Observations 828 Pseudo R-squared 0.138

p-value 0.000 *** 0.636 0.955 0.059 0.943 0.761 0.692 0.580 0.966 0.716 0.247 0.219 0.492 0.242 0.604 0.841 0.041 ** 0.042 **

Ave. predicted probability of enrollment, full sample
35% 35%

Ave. predicted probability of enrollment, HP sample
30%

34.33%

30%

25%

23.64%

25%

20%

20%

15%

15%

10%

10%

7.66%

5%

5% 2.55% 0% Control Control Treatment Treatment Without pick-up Without pick-up With pick-up With pick-up

0%

Preliminary analysis indicates that the 3P treatment consisting of the prepaid vouchers, information materials and pick-up of forms is associated with a higher likelihood to enrol in the PhilHealth IPP.
• This indicates that premium subsidies could overcome some of the

financial barriers to enrolment and coverage of those eligible to be in the IPP.

Pick-up of the accomplished forms is associated with higher enrollment in the IPP.
• This implies that aside from reducing the financial barriers, reducing the

transactional barriers may result in higher coverage of the informal sector in the IPP.

However, offering the vouchers alone is more likely to encourage enrolment of higher risk segment of the informal sector. Additional interventions may be necessary to attract the healthier segment.

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