The Philippine UHC Law

“The Path Towards Sustainable Healthcare Finance and

Universal Healthcare Coverage in The ASEAN Region”

MARIA EUFEMIA YAP, MD, MSC

CSIS ONLINE POLICY DIALOGUE: AUGUST 26, 2021
OUTLINE

— Background and Milestones related to UHC

— A Unique Opportunity: the Philippine UHC Law 2019 (RA No. 11223)
— Financing Reforms of the UHC Law
— Reflections and Early lessons

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 BACKGROUND AND MILESTONES RELATED TO UHC

1947 1982 1995 2012

EO No. 94 - Initially dictated the EO No. 851 – Formation of local Establishment of the National The Sin Tax Law in 2012
structure and function of the health systems (public health and Health Insurance Program (NHIP) (RA No. 10351) increased ear-
Department of Health (DOH) hospitals) still under the mandate and PhilHealth; signified shift to marked fiscal space for health to
of the DOH demand-side financing cover vulnerable sectors

Local Government Code devolved Succession of DOH led reform

accountability of health service agendas (HSRA, the F1 for Health, The UHC Law (RA No. 11223)
RA No. 1982 - Created a national provision in the public sector to the Kalusugang Pangkalahatan) introduced opportunities for
network of public health facilities local government units (LGUs), strengthened focus on financing additional health financing reforms
at community level including generation of resources and universal health care (UHC) for the health sector

1954 1991 1998 onwards 2019

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Source: Compiled by authors
A UNIQUE OPPORTUNITY:
THE PHILIPPINE UHC LAW 2019 (RA NO. 11223)

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A UNIQUE OPPORTUNITY:
THE PHILIPPINE UHC LAW 2019 (RA NO. 11223)
INTEGRATION UHC GOALS of UHC
SIMPLIFIED
Confusing membership
LAW
Guaranteed PhilHealth
schemes
Membership Types Membership for all Every Filipino…
Poor prioritization
Provincial Synergy of public
in the Effective & well-resourced
public health programs …is prevented from
health programs
Delivery of PH Services being sick.
PUBLIC HEALTH Primary Care Provider for
Overburdened RHUs, doing Health Promotion
INTEGRATION
both primary care & PH each Filipino
Lack & misdistribution of HC Enough, competent
Province-wide
ProfessionalsHealth …is managed well
Health Professionals
Care Provider Networks if sick, which means:
Few resources
open & incentives
to private sector Good, adequate facilities • Seen by an HCP
to improve facilities
participation • Seen at a facility
CLINICAL INTEGRATION
Procurement failures, Sustainable supply of
• Treated sufficiently
High prices of medicines quality Medicines
• Provided meds
Unreliable, disconnected
Provincialize health Reliable referral network Responsiveness
referral networksand
systems leadership that is easy to navigate
administration
Devolved health systems
MANAGERIAL
have limited resources & Effective planning, …with Good health
INTEGRATION
technical know-how leadership & monitoring outcomes
So much money,
Pooling
weak of money
purchasing into a
power Government as strategic …and protected
Special Health Fund
High out of pocket despite
purchaser of affordable, financially from
FINANCIAL INTEGRATION quality services being poor
High health expenditures
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UNIVERSAL HEALTH CARE: CLOSING THE GAP

COSTS
Proportion of the costs covered

Pool of Funds

SERVICES
Which services are covered?
POPULATION
Who is covered?

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UNIVERSAL HEALTH CARE: CLOSING THE GAP

COSTS
Proportion of the costs covered

Pool of Funds

SERVICES
Which services are covered?
POPULATION
EXTEND POPULATION COVERAGE
Current: 92% coverage
2019: UNIVERSAL population coverage
Every Filipino citizen shall be covered by the
National Health Insurance Program 7
UNIVERSAL HEALTH CARE: CLOSING THE GAP

COSTS
Proportion of the costs covered
Current: 40% support value
Government as a
2022: HIGH support value single purchaser
Pool of Funds 2030: FULL support value

SERVICES
Which services are covered?
POPULATION
Who is covered?
Current: 92% coverage
2019: UNIVERSAL population coverage
Every Filipino citizen shall be covered by the
National Health Insurance Program 8
UNIVERSAL HEALTH CARE: CLOSING THE GAP
Pool of Funds
Pool of Funds
POPULATION
Who is covered?
Current: 92% coverage
2019: UNIVERSAL population coverage
Every Filipino citizen shall be covered by the
National Health Insurance Program
COSTS
REDUCE COST SHARING AND FEES
Current: 40% support value
Government as a
2022: HIGH support value single purchaser
2030: FULL support value
SERVICES
INCLUDE OTHER SERVICES
Current: many gaps, overlapsed; biased towards inpatient
2028: COMPREHENSIVE service coverage
HTA-guided expansion of benefits
Comprehensive primary care package for all members
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UNIVERSAL HEALTH CARE: CLOSING THE GAP

2022: HIGH support value

2030: FULL support value
Government as a single
Pool of Funds purchaser
Pool of Funds

2028: COMPREHENSIVE service coverage

HTA-guided expansion of benefits
2019: UNIVERSAL population coverage Comprehensive primary care package for all members
Every Filipino citizen shall be covered by
the National Health Insurance Program

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UNIVERSAL HEALTH CARE: FINANCING REFORMS
Clarifying roles:
1. DOH and LGU for
population-based services
2. PhilHealth for
individual-based services
Pooling funds to PhilHealth
for all individual-based
health services
(e.g. Sin Tax, PAGCOR, PCSO)
Simplifying membership
into two types:
Direct & Indirect Contributory
Contracting of health care
provider networks based on
adherence to quality and
co-payment standards by
prospective payment
mechanisms
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UNIVERSAL HEALTH CARE: FINANCING REFORMS
CLARIFYING PURCHASING ROLES

Clarifying roles:
Simplifying membership
1. DOH and LGU for
into two types:
population-based services
Direct & Indirect Contributory
2. PhilHealth for
individual-based services

Contracting of health care

Pooling funds to PhilHealth
for all individual-based
health services
(e.g. Sin Tax, PAGCOR, PCSO)
provider networks based on
adherence to quality and
co-payment standards by
prospective payment
mechanisms

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UNIVERSAL HEALTH CARE: FINANCING REFORMS
CLARIFYING PURCHASING ROLES

CURRENT POLICY

PAGCOR,
DOH PCSO,
DSWD

PhilHealth

Redundant, fragmented

Low premium + ceiling

Multiple purchasers >> smaller pools, less leverage,

weak power to influence prices of goods and
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services
UNIVERSAL HEALTH CARE: FINANCING REFORMS
CLARIFYING PURCHASING ROLES

CURRENT POLICY UHC REFORMS

PAGCOR,
DOH PCSO, PhilHealth
DOH DSWD
DSWD +PCSO

PhilHealth
Population-level Individual-level Non-direct medical
services services expenditures

Redundant, fragmented Clear delineation, pooling to efficiently mobilize

existing funds

Low premium + ceiling Higher premium, no ceiling

Multiple purchasers >> smaller pools, less leverage,

Single purchaser >> No overlaps, more powerful
weak power to influence prices of goods and
negotiation and price control 14
services
UNIVERSAL HEALTH CARE: FINANCING REFORMS
STRENGTHENING PHILHEALTH AS STRATEGIC PURCHASER
OF INDIVIDUAL-BASED SERVICES
Clarifying roles:
Simplifying membership
1. DOH and LGU for
into two types:
population-based services
Direct & Indirect Contributory
2. PhilHealth for
individual-based services

Contracting of health care

Pooling funds to PhilHealth
for all individual-based
health services
(e.g. Sin Tax, PAGCOR, PCSO)
provider networks based on
adherence to quality and
co-payment standards by
prospective payment
mechanisms

15
UNIVERSAL HEALTH CARE: FINANCING REFORMS
STRENGTHENING PHILHEALTH AS STRATEGIC PURCHASER
OF INDIVIDUAL-BASED SERVICES
CURRENT POLICY

PAGCOR,
DOH PCSO,
DSWD

PhilHealth

PhilHealth is a passive payer

No clear expansion plan, not guided by HTA: not

responsive, what is covered does not correspond to
burden
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UNIVERSAL HEALTH CARE: FINANCING REFORMS
STRENGTHENING PHILHEALTH AS STRATEGIC PURCHASER
OF INDIVIDUAL-BASED SERVICES
CURRENT POLICY UHC REFORMS

PAGCOR,
DOH PCSO, PhilHealth
DOH DSWD
DSWD +PCSO

PhilHealth
Population-level Individual-level Non-direct medical
services services expenditures

PhilHealth is the strategic contracting agent;

PhilHealth is a passive payer purchasing power can be leveraged to reduce costs
and improve quality

No clear expansion plan for benefit packages, not

HTA-guided with clear expansion pathway;
guided by HTA: not responsive, what is covered
responsive prioritization of service coverage
does not correspond to burden
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UNIVERSAL HEALTH CARE: FINANCING REFORMS
SIMPLIFYING PHILHEALTH MEMBERSHIP

Clarifying roles:
Simplifying membership
1. DOH and LGU for
into two types:
population-based services
Direct & Indirect Contributory
2. PhilHealth for
individual-based services

Contracting of health care

Pooling funds to PhilHealth
for all individual-based
health services
(e.g. Sin Tax, PAGCOR, PCSO)
provider networks based on
adherence to quality and
co-payment standards by
prospective payment
mechanisms

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UNIVERSAL HEALTH CARE: FINANCING REFORMS
SIMPLIFYING PHILHEALTH MEMBERSHIP

CURRENT POLICY

-- Senior citizens
Formal Informal -- IPP – Voluntary NHTS
sector sector -- Kasambahay poor
(36%) (8%) -- Point of Care (55%)
-- OFW

Contributory Contributory Full subsidy

(employer-employee) (voluntary) c/o National Government

Difficult to reach and enroll the informal sector

Adverse selection: the sickly take advantage of

benefits, especially the informal sector

Poor continuity: members fall in and out of

eligibility
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UNIVERSAL HEALTH CARE: FINANCING REFORMS
SIMPLIFYING PHILHEALTH MEMBERSHIP

CURRENT POLICY UHC REFORMS

-- Senior citizens
Formal Informal -- IPP – Voluntary NHTS Non-
-- Kasambahay
Formal
sector sector poor formal
(36%) (8%) -- Point of Care (55%)
sector
sector
-- OFW

Contributory Contributory Full subsidy Contributory Full subsidy

(employer-employee) (voluntary) c/o National Government (employer-employee) c/o National Government
No ceiling

Difficult to reach and enroll the informal sector All Filipinos are automatically covered by the
National Health Insurance Program
Adverse selection: the sickly take advantage of
benefits, especially the informal sector All members receive the same benefits

Poor continuity: members fall in and out of Shift from a membership issue to a premium
eligibility collection issue
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UNIVERSAL HEALTH CARE: FINANCING REFORMS
CONTRACTING OF HEALTH CARE PROVIDER NETWORKS

Clarifying roles:
Simplifying membership
1. DOH and LGU for
into two types:
population-based services
Direct & Indirect Contributory
2. PhilHealth for
individual-based services

Contracting of health care

Pooling funds to PhilHealth
for all individual-based
health services
(e.g. Sin Tax, PAGCOR, PCSO)
provider networks based on
adherence to quality and
co-payment standards by
prospective payment
mechanisms

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UNIVERSAL HEALTH CARE: FINANCING REFORMS
CONTRACTING OF HEALTH CARE PROVIDER NETWORKS

POPULATION-BASED Teaching
and Training
National & Local Government Budgets
SPECIAL HEALTH FUND
Tertiary
Hospitals
INDIVIDUAL-BASED
Primary &
Case Mix (DRG) Extra Payments for
PHILHEALTH Secondary
“Convenience
“Basic Package” Amenities, Incentives” Hospitals

SOURCE:
SOURCE: Out-of-Pocket Specialty Clinics/
PhilHealth Payment; Private ASC / Drugstores/
Health Insurance; Laboratory
Health Maintenance
Organization

OP Clinics

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UNIVERSAL HEALTH CARE: FINANCING REFORMS
Clarifying roles:
1. DOH and LGU for
population-based services
2. PhilHealth for
individual-based services
Pooling funds to PhilHealth
for all individual-based
health services
(e.g. Sin Tax, PAGCOR, PCSO)
Simplifying membership
into two types:
Direct & Indirect Contributory
Contracting of health care
provider networks based on
adherence to quality and
co-payment standards by
prospective payment
mechanisms
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Best Practice:
Oncology Financing
ONCOLOGY FINANCING FUND FLOW– PHILIPPINES
(UHC and NICCA Laws in Transition 2020-2025)
PUBLIC PRIVATE
Implication to Oncology
Financing
Sources PAGCOR
PAGCOR
Central
Central Local
Local Government 
Government 
Employer
Employer Donor
Donor Individual
Individual and
and  Better delineation of who
PCSO
PCSO Revenue
Revenue Sin
Sin Tax
Tax Revenue
Revenue government
government contributions
contributions funds
funds household
household funds
funds
Revenue  Revenues
Revenue revenue*
revenue*
 Revenues
will pay for what
 All Filipinos will have
better of coverage
Local
Local Government 
Government   Coverage for full spectrum
Pools and Agents

 General
 General Fund
Fund
of cancer care
 Incentives can be shifted
towards preventive
PhilHealth Local
Local NGOs
DOH
DOH
PhilHealth Health Units
Health Units HMOs,
HMOs, Life
Life
Insurance
Insurance
NGOs
Local
services
Department
Philippine
Philippine Health
Health Local and
and
Department Insurance Provincial,
Provincial, International
International
of Insurance
of Health
Health Corporation City,
City, Municipal
Municipal
Corporation
Cost functions across care continuum

Follow-up Legend of lines

… partial assistance
Governance Prevention Screening Diagnosis Treatment Survivorship
-- - - In transition mandated by law
and
͞ in place/ mandated by law
Hospice Care
Early Detection Palliative Care
HTA *Other sources of central government revenue
are taxes not earmarked for health. In
Clinical Practice
Guidelines
Transition, Department of Social Welfare and
Population-Based Individual-Based Development (DSWD) cancer assistance should
Malasakit Center • Vaccination • Clinical • Clinical • Systemic Therapy • Clinical go to DOH.
• Health Examinations Assessment • Radiotherapy assessment
• Endoscopy • •
UHC – Universal Health Care Law (RA 11223)
Recommendations for: Promotion Medical Imaging Surgery • Medical Imaging
• Procurement (Colonoscopy) (Mammogram) • Nuclear Medicine • Clinical Laboratory NICCA – National Integrated Cancer Control Act (RA 11215)
• Pricing
• PhilHealth Cancer Packages and
• Medical Imaging • Clinical Laboratory • Chemotherapy • Hospice
Cancer Medical Access Programs (Mammogram) • Pathologuy • Immunotherapy
Drugs Clinical Laboratory
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REFLECTIONS AND EARLY LESSONS

— The UHC Law could bring about opportunities for

reform to ensure effective financing of health
services, but its realization will be progressively
realized.
— Political milieu and COVID-19 pandemic has delayed
the implementation of some of the key mandates,
but policy implementers continue to pursue its
operationalization
— Moving forward, PhilHealth needs resources and
support to be able to meet its mandates

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 Salamat
Thank You

Merci
Obrigado

Asante

ধন্যবাদ
Terima kasih
LOOKING FORWARD TO YOUR FEEDBACK AND QUESTIONS
MARAMING SALAMAT PO!

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