Blog

Christian Edward Nuevo¹, Maria Eufemia Yap¹, Matt Boxshall², & Nirmala Ravishankar²

1. ThinkWell, Quezon City, Metro Manila, Philippines
2. ThinkWell, Washington DC, United States of America

Correspondence to Christian Edward Nuevo (email: ian.nuevo@gmail.com)

INTRODUCTION

Primary health care (PHC), first introduced through the Alma Ata Declaration of 1978, emphasizes that addressing health needs should be people-centered and multi-sectoral in approach. The recently passed Universal Health Care (UHC) Law in the Philippines puts PHC center stage through reforms aimed to improve health system performance. While the vision is laudable, making it happen is challenging. This article offers early learnings from the implementation of the UHC Law drawn from ThinkWell Philippines’ program of technical assistance and policy research to support the Department of Health (DOH) and the Philippine Health Insurance Corporation (PhilHealth)¹. We identified key opportunities and challenges created by the UHC Law against the three main pillars of strengthening PHC [1]. The UHC vision will have to be progressively realized through paradigm shifts, communication interventions, and a clear and strategic roll out plan.

¹ These activities are part of the Strategic Purchasing for Primary Health Care project supported by the Bill & Melinda Gates Foundation and implemented by ThinkWell. For more information, please visit our website at https://thinkwell.global/projects/sp4phc/. For questions, please write to us at sp4phc@thinkwell.global.

Philippine Health Sector Reform: The UHC Law

Health sector reform in the Philippines has been accelerated by the passage of Republic Act 11223, more commonly known as the UHC Law [2]. This landmark piece of legislation seeks to revitalize health care through a whole-of-system, whole-of-government, whole-of-society, people-centered approach. It recognizes that health systems are naturally complex, dynamic, and adaptive. The legislation acknowledges that improving health system performance requires sustainable, wholesale changes [3]. The pillars of PHC underpin the entire UHC reform [1][2].

PHC and the UHC Law

The 2030 Agenda for Sustainable Development as well as other landmark resolutions [4] all champion the crucial role of PHC in achieving responsive and resilient country health systems [5]. The UHC Law is anchored on the three main pillars of PHC [6] in the following way:

• Primary care and essential public health functions as the core of integrated health services: The UHC Law seeks to re-integrate the Philippines’ highly devolved governance system into province-wide health systems. These integrated provincial health systems promise more efficient use of resources and delivery of comprehensive care. Providers are encouraged to consolidate into health care provider networks, capable of delivering a range of services, grounded on a strong primary care base. PhilHealth is expanding its currently limited primary care benefit to a new package called “Konsulta”², with expanded rates and service inclusions, accessible to all membership types. Health care provider networks will be contracted by PhilHealth as one entity, aligning their incentives and accountabilities, and promoting continuity of care. Regrettably, the law does not mandate this re-integration. Resistance to change, and politics of intervening laws such as the Local Government Code stand in the way. Municipal mayors stand to lose authority over their health spending, personnel, and resources, and will only influence these as a member of the health board. Adequacy and supply-side readiness of health facilities, as well as financial constraints and the sustainability of PhilHealth are still prevailing realities [7][8][9].

Key areas for priority action

One of the biggest prerequisites in this reform process is a shift in governance paradigms. The UHC reform requires provincial governments to be more accountable for care of their constituents and management of their health systems. They must reduce dependence on current national government support on personnel deployment, commodities, and infrastructure investments. Provincial governments must work to contextualize the benefits of integrating into province-wide health systems and health care provider networks, and rally support from people and providers within their jurisdiction. Central offices, on the other hand, should pivot back to their role of being technical stewards of the health sector, crafting strong policies, standards, and regulatory thrusts. These transitions from old to new ways need to be championed by the Department of Health, generating buy-in from other government agencies to ensure a genuine whole-of-government approach.

As new policies and guidelines are formulated, strong communication and promotion interventions must be pursued by both the national and local governments. Patients need to be informed of all their entitlements, and the merits of living healthy lifestyles. Likewise, health care providers must understand the need for instituting strong gatekeeping mechanisms and facilitating synergistic relationships between primary and specialty practitioners. By engaging various stakeholders and communicating a compelling value proposition, key players will better understand their respective roles, leading to greater alignment with the UHC agenda.

Finally, a clear, strategic, year-on-year rollout chronology towards achieving the vision for UHC should be laid out in a transparent manner. Sequencing of reforms should start with generating clear demand for primary care through patient empowerment and incentive schemes for providers. This can drive the necessary motivation for the public sector to build capacity, and similarly attract the private sector to participate and coordinate. By committing to a clear plan of action, the Philippines DOH can build confidence amongst all stakeholders, public and private, local and national, and across government. Clarity of vision will be essential to deliver on the promise of UHC in the Philippines.

REFERENCES

1. World Health Organization. 2019. Primary health care towards universal health coverage. In: Seventy-second World Health Assembly, 1 April 2019. Geneva: World Health Organization. Available from: https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_12-en.pdf [cited 2020 Feb 08].
2. Republic of the Philippines. 2019. Republic Act 11223. An Act Instituting Universal Health Care for All Filipinos, Prescribing Reforms in the Health Care System, and Appropriating Funds Therefor.
3. Fattore G, Tediosi F. 2013. The Importance of Values in Shaping How Health Systems Governance and Management Can Support Universal Health Coverage. Elsevier: Value in Health 16, S19-S23. http://dx.doi.org/10.1016/j.jval.2012.10.008
4. 2012 UN Resolution on Universal Health Coverage, 2018 Declaration of Astana, 2019 World Health Assembly
5. World Health Organization. 1978. Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR.
6. Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, et al. 2018. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health. 11;6(11):e1196–252. http://dx.doi.org/10.1016/S2214-109X(18)30386-3 pmid: 30196093
7. Bredenkamp C, Gomez V, Bales S. 2017. Pooling Health Risks to Protect People: An Assessment of Health Insurance Coverage in the Philippines.
8. Dayrit MM, Lagrada LP, Picazo OF, Pons MC, Villaverde MC. 2018. The Philippines Health System Review. Vol. 8 No. 2. New Delhi: World Health Organization, Regional Office for SouthEast Asia. Available from: http://apps.searo.who.int/PDS_DOCS/B5438.pdf [cited 2020 Feb 10].
9. Romualdez JR, Rosa J, Flavier J, Quimbo S, Hartigan-Go K, Lagrada L, et al. 2011. The Philippines Health System Review. Vol. 1 No. 2. Manila: World Health organization, Regional Office for the Western Pacific.
10. Picazo OF et al. 2015. A Critical Analysis of Purchasing of Health Services in the Philippines: A Case Study of PhilHealth. Philippine Institute for Development Studies. Discussion Paper Series No 2015-54.
11. Department of Health. 2019. Budget Briefer FY 2019. Health Policy Development and Planning Bureau. Available from: https://www.doh.gov.ph/publication/serials/2019-Budget-Briefer [cited 2020 Feb 10].

The 2030 Agenda for Sustainable Development as well as other landmark resolutions [4] all champion the crucial role of PHC in achieving responsive and resilient country health systems [5]. The UHC Law is anchored on the three main pillars of PHC [6] in the following way:

• Primary care and essential public health functions as the core of integrated health services: The UHC Law seeks to re-integrate the Philippines’ highly devolved governance system into province-wide health systems. These integrated provincial health systems promise more efficient use of resources and delivery of comprehensive care. Providers are encouraged to consolidate into health care provider networks, capable of delivering a range of services, grounded on a strong primary care base. PhilHealth is expanding its currently limited primary care benefit to a new package called “Konsulta”[1], with expanded rates and service inclusions, accessible to all membership types. Health care provider networks will be contracted by PhilHealth as one entity, aligning their incentives and accountabilities, and promoting continuity of care. Regrettably, the law does not mandate this re-integration.  Resistance to change, and politics of intervening laws such as the Local Government Code stand in the way. Municipal mayors stand to lose authority over their health spending, personnel, and resources, and will only influence these as a member of the health board. Adequacy and supply-side readiness of health facilities, as well as financial constraints and the sustainability of PhilHealth are still prevailing realities [7][8][9].
• Empowered people and communities: With the UHC Law, all Filipinos are automatically members of PhilHealth, and are immediately entitled to benefits. Families and households are also given the freedom to choose the primary care provider they prefer and trust. Patient involvement in key decision areas is enhanced through representation in the Health Technology Assessment Committee that decides on benefit inclusions, and in the provincial health board that develops and monitors the province health plan.These opportunities for patients to directly influence matters concerning their own health contribute to a system that is truly responsive. However, patient knowledge is coming from a rather weak base. Data shows that for PhilHealth covered indigent families, only 53% knew of their entitlement for no balance billing, and around 39.6% are misinformed of their sponsorship[8]. This and other knowledge gaps present real challenges in affording people genuine participation even in institutionalized processes.
• Multi-sectoral policy action: The UHC Law mandates the institutionalization of cooperative intergovernmental decision-making and implementation, particularly on areas such as health impact assessment, health professional education, and monitoring and evaluation of health system performance. The private sector is also enjoined to respond to service delivery needs as health care provider networks, and to generate evidence together with the academe through data sharing and commissioning of relevant health policy and systems studies.Through these more inclusive and regular stakeholder engagement processes, strategic complementation with partners within and outside government is encouraged. Still, differences in perspectives and interests are among the greatest hurdles that affect cooperation and resource allocation. For one, adequacy of PhilHealth benefit package rates are continuously criticized[10], particularly by for-profit private facilities that do not enjoy the government subsidy afforded to public facilities. Even between government units, changes in processes meant to improve efficiency of one agency, may result to negative effects for another. When the Department of Budget and Management (DBM) transitioned to a new budgeting mechanism, it resulted to a 28% decrease in DOH appropriation from 2018 to 2019[11].

[1] An expanded primary care benefit package known as PhilHealth Konsulta (PhilHealth Konsultasyong Sulit at Tama) to cover all Filipinos and to ensure access to essential, preventive, promotive, and curative services.

• Empowered people and communities: With the UHC Law, all Filipinos are automatically members of PhilHealth, and are immediately entitled to benefits. Families and households are also given the freedom to choose the primary care provider they prefer and trust. Patient involvement in key decision areas is enhanced through representation in the Health Technology Assessment Committee that decides on benefit inclusions, and in the provincial health board that develops and monitors the province health plan.These opportunities for patients to directly influence matters concerning their own health contribute to a system that is truly responsive. However, patient knowledge is coming from a rather weak base. Data shows that for PhilHealth covered indigent families, only 53% knew of their entitlement for no balance billing, and around 39.6% are misinformed of their sponsorship [8]. This and other knowledge gaps present real challenges in affording people genuine participation even in institutionalized processes.

• Multi-sectoral policy action: The UHC Law mandates the institutionalization of cooperative intergovernmental decision-making and implementation, particularly on areas such as health impact assessment, health professional education, and monitoring and evaluation of health system performance. The private sector is also enjoined to respond to service delivery needs as health care provider networks, and to generate evidence together with the academe through data sharing and commissioning of relevant health policy and systems studies.Through these more inclusive and regular stakeholder engagement processes, strategic complementation with partners within and outside government is encouraged. Still, differences in perspectives and interests are among the greatest hurdles that affect cooperation and resource allocation. For one, adequacy of PhilHealth benefit package rates are continuously criticized [10], particularly by for-profit private facilities that do not enjoy the government subsidy afforded to public facilities. Even between government units, changes in processes meant to improve efficiency of one agency, may result to negative effects for another. When the Department of Budget and Management (DBM) transitioned to a new budgeting mechanism, it resulted to a 28% decrease in DOH appropriation from 2018 to 2019 [11].

² An expanded primary care benefit package known as PhilHealth Konsulta (PhilHealth Konsultasyong Sulit at Tama) to cover all Filipinos and to ensure access to essential, preventive, promotive, and curative services.