21/02/2020

General Objectives

• To progressively realize universal health care through

Universal Health Care Act systemic approach and clear role delineation of
stakeholders
Republic Act No. 11223 • To ensure equitable access to quality and affordable
health care and protection against financial risk
Jenell Y. Oczon, MD, MPH, FPAFP

Department of Health, Philippines Department of Health, Philippines

1 4

Acknowledgement Universal Health Care

Population Coverage – automatic inclusion of every Filipino
citizen into the NHIP
Universal Health Care Act
Service Coverage
Republic Act No. 11223
• Immediate eligibility and access to population-based and
individual-based health services
Lyndon L. Lee Suy, MD, MPH, CESE • Comprehensive outpatient benefit package
Assistant Secretary of Health
Health Policy and Systems Development Team • Provision of primary care provider

Department of Health, Philippines Department of Health, Philippines

2 5

Declaration of Principles Universal Health Care

• Integrated and comprehensive approach to ensure health
Financial Coverage
literacy, healthy living, and protection from hazards and risks
• Health care model that provides comprehensive health Population-based health services
services without causing financial hardship • Funded by National Government through DOH
• Whole-of-system, whole-of-government, whole-of- • Free at point of service
society approach in the development of health policies Individual-based health services
• People-oriented approach centered on people’s needs and • Primarily through pre-payment mechanisms (SHI, PHI,
well-being HMO)

Department of Health, Philippines Department of Health, Philippines

3 6

1
 21/02/2020

National Health Insurance Program National Health Insurance Program

Membership • Program Reserve Funds

• Direct contributors – those who have the capacity to • Administrative Expense
pay premiums • PhilHealth Board of Directors
• Indirect contributors – those whose premiums are • President and Chief Executive Officer
subsidized by the national government • PhilHealth Personnel as Public Health Workers
• Additional Powers and Functions of PhilHealth

Department of Health, Philippines Department of Health, Philippines

7 10

National Health Insurance Program Health Services Delivery

Entitlement to Benefits Population-based Health Services

• Immediate eligibility • DOH to contract province-wide and city-wide health
• No co-payment in basic or ward accommodation systems
• Co-payment and co-insurance for amenities in public • Minimum components:
hospitals regulated by DOH and PhilHealth • Primary care provider network
• No reduction in current PhilHealth package • Epidemiologic surveillance systems
• Additional benefits for direct contributors, where applicable • Health promotion programs/campaigns

Department of Health, Philippines Department of Health, Philippines

8 11

National Health Insurance Program Health Services Delivery

Premium Contributions
Individual-based Health Services
For direct contributors
Year Premium Rate Income Floor Income Ceiling
• Philhealth to contract public, private or mixed health care
2019 2.75 % P10,000.00 P50,000.00 provider networks
2020
2021
3.00 %
3.50 %
P10,000.00
P10,000.00
P60,000.00
P70,000.00
• Service quality
2022 4.00 % P10,000.00 P80,000.00 • Co-payment/co-insurance
2023 4.50 % P10,000.00 P90,000.00
2024 5.00 % P10,000.00 P100,000.00
• Data submission
2025 5.00 % P10,000.00 P100,000.00
• PhilHealth and DOH to incentivize health care providers
For indirect contributors – to be gradually adjusted and included in the GAA that form networks

Department of Health, Philippines Department of Health, Philippines

9 12

2

Health Services Delivery
Individual-based Health Services
• DOH to determine apex or end-referral hospitals; may be
contracted by PhilHealth as stand-alone providers
• PhilHealth to:
• Shift to performance-driven, close-end, prospective
payments based on DRGs, validated costing methods, and
no differentiation between facility and professional fees
• Develop differential payment considering service quality
• Institute strong surveillance and audit mechanisms
Department of Health, Philippines
13
Organization of Local Health Systems
Integration into Province-wide and City-wide Health
Systems
• Provincial/City Health Board to:
• 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 to be represented in the Board
Department of Health, Philippines
14
Organization of Local Health Systems
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
Department of Health, Philippines
15
21/02/2020
Organization of Local Health Systems
Income derived from PhilHealth payments
• PhilHealth payments shall accrue to the Special Health Fund
and credited as Annual Regular Income (ARI) of the LGU
Incentives for improving competitiveness of the Public
Health Service Delivery System
• National Government to provide financial and non-financial
matching grants in accordance with province-wide and city-
wide investment plans
Department of Health, Philippines
16
Human Resources for Health
National Health Human Resources Master Plan
• Provision of policies and strategies for appropriate health
workforce based on population needs, and for guaranteed
permanent employment and competitive salaries
National Health Workforce (NHW) Support System
• Support to local public health systems in addressing human
health needs, especially for GIDAs
Department of Health, Philippines
17
Human Resources for Health
Scholarship and Training Program
• Expansion of existing and new health related degree and
training programs
• Regulation of the number of enrollees based on health needs
• Expansion of scholarship grants for undergraduate and
graduate programs
• Setting-up of registry of medical and allied health professionals
• Re-orientation of health professional education, certification
and regulation towards provision of primary care services
Department of Health, Philippines
18
3

Human Resources for Health
Return Service Agreement
• Return service for at least three (3) years for recipients of
government-funded scholarship programs
• Provision of additional incentives for those rendering
additional two (2) years of service
• Establishment of guidelines for non-compliance
Department of Health, Philippines
19
Regulation
Safety and Quality
PhilHealth to:
• Establish a rating system under an incentive scheme
based on service quality, efficiency and equity
• Recognize third party accreditation mechanism
Department of Health, Philippines
20
Regulation
Safety and Quality
DOH to:
• Institute a licensing and regulatory system for stand-
alone health facilities, ambulatory and primary care
providers
• Set standards for clinical care through development
and use of clinical practice guidelines
Department of Health, Philippines
21
21/02/2020
Regulation
Affordability
• Procurement of Drugs and Devices of DOH-owned Health
Care Providers
• Follow centrally negotiated prices
• Sell in prescribed maximum mark-ups
• Submit a price list of all drugs/devices procured and sold
• Independent Price Negotiation Board
• Negotiate prices on behalf of DOH and PhilHealth
Department of Health, Philippines
22
Regulation
Affordability
• Health care providers to make price information of
health goods and services readily accessible
• Drug outlets to carry the generic equivalent of all drugs
in the Primary Care Formulary
• DOH, PhilHealth, HMOs and PHIs to develop policies
and plans for complementation of health benefits
Department of Health, Philippines
23
Regulation
Equity
• Preferential licensing of health facilities and contracting of
health services for underserved areas
• Equitable distribution of health services and benefits
prioritizing GIDA
• All government hospitals to operate not less than 90% of bed
capacity as basic accommodation; specialty hospitals not less
than 70%; private hospitals not less than 10%
Department of Health, Philippines
24
4

Governance and Accountability Governance and Accountability
Health Promotion
Transformation of HPCS to Health Promotion Bureau
• Formulation of strategy for increasing health literacy
• Implementation of health promotion programs and activities
across social determinants of health
• Policy coordination across government instrumentalities
• Provision of technical support to local research and
development
Department of Health, Philippines
25 28
Governance and Accountability Governance and Accountability
Health Promotion
• At least one percent (1%) of total DOH budget
earmarked for health promotion programs
• DepEd schools to be designated as healthy settings
• Incorporation of health promotion in school curricula
• LGU to enact stricter ordinances to promote health
literacy and healthy lifestyle
Department of Health, Philippines
26 29
Governance and Accountability Governance and Accountability
Evidence-Informed Sectoral Policy and Planning for UHC
• all health-related entities to submit health data to PhilHealth
• DOH and DOST to develop cadre of policy systems
researchers, experts and managers through training grants
• administrative and survey data generated using public funds
considered as public records and made accessible to the
public
• action researches on health promotion and social mobilization
as part of the national health research agenda
Department of Health, Philippines
27 30
21/02/2020
Monitoring and Evaluation
• PSA to conduct relevant modules of household surveys annually
for the first ten (10) years of implementation
• DOH to publish annual provincial burden of disease estimates
Health Impact Assessment
• HIA as requirement for all policies, programs and projects
Department of Health, Philippines
Health Technology Assessment
• institutionalizaton of HTA process to inform policies and
decisions of DOH and PhilHealth
• creation of HTAC within DOH
• within five (5) years after establishment, HTAC to be an
independent entity separate from DOH, attached to
DOST
Department of Health, Philippines
Ethics in Public Health Policy and Practice
• declaration and management of conflict of interest
• collection and tracking of financial relationships with
health care professionals/providers for all manufacturers
of drugs, medical devices, and medical supplies
registered by FDA
• Public health ethics committee as an advisory body to
the Secretary of Health
Department of Health, Philippines
5

Governance and Accountability
Health Information System
• health service providers and insurers to maintain a health
information system to be electronically uploaded on a
regular basis through interoperable system
• enterprise resource planning
• human resource information
• electronic health records
• electronic prescription log
Department of Health, Philippines
31
Appropriations
Source of Funding for UHC
• Total incremental sin tax collections
• 50% of the National Government share from PAGCOR
• 40% of the Charity Fund, net of Documentary Stamp Tax
Payments and mandatory contributions of PCSO
• Premium contributions of members
• Annual appropriations of the DOH
• National Government subsidy to PhilHealth
• Supplemental funding
Department of Health, Philippines
32
Penal Provisions
Penalties and sanctions cover the following:
• health care provider of population-based health services
• health care provider of individual-based health services
• PhilHealth member
• employer
• Director, officer or employee of PhilHealth
Department of Health, Philippines
33
21/02/2020
Miscellaneous Provisions
Oversight Provision
• Creation of Joint Congressional Oversight Committee on
UHC
• NEDA, PSA, NIH and other academic institution to
validate and evaluate UHC accomplishments
• DOH and PhilHealth to allocate adequate funding for
these studies
Department of Health, Philippines
34
Miscellaneous Provisions
Performance Monitoring Division
• Establishment of Performance Monitoring Division to
monitor and evaluate the implementation of UHC
• Office-in-charge of field implementation performance to
comprise the core personnel of the office
Department of Health, Philippines
35
Miscellaneous Provisions
Transitory Provision
• President of the Philippines to appoint new members of the
Board and the PCEO of PhilHealth within thirty (30) days
• All officers and personnel of PhilHealth, except for the members
of the Board, to continuously perform their duties and receive
their corresponding salaries and benefits
• All affected officers and personnel of the PCSO to be absorbed
by the agency without demotion of rank or salary/benefits
Department of Health, Philippines
36
6
 21/02/2020

Miscellaneous Provisions
Summary - Financing
• National Government to provide technical and financial support
to LGUs that commit to province-wide integration in the first 6 Clarifying roles: Simplifying
1.DOH and LGU for membership into two
years population-based types: Direct and Indirect
• managerial integration of province-wide and city-wide systems services Contributory
2. PhilHealth for
within the first 3 years; financial integration within the next 3 individual-based services
years Pooling funds to Contracting by network
PhilHealth for all based on adherence to
• upon positive recommendation by an independent study and by individual-based health quality and co-payment
the Secretary of Health all local health systems shall be services (e.g. Sin Tax, standards + third party
PAGCOR, PCSO) accreditation
integrated through issuance of an E.O. by the President

40

Department of Health, Philippines Department of Health, Philippines

37 40

Miscellaneous Provisions
Summary - Service Delivery
• PhilHealth to outsource certain functions to ensure
operational efficiency and fulfillment of the Act in the first
ten (10) years
• Philhealth and DOH to provide reasonable financial and
licensing incentives to contracted health facilities to form
health care provider networks in the first three (3) years Institutionalizing primary
care as a prerequisite to
Consolidating fragmented providers
into province-wide and city-wide
Enabling income retention
for all public providers
access higher level of care service delivery networks to through a Special Health
and contracting by network navigate and coordinate Fund

41

Department of Health, Philippines Department of Health, Philippines

38 41

Miscellaneous Provisions
Summary - Regulation
• HTAC under the DOH to be established within one (1) year
• PHIs and HMOs, together with DOH and PhilHealth, to develop a Mandating transparent Ensuring benefit complementation
between PhilHealth and Private Health
pricing of health goods
system of co-payment that complements PhilHealth benefit and services Insurance (PHIs) and Health Maintenance
Organizations (HMOs)
packages within three (3) years
Basic and non-basic Expanding scholarship programs,
• Within ten (10) years, only those certified by DOH and PRC as accommodation bed requiring 3 years return service in
underserved areas for government
capable of providing primary care will be eligible as primary care ratio of 90:10 for
scholars, augmenting HRH through
government hospitals,
provider 70:30 for specialty
national health workforce support
system, primary care-oriented
hospitals, and 10:90 for
• For the first two (2) years, PCSO to transfer at least fifty percent private hospitals
education, health professionals registry

(50%) of the forty percent (40%) of the charity fund per year
42

Department of Health, Philippines Department of Health, Philippines

39 42

7
 21/02/2020

Summary - Governance
Requiring submission of health and
Strengthening Health
financial data by healthcare providers
Promotion and medicines
and suppliers harmonized to an
interoperable system; sharing of procurement
publicly-funded data sets

Institutionalizing Streamlining
Health Technology Assessment as PhilHealth Board
prerequisite for public financing of from 17 to 13
goods/services, and Health Impact members
Assessment for various programs,
policies, and projects

43

Department of Health, Philippines

43

Maraming salamat po!

44