La couverture sanitaire des pauvres, quelles leçons tirées des expériences internationales pour le RAMED? Expérience de Philippine Mme Leizel P. Lagrada

Evolution of Social Insurance Coverage in the Philippines 1995National Health Insurance Act of 1995 (Republic Act No. 7875) 1969Philippine Medical Care Act of 1969 (Republic Act No. 6111) 1997Assumed coverage of government employees from the Government Service Insurance System (GSIS) 1998Assumed coverage of private employees from the Social Security System (SSS) 1998Implemented coverage of indigent families with the local government units 1999Implemented coverage of the self-employed 2004RA No amendment (Republic Act No. 9241) 2005Assumed coverage of Overseas Filipino Workers from the Overseas Workers Welfare Administration (OWWA) 2013RA No amendment (Republic Act No ) 2012*-2013 National Government assumed payment of full premium for the indigents 2014The Expanded Senior Citizen Act (Republic Act No. 9994)

The National Health Insurance Program provides all citizens with the mechanism to gain financial access to health services RA 7875 (1995) as amended by RA 9241(2004) & RA (2013) 17 REGIONAL O F F I C E S 106 L O C A L OFFICES 6,400 OFFICERS S T A F F ~100,000,000 F I L I P I N O S

Characteristics of the National Health Insurance Program Coverage Compulsory coverage for all citizens; Family-based membership where primary member and qualified dependents have almost the same benefit coverage AdministrationSingle-payer system Financing For employed: Payroll-based premium with employer and employee contributions (2.5% of basic salary) For Self-employed: Two-tiered annual premium  PhP2,400 (US$54) with less than P25,000 (US$563.5) monthly income)  PhP3,600 (US$81) for those earning P25,000 or higher monthly income Government subsidy for the poor and senior citizen (PhP2,400 annual premium) Benefits Uniform in-patient package (paid as case rate) including catastrophic benefit packages Primary care benefit for the indigents and other sponsored members (will also be rolled out to all members …)

Characteristics of the National Health Insurance Program Providers Accreditation of both government and private-owned health facilities, voluntary basis Contract-based for hospitals engaged to deliver catastrophic benefit packages (in addition to accreditation) Payment Case rate for in-patient benefits Special Case Rate for Z packages Per Family Payment Rate (PFPR) for Primary Care Benefit (Tsekap) Privileges Automatic coverage of the poor assessed by the National Household Targeting System for Poverty Reduction (NHTS-PR) of the Department of Social Welfare and Development (DSWD) No Balance Billing for indigents and sponsored members when admitted in government hospitals Automatic availment of benefits by pregnant women and those enrolled as sponsored member at point-of-care Lifetime entitlement to senior citizens (60 years old and above)

Targeting the poor through NHTS-PR 1) Geographic Targeting Enumeration strategy was defined using poverty maps Poorest municipalities were covered first and all households were assessed Less poor municipalities had combination of enumeration of pockets of poverty and on demand applications 2) Household Assessment Households were assessed through home interviews to gather information on Household Assessment Form (HAF) Supervision was randomly done during the field work to ensure good quality of information Processing was done online at regional offices with validation routines to check the quality of data PMT scoring was applied to PMT ready data 3) Validation List of poor household selected through PMT as those below provincial poverty thresholds was published at the village level Addressing complaints about exclusion and inclusion Verification of data, gathering of evidence, assessing the excluded Providing evidence for Local Verification Committee for final decision Processing of validated data Reference: Fernandez, L. Design and Implementation Features of the National household Targeting System in the Philippines, Philippine Social Protection Note No. 5. WB and AusAID, June 2012

NHTS-PR result was used to enroll the poor to NHIP ….and coverage extended to near poor

Data source: NDHS 2008, NFHS 2011, NDHS 2013 Distribution of health insurance is becoming more pro-poor over time

Utilization of health services by the poor went up over time…. Source: PhilHealth Stats and Charts, , Analysis of claims Jan-Oct 2014

Sustainability of coverage of the poor is assured by the Sin Tax Law (RA 10351)… 85% of incremental revenues from Sin Taxes intended for the Universal Health Coverage 80% to cover the poor under NHIP 20% to upgrade government health facilities Collection for health from Sin Taxes, in billion pesos. Source: DOH

Primary challenges to covering the poor Updating of NHTS-PR list and ensuring that every member of the household is covered Providing coverage for the poor families/households missed by the NHTS-PR survey: enroll through Point of Care Ensuring that the poor knows their benefits and uses them appropriately Guaranteeing that the poor have access to accredited health care providers

Perspectives for future Guarantee full financial risk protection for the poor through No Balance Billing policy Protect the non-poor from impoverishing effect of health care cost through fixed co-pay Monitor and measure the financial risk protection and health care utilization (health outcomes) provided by the NHIP and use the evidence to further improve the program

Maraming Salamat... Thank You… Merci Beaucoup... For question/clarification: ail.com