1. 1 PhilHealth Programs and their impact on women’s utilization of health services during child-delivery – the evidence using National Demographic Health Survey data* Raymunda Silfverberg, PhL., Rouselle Lavado, PhD., Anna Lindgren, PhD., and Björn Lindgren, PhD. Paper extracted from Licentiate Degree Thesis of the first author from the Department of Health Sciences, Faculty of Medicine, Lund University, Sweden, 2009

2. 2 RESEARCH ISSUES General objective: To analyze the contribution of a national health-insurance program towards improving utilization of health services for households in a low- to middle- income country; the Philippines and its reforms in the second half of the 1990s served as a case for the empirical analysis. R R. Silfverberg et al, June 2009

3. 3 Specific objectives 1.) To analyze the impact of the Philippine national health insurance on women’s utilization of maternity care services during child delivery: place of delivery and skilled birth attendance R R. Silfverberg et al, June 2009

4. 4 PRESENTATION OF THE PAPER: Brief background on maternal health care issues Applied methodology Main Findings Lessons to be learnt R R. Silfverberg, et al., June 2009

5. 5 Table 1. Selected health status indicators, Philippines, Sweden and selected regions R R. Silfverberg et al, June 2009

6. 6 RRSilfverberg et al., June 2009

7. 7 a.) Place of delivery RRSilfverberg et al., June 2009

8. 8

9. 9 Philippine health care spending Figure 2. Trends in per capita health expenditure at current and Constant (1985) prices, Philippines 1995-2005

10. 10 Figure 1.4 Trend in share of total health expenditure to GDP, Philippines, 1995-2005

11. 11 RRSilfverberg et al., June 2009

12. 12 Philippine health care financing National Health Insurance – PhilHealth Legislated1995 Fully implemented1998 Programs: Employment Program Individually-Paying Program Sponsorship Indigent Program Non-Paying Program (Lifetime Program) Overseas Filipino Workers Program (established 2005) RRSilfverberg et al., June 2009

13. 13 Philippine Health Insurance… Benefits In-patient care coverage Out-patient care coverage Ambulatory surgeries and procedures incl. dialysis, radiotherapy and chemotherapy Professional feesmax 1,200 Operating room 385 Special benefit packages Natural spontaneous delivery (2003)4,500 Hospital charges2,500 Professional fees2000 Newborn care package (2006)1000 Applicable to PHI Corporation accredited facilities/ health professionals, public and private. Benefits portable nationwide. RRSilfverberg et al., June 2009

14. 14 Why do Filipino women continue to give birth at home and seek the services of traditional birth attendants? Why the slow uptake in skilled professional birth attendance and delivery in health facilities, despite expansion of PHI population and benefit coverage? Impact of health insurance, PhilHealth programs on mother’s access to (or utilization of) prenatal care, child delivery and post-partum care?

15. 15 APPLIED METHODOLOGY Theoretical framework: Grossman model : Demand for health and health care (1972) in the context of developing country Bolin, Jacobsson and Lindgren : Extended Grossman model to family unit (2002) Liljas : Demand for health with insurance (1998) RRSilfverberg et al., June 2009

16. 16 APPLIED METHODOLOGY … Data used: National Demographic Health Survey Philippines 2003 Women interviewed: 13, 633 individual women aged 15 – 49 Only women with the most recent pregnancy and live birth during the past five years prior to survey - 4,920 women out of 6,954 livebirths Only NSD births, excluding caesarian cases: final sample - 4,519 women RRSilfverberg et al., June 2009

17. 17 Descriptive analysis Econometric analysis: Multinomial logit model Dependent variables in MNL models: Place of delivery: Public or private health care facility with home setting as base group Birth attendant: Medical doctor or nurse/midwife with traditiona birth attendant as base group RRSilfverberg et al., June 2009

18. 18 Independent variables PhilHealth insurance by type of program – main interest of the study (excluded other types of health Insurance) PHI-None, PHI-Employed, PHI-IPP/SIP/NPP PHI status of woman, husband, father of daughter below 21 years RRSilfverberg et al., June 2009

19. 19 Independent control variables: Individual characteristics: woman’s age, child’s birth order, birth complications, antenatal care visits; Household level characteristics: wealth status, woman’s education, partner’s education, woman’s employment status, woman’s empowerment status, number of children below 5 years old, household size; Community variables: urban/rural residence with/without accessibility problems, regional location. Important econometric considerations in analyses Treatment of the endogeneity problem of health insurance RRSilfverberg et al., June 2009

20. 20 MAIN FINDINGS Descriptive statistics: selected variables N = 4519 Place of delivery: Home delivery67.4 % Public health facility21.4 % Private health facility11.0% Skilled birth attendants Traditional birth attendant43.9% Midwife/nurse28.2% Doctor27.5% PHI membership status of women PHI none76.0% PHI-EP15.5% PHI-IPP/SIP/NPP 8.2%

21. 21 MAIN FINDINGS I.Descriptives Figure I.1 Distribution of women by PHI insurance and wealth status, and by educational background RRSilfverberg et al., June 2009

22. 22 MAIN FINDINGS I.Descriptives: Women’s utilization of health services: Place of delivery and skilled birth attendance Figure I.3 Women’s health service utilization by PHI status RRSilfverberg et al., June 2009

23. 23 MAIN FINDINGS I.Descriptives: Figure I.3 Women’s health service utilization by wealth status RRSilfverberg et al., June 2009

24. 24 MAIN FINDINGS Descriptives: Figure I.4 Women’s health service utilization by educational background RRSilfverberg et al., June 2009

25. 25 MAIN FINDINGS Descriptives: Figure I.5 Women’s health service utilization by residence/accessibility problems RRSilfverberg et al., June 2009

26. 26 MAIN FINDINGS Descriptives: Figure I.6 Women’s health service utilization by antenatal care visits to health professionals RRSilfverberg et al., June 2009

27. 27 MAIN FINDINGS Descriptives: Figure I.6 Women’s health service utilization with pregnancy complications RRSilfverberg et al., June 2009

28. 28 MAIN FINDINGS Descriptives: Figure I.6 Women’s health service utilization with birth complications RRSilfverberg et al., June 2009

29. 29 MAIN FINDINGS MNL regression results: Direct and positive impact of the Philippine Health Insurance Employment Program (PHI-EP) on women’s utilization of private care facilities and the services of medical doctor during child- delivery. RRSilfverberg et al., June 2009

30. 30 RRSilfverberg et al., June 2009 Public carePrivate care PredictedEstimatedPredictedEstimated Insurance status : with PHI-EP ++++ *** PHI-SIP/NPP ++-- Midwife/nurseDoctor PredictedEstimatedPredictedEstimated Insurance status : with PHI-EP ++++ ** PHI-SIP/NPP ++-- Table 5. Predicted versus estimated signs of coefficients of insurance variables on women's utilization of health services during child-delivery Significance level: (**) 5%; (***) 1%

31. 31 MAIN FINDINGS MNL regression results… Effects of control policy variables on use of public and private care, midwife/nurse and medical doctor delivery attendance Positive effects: Child’s lower birth order Birth time complications With antenatal care visits with health professionals Maternal and paternal higher educational level Household higher wealth status Household size (small to large) Negative effects: Presence of distance and transport problems (especially in rural areas) Location in non-metropolitan regions

32. 32 RRSilfverberg et al., June 2009 LESSONS TO BE LEARNT FOR PHILIPPINE POLICY-MAKERS Potential effectiveness of programs in improving access to affordable health care for target population groups: general population (informal sector),and indigent IPP,SIP – no impact yet on maternal health care utilization Determination of actual population coverage.

33. 33 RSilfverberg et al., June 2009 Lessons to be learnt for Philippine policy-makers … Design and features of the PHI programs - influence on utilization o Hospital vs primary care setting o For the less-wealthy IPP/NPP members?

34. 34 Lessons to be learnt for Philippine policy- makers… Promotional efforts of program directed to: o women/mothers o lowly-educated o poor o rural segments of the society Picture- philhealth premium payment RRSilfverberg et al., June 2009

35. 35 RRSilfverberg et al., June 2009 Lesson to be learnt for Philippine policy-makers… PHIC’s incentives to LGUs (as insurer) to widen enrollment of indigents PHIC and DOH’s incentives to LGUs (as provider) – improvement of quality of care and accreditation of public health care facilities, i.e. birthing facilities

36. 36 Lesson to be learnt for Philippine policy-makers… More attention for in-depth empirical studies on the demand for health care alongside supply- related determinants of health care utilization. PHI Corporation in coordination with other stakeholders: government agencies and research institutions (RITM, PIDS, UPSE, UPHA) Separate assessment of different health insurance schemes vs target populations RRSilfverberg et al., June 2009

37. 37 RRSilfverberg et al., June 2009 MORE IMPORTANT ISSUES FOR FUTURE ANALYSES Impact of specific insurance programs from demand-side - target household populations: poor, women, children, rural sectors D emand (utilization) studies with insurance factor, focused on major policy agenda, i.e. maternal health care Impact of health insurance programs on equity issues in access across income groups Impact of health insurance programs on the quality of public care Impact of health insurance on women’s health per se.

38. 38 Thank you! RRSilfverberg et al., June 2009