This document discusses leveraging social health insurance in the Philippines to ensure access to primary care services for the poorest families. It finds that the National Health Insurance System payment for primary care benefits has increased access to primary care providers by 81% and utilization of services by 77.5%. However, full care at outpatient settings is not assured due to low doctor-patient ratios and increasing out-of-pocket costs. The document recommends engaging private providers, enhancing benefit packages, improving payment mechanisms, establishing responsive health information systems, and strengthening communication strategies to better ensure access to primary care benefits.

1. Leveraging Social Health
Insurance to Ensure Access of
Poorest Families to Primary
Care Services in the Philippines
Leizel P. Lagrada, MD, MPH, PhD

2. PRIMARY CARE BENEFIT
•OPB was enhanced in 2012 to the PCB
•Capitation of Php 500 per family per year
•Expanded entitlement to more members
Sponsored
Program
Organized
Groups
Overseas
Workers
Program
DepEd
Personnel
D E P E N D E N T S

3. PCB PACKAGE INCLUSIONS

4. OBJECTIVES
•To assess effectiveness of the National
Health Insurance System (NHIP)
payment in:
1. Influencing access to PCB services
2. Promoting utilization of PCB services among
Sponsored families
3. Enjoining local governments to allocate
resources to sustain primary care services

5. METHODS
•Analysis of Reports
• PCB1 Required Reports from providers,
consolidated per region
• PhilHealth Accreditation Database
• PhilHealth Claims/ Capitation Payment
• Program Assessment Feedback
•Key informant interviews

6. PROVIDERS
2010 (OPB)
2012 (PCB)
2013 (PCB)
81% INCREASE
18% INCREASE52% INCREASE1,404
2,134
2,546
ARMM CAR
CARAG
A
I II III IVA IVB IX NCR V VI VII VIII X XI XII
RHU 104 81 82 135 88 189 152 73 83 426 121 148 125 160 107 42 57
HOSPITAL 0 35 10 8 26 24 37 16 8 1 29 42 33 49 31 13 3
0
50
100
150
200
250
300
350
400
450
DiagrammtitelTotal PCB Providers per Region
As of December 31, 2013

7. PROVIDERS
1 2 3 4A 4B 5 6 7 8 9 10 11 12 NCR CAR
CARA
GA
ARM
M
LGU W/O PCB 3 4 13 14 3 7 0 10 0 2 3 3 3 2 14 1 21
LGU W/ PCB 122 89 117 128 70 107 133 122 143 69 90 46 47 15 63 72 98
98%
96%
90% 90%
96%
94%
100% 92%
100%
97%
97%
94%
94%
88%
82% 99%
82%
0
20
40
60
80
100
120
140
160
ToalNumberofLGUs
Local Government Units with PCB Provider
As of December 31, 2013

8. 3,084,888
1,801,651
2,576,142
840,574
Assigned Enlisted
UTILIZATION
4,626,787
2,646,980
3,219,907
3,779,966
1,506,478
1,904,968
5,663,014
3,221,672
2,879,604
1,083,732
Assigned Enlisted Profiled
4,153,458 Members
8,543,618 Dependents
5,124,875 Members
4,305,404 Dependents
8,406,753 Members
5,661,030 Members
2,642,225 Members
Non-NHTS dependents
NHTS dependents
Non-NHTS members
NHTS members

9. UTILIZATION
Utilization rate based on initial assessment of the first two
quarters after implementation using manual reports,
sample size 1.02 M population

10. PAYMENT
PHP 1,008,057,516
PHP 3,624,761,901
PHP 3,026,170,777
PHP 300 per family
Payment computed using
services given
PHP 500 per family
Payment computed using
number assigned and enlisted
PHP 500 per family
Payment computed using
number enlisted and profiled
89% of LGUs
With TRUST FUND

11. CONCLUSIONS
•Increased access to primary care providers
• Increased PCB accredited providers by 81%
•Improved utilization of services
• Increased visit to primary care providers  77.5%
of enlisted poor families were seen at least once
by their primary care providers
• Improved financial allocation for primary
care services
• Assured payment for PCB services  Inc payout
by 200%; trust fund in 89% of LGUs with acc PCB

12. HOWEVER, DESPITE THESE GAINS:
Full care at the
outpatient
setting is not
assured
Low doctor to
patient ratio
Increasing out
of pocket
expenditure
Private sector
is not engaged
to provide PCB
Inconsistent
enrolment of
informal sector

13. POLICY RECOMMENDATIONS
ENSURING ACCESS TO
PRIMARY CARE BENEFIT
Engaging both
public and
private providers
Enhancing the
benefit package
content
Improve provider
payment
mechanism
Establishing a
responsive
health
information
system
Strengthening
communication
strategies

14. POLICY RECOMMENDATION
•Review the scope of PCB so that all
interventions in the package will result
to better outcomes (DALY averted)

15. POLICY RECOMMENDATION
• Ensure complete course of treatment,
negotiate the price for medicines and engage
drug stores in ensuring access to medicines

16. POLICY RECOMMENDATION
•Expand provision to the private sector
116 Ambulatory
Surgical Clinics
681 Primary Care
Facilities
1,115 Hospitals
2,034 Current PCB Providers
*As of June 2014 List of
Accredited Facilities

17. POLICY RECOMMENDATION
•Design payment to ensure quality of
care resulting to better health outcomes
₱₱₱
Services &
Diagnostics
₱₱₱
Medicines
₱₱₱
cost per
family
Paid to PCB Providers
Paid to accredited drugstores, per meds
prescribed by PCB Providers

18. POLICY RECOMMENDATION
•Create enhanced IT system to connect
providers, drug outlets and PhilHealth
• Efficient payment of providers
• Effective data analysis
• Timely policy monitoring

19. POLICY RECOMMENDATION
•Inform the SP members and dependents
of their benefit

20. lagradal@philhealth.gov.ph
THANK YOU