Orientation on Republic Act No. 11223 or the UHC Act, delivered at the UPLB College of Public Affairs and Development, 4 April 2019.

1. Universal Health Care
The Philippine journey towards
accessing quality health services without financial hardship
Albert Francis Domingo, MD MSc
Consultant for Health Systems Strengthening
Office of the WHO Representative to the Philippines
Email: domingoa@who.int
UPLB College of Public Affairs and Development – 4 April 2019

3. What is Universal Health Coverage/Care?
• All people having access to quality health services*
without suffering the financial hardship associated
with paying for care
– All people (population coverage)
– having access to quality health services (service coverage)
– without suffering financial hardship associated with paying
for care (financial risk protection)
*including prevention, promotion, treatment, rehabilitation and palliation

4. Senate Committees on Health and Demography, Ways and Means, and Finance
1 February 2018 | Cebu City, Philippines
Healthy population
Population at risk
Population with sickness
Sick that need
hospitalization
but have no
access to hospital
care
Sick
and
Hospitalized
People needing
rehabilitation

5. The Continuum of Care
Health
Risk
exposure
Risk contact
Latent
disease/injury
Early
disease/
injury
Disease
progression
Advanced
disease/injury
Chronic
Disease or
impairment
Death
Primary Prevention:
Reduce risk exposure
Secondary
Prevention:
Detect
and intervene early
Tertiary Prevention:
Reduce progress or
complications of
established disease
ResourceGeneration,
Financing,Stewardship
Interventions

6. (Berman, 2012)

7. Building blocks of health systems (especially the
linkages) are areas for adjustment of policy
People-Centred Health Care Services
Health
workforce
Resource
generation and
health
financing
Essential
medicines,
commodities
and
technologies
Health
information
system
Good Governance

8. UHC Index, etc.
Incentives
Regulatory Environment
Effective Services
What is your UHC road map?

9. What should be the roles and
responsibilities of the major institutions?
LGUs DOH PhilHealth
Private Sector Providers

10. How can we reduce out of pocket payments?
55.7 54.8 54.2
16.0 17.9 17.4
7.8 9.0 10.0
7.1 6.8 7.1
7.8 5.3 5.4
2.5 2.8 2.4
1.3 1.8 …
0%
25%
50%
75%
100%
2014 2015 2016
ShareinHealthExpenditures
Financing Agents for Health Care Services (National Health Accounts)
Households PhilHealth DOH LGUs HMOs Other NGAs Private insurance GSIS, SSS

11. Who does what to deliver health services?
State/government: per Sec. 17, RA 7160 – LGC; DOH standards
LGU Minimum Basic Health Services and Facilities
Barangay Health and social welfare services which include maintenance of
barangay health center and day-care center
Municipality Health services which include the implementation of programs and
projects on primary health care, maternal and child care, and
communicable and non-communicable disease control services,
access to secondary and tertiary health services; purchase of
medicines, medical supplies, and equipment needed to carry out
the services herein enumerated
Province health services which include hospitals and other tertiary health
services
City All the services and facilities of the municipality and province
Non-state: private facilities, regulated by the DOH (HFSRB, etc.)

12. The mandate to consolidate
Local government units may group themselves, consolidate or
coordinate their efforts, services, and resources for purposes
commonly beneficial to them in accordance with law.
(Sec 13, Art X, 1987 Constitution)
The national government or the next higher level of local
government unit may provide or augment the basic services and
facilities assigned to a lower level of local government unit when
such services or facilities are not made available or, if made
available, are inadequate to meet the requirements of its
inhabitants.
(Sec 17f, Ch II, Title I, Book 1, Local Government Code)

13. How can decentralization work for UHC?
• Need to clearly identify the role delineation between national
and local governments
• Need to consolidate local governments to reduce
inefficiencies and transactions cost in health: through referral
systems, pooling of resources, complementation with other
social services
• Need to adequately license, regulate, supervise and engage
private sector providers
• Need to support the devolution of powers and functions with
adequate financing (intergovernmental transfers)
• Need to institutionalize accountability mechanisms

14. 1515
Service Delivery
Financing
Population
Private
Hospitals/Clinics
Pharmacies
Premium Payments
Taxes,
Including “Sin Tax”
Out of Pocket
Subsidy
Capitation
Primary
Health
Care
Referral/Secondary Care
Essential Drugs
DOH
Budget
Local
Government
Budget
DOH Referral
Hospitals
City Health Centers
Rural Health Units
Barangay Health Stations
Provincial Hospitals
District Hospitals
PHC, Secondary,
Referral CareReimbursement
Moving forward: how to integrate Primary Health Care

15. Philippines: Universal Health Care legislation
(Current Situation)
• The Philippines has long instituted a National Health
Insurance Program (PhilHealth) to be the preferred single
payer for healthcare services for patients
• Essential public health functions (e.g. health promotion,
disease surveillance, quarantine) are funded by line-item
government budgets
• Service delivery is through a dual system composed of the
public sector and a strong private sector

16. The Philippines uses Universal Health Care interchangeably with Universal
Health Coverage.
It has been an iterative process of health reform, ongoing for almost 50 years
and under different names:
Year Name of policy Focus area Type of
issuance
1969 Philippine Medical Care Act (Medicare) Financing Statute
1991 Local Government Code (devolution) Governance Statute
1995 National Health Insurance Act (PhilHealth) Financing Statute
1999 Health Sector Reform Agenda Policy framework Regulation
2005 FOURmula ONE (F1) for Health Strategy Regulation
2011 Kalusugan Pangkalahatan (KP/UHC) Strategy Regulation
2012 Sin Tax Reform Act of 2012 Revenue generation Statute
2013 Amendments to PhilHealth law Financing Statute
2016 Philippine Health Agenda Policy framework Regulation
2018 FOURmula ONE Plus Strategy Regulation

17. Legislative Process House of Representatives Senate
Preliminaries
Highlighted by the President during
State of the Nation Address 2018
Introduction and
referral of bills
30 Jun 2016 – first bill (HB 225)
26 Jul 2016 – referred to committee
16 May 2017 – first bill (SB 60)
17 May 2017 – referred to committee
Committee level
23 May 2017 – public hearing and
approval of substitute bill
30 May 2017 – committee report
2 Aug 2017 – first public hearing
Feb, Mar 2018 – nationwide public
hearings
30 Jul 2018 – committee report
Floor consideration
16, 22 Aug 2017 – sponsorship and
interpellation
22 Aug 2017 – approved on second reading
6 Sep 2017 – approved on third
reading: HB 5784
31 Jul 2018 – sponsorship
Aug, Sep 2018 – interpellation
9 Oct 2018 – approved on second reading
10 Oct 2018 – certified by the President for
immediate enactment
10 Oct 2018 – approved on third
reading: SB 1896
Bicameral Conference
Committee
Pre-bicam meetings: 23, 30 Oct 2018
Bicameral Conference Committee Report ratified: 10 December 2018
Presidential action
Signed into law as RA 11223
on 20 February 2019

19. Republic Act No. 11223
Universal Health Care Act

20. Overview of RA 11223 – UHC Act
• The UHC bill seeks to realize universal health coverage through a systemic
approach and clear delineation of the roles of key agencies and stakeholders
• The major reforms seek to:
– consolidate existing yet fragmented financial flows
– increase the fiscal space for benefit delivery
– improve the governance and performance of devolved local health systems
– institutionalize support mechanisms such as health technology assessment
and health promotion

21. Department of Health, Philippines
Integrated and comprehensive
approach to ensure health
literacy, healthy living, and
protection from hazards and risks
Health care model that provides
comprehensive health services
without causing financial
hardship
Whole-of-system, whole-of-
government, whole-of-
society approach in the
development of health policies
People-oriented approach
centered on people’s needs and
well-being
Source: Usec Mario C. Villaverde, DOH
Declaration of Principles

22. Department of Health, Philippines
To ensure equitable access
to quality and affordable
health care and protection
against financial risk
To progressively realize
universal health care
through systemic approach
and clear role delineation
of stakeholders
Source: Usec Mario C. Villaverde, DOH
General Objectives

23. Department of Health, Philippines
Automatic inclusion of
every Filipino citizen
into the NHIP
Population Coverage
Immediate eligibility and
access to population- and
individual- based health
services
Service Coverage
Source: Usec Mario C. Villaverde, DOH
Individual-based
Health Services:
• primarily through
pre-payment
mechanisms (SHI,
PHI, HMO)
Population-based
Health Services:
• funded by National
Government
through DOH
• free at point of
service
Financial Coverage
Universal Health Care (UHC)

24. Department of Health, Philippines
Pooling funds to
PhilHealth for all individual-
based health services
Simplification of NHIP
membership into:
• Direct contributors – those who
have the capacity to pay premiums
• Indirect contributors – those whose
premiums are subsidized by the
National Government
Source: Usec Mario C. Villaverde, DOH
National Health Insurance Program

25. Department of Health, Philippines
 Immediate eligibility
 No co-payment in basic or ward
accommodation
 Co-payment/-insurance for amenities in
public hospitals regulated by
DOH/PhilHealth
 No reduction in current PhilHealth package
 Additional benefits for direct contributors
Entitlement to
Benefits
Source: Usec Mario C. Villaverde, DOH
National Health Insurance Program

26. Department of Health, Philippines
Consolidation of
fragmented providers into
province- 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
Pooling PhilHealth
payments for all LGU
providers through a
Special Health Fund
Adapted from: Usec Mario C. Villaverde, DOH
Organization of Local Health Systems

27. A group of primary to tertiary care providers, whether
public or private, offering people-centered and
comprehensive care in an integrated and coordinated
manner with the primary care provider acting as the
navigator and coordinator of health care within the
network.
(UHC Act Sec. 4l)
Source: SVP Israel Francis Pargas, PhilHealth
Health Care Provider Network (HCPN)

28. Department of Health, Philippines
Primary care
provider
network
Epidemiologic
surveillance
systems
Health promotion
programs/
campaigns
Population-based Health Services
DOH to contract province- and city-
wide health systems with the
following minimum components:
Source: Usec Mario C. Villaverde, DOH
Delivery of Population-based Health Services

29. Department of Health, Philippines
✓ Data submission
Individual-based Health Services
PhilHealth to contract public, private
or mixed health care provider
networks that would agree on:
✓ Service
quality
✓ Co-payment/
co-insurance
Source: Usec Mario C. Villaverde, DOH
Delivery of Individual-based Health Services

30. Apex
Hospital
Primary Care
Provider of Choice
Population and
Individual-
based Services
Specialty Care
(e.g. dialysis,surgeries,
special procedures)
Individual-
based
Services
Source: SVP Israel Francis Pargas, PhilHealth

31. PhilHealth to contract public, private, or mixed health
care provider networks, provided that:
• Member access is not compromised
• Networks agree to service quality, co-payment/co-
insurance and data submission standards
• During the transition, PhilHealth and DOH shall
incentivize providers that will form networks
• Apex or end-referral hospitals as determined by the
DOH may be contracted by PhilHealth as stand-alone
providers
Source: SVP Israel Francis Pargas, PhilHealth
Strategic Contracting
(UHC Act Sec. 18a)

32. PhilHealth will:
• shift to performance-driven, close-end, prospective
payments based on Diagnosis-Related Groupings
(DRGs), validated costing methods, and no
differentiation between facility and professional fees
• develop differential payment schemes considering
service quality, efficiency and equity
• institute strong surveillance and audit mechanisms to
ensure networks’ compliance to contractual
obligations
Source: SVP Israel Francis Pargas, PhilHealth
Strategic Purchasing
(UHC Act Sec. 18b)

33. Department of Health, Philippines
34
National Health
Human Resources
Master Plan
National Health Workforce
Support System
Scholarship and
Training Program
including Return
Service Agreement
Source: Usec Mario C. Villaverde, DOH
Human Resources for Health

34. Department of Health, Philippines
35
• Institutionalization of
a licensing and
regulatory system in
DOH for primary
care facilities
• Establishment of a
rating system in
PhilHealth
Safety and
Quality
Affordability
• Mandating
transparent pricing
of health goods and
services
• Independent Price
Negotiation Board
to negotiate prices on
behalf of DOH and
PhilHealth
Basic
accommodation:
• at least 90% for
government
hospitals;
• at least 70% for
specialty hospitals;
and
• at least 10% for
private hospitals
Equity
Source: Usec Mario C. Villaverde, DOH
Regulation

35. Department of Health, Philippines
36
• Health Promotion
Bureau
• Incorporation of
health promotion
in school curricula
Evidence-
Informed Sectoral
Policy and
Planning for UHC
Monitoring and Evaluation
Source: Usec Mario C. Villaverde, DOH
Governance and Accountability

36. Department of Health, Philippines
37
Health Impact
Assessment
Health Technology
Assessment
Ethics in Public Health Policy
and Practice
Health Information System
Source: Usec Mario C. Villaverde, DOH
Governance and Accountability

37. Department of Health, Philippines
38
Sources of Funding for UHC
• Premium contributions of members
• Annual appropriations of the DOH
• National Government subsidy to
PhilHealth
• Supplemental funding
• 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
Source: Usec Mario C. Villaverde, DOH
Appropriations

38. Challenges and Opportunities
• Complementary bills to increase tobacco excise taxes and provide more
funds for UHC are still pending
• There are varied perspectives on the major reforms; strategic
communication is needed
• Implementing rules and regulations

39. Advanced Implementation Sites

40. Local health systems will lead

41. HEALTH AND THE ENVIRONMENT
Division of Noncommunicable Diseases and Health through the Lifecourse