Moving from universal health coverage
to effective financial protection:
Evidence from a health insurance
experiment in the Philippines
SA. Quimbo
University of the Philippines School of Economics Prince Claus Chairholder, 2011/13
Prince Claus Chair Symposium
on Health Insurance & Access to Health
International Institute of Social Studies The Hague, The Netherlands
Key
Messages
•
The
Philippines
aspires
for
universal
health
coverage
(UHC)
•
Effectively
measuring
effective
financial
risk
protection
should
be
a
key
element
in
a
UHC
strategy
•
In
the
Philippines,
premium
subsidies/
and
or
reducing
non
‐
price
barriers
may
not
be
a
cost
‐
effective
way
of
increasing
effective
financial
risk
Background
Indicator(2011) Philippines Indonesia Population,total 94,852,030 242,325,638 Populationdensity,peoplepersqkm 318 134 PercapitaGNP,USD* 2,210 2,940 Povertyheadcountratioat2USD** 41.5 52.7 Healthexpenditurepercapita,currentUSD 97 95 Mortalityrate,infant(per1,000livebirths) 20.2 24.8
Health
Care
Financing
System
in
the
Philippines
The
PhilHealth and
the
UHC
goal
•
PhilHealth protection,
in
peso
terms:
- Finances less than 10% of total spending on health care
(Philippine National Health Accounts, various years)
- Out of pocket payments still the dominant mode of financing
•
PhilHealth protection,
in
“household”
terms:
- Only about 3 percent of households that faced health shocks
said that they coped through PhilHealth
•
PhilHealth protection,
in
coverage
terms
:- Overall PhilHealth coverage is 69 percent
- Sponsored Program beneficiaries account for 35% of total population
- Informal sector beneficiaries account for only 11.5% of total
The near-poor and informal sector
are among the least protected
• Poor and near-poor are equally vulnerable to health shocks, at least in terms of incidence of health shocks
• The formal sector and the poor have more secure mechanisms for coverage (e.g., Sponsored Program).
• The near poor and informal sector are expected to voluntarily participate in the Individually Paying Program.
Measurement
should
be
an
integral
part
of
the
UHC
strategy
•
In
2008,
we
proposed
a
summary
measure
of
financial
risk
protection
provided
by
social
health
insurance
(estimated
with
2008
PhilHealth data
and
then
with
2011
survey
data)
BDR
timeline
2008 Start of BDR Research and Dissemination Feb 2009 PhilHealth’s Toast to Universal Coverage June 2010 President Aquino’s first State of the Nation Address Dec 2010 DOH’s Aquino Health Agenda on Universal Health Coverage 6 Jan 2012 PhilHealth introduced a performance “dashboard” 2013 Increased interest in BDR by other executive offices“Financial risk protection through
regional benefit delivery ratios.” “Financial risk protection through
improvement in NHIP benefit delivery
shall be achieved by: Redirecting
PhilHealth operations towards the
improvement of national and
regional benefit delivery ratios.”
“At present, the data are not consistent.
According to PhilHealth, 87 percent have
(PhilHealth) coverage. Other sources say, 53
percent. And according to the National
BDR
in
the
news
“… Mr. Aquino was dismayed at the miserable benefit delivery
rate of the National Health Insurance Program in the country
which stands at only 8 percent. He said the figure translated to
only four out of 50 patients who considered PhilHealth beneficial
and knew what insurance coverage was all about. Only 50 percent
of members who went to private hospitals used their PhilHealth benefits, and only 24 percent in government institutions, Mr.
Aquino said. In short, even members don’t have sufficient
knowledge of how PhilHealth can help with their health‐care
expenses, he said.”
Source: Philippine Daily Inquirer, October 2, 2010 Tondo poor first of 4.6M set to get free PhilHealth by
Christian V. Esguerra
What
is
the
BDR?
• The benefit delivery rate (BDR) is a summary measure of social health
insurance performance that reflects
The capacity of social health insurance to cover/enrol the target population
(coverage rate)
The accessibility of social health insurance benefits to beneficiaries who
utilize health care (claim rate)
The magnitude of social health insurance benefits relative to medical
expenditures (reimbursement rate)
= Coverage rate x claim rate x reimbursement rate
Enroll
Enroll
Claim
Claim
Reimburse
Reimburse
Motivating
the
BDR
•
The
BDR
is
the
average
reimbursement
rate
for
the
general
population
needing
health
care
Example 1: Reimbursement rate is 36% Coverage rate =100%
Claim rate=100%
BDR = 36%
Example 2: Reimbursement rate is 36% Coverage rate is 50%
Claim rate is 59%
BDR is 50% x 59% x 36% = 11%
The 36% reimbursement rate is expected for only 29% of the population who used health care
Reimburse‐
Effect
on
BDR
of
reducing
barriers
to
health
insurance
•
“3P”
randomized
experiment
from
2011
‐
2012
• Insurance subsidies amounted to 50 percent of premiums • Information
• Fill up and pick‐up of forms
•
Covered
15
of
17
regions
nationwide,
954
households
in
treatment
sites,
and
647
households
in
control
sites
•
Part
of
the
Health
Equity
and
Financial
Protection
in
Asia
(HEFPA)
Project,
a
four
‐
year,
EU
‐
funded
research
project
of
a
consortium
of
ten
research
Reducing barriers to health insurance:
Premium subsidies and information
100 percent subsidy for the first 6 months of coverage, or 50 percent subsidy for 12 months of coverage
Reducing barriers to health insurance:
Reducing the burden of documentation
Experiment
Results
•
Premium
subsidies
and
information
increased
insurance
take
up
rates
by
13
percent
•
Reduced
burden
of
documentation
increased
insurance
take
up
rate
by
13+
percent
•
However,
these
levels
of
increase
in
insurance
take
up
rate
is
small
compared
to
the
cost
Source: “Squeezing the Middle:
A Randomized Experiment to Promote Voluntary Enrollment in a Social Health Insurance Program.” JJCapuno, ADKraft,
Policy
Simulations
9.05% 11.14% 12.81% 14.43% 30.44% 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 35.00% OVERALL BDR (ACTUAL, BASELINE) OVERALL BDR (ACTUAL, POST EXPERIMENT)POLICY SCENARIO 1 POLICY SCENARIO 2 POLICY SCENARIO 3
BDR
SCENARIO 1: all indigent and formal sector covered + take up due to experiment + 100% reimbursement in public hospitals SCENARIO 2: all indigent and formal sector covered + second poorest quintile + 100% reimbursement in public hospitals SCENARIO 3: all indigent and formal sector covered + second poorest quintile + 100% reimbursement in public hospitals +
Conclusions
•
Measuring,
monitoring,
and
giving
feedback
should
be
integral
to
any
UHC
strategy
– In the Philippines, the BDR measure and process has partly
addressed this need
– Beyond the Philippines, MMF could be generally useful
•
Premium
subsidies,
information
and
reduced
transaction
costs
aimed
at
the
near
poor
and
informal
sector
can
increase
BDR
only
in
a
limited
way
– Increased enrolment efforts need to be combined with other
interventions to ensure effective financial protection
