Solutions Panorama

HOW DOES IT WORK?
The program initially covered citizens with Medicare,
but has expanded progressively to one universal health
insurance program for the entire population. In 2000
and 2005, additional reform efforts were outlined to
make decentralization and health insurance coverage
more effective. This included expanding government
subsidies to enroll low-income citizens, the creation
of local health service delivery and planning units to
reduce fragmentation, and a stronger Department of
Health role in regulation.
Since its creation in 1995, PhilHealth has expanded
health coverage and now has four categories of
enrollees who encompass nearly the entire population:
• Formal sector workers employed by companies and
other institutions;
• Low-income citizens who are financed by central
and local governments;
• Retirees (non-paying members) who have already
paid 120 months of membership and are 60 years
or older;
• The individual paying program (IPP) for those not
eligible for the other three categories.
Beneficiaries have access to a comprehensive package
of services, including inpatient care, catastrophic
coverage, ambulatory surgeries, deliveries, and
outpatient treatment for malaria and tuberculosis.
Those identified as low-income are also entitled to
outpatient primary care. In terms of the delivery
system, the private sector is a major player, and
PhilHealth has introduced an accreditation program for
private hospitals.
Provider payment methods differ based on the type
of care. Fee-for-service reimbursements are used for
inpatient care and most day surgeries, while primary
care providers are reimbursed based on a capitation
system. For other treatments, a case-based payment
methodology is utilized. Since doctors are usually
independent providers who practice in hospitals,
PhilHealth has developed incentive-based payment
pilots, such as the Quality Improvement Demonstration
Study (QIDS), which uses clinical vignettes to measure
quality of care for illnesses of children under six. If
a hospital passes a given quality of care score, the
payment for physicians is increased.
IMPACT
Healthcare coverage now extends to about 82 percent of the population, and the government’s aim to ensure
universal healthcare to the entire population is taking shape. On average, 90 out of every 100 claims are paid.
LEARN MORE
Universal Healthcare’s Drive of Health Sector Growth in the Philippines;
oxfordbusinessgroup.com
PhilHealth’s Mandate;
philhealth.gov
Philippines: PhilHealth;
jointlearningnetwork.org
Submitted by Population Services International (PSI)
WOMEN DELIVER 2016 CONFERENCE: SOLUTIONS PANORAMA 44