UHC Summit Sept Oct 2010 Final Report

8/13/2019 UHC Summit Sept Oct 2010 Final Report

1/21

1

FFIINNAALLRREEPPOORRTT

TTOOWWAARRDDSSUUNNIIVVEERRSSAALLHHEEAALLTTHHCCAARREE::

PPOOLLIICCYYOOPPTTIIOONNSSFFOORRTTHHEEPPHHIILLIIPPPPIINNEESS

PART 1Asian Institute of Management, Paseo de Roxas, Makati City

16 17 September 2010

PART 2Ramon Magsaysay Center, 1680 Roxas Blvd., Manila

27 28 October 2010

PPrreeppaarreeddbbyy::

CCEECCIILLIIAACC..SSIISSOONNSSeeccrreettaarryy,,MMeeddiicciinneessTTrraannssppaarreennccyyAAlllliiaannccee((MMeeTTAA))PPhhiilliippppiinneess


2/21

2

CCOONNTTEENNTTSS

PAPER

A MeTA Perspective: Fasttracking Universal Health Care in the Philippines by

Roberto M. Pagdanganan, Chairman, Medicines Transparency Alliance (MeTA)Philippines, December 2010

BACKGROUND

Medicines Transparency Alliance (MeTA) Global Context: Looking at Universal Health Care The Case for Universal Health Care in the Philippines

THE UNIVERSAL HEALTH CARE SUMMIT

Rationale and Objectives Brief Description Program Participants Presentations: Part 1 Presentations: Part 2

HIGHLIGHTS OF DISCUSSIONS

Perspectives on the Health Care System

Health System Reform: A Holistic View Ingredients for Health System Reform Towards Total Reform: Other Ingredients Political Will and Governance Public-Private Partnership Reforming Philhealth Medical Professionals

ANNEXES

Annex 1 MeTA Philippines Executive Committee 2010-2012

Annex 2 Program: National Summit on Transparency and Governance in UniversalHealth Care, 16-17 September 2010, Asian Institute of Management (AIM)

Annex 3 Program: Towards Universal Health Care: Policy Options for the Philippines,27-28 October 2010, Ramon Magsaysay Center

Annex 4 List of Participants: Part 1 (16-17 September 2010)

Annex 5 List of Participants: Part 2 (27-28 October 2010)


3/21

3

PRESENTATIONS: PART 1

Annex 6 MeTA Multi-Stakeholder Collaboration A Way to Achieve Transparencyand Governance in Universal Health CareDr. William Bannenberg, MeTA International Secretariat

Annex 7 State of Health Care in the Philippines: Supplier Side

Dr. Alvin Caballes, UP College of Medicine

Annex 8 Survey of Health Financing Mechanisms for Access to Medicines by thePoor in Rural and Urban PhilippinesMs. Marcia F. Miranda, Punla sa Tao Foundation

Annex 9 What the Poor Want in Healthcare (2010 SWS Survey on HealthcareServices and Financing)Ms. Linda Luz Guerrero, Social Weather Stations

Annex 10 People-Centered Health Reform AgendaDr. Suzette H. Lazo, UP College of Medicine

Annex 11 Health Financing Strategy: Building a Path Towards Universal Health CareDr. Liezel P. Lagrada, Department of Health

Annex 12 Models of Best Practice: The UK National Health ServiceAmbassador Stephen Lillie, Embassy of the UK in the Philippines

Annex 13 Universal Coverage Experiences of ThailandMs. Netnapis Suchonwanich, National Health Security Office, Thailand

Annex 14 Achieving Better Health Systems and FinancingDr. Dorsjuren Byarsaikhan, WHO Regional Office for the Western Pacific

Annex 15 National Center for Pharmaceutical Access and Management

Dr. Irene Farinas, Department of Health


Annex 16 Chairmans Report: Laying the Foundations. Effecting Change. LookingForward - Roberto M. Pagdanganan, MeTA Philippines

Annex 17 The Aquino Health Agenda: Universal Health CareAlexander A. Padilla, Department of Health

Annex 18 Towards Universal Health Care: Insights, Perspectives, Lessons,Recommendations - Cecilia C. Sison, MeTA Philippines

Annex 19 Gamot ay Buhay: Factbook on Medicines Access and the FilipinoSuzette H. Lazo, M.D., WHO Consultant

Annex 20 Towards Universal Health CareReiner W. Gloor, Pharmaceutical and Healthcare Association of thePhilippines (PHAP)

Annex 21 Alternative Budget Initiative and its Implications on Health Spending in thePhilippines - Alce C. Quitalig, Alternative Budget Initiative Health Cluster


4/21

4

Annex 22 Universal Health Care: Civil Society InitiativesPaula Mae B. Tanquieng, Coalition for Health Advocacy and Transparency

Annex 23 15thCongress Multi-Sectoral Health Policy AgendaRamon San Pascual, Philippine Legislators Committee on Population andDevelopment (PLCPD) Foundation, Inc.

Annex 24 Universal Health Care: The PMA Perspective

Arthur T. Catli, M.D., Philippine Medical Association (PMA)

Annex 25 Towards Universal Health Care: PPhA InitiativesLeonila M. Ocampo, Philippine Pharmacists Association (PPhA)

Annex 26 DSAPs Role in HealthJosephine Inocencio, Drugstores Association of the Philippines (DSAP)

Annex 27 National Center for Pharmaceutical Access and ManagementRobert Louie P. So, M.D., DOH NCPAM

Annex 28 The New FDAAtty. Christine Macaranas de Guzman, FDA

Annex 29 Health Financing and Service Delivery Programs in San Fernando City,Pampanga - Eloisa Aquino, M.D., San Fernando City, Pampanga

Annex 30 The La Union Medical CenterDr. Fernando Astom, La Union Medical Center

Annex 31 Health Financing and Service Delivery Programs of the ProvincialGovernment of Tarlac- Gov. Victor Yap, Province of Tarlac

Annex 32 PLAN PhilippinesMa. Loida Y. Sevilla, PLAN Philippines

Annex 33 The Role of Media in Health CareRodolfo Cornejo, GMA Network


5/21

5

AAMMeeTTAAPPEERRSSPPEECCTTIIVVEE

FFAASSTTTTRRAACCKKIINNGGUUNNIIVVEERRSSAALLHHEEAALLTTHHCCAARREE

IINNTTHHEEPPHHIILLIIPPPPIINNEESS

bbyy

RROOBBEERRTTOOMM..PPAAGGDDAANNGGAANNAANNCChhaaiirrmmaann,,MMeeddiicciinneessTTrraannssppaarreennccyyAAlllliiaannccee((MMeeTTAA))PPhhiilliippppiinneess

Health Sector Reform in the Philippines

For over two (2) decades of health sector reform in the Philippines, particularly in the areaof health insurance, attention has been focused on organizing and building the institutionsthat implement it.

As the successor to Medicare, the Philippine Health Insurance Corporation (Philhealth)was created through the National Health Insurance Act of 1995 (Republic Act No. 7875)toimplement the National Health Insurance Program (NHIP). We note the following:

The main purpose of the Act was to provide compulsory health insurance coverageand ensure access of all Filipinos to healthcare services. (Art. I, Sec. 2(1))

As a social insurance program, the NHIP was to serve as the means for the healthy tohelp pay for the care of the sick and for those who can afford medical care tosubsidize those who cannot. (Art. III, Sec. 5)

The government is responsible for providing a basic package of personal healthservices to indigents through subsidy of premiums, or directly until such time that theprogram is fully implemented. (Art. I, Sec. 2(r))

The target was to achieve universal coverage within 15 years from its implementation

or by 2010. (Sec. 4, IRR of RA 7875, As Amended)

The Philhealth PlusStrategy, developed in the early years of Philhealth, was designed toachieve universal coverage through the following components:

1. Universal coverage in all geographic areas2. Outpatient benefits package (OPB) to start with indigent members3. Philhealth-accredited facilities to provide outpatient services on a capitation basis4. LGU participation in providing health services and ensuring universal coverage5. Technical assistance from DOH


6/21

6

Relatedly, among the strategic directions of the DOH Health Sector Reform Agenda(HSRA)launched in 1999 was the reduction of the financial burden on individual familiesthrough universal coverage under the NHIP or the social health insurance program.

A Situationer: Health Expenditures

Yet, consider the following statistics:

The Philippines is still far from achieving universal health care with figures oncoverage varying from 38% (2008 PDHS) to 85% (Philhealth) depending on thesource of information. The WHO recommends that coverage be targeted for over90% of the population by prepayment and risk pooling schemes, and close to 100% ofthe vulnerable population.

Filipino households bear the heaviest burden in terms of spending for their healthneeds, with private out-of-pocket (OOP) expenditures reaching 54.3% of total healthexpenditures (THE) in 2007. The WHO recommends that OOP expenses be kept to aminimum of 30-40% of THE.

Social health insurance (Philhealth) contributes only 8.5% of THE. There is a lack of

sustainable support from the existing health delivery system.

That Filipino families are driven to poverty as a result of catastrophic illness point to theurgent need to fasttrack the implementation of a universal health care program for thePhilippines, with reforms necessary both in the health financing and service deliverysystems.

Learning From Other Countries

There are lessons to be learned from the experiences of other countries as we go throughthe process of developing a system that is responsive to the aspirations of our people,

cognizant of long-held traditions, and grounded on resource limitations and realities.

More progressive countries like the United Kingdom have long achieved universal healthcare under a centralized tax-financed system. UK Ambassador to the Philippines StephenLillie reported that their National Health Service (NHS) provides

a comprehensive range of services from ante-natal care through to end-of-life care

services for free at the point of delivery

services based on clinical need and not ability to pay. The UK NHS continues to workunder the fundamental principle articulated by its founder, Minister Aneurin Bevan,who said No nation can legitimately call itself civilized if a sick person is denied

medical aid due to lack of means.

According to Ambassador Lillie, the NHS is the worlds 4thlargest direct employer, nextonly to the Chinese Army, Wal-Mart Stores, and the Indian railways system.(Presentation made during Part 1, Universal Health Care Summit, AIM, 17 Sept 2010)

Working under a similar centralized system, provinces and the national government inCanada share equally in the cost of providing health services. Overall policies aredetermined and enforcement regulated by the national government, whereas theprovincial governments ensure the prompt and effective delivery of health servicesthrough hospitals and facilities which they operate.


7/21

7

Among our neighbors, Taiwan, Malaysia and Hong Kong have undertaken dramaticreforms in their respective health sectors that have allowed them, albeit through varyingmechanisms, to provide more comprehensive services to their citizens and improve healthoutcomes.

The Thailand Experience

We note, with keen interest, the success of Thailand in achieving coverage for 99.47% ofits population, despite their national health insurance program having been enacted onlyin November 2002, over 7 years later than the Philippines. Today, the Thai governmentimplements three (3) insurance schemes the Universal Coverage Scheme (UCS), CivilServant Medical Benefits Scheme (CSMBS) and the Social Security Scheme (SSS) which provide access to health services and goods to 74%, 10% and 15% of thepopulation respectively.

The case of Thailand is notable considering its attainment of universal coverage withinone (1) year from the start of the so-called 30-baht schemeunder the leadership of thenPrime Minister Thaksin Shinawatra (who had been elected on a populist platformcommitting to, among others, universal access to healthcare).

The popular 30-baht scheme (user fee of 30 baht per visit paid by all Thais under theUCS) was implemented even before the enactment of the health insurance law in 2002.In April 2001, the concept was piloted in 6 provinces, and then in 15 provinces by June2001. Within a year (2002), the scheme was implemented nationwide, with 92% of thepopulation covered by some form of health insurance.

Considering Reforms in the Health Sector

The body of data and experiential evidence point to the need for the Philippines toconsider certain reforms in the current health delivery system and infrastructure. Some ofthese are as follows:

Shift to a new provider-payment mechanism. The fee-for-service (FFS) scheme thatis currently applied poses certain disadvantages like cost escalation and inefficiencies.There is a tendency among doctors to maximize income through reimbursements forservices by providing expensive and/or unnecessary treatment.

In contrast, the capitation system for outpatients has been found to be more effectiveas a cost containment measure, while providing more acceptable levels and quality ofservice. There is, however, also a tendency for providers to limit services especially tothose needing expensive care or to patients with chronic conditions.

Emphasis on preventive and promotive health care. Primary care units (or rural healthunits) should play a significant role as gatekeepers and by providing services to

patients nearer their homes, thereby increasing physical access to health centers andreducing costs of medication.

Improvements in the health services delivery infrastructure through investments inupgrading primary care facilities, like rural health units (RHUs), and hospitals.

Institutionalization of training and sustained capacity-building of health workers. InThailand, for example, the consortium of medical schools agreed on revisions in theircurriculum placing more emphasis on primary care.


8/21

8

More rational dispersal of health professionals in the countryside, primarily through ascheme of incentives to encourage practice in rural areas administered by thegovernment social insurance program, or Philhealth. The schedule of professionalfees paid to General Practitioners (GPs) vis--vis specialists under the NHIP mustalso be re-assessed with the view to improving delivery of health services whileminimizing costs, and encouraging professional development of GPs.

While the Philippines has the highest density of medical personnel relative to its Asian

neighbors, professionals are clustered in urban areas like Metro Manila where salariestend to be higher, leaving far-flung communities with very limited access to medicalcare. According to the 2010 World Health Statistics, the professional to populationdensities in the Philippines are as follows: physicians - 12:10,000; nurses andmidwives - 61:10,000; dentists 6:10,000; other pharmaceutical personnel 6:10,000.

In contrast, Thailand registered the following statistics: physicians 3:10,000; nursesand midwives 14:10,000; dentists 1:10,000; other pharmaceutical personnel 1:10,000.

Capability-building and augmentation of resources of local governments to enablethem to more effectively participate in the delivery of health services in their respective

localities.

The National Health Security Office (NHSO) of Thailand administers the UniversalCoverage Scheme (UCS) in partnership with local governments, through ContractingUnits for Primary Care (CUPs) and Primary Care Units (PCUs) which provide healthservices through their facilities and hospitals devolved to them.

Piloting Reforms in 2011

The Medicines Transparency Alliance (MeTA) - a multi-country, multi-stakeholder groupconcerned with improving transparency and accountability in the pharmaceuticals supplychain as a means to achieve better health outcomes - recommends the following for

consideration:

Immediate implementation of policy reforms and expansion of benefits towardsuniversal coverage by piloting the scheme in ten (10) provinces and five (5) cities, withproportionate geographical representation based on population, i.e., for provinces: 6in Luzon, 2 in Visayas, 2 in Mindanao; for cities: 3 in Luzon (including Metro Manila),1 in Visayas, 1 in Mindanao.

An acceptable cost sharing scheme between the National Government andparticipating local governments shall be determined on the basis of need as well as theincome classification of the LGU.

The target is to commence the pilot program in 2011 and expand after a six (6)-month

trial period until nationwide coverage is attained, to the extent current realities andresource limitations allow.

Conduct of actuarial studies to determine an appropriate payment per visit figure,similar to the 30 baht identified in Thailand, and considering the experience of LGUsthat have been employing a similar per-visit scheme.

Lessons from other countries and from our own experience may then be successivelyapplied, and modifications made as may be necessary, to conform with our peoplesneeds and traditions and considering our current resource limitations. The objective is the


9/21

9

reduction of out-of-pocket health expenditures that will leave more resources for the otherbasic needs of Filipino households.

We believe Philhealth has the cumulative experience, research-based evidence,capabilities and resources to undertake the necessary reforms, under the leadership of theDOH and in collaboration with local governments, that will realize President Benigno C.Aquino IIIs commitment to provide universal coverage even before the end of the 3-yeartarget or by 2013.

On the part of MeTA Philippines, we are determined to extend the support of an activemulti-stakeholder network which includes a strong civil society coalition, to attain ourcollective aspirations for universal access to healthcare for all Filipinos, regardless ofcapacity to pay.

(ROBERTO M. PAGDANGANAN is Chairman of the Medicines Transparency Alliance(MeTA) Philippines and Founding Chair of the Coalition for Health Advocacy andTransparency (CHAT). This paper presents a set of policy recommendations andlearnings distilled from discussions during the Universal Health Care Summit held on 16-17 September 2010 and 27-28 October 2010, and Mr. Pagdanganans various meetingswith the National Health Security Office (NHSO) in Bangkok, Thailand from 2007-2010.)


10/21

10

BBAACCKKGGRROOUUNNDD

MEDICINES TRANSPARENCY ALLIANCE (MeTA)

The Medicines Transparency Alliance (MeTA) is a multi-stakeholder group working toimprove availability and affordability for a third of the worlds 6 billion people who lackaccess to basic and essential medicines. Millions die every year from HIV and AIDS,tuberculosis, malaria, pneumonia, measles, diarrhea and cardiovascular ailments yetmedicines already exist for nearly all these diseases.

The MeTA acronym stands for

Medicines essential health commodities such as drugs, vaccines,contraceptives, diagnostics and laboratory supplies

Transparency improving information access, scrutiny and use to support thedevelopment of viable and effective pharmaceutical markets and health systemsthat benefit all consumers in developing countries

Alliance stakeholders from the public, private and non-profit sectors workingtogether to effect significant positive change

In each of 7 pilot countries Ghana, Jordan, Kyrgyzstan, Peru, Philippines, Uganda andZambia representatives of government, the private sector and civil society are workingtogether to increase the poors access to affordable essential medicines. MeTA supportsefforts to improve the way medicines are purchased, supplied, and used; to implementinnovative and responsible business practices; and to encourage views from a wide

range of interests, including patients and consumers.

In the Philippines, MeTA programs are anchored on the following core principles:

Governments are responsible for providing access to health care, including access toessential medicines.

Stronger and more transparent systems and improved supply chain management willimprove access.

Increasing equitable access to medicines improves health and enables other humandevelopment objectives to be achieved.

Improved information about medicines can inform public debate, and provide a basisfor better policy.

A multi-stakeholder approach that involves all sectors public, private and civil society will lead to greater accountability.

MeTAs national fora are not simply generating and uncovering data and information, butare committed to making it public and encouraging people and organizations to act on itand producing policies which make such action possible.

The composition of the MeTA Philippines Executive Committee is in Annex 1.


11/21

11

GLOBAL CONTEXT: LOOKING AT UNIVERSAL HEALTH CARE

The World Health Report 2008 entitled Primary Health Care: Now More Than Ever citesthe following:

. . . it is always the wealthier folk, whether measured as an individual or as asociety, who have access to quality care, while the world's poorestandtypically as a result the poorest in healthwho have the least access to qualitycare or even the most basic health care.

"When countries at the same level of economic development are compared,those where health care is organized around the tenets of primary health careproduce a higher level of health for the same investment . . .

The same Report identifies five (5) global shortcomings in the delivery of health care:

1. Inverse care: people with the most means consume the most care; those with the

least means but the greatest health problems consume the least

2. Impoverishing care: lack of social protection and large out-of-pocket payments resultin catastrophic expenses

3. Fragmented and fragmenting care: excessive specialization of health care providers;narrow focus of many disease control programs; need for continuity in care

4. Unsafe care: poor standards in safety and hygiene; hospital-acquired infections;medication efforts; avoidable adverse effectives; underestimated cost of ill-health anddeath

5. Misdirected care: resource allocation clustering around curative care at great cost;neglects potential of primary prevention and health promotion to prevent up to 70% ofdisease burden

THE CASE FOR UNIVERSAL HEALTH CARE IN THE PHILIPPINES

President Benigno C. Aquino III committed to provide health services for all in hisInaugural Address on 30 June 2010. He said:

. . . serbisyong pangkalusugan, tulad ng Philhealth para sa lahat sa loob ngtatlong taon (Improved public health services such as PhilHealth for all withinthree years)

In his State of the Nation Address on 26 July 2010, the President reiterated

. . . tutukuyin natin ang tunay na bilang ng mga nangangailangan nito. Sangayon, hindi magkakatugma ang datos. Sabi ng PhilHealth sa isang bibig,87% na raw ang merong coverage. Sa kabilang bibig naman, 53% naman.Ayon naman sa National Statistics Office, 38% ang may coverage.

. . . National Household Targetting System, na magtutukoy sa mga pamilyanghigit na nangangailangan ng tulong. Tinatayang 9 bilyon ang kailangan paramabigyan ng PhilHealth ang 5 milyong pinakamaralitang pamilyang Pilipino.


12/21

12

. . . Kasama na po natin ang pribadong sektor, at kasama na rin natin angLeague of Provinces . . . Handa na pong makipagtulungan para makibahagi sapagtustos ng mga gastusin. Alam ko rin pong hindi magpapahuli ang League ofCities . . .

To finance health services for the poor, President Aquino said in his message dated 24August 2010 to the 15thCongress on the 2011 budget:

. . . National Household Targeting System (NHTS) . . . identify and locate the4.6 million households in the country who are poor . . . central database of ournations poor so that direct subsidies for them - DSWDs conditional cashtransfer and rice subsidy, DAs farm input subsidies, Philippine HealthInsurance Corporation (PHIC) health insurance for indigents can converge formaximum impact.

. . . The NHIP, for instance, could, and should, include preventive healthcareinsurance under its coverage.

The Department of Health ranks 7th with P33.3 billion, up by 13.6 percent fromthe 2010 level of P29.3 billion.

We put importance on the advancement and protection of public health.Equally important is making healthcare services accessible to all.

. . . channeling more funds to the health sector to expand the healthinsurance coverage of indigents as the more efficient mode of public healthintervention. Some P3.5 billion is being provided for the Health InsurancePremium of 4.6 million indigent families . . . for the very first time, 1.4 millionhouseholds in the informal sector. Small self-employed/underground economyworkers will be given preference for this health care benefit.

. . . sustain the provision of low-cost medicines through the establishment ofan additional 3,931 Botika ng Barangay (BnB), each BnB to be providedP25,000 worth of medicines. Some P98 million has been allotted for thisendeavor as part of the P1 billion allocation for DOH to support theimplementation of the Cheaper Medicines Act.


13/21

13

TTHHEEUUNNIIVVEERRSSAALLHHEEAALLTTHHCCAARREESSUUMMMMIITT

RATIONALE AND OBJECTIVES

The Aquino Health Agenda identifies universal health care as among its most importantprograms. The goal is to achieve universal coverage within three (3) years or by 2013.

The Department of Health (DOH) reform agenda for 2010-2016 is, in fact, anchored on theattainment of universal health care. The Administrations strategic directions for healthinclude the following:

1. Universal health care through a refocused Philhealth2. Construction and rehabilitation of, and support for, public health facilities3. Attainment of MDG 4, 5 and 6 (reduction of maternal, neonatal and infant mortality;

eradication of public health diseases such as tuberculosis, malaria and dengue)

The focus on universal health care is also evident in the initiatives articulated by variousstakeholder groups in the country:

1. The Health Care Financing Strategy 2010 2020 recognizes that the increase inoverall health spending is spurred by an increase in out-of-pocket expenditures; thatthere is a fragmentation in the financing system; and that past health reforms havehad marginal impact. Specific strategies include:

Increase in resources for health Sustaining membership in the national insurance program Funding for health infrastructure Effective provider payment mechanisms (capitation to be a major tool to pay for

primary health care services; case-mix system) Fiscal autonomy of health facilities

2. The DOH will be implementing strategies identified in the Philippine Medicines Policy2010, the result of multi-stakeholder consultations on a framework to increase accessto quality affordable medicines in the country. Key components of the SARAH AccessFramework include:

Safety, efficacy and qualityAvailability and affordabilityRational drug useAccountability and transparencyHealth systems support

3. A multisectoral alliance with strong participation from health advocates and civil societyhas put forward a proposed health legislative agenda. The institution of reforms in thehealth insurance program through revisions in the National Health Insurance Act of1995 (RA 7875, s.1995) is among the key thrusts in the legislative agenda for the 15 thCongress.

4. The Implementing Rules and Regulations (IRR) of the FDA Law (RA 9711, s. 2009)are expected to be issued shortly, and these will impact on the pharmaceuticals andregulatory environment in the Philippines. This will support continuing efforts to ensurethe safety, quality and efficacy of medicines distributed in the market.


14/21

14

While there have been lively public discussions on the topic, there is need for deeperappreciation among various stakeholders of the building blocks for overall health sectorreform, and the resources required to effect the necessary changes in the system.Leaders and concerned groups must, however, plan beyond discussing the issues anddeveloping policy recommendations - these plans need to be translated into concreteaction to achieve tangible results.

Within this context, the objectives of the two (2)-part multi-stakeholder Summit were:

a. To explore national health care system models and best practices in the context ofdeveloping an appropriate universal health care program for the Philippines

b. To serve as a forum for the discussion of current priority healthcare and healthfinancing issues that will impact on the attainment of the goal of universal coverage forall Filipinos by 2013

c. To develop a concrete program for public-private partnership, and define the roles andcontribution of all stakeholders

d. To generate public awareness and demand for a more responsive healthcare programthat will benefit all Filipinos

e. To document lessons into a set of recommendations for executive and legislativepolicy makers, the Department of Health (DOH), the Philippine Health InsuranceCorporation (PHIC), and local governments

BRIEF DESCRIPTION

The two (2)-part Summit was organized by the Medicines Transparency Alliance (MeTA)Philippines in partnership with the World Health Organization (WHO), Department ofHealth (DOH) and the Asian Institute of Management Center for DevelopmentManagement (AIM CDM).

MeTA organized the following:

National Summit on Transparency and Governance in Universal Health CareAsian Institute of Management, Paseo de Roxas, Makati City16 17 September 2010

Towards Universal Health Care: Policy Options for the PhilippinesRamon Magsaysay Center, 1680 Roxas Blvd., Manila27 28 October 2010

The first two (2)-day forum was attended by over fifty (50) representatives from variousstakeholder groups concerned with improving health care in the Philippines. Expert inputswere consolidated into a set of lessons and policy recommendations which were to be

presented to a wider audience in Part 2.

In Part 2, concerned stakeholders private industry, civil society, and health professionalorganizations had an opportunity to present their respective initiatives to improve thequality and delivery of health services to the public. These initiatives were discussed inthe context of the overall programs of both the national and local governments to achievethe targets of universal health care. Expert panel discussions tackled these critical issueswith the view to developing policy options and programs that shall be submitted as theplatform for multi-stakeholder partnerships.


15/21

15

PROGRAM

The final Programs for Parts 1 and 2 of the Universal Health Care Summit are attached asAnnex 2 and Annex 3 respectively.

PARTICIPANTS

The list of participants for Parts 1 and 2 of the Universal Health Care Summit are attachedas Annex 4 and Annex 5 respectively.


Copies of presentations made during Part 1 of the Universal Health Care Summit areattached as Annexes 6-15 (please refer to CONTENTS).


Copies of presentations made during Part 1 of the Universal Health Care Summit areattached as Annexes 16-33 (please refer to CONTENTS).


16/21

16

HHIIGGHHLLIIGGHHTTSSOOFFDDIISSCCUUSSSSIIOONNSS

During the Panel Discussions and Open Forums during the MeTA Universal Health CareSummit, there were a number of observations made, specific suggestions put forward,and expert recommendations articulated for the implementation of reforms in the healthsector. These are summarized as follows:

Perspectives on the Health Care System

The World Health Organization (WHO) has recommended that the Philippinesconsider the following indicators or benchmarks for universal health care:

1. Out-of-pocket expenditures should not exceed 30-40% of total health expenditures

2. Total health expenditures should be at least 4-5% of GDP

3. Over 90% of population covered by prepayment and risk pooling schemes

4. Close to 100% coverage of the vulnerable population through social assistanceand safety nets.

On the dispersal of the health workforce and facilities, the following observations weremade regarding the situation in the Philippines:

Majority of doctors are engaged in lucrative private practice in urban areas. While the human resource pool is large, the practitioners are unevenly distributed.

There are no health workers where they are needed most. There is continued preference for private over public health facilities because the

latter are oftentimes poorly equipped and poorly staffed.

Health policies are formulated at the national level, but operationalization of programs

and services is done at the local. The devolution of health programs to localgovernments has led to fragmentation, and confusion regarding roles, responsibilitiesand accountabilities. While devolution should have made the system moreresponsive, LGUs are not made accountable for health outcomes.

While government has often targeted to provide free medicines and services in healthcenters and charity hospitals, feedback from the ground indicates that these schemeshave not and will not be effective and sustainable given the current resources andconstraints.

The current health system encourages inequities. More attention must be given toaddressing specific challenges that have led to such inequity by, among others,ensuring more efficient use of resources for sectors needing better and regular health

care like the poor.

Health System Reform: A Holistic View

While health financing is an important component of discussions regarding universalhealth care, many sectors strongly advocate a focus as well on preventive andpromotive health care. Such focus will result in savings in the long run. A seriousassessment of strengthening the capitation system for primary care (vs traditional fee-for-service schemes) is imperative.


17/21

17

Discussions around universal health care are not just about financing. There is aneed, as well, to address such issues as reforms in human health resources, theorganization of health systems, gate-keeping concepts, regulations on drug quality,regulations on private medical practice, governance, and multi-stakeholdercollaboration in addressing other determinants of health.

There is a need for a more holistic view of the problem and a serious reengineering ofthe entire health system. The problem of health care is systemic and cannot be

addressed on a piece-meal basis. While there is a tendency of government to plan in6-year cycles, policy makers must take a more long term view. Investments in and forhealth must be viewed beyond a 6-year time frame to be responsive and effective.

There is a strong need to also look into the problems of other systems, social servicesand sectors when planning for a more responsive health care system. Issuesregarding education, housing, access to potable water, sanitation, employment andfood must be addressed as well, as they affect the level of health outcomes.

Implementing a universal health care program necessitates, as well, looking closely atimproving access and availability of affordable quality essential medicines. Accesspoints for essential medicines and drug entitlement programs must be rationalized.

Ingredients for Health System Reform

Efficiently channel financial and other resources into the development of andimprovements in the countrys health infrastructure, such as public hospitals andhealth centers, and especially primary care units.

Encourage the DILG and the DOH to work together on the formulation of firm policyguidelines and programs to ensure regular supply and availability of quality andaffordable essential medicines in health facilities through LGUs. Stockouts must beminimized and essential health care services provided. Notwithstanding devolution,the national and local governments must find a mutually beneficial arrangement tocoordinate efforts towards better health outcomes.

Rationalize DOH programs which aim to improve public access to essential medicines.These programs include the Botika ng Barangay, P100 drug packages, specific drugentitlement schemes, and generics promotion, among others. Such initiatives arelaudable, although there is much room for improvements in implementation, an evidentneed for streamlining, and maximum and effective use of allocated resources.

Improve the system for procurement and distribution of medicines by the public sector.The feasibility of tapping private groups to undertake bulk procurement, centralizedpurchasing, warehousing and distribution for government should be seriouslyconsidered. The private sector will be in a better position to provide such servicesmore efficiently and promptly.

Implement immediately the basic health package proposal which covers essential andfront line drugs which, based on expert computations, will cost PhP 1,400.00 perperson per year.

Promote the principle of solidarity through a social health insurance program. AllFilipinos should have access to health care, regardless of capacity to pay. Those whohave more means to finance their health needs should contribute towards subsidizingthe poor.

Actualize the proposal for the health sector to operate under a federal-type structure:The national government shall focus work on the development of standards,


18/21

18

monitoring compliance and mobilization of resources. LGUs, under this structure, shalloperationalize health programs and directly provide services to their respectiveconstituents.

Review the effectiveness of devolving health services to local governments andestablish a scheme of accountabilities to improve the delivery system.

Undertake health education campaigns on access to and rational use of medicines.

Develop a national strategic plan for health which defines indicators, budgets and aclear mechanism of accounting. The plan should also incorporate a healthinformation, education and communications agenda.

Develop innovative and non-traditional health financing schemes and savingsmechanisms that will improve access of the poor and vulnerable to essential qualitymedicines. Promote public-private partnerships to address the problem.

Relatedly, continuously assess the conditional cash transfer (CCT) program of thegovernment. There must be a clearer delineation of roles and accountabilitiesbetween the national and local governments. Access of LGUs to CCT funds mustcontinue to be dependent on ability to provide services, and LGU efforts to improve

service delivery must be strongly supported. Many are advocating for CCT programsto also cover granting drug benefits to the identified poor.

Towards Total Reform: Other Ingredients

That higher health spending translates to more effective care is a major myth. Healthoutcomes are also determined by lifestyle, genetics and environment. There must bea continuing and conscious effort to encourage healthy lifestyles.

Current realities require the organization of an IT-based system for health. Manysectors are concerned, for example, that the Philippines does not even have reliablemapping of health professionals and facilities.

The strengthening of the national regulatory agency (FDA) will have significant impacton the pharmaceuticals and healthcare markets. National self-reliance in drugmanufacturing should be encouraged, but enforcing global GMP standards must beensured.

Micro-financing schemes will not be enough to solve the gargantuan problem of thelack of financial resources to access medicines and health care. But if they must beused, policy guidelines must be developed to ensure that micro-insurance programsactually mitigate hardship financing.

Many sectors have articulated the need to incorporate courses around public health,access to medicines, and universal health care in the curriculum of medical schools,

as well as in continuing medical education (CME) programs.

The gate-keeping concept must be seriously studied as a means to improve thedelivery of health care, and to maximize access and rationalize use of health services.Instilling such concept in the mindset and culture of all stakeholders in the healthsystem will take time and realizing the full impact is expected only in the long term, butthis must be promoted and started beginning immediately.

There are many lessons to be learned from other country models. While no onescheme will address the problems of our current health system, each countryssituation being unique, the Philippines can choose to adopt specific best practices.


19/21

19

Global, regional and country experiences provide important policy guides for healthsystem and financing reforms. The UK and Thai models, discussed during the MeTASummit, present specific features that can be adopted in the Philippines.

Although there are advantages to having a single health insurance provider controlledby the state, safety nets and safeguards are necessary to prevent the inefficienciesresulting from the monopoly. Private HMOs and providers should also be encouragedto complement health coverage efforts of Philhealth.

Many stakeholder groups have strongly suggested that the government seriouslyreview the possibility of imposing a health expenditures allocation for LGUs, similar tothe 5% required for gender-related programs.

Political Will and Governance

The Philippines needs a very high-level champion who shall advocate and pushstrongly for universal health care, as well as for reforms in the current health system.Political will is imperative.

Health care reform requires a huge degree of political will. A publicly funded health

care system requires strong government financing capacity not only to collect taxesefficiently, but to direct revenues towards health. Innovations in reform are necessaryto keep up with changing expectations and needs.

Government must take advantage of donor funds directed towards improving thedelivery of public health services and access to medicines. However, strongerstandards for accountability and control need to be established. It is necessary toensure that such grants and/or funds are consistent with national objectives for health.

Fraud exists in the health care system. There is a need to look into the problem ofcounterfeit drugs, over-servicing and excessive claims in health insurance, physiciansordering unnecessary diagnostic or medical procedures, exorbitant procurement pricesfor medicines and services, etc.

The development of a transparent and reliable procurement system in the public sectoris an essential element to ensure the availability of quality affordable medicines.

While there is a need to increase the level of public sector spending, it is equallyimportant to ensure the efficient and effective use of health resources. There areinitiatives to increase resources for health. The government should look at earmarkingrevenues from tobacco taxes for health promotion.

Public-Private Partnership

The public has very high expectations of government and the medical profession as

the vehicles to provide quality and adequate health care services. Private sectorefforts should supplement, rather than compete with or duplicate governments work.

The private sector is taking a more proactive role than government in discussing theissues and involving all stakeholders. Public-private partnership is still not evident.

Public sector agencies involved in providing health care services must not only learn towork together and innovate, but create synergy for better results and more efficientuse of resources. There is fragmentation in policies and programs between thenational and local governments, and between DOH and Philhealth. Government


20/21

20

strategies must be formulated with more firm planning and a clear articulation ofdesired outcomes.

There are initiatives from enlightened groups and/or donor-assisted organizations.Their role and resources must be harnessed, instead of disregarded. Civil society isencouraged to take an even more active role in advocacy, monitoring andcommunication with other stakeholders. Non-government organizations (NGOs) havea strong community-level network which may be harnessed in the advocacy for

universal health care.

Public health advocates, media and the medical profession need to work with eachother to promote healthy lifestyles. Efforts must be directed towards providing correctinformation to enable the public to make the right choices. In other areas, partnershipsamong key stakeholders must be strengthened. Civil society can be harnessed notonly for mobilizing at the community-level, but also for information dissemination andlobbying for legislative attention and support for its initiatives.

There was a strong expression of the belief that for reforms to work, there is a need forinstilling a culture of good governance, transparency and accountability. While thereare pockets of success in some provinces and cities in the Philippines, there is greatroom for continuing education in pharmaceuticals management and good governance

in health.

Reforming Philhealth

Philhealth enrollment has become politicized and used as a tool for patronage. Thispractice has not succeeded in maximizing utilization of coverage. The use of thecapitation fund intended to pay for services of health practitioners must be free fromthe influence of local government executives.

There are inefficiencies and gaps in current Philhealth processes and systems whichmust be addressed. Benefits are not adequate to meet health care needs, especiallythose of the poor.

Local governments are concerned about the reported plan of Philhealth to graduallydecrease its share in the payment of premiums for the poor. There is a need tostrengthen capacity for the management of health funds as well as for improvementsin the quality of health services in primary facilities.

Noting the important role that Philhealth will continue to play in the attainment ofuniversal health care, more attention must be given to improving the quality and levelof delivery of services to its members, as well as its systems and procedures. Thepublic is concerned that Philhealth has shown a propensity for investing their funds infinancial instruments instead of providing more services for the poor.

In addition to increasing enrollment, Philhealth must also direct its efforts towards

upgrading health facilities, as well as improving the professional capacity and benefitsfor accredited health professionals.

While Philhealth should encourage increased enrollment, it must also seriously lookinto maximizing utilization. Specific programs should be directed to allow regular andeffective utilization of benefits for actual health needs. Accredited health facilities mustbe equipped to provide services at the time members avail of these.

Review the Philhealth law, and implement reforms where needed. Among the keyfactors that should be considered are the delineation of responsibilities between DOH,Philhealth and the LGUs, as well as the sharing of the financial burden for premiums.


21/21

Some sectors have suggested that DOH focus on regulations, policy and informationprograms, leaving service delivery as the responsibility and accountability of LGUs.

For marked and immediate impact, develop a Philhealth outpatient drug benefitpackage as soon as possible covering chronic and non-communicable diseases aswell. Ongoing efforts to improve benefits to members must be supported. Strongrecommendations have been aired about the need for Philhealth to bettercommunicate with and serve a more aware and discerning public.

Medical Professionals

Specific issues pertaining to the role and contribution of medical professionals in thedelivery of health services still need to be addressed. There is an urgent need, forexample, to look into the wide disparity in fees paid to General Practitioners (GPs) vis-a-vis medical specialists.

Marketing to doctors contributes to high prices of medicines and is among the keycauses of irrational use. Some sectors have suggested that government and/orprivate industry look into forms of regulation and monitoring of advertising, promotionand marketing practices of pharmaceutical companies to safeguard the interest of

patients and consumers.

UHC Summit Sept Oct 2010 Final Report

Documents