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Policy analysis on province-level integration of healthcare system in light of the Universal Health Care Act

Hilton Y. Lam ; Ma-Ann M. Zarsuelo ; Theo Prudencio Juhani Z. Capeding ; Ma. Esmeralda C. Silva ; Michael Antonio F. Mendoza ; Carmencita D. Padilla

Acta Medica Philippina.2020;54(6):650-658. doi:10.47895/amp.v54i6.2608

Background: The enactment of the Universal Healthcare (UHC) Act affirms the commitment of the State to safeguard the health of all Filipinos. One of the objectives of the Act is to integrate the different local health systems at the provincial level in order to minimize fragmentation in the delivery of health services. This significant undertaking needs effective inter-sectoral collaborations of various stakeholders both at the local and national levels. Methods: A systematic review of literature was conducted to generate evidence-based policy tools. A roundtable discussion (RTD) was organized in collaboration with the Department of Health (DOH) to frame the current issues of the devolved health system and the anticipated challenges surrounding the integration to the provincial level. Policy discussion was guided by specific operational concerns put forth by the DOH such as the roles and functions of key local actors, organizational models, and metrics of integration. Results: Inputs in the proposed organogram for the province-level integrated health system and assessment tool for identifying readiness of provinces were discussed and agreed upon. Critical issues in the composition of the members of the Provincial Health Board (PHB) and the line of command among constituents were raised. Conclusion and Recommendations Eight consensus key policy recommendations have been identified. These could be translated into operational guidelines for the DOH, local government units (LGUs), and other related national government agencies (NGAs) in implementing the local health systems integration as prescribed in the UHC Act.
Health Care Reform ; Delivery of Health Care, Integrated ; Policy

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A call for an evidence-informed criteria selection to guide equitable health investments in the era of Universal Health Care: Policy analysis

Ma. Esmeralda C. Silva ; Ma-Ann M. Zarsuelo ; Marianne Joy N. Naria-Maritana ; Zenith D. Zordilla ; Hilton Y. Lam ; Michael Antonio F. Mendoza ; Ara Karizza G. Buan ; Frances Karen A. Nuestro ; Janvic A. Dela Rosa ; Carmencita D. Padilla

Acta Medica Philippina.2020;54(6):659-667. doi:10.47895/amp.v54i6.2587

Background: The passage of the Universal Health Care (UHC) Act in the Philippines in early 2019 intensified the need to ensure equitable health investments by the government. Exploring the different criteria and indicators that are used to determine areas that are most in need of health services can help local and national health authorities determine priorities for health investments given finite resources. Methods: A systematic review of literature on determinants of health equity and other indicators was conducted as pre-work to generate discussion points to the roundtable discussion participated by all major key stakeholders. Shared insights and expertise were thematically analyzed to produce a policy paper with consensus policy recommendations. Results: Based on the review of the literature and the discussion, indicators (mainly physical inaccessibility and socioeconomic factors) for identifying Geographically Isolated and Disadvantaged Areas (GIDA) in DOH Administrative Order 185, s. 2004 is used to prioritize municipalities for health investments. Review of other policies and guidelines to determine the level of health needs and prioritizing investments yielded to four laddered domains: geographic, population characteristics (e.g., social and cultural determinants of access), health system (e.g., health service delivery), and health status. These domains may provide a more equitable set of metrics for health investment. The Local Investment Plan for Health (LIPH) is the current process used for health-related investments at the local level and may be revised to be more responsive to the requirements set by the UHC Act 2018. Hot spotting to concentrate health services by communities may be a more rapid approach to investment planning for health. Bed capacity as a specific metric in the UHC Act 2018 highlights the need for a review of the Hospital Licensure Act 2004. Conclusion and Recommendations To aid in determining priorities for health investments, a comprehensive integrated analysis of resources, determinants, and indicators should be done to determine the need and the gaps in the available resources. Innovative strategies can also be best implemented such as mathematical models or formulas. Lastly, current strategies in the development, monitoring, and evaluation of investment planning for health at different levels should be strengthened, expanded, and harmonized with other existing development plans.
Universal Health Care ; Health Equity ; Investments

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Policy analysis on determining hospital bed capacity in light of Universal Health Care

Ma. Esmeralda C. Silva ; Ma-Ann M. Zarsuelo ; Marianne Joy N. Naria-Maritana ; Zenith D. Zordilla ; Hilton Y. Lam ; Michael Antonio F. Mendoza ; Ara Karizza G. Buan ; Frances Karen A. Nuestro ; Janvic A. Dela Rosa ; Carmencita D. Padilla

Acta Medica Philippina.2020;54(6):668-676. doi:10.47895/amp.v54i6.2596

Background: Through the years of improving quality health service delivery, hospital bed capacity in the Philippines has remained to be a persistent challenge. In light of the aim of the Universal Health Care Act to protect and promote the right to health of every Filipino, one metric used to identify areas that are in most need or are under served, is the number of public hospital beds vis a vis the catchment population. Methods: The systematic review of literature was utilized to generate a policy brief presented to the invited stakeholders of the policy issue for the roundtable discussion participated by all key stakeholders of the policy issue. Evidence and insights were thematically analyzed to generate consensus policy recommendations. Results: With the current hospital bed availability and maldistribution, the Philippines still faces compounded issues in addressing healthcare demands. Currently, the request for increasing bed capacity is done through legislation. In context, this request is also parallel in expanding service capacity through the allocation of more funds and personnel. The ratio of private and charity beds must ensure to have equity among all patients of varying segments of the population. Enjoining private hospitals to share bed capacity for public service was also explored given appropriate subsidies. Conclusion and Recommendation To ensure equity in health service delivery, it is imperative to assess, strategize, and conduct prioritization of the needs of government hospitals for increased bed capacity, considering the distribution, socio-demographic profile, and health needs of the catchment population.
Privatization ; Philippines ; Hospital Bed Capacity

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Policy analysis on establishing criteria for population versus individual-based health services towards achieving Universal Health Care

Leonardo Jr. R. Estacio ; Ma-Ann M. Zarsuelo ; Christine Mae S. Avila ; Ma. Esmeralda C. Silva ; Michael Antonio F. Mendoza ; Carmencita D. Padilla

Acta Medica Philippina.2020;54(6):677-685.

Background: The enactment of the Universal Health Care Act is anticipated to bring wider coverage and accessibility of quality healthcare services as stipulated in its objectives. With the integration of the healthcare system at the provincial level, determining population- and individual-based services is crucial in mapping the managerial and financial roles. Hence, this study aimed to establish the criteria for identifying population-based and individualbased health services in the Philippines. Methods: A systematic review of literature was conducted to generate evidence for the policy brief and discussion points on the roundtable discussion spearheaded by the UP Manila Health Policy Development Hub in collaboration with the Department of Health. Key stakeholders of the policy issue convened to share expertise and insights in determining criteria for population- and individual-based services, intending to generate consensus policy recommendations. Results: The general scope of individual-based health services stipulated in the Law are to be financed under the benefit packages of PHIC and HMOs. Meanwhile, population-based services are those that address public health issues such as health promotion and disease surveillance. Several services considered as ‘grey areas’ are those that fall in the overlap of the individual- and population-based services. These services may be examined through an outcome-based algorithm that examines fragmentation issues both in the supply and demand side of service delivery. Conclusion and Recommendation Proposed criteria in identifying individual- and population-based services include the number of recipient/s, the effectivity of service delivery and utilization, and source of funding. Health programs that are in the grey areas can be examined through an outcome-based algorithm.
Healthcare Financing ; Health Services Accessibility

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Policy analysis on financing roles for Population- and Individual-based health services in light of the Universal Health Care Act

Leonardo Jr. R. Estacio ; Christine Mae S. Avila ; Ma-Ann M. Zarsuelo ; Ma. Esmeralda C. Silva ; Michael Antonio F. Mendoza ; Carmencita D. Padilla

Acta Medica Philippina.2020;54(6):686-691.

Objectives: The health financing scheme brought by the Universal Health Care Act has a significant change in the landscape of allocating funds for health services, as well as in the delineation of roles among the key actors. Consistent with the law, the protection from the health financial risks of Filipinos must be guaranteed. This study aimed to determine the roles of the government and other key agencies in financing population-based and individual-based health services in the Philippines. Methods: A systematic review of literature was done to generate evidence for the policy brief and proposed policy alternatives. The UP Manila Health Policy Development Hub organized a roundtable discussion in collaboration with the Department of Health participated by key stakeholders from various sectors involved in the policy issue. Systematic review and insights from the discussion were analyzed to produce consensus policy recommendations. Results: Given the current procurement and financing, the DOH should fund population-based services while PhilHealth, with the assistance of Health Maintenance Organizations (HMO) for premium holders, should fund individual-based services. Health programs with grey areas (i.e. with both individual- and population-based service) need further technical discussions. It is imperative to have clear-cut specific guidelines on the managerial and financial roles of the provincial health board and the scope of financing service delivery. Conclusion Delineating the roles of DOH, PhilHealth, and HMOs in financing health services is not without risks. The utilization of the special health fund at the provincial level should be carefully implemented and monitored to minimize inefficiencies and fraud.
Healthcare Financing ; Universal Health Insurance ; Insurance, Health

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Rationalizing health personnel financing schemes for evidence-informed policy reforms: Policy analysis

Hilton Y. Lam ; Katrina Loren R. Rey, Ma-Ann M. Zarsuelo ; Ma. Esmeralda C. Silva ; Michael Antonio F. Mendoza ; Carmencita D. Padilla ; Katrina Loren R. Rey

Acta Medica Philippina.2020;54(6):692-700. doi:10.47895/amp.v54i6.2611

Background: The Universal Health Care Law seeks to optimize financing of personnel costs without compromising quality and equitable health care among the health care facilities. This position statement aimed to identify strategies and policy recommendations for the cost-effective financing of health personnel in public healthcare facilities. Methods: A systematic review of literature was done to generate policy brief and key points for roundtable discussion in collaboration with the Department of Health (DOH). The discussion was guided by the three health financing options of DOH: (a) retain Personnel Services (PS) as DOH budget but shift Maintenance and Other Operating Expenses (MOOE) to PhilHealth; (b) shift PS and MOOE to PhilHealth, and (c) rationalize part-time status in government hospitals. Results: The pros and cons of financing options were cross-examined. In Option 1, physicians in government hospitals would receive fixed salaries from DOH / Local Government Units. In Option 2, there would be a monopsony between PhilHealth and provincial power. Payment will be performance-driven, and balance billing will be eliminated. Option 3 would be a set up of retaining part-time positions for physicians. Conclusion and Recommendation Participants deduced that for Option 1, provision of salary augmentation sources and ensuring adequate plantilla items and level of remuneration in government hospitals should be considered, in order to sufficiently compete with physicians’ income from private practice. For Option 2, the PhilHealth reimbursement system should ensure timely reimbursement so as not to subject care providers to financial instabilities. For Option 3, rationalizing part-time status should be flexible and can be applied regardless of how physicians are paid, as this would incentivize caregivers to work harder and smarter.
Universal Health Insurance ; Healthcare Financing ; Physicians ; Universal Health Care ; Reimbursement Mechanisms

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Policy analysis on identifying copayment services for the shift in financing scheme of health care services

Hilton Y. Lam ; Ma-Ann M. Zarsuelo ; Katrina Loren R. Rey ; Ma. Esmeralda C. Silva ; Michael Antonio F. Mendoza ; Carmencita D. Padilla

Acta Medica Philippina.2020;54(6):701-709. doi:10.47895/amp.v54i6.2599

Background: As the Philippines moves toward universal health coverage, it is imperative to examine how to eliminate inefficiencies, particularly misuse, overutilization, and risks of fraudulent claims. This position statement aimed to identify health services requiring copayments for cost-efficient health financing for the Universal Health Care Act. Methods: A qualitative study was employed using a systematic review of literature, and thematic analysis of policy roundtable discussion (RTD) was conducted. The systematic review of literature generated evidence for the policy brief and critical points for discussion in the stakeholders’ RTD forum. The RTD was organized by the UP Manila Health Policy Development Hub (UPM HPDH) with the Department of Health (DOH) and was participated by key stakeholders of the policy issue to attain consensus recommendations and develop criteria for identifying services requiring copayments. Results: An algorithm is proposed by the UPM HPDH based on collective expertise as a guide for policymakers to assess each benefit package in terms of overutilization, the danger of depleting government funds, and the risk of fraud. The use of clinical pathways is suggested to assess the misuse and overutilization of health services. In addition to copayments, benefits packages prone to fraudulent activities should be subjected to fraud prevention processes. Copayment should be linked inversely to the preventability level of the disease or condition. Conclusion There were gaps in the current policies to identify services requiring copayment services. Copayment schemes should be carefully determined to prevent misuse, overuse, and fraud of appropriate and necessary health services, while at the same time not limit access to needed care.
Universal Health Insurance ; Cost Sharing ; Medical Overuse

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Moving towards evidence-informed policy development on third party accreditation of healthcare facilities in Light of the Universal Health Care Act: Policy analysis

Michael Antonio F. Mendoza ; Ma-Ann M. Zarsuelo ; Gabriel R. Borlongan ; Ma. Esmeralda C. Silva ; Hilton Y. Lam ; Carmencita D. Padilla

Acta Medica Philippina.2020;54(6):710-721. doi:10.47895/amp.v54i6.2617

Background: The Universal Health Care (UHC) Act seeks to delineate the roles of key agencies and stakeholders towards equity in access to quality and affordable health care. Under the pillar of health regulation, the Philippine Health Insurance Corporation is mandated to recognize third party accreditation mechanisms as a basis for granting incentives to health facilities that provide better service quality, efficiency, and equity. Methods: A systematic review of literature was conducted to generate a policy brief that outlined the strengths and weaknesses of the current accreditation system, and how to address arising fragmentation issues in implementation based on international and local evidence. To generate recommendations from a multi-stakeholder approach, a roundtable discussion enjoined by all major stakeholders of the policy issue was conducted by the University of the Philippines Manila Health Policy Development Hub in collaboration with the Department of Health. Thematic analysis of the RTD and the literature review were utilized in crafting the position statement with the general aim of producing consensus policy recommendations, as inputs in the Implementing Rules and Regulations of the Act. Results: Policy analysis using results of literature review and policy discussion was crafted, with thematically arranged recommendations in the domains of leadership and governance, financing and sustainability, standards development, program development, and continuing quality improvement that could help the national health system in determining third party accreditation mechanisms set forth by the UHC Act. Significant issues raised was the composition and requirements of the third party accreditor and the risks in transition. Conclusion and Recommendation With the PhilHealth Benchbook setting the standards and with the expressed commitment of stakeholders for third party accreditation, it is an opportune time for the UHC Act to institutionalize the accreditation mechanisms that will address existing challenges of PhilHealth accreditation. The literature review and discussion bring forth the proposed tool for the criteria in selecting third party accreditors.
Universal Health Care ; National Health Programs ; Accreditation

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Addressing primary care inequities in underserved areas of the Philippines: A review

Marianne Joy N. Naria-Maritana ; Gabriel R. Borlongan ; Ma-Ann M. Zarsuelo ; Ara Karizza G. Buan ; Frances Karen A. Nuestro ; Janvic A. Dela Rosa ; Ma. Esmeralda C. Silva ; Michael Antonio F. Mendoza ; Leonardo R. Estacio

Acta Medica Philippina.2020;54(6):722-733 . doi:10.47895/amp.v54i6.2578

: Background. Inequities in health care exist in the Philippines due to various modifiable and non-modifiable determinants. Through the years, different interventions were undertaken by the government and various stakeholders to address these inequities in primary care. However, inequities still continue to persist. The enactment of the Universal Health Care (UHC) Act aims to ensure that every Filipino will have equitable access to comprehensive and quality health care services by strengthening primary care. As a step towards UHC, the government endeavors to guarantee equity by prioritizing assistance and support to underserved areas in the country. This paper aims to review different interventions to promote equity in the underserved areas that could aid in needs assessment. Methods: A search through PUBMED and Google Scholar was conducted using the keywords, “inequity,” “primary care” and “Philippines.” The search yielded more than 10,000 articles which were further filtered to publication date, relevance to the topic, and credibility of source. A total of 58 full-text records were included in the review. Results and Discussion: In the Philippines, inequities in primary care exist in the context of health programs, facilities, human health resources, finances, and training. These were recognized by various stakeholders, from government and private sector, and nongovernment organizations, taking actions to address inequities, applying different strategies and approaches but with a shared goal of improving primary care. On another end, social accountability must also be instilled among Filipinos to address identified social and behavioral barriers in seeking primary care. With political commitment, improvement in primary care towards health equity can be achieved. Conclusion and Recommendation To address inequities in primary care, there is a need to ensure adequate human resources for health, facilities, supplies such as medications, vaccination, clean water, and sources of funds. Moreover, regular conduct of training on healthcare services and delivery are needed. These will capacitate health workers and government leaders with continuous advancement in knowledge and skills, to be effective providers of primary care. Institutionalizing advocacy in equity through policies in healthcare provision would help realize the aims of the Universal Health Care Act.
Philippines ; Universal Health Care ; Primary Health Care

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Contracting out of health services for province-level integration of healthcare system: Effect on equity

Theo Prudencio Juhani Z. Capeding ; Ma-Ann M. Zarsuelo ; Hilton Y. Lam ; Ma. Esmeralda C. Silva ; Michael Antonio F. Mendoza

Acta Medica Philippina.2020;54(6):734-741. doi:10.47895/amp.v54i6.2581

Background: The recently enacted Universal Health Care (UHC) Act prioritizes the provision of a comprehensive set of quality and accessible services. However, the devolution of health services has led to inequitable investments in healthcare resulting to disparities in health outcomes between areas. One of the strategies considered that could minimize these differences is the contracting out of health services to the private sector. This review focuses on mapping equity-related issues and concerns with regard to contracting out health services. Methods: A modified systematic search of literature using published journal articles through PubMed and Google Scholar and other pertinent reports and manuals was conducted on issues of equity and health service contracting. Results and Discussion: There is currently a dearth of literature on the effect of contracting services on health equity outcomes, particularly on the impact of contracting out on equity. Limited studies showed that contracting out can potentially improve equity by increasing service utilization. Mechanisms on how contracting out could potentially affect equity were also found. Results mainly suggest that concrete steps should be taken to ensure equitable access and improvement in health outcomes among population subgroups. To provide a framework in applying possible insights from the review, discussion of the literature review was framed in the context of establishing performance-based contracting. It was emphasized that including representatives from the underserved populations and patient groups during stakeholder consultations were crucial to provide localized context for the inclusive development of contracting arrangements. Other strategies that were highlighted included: establishing monitoring systems that disaggregate data between groups, selecting contractors that have the capacity to reach and provide services to the underserved, and making sure that these contractors are also open to data sharing for economic evaluation of services. Conclusion and Recommendations Despite the paucity of data on the impact of contracting out services on equity, mechanisms explaining the effect of contracting on equity were put forward and illustrated. These findings can be considered by policy makers and program developers in the operationalization of service agreements between the public and private sectors.
Health Equity ; Contract Services ; Health Services

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