PhilHealth AtAGlance

AG0901

November2009 TheNationalHealthInsuranceProgram

The National Health Insurance Act of 1995 (RA No. 7875) institutionalized social health insurance in the country through the National Health Insurance Program (NHIP) or PhilHealth. The NHIP aims to reduce outofpocket spendingaswellastheinequitiesinhealthfinancing.Thisisdonebypoolingfundsfrommemberswhoarehealthy, andcanaffordhealthpayments,andsubsidizingthosewhoaresicklyandcannotaffordmedicalcare. For employed members, the amount of premium shall not Figure1.Totalhealthexpenditures exceed3percentofthemembersrespectivemonthlysalaries bysourceoffunds,2005(in%) tobesharedequallybytheemployerandemployee.Forthose without visible means of income, the national government Private Others (NG) and the local government unit (LGU) share the payment Government Sources 1% 29% of premium. The Philippine Health Insurance Corporation 11% (PHIC)managesPhilhealth.

In2005,Philhealthcontributed11.0percentorPhP19.2billion to the countrys total health expenditure (THE) which Outof amountedtoPhP180.8billion.Theburdenoffinancinghealth Pocket 48% carewasstillheaviestonindividualfamilieswith48.4percent orPhP87.5comingfromhouseholdsoutofpocketspending. TheNG contributed16percentorPhP26.0billionwhilelocal Social governments gave 13 percent or PhP 24.7 billion. One of the Insurance 11% targets of the National Objectives for Health is to have 15 percentofTHEfinancedbyPhilHealthby2010. Source:PhilippineNationalHealthAccounts.2005. Table1.NHIPMembershipbySector(inmillions) Membership.AccordingtoPHICestimates, Sector Members Beneficiaries 77million(or82percent)ofthe92million 1.88 8.85 Governmentemployed Filipinos are covered by PhilHealth as of (anemployeewhetherregular,casualor March2009. contractual,whorendersservicesinanyofthe
governmentbranches) Privateemployed (anemployeewhorendersservicesinlocalor foreigncorporations/organizations,foreign embassies,andhouseholdemployers) Sponsored/Indigentprogram (apersonwhohasnovisiblemeansofincomeor whoseincomeisinsufficientforthesubsistence ofthefamily) Individuallypaying (a member who is self employed or who is not employed/indigent/retiredmemberbutpaysthe required contribution or whose contribution is beingpaidbyanotherindividualorprivateentity) Lifetimemembers (OldageretireesandpensionersofGSISandSSS) Overseasworkers (members employed abroad, maybe land or sea based) TOTAL
Source:PhilHealthStatisticsandCharts.2009 6.58 27.95

3.39

17.08

3.09

14.61

The Sponsored Program. The Sponsored Program of the PHIC caters specifically to indigents. Beneficiaries are given health insurance coverage for one year and are identified using the CommunityBased InformationSystemMinimumBasicNeeds (CBISMBN) framework administered by the City/ Municipal Social Welfare and Development Office (C/MSWDO) and/or thebarangay. Cities and 1st to 3rd class municipalities shoulder half of the PhP 1,200 annual premiumwhiletheotherhalfispaidbythe NG. A different sharing schedule is followed for 4th to 6th class municipalities. In some cases, private individuals and corporations, and members of Congress alsosponsorsomeindigentfamilies.

0.41 1.90

0.69 8.35

17.24

77.38

 Benefits for indigents. PhilHealth provides in Figure2.Numberoffamiliesactivelyenrolledinthe patient coverage, namely subsidy for room and SponsoredProgramfrom20002009(in000) board, drugs and medicines, laboratories, 7,000 operating room and professional fees for 6,258 confinements, as well as outpatient coverage 6,000 such as day surgeries, dialysis and cancer 4,946 treatmentprocedures,subjecttorateceilingsand 5,000 maximum allowances. For confinements in Department of Health (DoH) hospitals, indigent 4,000 memberswillnolongerhavetopayanything. 3,264 3,389 3,000 2,492 2,271 Universal coverage of indigents. As of March 1,762 2009,72percent(3.4familiesorabout17million 2,000 1,261 beneficiaries) of the 4.7 million indigent families are enrolled in the Sponsored Program. RA No. 1,000 619 347 7875targets100percentcoverageoftheindigent populationby2010. 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Membership of families in the program is evaluated yearly by the PHIC and the LGUs. Source:PhilHealthStatisticsandCharts.2009. According to the PHIC, noncompliance to their rules or an increase in family income above the povertythresholdrevokesorcancelsmembership in the program. However, critics have alleged Table2.PercentageofmemberswhousedPhilhealth thatthedeterminationofwhowillbeincludedto benefitsinthepast12months and who will be dropped from the indigents list No.ofPHIC Percentageof bythePHICandLGUsubjectstheprogramtothe members Memberswhoused biases of incumbent politicians. During the May Region amongNDHS PHICbenefitsinthe 2004polls,forinstance,PhilHealthcardsaresaid respondents past12months to have been distributed for campaign purposes. PHILIPPINES 4,642 27.76 Figure 2 shows the noticeable increase of 255 percent in indigent members during that year. WealthIndexQuintile Senate Bill No. 3328 by Senator Loren Legarda Quintile1(poorest) 296 17.60 proposes that the national government fully Quintile2 508 23.17 subsidize the annual required premium Quintile3 806 24.50 contributions of indigent members. The bill also Quintile4 1,200 28.16 mandates the Department of Social Welfare Quintile5(richest) 1,832 32.68 Developmenttoleadtheidentificationofindigent Source:NDHS.2003. familiestobeincludedintheprogram. Claims and benefit utilization. For the 1st quarter of 2009, 58 percent of total claims was paid to the employed members;18percenttotheindividuallypayingmembers;14percenttotheSponsoredProgrammembersandthe restwenttolifetimemembersandoverseasworkers. WhilePhilHealthandCongressstriveforuniversal coverageofindigentfamilies,therecentNationalDemographic andHealthSurvey(NDHS)showedthatthereisverylowutilizationofNHIPbenefitsamongtheverypoormembers. ThirtytwopercentofPhilHealthmembersfromtherichestincomequintileusedPhilHealthinthepast12months, whileofthepoorest20percent,only17percentavailedofthebenefits. ThesurveyexplainedthatthehigherutilizationratesofPhilHealthbytheupperincomegroupispossiblydueto:(i) having more resources to pay for the remainder of the hospital bill after deducting the PhilHealth benefit, (ii) a greatercapacitytofulfillrequirementsforclaims,(iii)havingbetteraccesstoPhilHealthaccreditedfacilities,and(iv) havingmoreinformationontheproceduresforfilingclaims. Stillaccordingtosurvey,thelackofinformationonthebenefitsandhowtoavailthem,lackofaccreditednearby health facility and lack of money for excess billing prevented the indigent beneficiaries from utilizing PhilHealth benefits.