ILIGAN MEDICAL CENTER COLLEGE

POLICY ANALYSIS:

Republic Act No. 7875

PHILIPPINE HEALTH INSURANCE CORPORATION

(PHILHEALTH)

Submitted by:

Caye Almira A
Balignot Kenneth
Perocillo Madelyn

Submitted to:

Ms. Fatma Zaena S. Saripada, RSW

 Republic Act No. 7875

PHILIPPINE HEALTH INSURANCE CORPORATION

(PHILHEALTH)

Introduction

RA 7875, also known as the National Health Insurance Act of 1995, established the

Philippine Health Insurance Corporation (PhilHealth) as the country's national health

insurance program. The law aims to provide affordable and accessible health care to all

Filipinos, particularly the marginalized sectors of society. (Philippine Health Insurance

Corporation,1995).

Under the law, PhilHealth is mandated to enroll all citizens and permanent residents in

the country, including those who are indigent, self-employed, and overseas Filipino workers.

PhilHealth provides financial protection to its members against the costs of health care

services, including hospitalization, medical treatment, and other related services.

(Weltbankgruppe, 2019)

The Philippine Health Insurance Corporation (PhilHealth) are important and relevant

issues because they address one of the most significant challenges facing the Philippine

healthcare system: the lack of access to affordable and quality healthcare services.With

PhilHealth, Filipinos are given the opportunity to avail of medical services without worrying

about the high cost of medical care. The health insurance program provides financial

protection to its members, particularly the poor and marginalized, against the high costs of

healthcare services such as hospitalization, medical treatments, and other related services. RA

7875 also mandates PhilHealth to develop and implement programs for the prevention and

control of diseases, as well as to provide health education and information to the public.
 In a country where the majority of the population still live below the poverty line, the

health insurance program plays a crucial role in addressing the problem of health inequality.

It is relevant because it provides a safety net for those who cannot afford healthcare services

and helps ensure that they receive the care they need. It also encourages people to seek

medical attention promptly, preventing their health problems from worsening and reducing

the burden of catastrophic health expenses on households.

In this policy analysis, we will argue that the implementation of RA 7875 has had

positive outcomes, including expanded coverage, improved financial protection, and the

implementation of health programs that address the needs of vulnerable and marginalized

Filipinos. However, there are still challenges to achieving universal healthcare coverage in

the Philippines, including issues related to funding, transparency, and governance. Overall,

the successful implementation of RA 7875 is essential in achieving better health outcomes for

the Filipino population, reducing health inequality, and contributing to the country's overall

economic development.

Background

RA 7875, also known as the National Health Insurance Act of 1995, was implemented

on January 1, 1996, during the administration of former President Fidel V. Ramos. The policy

was the result of years of advocacy by various stakeholders, including civil society

organizations, health professionals, and politicians, who recognized the need for a national

health insurance program to address the challenges of the Philippine healthcare system.

(Republic Act No. 7875, 1995)

The idea of a national health insurance program was first proposed in the early 1960s

by the Philippine Medical Association and the Philippine Hospital Association. However, it
was not until the 1990s that the government seriously considered the idea. In 1993, a study

commissioned by the Department of Health recommended the establishment of a national

health insurance program as a way to address the inequities in the healthcare system.(Flavier,

1999)

In response to the recommendations of the study, the Philippine Congress passed RA

7875 in 1995, which established the Philippine Health Insurance Corporation (PhilHealth)

and mandated the creation of a national health insurance program. The policy aimed to

provide financial protection to all Filipinos, particularly the poor and marginalized, against

the high cost of healthcare services.(Gonzales, 2020)

The proponents of RA 7875 included various stakeholders, such as the government,

philhealth management, healthcare providers, Philhealth members, Civil Society, Patients and

general public, Insurance industry and Healthcare Advocacy groups and NGOs. The

Philippine Medical Association, the Philippine Hospital Association, and the Philippine

Nurses Association were among the professional organizations that supported the policy.

Civil society groups, such as the Citizens' Health Initiative and the Community Health

Education Emergency Rescue Services Foundation, also advocated for the establishment of a

national health insurance program. Politicians from both the ruling and opposition parties,

including Senator Juan Flavier, former Health Secretary Carmencita Reodica, and former

President Fidel V. Ramos, were also proponents of the policy. The government is responsible

for providing funding to PhilHealth, while healthcare providers are responsible for providing

quality healthcare services to PhilHealth members. PhilHealth members are responsible for

enrolling and paying their premiums, while the general public benefits from the expanded

coverage and improved access to healthcare services. (CHAKRABORTY, S. (2013)

The establishment of PhilHealth under RA 7875 was a significant milestone in the

history of the Philippine healthcare system. Before the policy, healthcare services in the
Philippines were fragmented, with different insurance schemes catering to different groups of

people. Medicare, the government's health insurance program at the time, only covered

government employees and their dependents. This left a significant portion of the population

without access to affordable healthcare services.(Tangcharoensathien et al., 2015)

RA 7875 addressed this issue by creating a national health insurance program that

aimed to provide financial protection to all Filipinos against the high cost of healthcare

services. PhilHealth's benefits package includes primary care services, hospital care, and

outpatient care. The agency also offers various health programs, such as the "Z Benefit

Package," which provides financial assistance for patients with catastrophic illnesses, and the

"No Balance Billing Policy," which prohibits hospitals from charging additional fees to

PhilHealth members. (Community Health Education Emergency Rescue Services

Foundation, n.d.)

Since its establishment, PhilHealth has made significant strides in expanding its

coverage and improving its services. In 2013, the agency achieved universal coverage, with

91% of the population enrolled in the program. PhilHealth has also implemented various

health programs, such as the Primary Care Benefit Package, which provides free consultation

and medicines for common illnesses, and the Case-Based Payment System, which seeks to

improve the efficiency and quality of healthcare services. (Aparis, A. R. (2016)

While RA 7875 has had positive outcomes, such as expanded coverage and improved

financial protection, there are still challenges to achieving universal healthcare coverage in

the Philippines. These include issues related to funding, transparency, and governance.

Relevant laws and regulations that relate to the issue include the Universal Health Care Act,

which aims to provide equitable and accessible health services for all Filipinos, and the

Magna Carta for Public Health Workers, which seeks to protect and promote the rights and

welfare of public health workers in the country. (Philippine Medical Association, n.d.)
Analysis

In analyzing this policy, the students use SWOT ANALYSIS. SWOT analysis is a

framework used to evaluate an organization's strengths, weaknesses, opportunities, and

threats. This analysis helps organizations identify internal and external factors that can impact

their operations and performance.

Strength:

Universal Health Coverage, RA 7875 mandates PhilHealth to provide universal health

coverage to all Filipinos, regardless of their socio-economic status. Improved Access to

Health Services, PhilHealth's coverage includes a wide range of health services, including

hospitalization, outpatient care, and preventive care, which can improve access to

healthcare services for Filipinos. Government Support, PhilHealth receives government

support and funding, which allows it to sustain its operations and expand its coverage. Cost

Sharing, PhilHealth employs a cost-sharing mechanism, where both the government and

the enrollee share the cost of health services. This approach makes healthcare services

more affordable for Filipinos. Health Financing, PhilHealth serves as a financing

mechanism for health services, which helps to address the issue of inadequate funding for

healthcare in the Philippines.Social Protection, PhilHealth's coverage provides social

protection for Filipinos, especially the poor and vulnerable, who are at risk of financial

hardship due to healthcare expenses. Improved Health Outcomes, PhilHealth's coverage

can lead to improved health outcomes, as Filipinos can access timely and appropriate

healthcare services. Strong Governance, PhilHealth has a well-established governance

structure, with a board of directors and senior management team overseeing its operations,

which can help ensure accountability and transparency.

Weaknesses:

Limited resources, PhilHealth's resources are limited, which can affect its ability to

provide adequate coverage and services to all Filipinos.Inefficient processes, PhilHealth's

processes and procedures can be bureaucratic and time-consuming, which can lead to

delays and inefficiencies in its operations.Fraud and corruption, PhilHealth has been

embroiled in fraud and corruption scandals, which can undermine its credibility and trust

among Filipinos.Inequitable access to healthcare, Although PhilHealth is mandated to

provide universal health coverage, there are still gaps in access to healthcare services,

especially in remote or underserved areas.Limited coverage of certain health services,

PhilHealth's coverage of certain health services, such as preventive care and mental health

services, can be limited, which can impact the health outcomes of Filipinos.Insufficient

funding, PhilHealth's funding is insufficient to meet the needs of all Filipinos, especially

the poor and marginalized.Fragmented healthcare system, The healthcare system in the

Philippines is fragmented, with a mix of private and public healthcare providers. This can

make it difficult for PhilHealth to coordinate and integrate healthcare services.Dependence

on government support, PhilHealth relies heavily on government support and funding,

which can be affected by changes in political priorities and economic conditions.

Opportunities:

Expansion of coverage, PhilHealth can expand its coverage to include more services and

benefits, such as preventive care, mental health services, and other essential health services

that are not yet covered.Strengthening of healthcare delivery systems, PhilHealth can

collaborate with healthcare providers to improve the quality of healthcare services and
ensure that they are accessible and affordable to all Filipinos.Promotion of health

education, PhilHealth can promote health education and awareness to Filipinos,

encouraging them to adopt healthy lifestyles and practices that can prevent illnesses and

promote better health outcomes.Development of health infrastructure, PhilHealth can

support the development of health infrastructure, such as hospitals, clinics, and other health

facilities, especially in underserved and remote areas.Partnership with the private sector,

PhilHealth can partner with the private sector to improve the delivery of healthcare

services, especially in areas where government facilities are limited or

non-existent.Promotion of health research, PhilHealth can promote health research and

development, such as studies on disease prevention, treatment, and healthcare system

improvements that can benefit Filipinos.Utilization of technology, PhilHealth can leverage

technology to streamline its operations and improve its services, such as through the

implementation of electronic health records, telemedicine, and other digital health

solutions.Promotion of financial sustainability, PhilHealth can promote financial

sustainability by improving its collection systems, reducing fraud and abuse, and ensuring

that its funds are used effectively to provide quality healthcare services to Filipinos.

Threats:

Political instability, PhilHealth's operations can be affected by changes in government

policies and leadership, which can impact its budget and priorities. Fraud and corruption,

PhilHealth has been plagued by fraud and corruption scandals, which can undermine the

public's trust in the organization and reduce its effectiveness.Rising healthcare costs,
Healthcare costs in the Philippines are increasing, which can strain PhilHealth's resources

and limit its ability to provide affordable and accessible healthcare services to all Filipinos.

Demographic changes, As the Philippines experiences an aging population and changing

health needs, PhilHealth may face new challenges in providing adequate coverage and

services.Natural disasters, The Philippines is prone to natural disasters such as typhoons

and earthquakes, which can damage healthcare facilities and disrupt PhilHealth's

operations.Technological advancements, Rapid changes in technology can disrupt the

healthcare industry and require PhilHealth to adapt its processes and services to meet the

evolving needs of Filipinos.Global pandemics, Global pandemics, such as the COVID-19

pandemic, can strain healthcare systems and require PhilHealth to respond to the public

health crisis, potentially diverting resources from other areas of its operations.

Stakeholder Analysis

Stakeholders Position Interest Influence

Government Is generally They are interested The government has

(Policymakers, supportive of the in effective significant influence
Regulatory body) law, as it aims to implementation, as the enactor and
provide universal financial regulator of RA
health coverage and sustainability, and 7875.
improve the overall achieving the
health system in the program's
country. However, objectives.
their stance may also
depend on political
considerations and
policy priorities.
PhilHealth They are responsible They are interested PhilHealth
Management for ensuring the in successful management has
(The executives, efficient and program direct control over
board of directors, effective operation implementation, the program's
and staff members) of the program, and financial viability, operations and
their position is member satisfaction, decision-making.
focused on and operational
achieving its efficiency.
objectives, financial
sustainability, and
enhancing member
services.

Healthcare They are directly They are interested Healthcare providers

Providers involved in in fair have a significant
( Hospitals, clinics, providing healthcare reimbursement, impact on the
doctors, and other services to streamlined delivery of services
healthcare PhilHealth processes, and to PhilHealth
professionals) members. access to timely members.
payments.

PhilHealth Is generally They are interested Members have

supportive, as the in affordable limited direct
Members
program provides premiums, influence but can
( individuals and
financial protection, comprehensive provide feedback
households) risk-sharing, and coverage, access to and voice concerns.
access to healthcare quality healthcare,
services. However, and efficient claims
members may have processing.
varying perspectives
on the quality of
services, coverage
limitations, and the
affordability of
 premiums.

Health Advocacy Focused on They are interested Advocacy groups

healthcare and social in promoting and NGOs have
Groups and NGOs
welfare often universal health influence through
(Health advocacy
support RA 7875, as coverage, addressing their expertise,
groups,non-governm
it aligns with their gaps in access, and public awareness
ental organizations
goals of achieving advocating for campaigns, and
(NGOs), and civil
universal health policy policy advocacy
society
coverage and improvements.
organizations)
improving
healthcare access.
They may actively
engage in promoting
the program,
advocating for
policy
improvements, and
monitoring its
implementation.

Insurance Industry Some may see it as They are interested The insurance
(Private health competition, as the in understanding industry can
insurance program offers a market dynamics, influence the
companies) government-backed potential development of the
alternative to private collaborations, and private health
health insurance. identifying business insurance market
Others may view it opportunities. and collaborate with
as an opportunity for PhilHealth.
collaboration or
supplementary
coverage. The
insurance industry's
position can vary
 depending on their
market focus and
business models.

Patients and While not directly They are interested Patients and the
General Public involved in the in accessible, general public can
program's affordable, and influence the
implementation, quality healthcare program through
patients and the services. their feedback,
general public have utilization patterns,
a stake as and advocacy.
beneficiaries and
potential participants
in the health system.

Auditing and involved in auditing They are interested Auditing and

Monitoring Bodies and monitoring in ensuring the monitoring bodies
( Commission on activities, focused program's integrity, ensure transparency,
Audit (COA) and on transparency and efficient use of accountability, and
civil society accountability, play funds, and compliance with
organizations) a role in ensuring compliance with regulations.
the program's legal and ethical
compliance and standards.
effectiveness.

Recommendation

Based on the SWOT analysis above, here are some specific recommendations for

policy changes or improvements that can help address the challenges faced by PhilHealth:

Address fraud and corruption: Addressing fraud and corruption within PhilHealth

can help improve the organization's credibility and trust among Filipinos. This can be
achieved through the implementation of stricter monitoring and enforcement measures, as

well as more transparency in its operations. By doing so, PhilHealth can restore public

confidence in its ability to effectively provide universal health coverage.

Expand coverage and services: Expanding PhilHealth's coverage and services can

help address the changing healthcare landscape and the evolving needs of Filipinos. By

including preventive care, mental health services, and access to medical technologies and

equipment, PhilHealth can improve the accessibility and quality of healthcare services

provided to Filipinos.

Leverage technology: PhilHealth can leverage technology to streamline its processes

and improve its operations. This can include the implementation of electronic health records,

telemedicine, and other digital solutions that can help improve access to healthcare services

and reduce inefficiencies. By doing so, PhilHealth can provide more efficient and

cost-effective healthcare services to Filipinos.

Improve resource allocation: Prioritizing resources effectively can help PhilHealth

ensure that they are allocated to areas that require the most attention. By investing in staffing

and infrastructure in underserved or remote areas and ensuring that funds are directed

towards areas that have the greatest need, PhilHealth can improve the accessibility and

quality of healthcare services provided to Filipinos.

Develop a long-term strategy: Developing a long-term strategy can help PhilHealth

remain relevant and effective in the face of new challenges and opportunities. By taking into

account the changing healthcare landscape and emerging trends in healthcare delivery,
PhilHealth can better position itself to meet the evolving needs of Filipinos and provide

effective universal health coverage.

In conclusion, by implementing these recommendations, PhilHealth can address the

issues identified in the SWOT analysis, improve its operations, expand its coverage and

services, and better meet the healthcare needs of Filipinos.

Conclusion

The SWOT analysis of RA 7875 (PhilHealth) highlights the program's strengths in

providing universal health coverage, solid network of healthcare providers, and risk-sharing

benefits. However, it also identifies weaknesses in coverage limitations, issues of fraud and

corruption, and financial sustainability. The analysis presents opportunities for enhanced

benefit packages, technology integration, and public awareness, while recognizing threats

such as rising healthcare costs, health disparities, and regulatory changes. By understanding

these factors, stakeholders can develop strategies to maximize strengths, address weaknesses,

seize opportunities, and mitigate threats in order to improve the overall effectiveness and

sustainability of RA 7875.

Addressing the policy issue of RA 7875 is of utmost importance as it directly affects

the well-being, financial security, and overall health outcomes of the Filipino population. By

taking proactive measures to improve the program, we can achieve universal health coverage,

promote health equity, protect individuals from financial hardship, enhance health outcomes,

and build a sustainable and trusted healthcare system.

Further research and action can play a vital role in enhancing the effectiveness and

impact of RA 7875. We would like to suggest to the future endeavours to further research on

Evaluation of Benefit Packages. Further research is needed to evaluate the adequacy and
relevance of benefit packages provided by RA 7875. Assessing the coverage limitations and

exclusions can help identify gaps and areas for improvement. Additionally, research can

explore the feasibility of expanding benefit packages to include emerging healthcare needs

and technologies, such as telemedicine and preventive care. Public Awareness and

Education Campaigns, Conduct targeted public awareness and education campaigns to

ensure that PhilHealth members and the general public are well-informed about their rights,

benefits, and responsibilities under RA 7875. These campaigns can help in maximizing

program utilization, promoting preventive care, and empowering individuals to make

informed healthcare decisions.

Taking these research and action suggestions into consideration will contribute to the

continuous improvement and effectiveness of RA 7875. By furthering our understanding,

strengthening collaboration, and implementing evidence-based strategies, we can ensure that

the program achieves its objectives of providing universal health coverage, improving health

outcomes, and promoting equitable access to healthcare for all Filipinos.

References:

Aparis, A. R. (2016). Achieving Universal Health Care in the Philippines: A Study of Health

Financing Reforms. Asian Journal of Social Sciences and Management Studies, 3(2),

128-142.

CHAKRABORTY, S. (2013). Philippines’ Government Sponsored Health Coverage Program

for Poor Households.

Flavier, (1999) Community Health Education Emergency Rescue Services Foundation

Gonzales, (2020). Philippine Health Insurance Corporation

(Ramos, 1995). Monthly Bulletin of the Philippine Health Service

Rembe, M. D., & Cueto, R. P. (2020). Universal Health Care Act (RA 11223) and the

Attainment of the Sustainable Development Goals in the Philippines. Philippine Journal of

Public Administration, 64(3/4), 253-285.

Reodica, (1996). Report of the Philippine Health and Medical Campaign (PHMC).

(Tangcharoensathien et al., 2015). World Health Systems.

Tan-Torres Edejer, (1999). Social health insurance in a developing country: The case of the

Philippines. Social Science & Medicine, 62(12), 3177–3185.

https://doi.org/10.1016/j.socscimed.2005.11.047

Weltbankgruppe. (2019). Supply-Side Readiness of Primary Health Care in the Philippines.

World Bank Group. (2017). Pooling Health Risk to Protect People.

(World Health Organization, 2019)