FINAL REPORT

TOWARDS UNIVERSAL HEALTH CARE:

POLICY OPTIONS FOR THE PHILIPPINES

PART 1 Asian Institute of Management, Paseo de Roxas, Makati City 16 17 September 2010 PART 2 Ramon Magsaysay Center, 1680 Roxas Blvd., Manila 27 28 October 2010

Prepared by: CECILIA C. SISON Secretary, Medicines Transparency Alliance (MeTA) Philippines

CONTENTS
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 Annex 2 Annex 3 Annex 4 Annex 5 MeTA Philippines Executive Committee 2010-2012 Program: National Summit on Transparency and Governance in Universal Health Care, 16-17 September 2010, Asian Institute of Management (AIM) Program: Towards Universal Health Care: Policy Options for the Philippines, 27-28 October 2010, Ramon Magsaysay Center List of Participants: Part 1 (16-17 September 2010) List of Participants: Part 2 (27-28 October 2010) 2

PRESENTATIONS: PART 1 Annex 6 MeTA Multi-Stakeholder Collaboration A Way to Achieve Transparency and Governance in Universal Health Care Dr. William Bannenberg, MeTA International Secretariat State of Health Care in the Philippines: Supplier Side Dr. Alvin Caballes, UP College of Medicine Survey of Health Financing Mechanisms for Access to Medicines by the Poor in Rural and Urban Philippines Ms. Marcia F. Miranda, Punla sa Tao Foundation What the Poor Want in Healthcare (2010 SWS Survey on Healthcare Services and Financing) Ms. Linda Luz Guerrero, Social Weather Stations People-Centered Health Reform Agenda Dr. Suzette H. Lazo, UP College of Medicine Health Financing Strategy: Building a Path Towards Universal Health Care Dr. Liezel P. Lagrada, Department of Health Models of Best Practice: The UK National Health Service Ambassador Stephen Lillie, Embassy of the UK in the Philippines Universal Coverage Experiences of Thailand Ms. Netnapis Suchonwanich, National Health Security Office, Thailand Achieving Better Health Systems and Financing Dr. Dorsjuren Byarsaikhan, WHO Regional Office for the Western Pacific National Center for Pharmaceutical Access and Management Dr. Irene Farinas, Department of Health

Annex 7 Annex 8

Annex 9

Annex 10 Annex 11 Annex 12 Annex 13 Annex 14 Annex 15

PRESENTATIONS: PART 2 Annex 16 Annex 17 Annex 18 Annex 19 Annex 20 Chairmans Report: Laying the Foundations. Effecting Change. Looking Forward - Roberto M. Pagdanganan, MeTA Philippines The Aquino Health Agenda: Universal Health Care Alexander A. Padilla, Department of Health Towards Universal Health Care: Insights, Perspectives, Lessons, Recommendations - Cecilia C. Sison, MeTA Philippines Gamot ay Buhay: Factbook on Medicines Access and the Filipino Suzette H. Lazo, M.D., WHO Consultant Towards Universal Health Care Reiner W. Gloor, Pharmaceutical and Healthcare Association of the Philippines (PHAP) Alternative Budget Initiative and its Implications on Health Spending in the Philippines - Alce C. Quitalig, Alternative Budget Initiative Health Cluster 3

Annex 21

Annex 22 Annex 23

Universal Health Care: Civil Society Initiatives Paula Mae B. Tanquieng, Coalition for Health Advocacy and Transparency 15th Congress Multi-Sectoral Health Policy Agenda Ramon San Pascual, Philippine Legislators Committee on Population and Development (PLCPD) Foundation, Inc. Universal Health Care: The PMA Perspective Arthur T. Catli, M.D., Philippine Medical Association (PMA) Towards Universal Health Care: PPhA Initiatives Leonila M. Ocampo, Philippine Pharmacists Association (PPhA) DSAPs Role in Health Josephine Inocencio, Drugstores Association of the Philippines (DSAP) National Center for Pharmaceutical Access and Management Robert Louie P. So, M.D., DOH NCPAM The New FDA Atty. Christine Macaranas de Guzman, FDA Health Financing and Service Delivery Programs in San Fernando City, Pampanga - Eloisa Aquino, M.D., San Fernando City, Pampanga The La Union Medical Center Dr. Fernando Astom, La Union Medical Center Health Financing and Service Delivery Programs of the Provincial Government of Tarlac - Gov. Victor Yap, Province of Tarlac PLAN Philippines Ma. Loida Y. Sevilla, PLAN Philippines The Role of Media in Health Care Rodolfo Cornejo, GMA Network

Annex 24 Annex 25 Annex 26

Annex 27 Annex 28 Annex 29 Annex 30 Annex 31 Annex 32 Annex 33

A MeTA PERSPECTIVE FASTTRACKING UNIVERSAL HEALTH CARE IN THE PHILIPPINES

by

ROBERTO M. PAGDANGANAN
Chairman, Medicines Transparency Alliance (MeTA) Philippines Health Sector Reform in the Philippines For over two (2) decades of health sector reform in the Philippines, particularly in the area of health insurance, attention has been focused on organizing and building the institutions that 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) to implement the National Health Insurance Program (NHIP). We note the following: The main purpose of the Act was to provide compulsory health insurance coverage and 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 to help pay for the care of the sick and for those who can afford medical care to subsidize those who cannot. (Art. III, Sec. 5) The government is responsible for providing a basic package of personal health services to indigents through subsidy of premiums, or directly until such time that the program 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 Plus Strategy, developed in the early years of Philhealth, was designed to achieve universal coverage through the following components: 1. 2. 3. 4. 5. Universal coverage in all geographic areas Outpatient benefits package (OPB) to start with indigent members Philhealth-accredited facilities to provide outpatient services on a capitation basis LGU participation in providing health services and ensuring universal coverage Technical assistance from DOH 5

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 families through 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 on coverage varying from 38% (2008 PDHS) to 85% (Philhealth) depending on the source of information. The WHO recommends that coverage be targeted for over 90% of the population by prepayment and risk pooling schemes, and close to 100% of the vulnerable population. Filipino households bear the heaviest burden in terms of spending for their health needs, with private out-of-pocket (OOP) expenditures reaching 54.3% of total health expenditures (THE) in 2007. The WHO recommends that OOP expenses be kept to a minimum 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 the urgent need to fasttrack the implementation of a universal health care program for the Philippines, with reforms necessary both in the health financing and service delivery systems. Learning From Other Countries There are lessons to be learned from the experiences of other countries as we go through the 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 health care under a centralized tax-financed system. UK Ambassador to the Philippines Stephen Lillie 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 work under 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 4th largest direct employer, next only 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 in Canada share equally in the cost of providing health services. Overall policies are determined and enforcement regulated by the national government, whereas the provincial governments ensure the prompt and effective delivery of health services through hospitals and facilities which they operate. 6

Among our neighbors, Taiwan, Malaysia and Hong Kong have undertaken dramatic reforms in their respective health sectors that have allowed them, albeit through varying mechanisms, to provide more comprehensive services to their citizens and improve health outcomes. The Thailand Experience We note, with keen interest, the success of Thailand in achieving coverage for 99.47% of its population, despite their national health insurance program having been enacted only in November 2002, over 7 years later than the Philippines. Today, the Thai government implements three (3) insurance schemes the Universal Coverage Scheme (UCS), Civil Servant Medical Benefits Scheme (CSMBS) and the Social Security Scheme (SSS) which provide access to health services and goods to 74%, 10% and 15% of the population respectively. The case of Thailand is notable considering its attainment of universal coverage within one (1) year from the start of the so-called 30-baht scheme under the leadership of then Prime Minister Thaksin Shinawatra (who had been elected on a populist platform committing to, among others, universal access to healthcare). The popular 30-baht scheme (user fee of 30 baht per visit paid by all Thais under the UCS) 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 June 2001. Within a year (2002), the scheme was implemented nationwide, with 92% of the population 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 to consider certain reforms in the current health delivery system and infrastructure. Some of these are as follows: Shift to a new provider-payment mechanism. The fee-for-service (FFS) scheme that is currently applied poses certain disadvantages like cost escalation and inefficiencies. There is a tendency among doctors to maximize income through reimbursements for services by providing expensive and/or unnecessary treatment. In contrast, the capitation system for outpatients has been found to be more effective as a cost containment measure, while providing more acceptable levels and quality of service. There is, however, also a tendency for providers to limit services especially to those needing expensive care or to patients with chronic conditions. Emphasis on preventive and promotive health care. Primary care units (or rural health units) should play a significant role as gatekeepers and by providing services to patients nearer their homes, thereby increasing physical access to health centers and reducing costs of medication. Improvements in the health services delivery infrastructure through investments in upgrading primary care facilities, like rural health units (RHUs), and hospitals. Institutionalization of training and sustained capacity-building of health workers. In Thailand, for example, the consortium of medical schools agreed on revisions in their curriculum placing more emphasis on primary care.

More rational dispersal of health professionals in the countryside, primarily through a scheme of incentives to encourage practice in rural areas administered by the government social insurance program, or Philhealth. The schedule of professional fees paid to General Practitioners (GPs) vis--vis specialists under the NHIP must also be re-assessed with the view to improving delivery of health services while minimizing 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 salaries tend to be higher, leaving far-flung communities with very limited access to medical care. According to the 2010 World Health Statistics, the professional to population densities in the Philippines are as follows: physicians - 12:10,000; nurses and midwives - 61:10,000; dentists 6:10,000; other pharmaceutical personnel 6:10,000. In contrast, Thailand registered the following statistics: physicians 3:10,000; nurses and midwives 14:10,000; dentists 1:10,000; other pharmaceutical personnel 1:10,000. Capability-building and augmentation of resources of local governments to enable them to more effectively participate in the delivery of health services in their respective localities. The National Health Security Office (NHSO) of Thailand administers the Universal Coverage Scheme (UCS) in partnership with local governments, through Contracting Units for Primary Care (CUPs) and Primary Care Units (PCUs) which provide health services through their facilities and hospitals devolved to them. Piloting Reforms in 2011 The Medicines Transparency Alliance (MeTA) - a multi-country, multi-stakeholder group concerned with improving transparency and accountability in the pharmaceuticals supply chain as a means to achieve better health outcomes - recommends the following for consideration: Immediate implementation of policy reforms and expansion of benefits towards universal coverage by piloting the scheme in ten (10) provinces and five (5) cities, with proportionate geographical representation based on population, i.e., for provinces: 6 in 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 and participating local governments shall be determined on the basis of need as well as the income 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 and resource 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 LGUs that have been employing a similar per-visit scheme. Lessons from other countries and from our own experience may then be successively applied, and modifications made as may be necessary, to conform with our peoples needs and traditions and considering our current resource limitations. The objective is the 8

reduction of out-of-pocket health expenditures that will leave more resources for the other basic 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 the DOH 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-year target or by 2013. On the part of MeTA Philippines, we are determined to extend the support of an active multi-stakeholder network which includes a strong civil society coalition, to attain our collective aspirations for universal access to healthcare for all Filipinos, regardless of capacity to pay.

(ROBERTO M. PAGDANGANAN is Chairman of the Medicines Transparency Alliance (MeTA) Philippines and Founding Chair of the Coalition for Health Advocacy and Transparency (CHAT). This paper presents a set of policy recommendations and learnings distilled from discussions during the Universal Health Care Summit held on 1617 September 2010 and 27-28 October 2010, and Mr. Pagdanganans various meetings with the National Health Security Office (NHSO) in Bangkok, Thailand from 2007-2010.) 9

BACKGROUND
MEDICINES TRANSPARENCY ALLIANCE (MeTA) The Medicines Transparency Alliance (MeTA) is a multi-stakeholder group working to improve availability and affordability for a third of the worlds 6 billion people who lack access to basic and essential medicines. Millions die every year from HIV and AIDS, tuberculosis, malaria, pneumonia, measles, diarrhea and cardiovascular ailments yet medicines already exist for nearly all these diseases. The MeTA acronym stands for Medicines essential health commodities such contraceptives, diagnostics and laboratory supplies as drugs, vaccines,

Transparency improving information access, scrutiny and use to support the development of viable and effective pharmaceutical markets and health systems that benefit all consumers in developing countries Alliance stakeholders from the public, private and non-profit sectors working together to effect significant positive change In each of 7 pilot countries Ghana, Jordan, Kyrgyzstan, Peru, Philippines, Uganda and Zambia representatives of government, the private sector and civil society are working together to increase the poors access to affordable essential medicines. MeTA supports efforts to improve the way medicines are purchased, supplied, and used; to implement innovative 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 to essential medicines. Stronger and more transparent systems and improved supply chain management will improve access. Increasing equitable access to medicines improves health and enables other human development objectives to be achieved. Improved information about medicines can inform public debate, and provide a basis for 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, but are committed to making it public and encouraging people and organizations to act on it and producing policies which make such action possible. The composition of the MeTA Philippines Executive Committee is in Annex 1. 10

GLOBAL CONTEXT: LOOKING AT UNIVERSAL HEALTH CARE The World Health Report 2008 entitled Primary Health Care: Now More Than Ever cites the following: . . . it is always the wealthier folk, whether measured as an individual or as a society, who have access to quality care, while the world's poorestand typically as a result the poorest in healthwho have the least access to quality care 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 care produce 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 result in 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 and death 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% of disease burden THE CASE FOR UNIVERSAL HEALTH CARE IN THE PHILIPPINES President Benigno C. Aquino III committed to provide health services for all in his Inaugural Address on 30 June 2010. He said: . . . serbisyong pangkalusugan, tulad ng Philhealth para sa lahat sa loob ng tatlong taon (Improved public health services such as PhilHealth for all within three 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. Sa ngayon, 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 pamilyang higit na nangangailangan ng tulong. Tinatayang 9 bilyon ang kailangan para mabigyan ng PhilHealth ang 5 milyong pinakamaralitang pamilyang Pilipino. 11

 . . . Kasama na po natin ang pribadong sektor, at kasama na rin natin ang League of Provinces . . . Handa na pong makipagtulungan para makibahagi sa pagtustos ng mga gastusin. Alam ko rin pong hindi magpapahuli ang League of Cities . . . To finance health services for the poor, President Aquino said in his message dated 24 August 2010 to the 15th Congress on the 2011 budget: . . . National Household Targeting System (NHTS) . . . identify and locate the 4.6 million households in the country who are poor . . . central database of our nations poor so that direct subsidies for them - DSWDs conditional cash transfer and rice subsidy, DAs farm input subsidies, Philippine Health Insurance Corporation (PHIC) health insurance for indigents can converge for maximum impact. . . . The NHIP, for instance, could, and should, include preventive healthcare insurance under its coverage. The Department of Health ranks 7th with P33.3 billion, up by 13.6 percent from the 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 health insurance coverage of indigents as the more efficient mode of public health intervention. Some P3.5 billion is being provided for the Health Insurance Premium of 4.6 million indigent families . . . for the very first time, 1.4 million households in the informal sector. Small self-employed/underground economy workers will be given preference for this health care benefit. . . . sustain the provision of low-cost medicines through the establishment of an additional 3,931 Botika ng Barangay (BnB), each BnB to be provided P25,000 worth of medicines. Some P98 million has been allotted for this endeavor as part of the P1 billion allocation for DOH to support the implementation of the Cheaper Medicines Act.

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THE UNIVERSAL HEALTH CARE SUMMIT

RATIONALE AND OBJECTIVES The Aquino Health Agenda identifies universal health care as among its most important programs. 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 the attainment of universal health care. The Administrations strategic directions for health include the following: 1. Universal health care through a refocused Philhealth 2. Construction and rehabilitation of, and support for, public health facilities 3. 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 various stakeholder groups in the country: 1. The Health Care Financing Strategy 2010 2020 recognizes that the increase in overall health spending is spurred by an increase in out-of-pocket expenditures; that there is a fragmentation in the financing system; and that past health reforms have had 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 Policy 2010, the result of multi-stakeholder consultations on a framework to increase access to quality affordable medicines in the country. Key components of the SARAH Access Framework include: Safety, efficacy and quality Availability and affordability Rational drug use Accountability and transparency Health systems support 3. A multisectoral alliance with strong participation from health advocates and civil society has put forward a proposed health legislative agenda. The institution of reforms in the health insurance program through revisions in the National Health Insurance Act of 1995 (RA 7875, s.1995) is among the key thrusts in the legislative agenda for the 15th Congress. 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 and regulatory environment in the Philippines. This will support continuing efforts to ensure the safety, quality and efficacy of medicines distributed in the market. 13

While there have been lively public discussions on the topic, there is need for deeper appreciation among various stakeholders of the building blocks for overall health sector reform, and the resources required to effect the necessary changes in the system. Leaders and concerned groups must, however, plan beyond discussing the issues and developing policy recommendations - these plans need to be translated into concrete action 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 of developing an appropriate universal health care program for the Philippines b. To serve as a forum for the discussion of current priority healthcare and health financing issues that will impact on the attainment of the goal of universal coverage for all Filipinos by 2013 c. To develop a concrete program for public-private partnership, and define the roles and contribution of all stakeholders d. To generate public awareness and demand for a more responsive healthcare program that will benefit all Filipinos e. To document lessons into a set of recommendations for executive and legislative policy makers, the Department of Health (DOH), the Philippine Health Insurance Corporation (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 of Health (DOH) and the Asian Institute of Management Center for Development Management (AIM CDM). MeTA organized the following: National Summit on Transparency and Governance in Universal Health Care Asian Institute of Management, Paseo de Roxas, Makati City 16 17 September 2010 Towards Universal Health Care: Policy Options for the Philippines Ramon Magsaysay Center, 1680 Roxas Blvd., Manila 27 28 October 2010 The first two (2)-day forum was attended by over fifty (50) representatives from various stakeholder groups concerned with improving health care in the Philippines. Expert inputs were 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 professional organizations had an opportunity to present their respective initiatives to improve the quality and delivery of health services to the public. These initiatives were discussed in the context of the overall programs of both the national and local governments to achieve the targets of universal health care. Expert panel discussions tackled these critical issues with the view to developing policy options and programs that shall be submitted as the platform for multi-stakeholder partnerships.

14

PROGRAM The final Programs for Parts 1 and 2 of the Universal Health Care Summit are attached as Annex 2 and Annex 3 respectively. PARTICIPANTS The list of participants for Parts 1 and 2 of the Universal Health Care Summit are attached as Annex 4 and Annex 5 respectively. PRESENTATIONS: PART 1 Copies of presentations made during Part 1 of the Universal Health Care Summit are attached as Annexes 6-15 (please refer to CONTENTS). PRESENTATIONS: PART 2 Copies of presentations made during Part 1 of the Universal Health Care Summit are attached as Annexes 16-33 (please refer to CONTENTS).

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HIGHLIGHTS OF DISCUSSIONS
During the Panel Discussions and Open Forums during the MeTA Universal Health Care Summit, there were a number of observations made, specific suggestions put forward, and expert recommendations articulated for the implementation of reforms in the health sector. These are summarized as follows: Perspectives on the Health Care System The World Health Organization (WHO) has recommended that the Philippines consider 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 assistance and safety nets. On the dispersal of the health workforce and facilities, the following observations were made 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 local governments has led to fragmentation, and confusion regarding roles, responsibilities and accountabilities. While devolution should have made the system more responsive, LGUs are not made accountable for health outcomes. While government has often targeted to provide free medicines and services in health centers and charity hospitals, feedback from the ground indicates that these schemes have not and will not be effective and sustainable given the current resources and constraints. The current health system encourages inequities. More attention must be given to addressing 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 universal health care, many sectors strongly advocate a focus as well on preventive and promotive health care. Such focus will result in savings in the long run. A serious assessment of strengthening the capitation system for primary care (vs traditional feefor-service schemes) is imperative. 16

Discussions around universal health care are not just about financing. There is a need, as well, to address such issues as reforms in human health resources, the organization of health systems, gate-keeping concepts, regulations on drug quality, regulations on private medical practice, governance, and multi-stakeholder collaboration in addressing other determinants of health. There is a need for a more holistic view of the problem and a serious reengineering of the 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 in 6-year cycles, policy makers must take a more long term view. Investments in and for health 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 services and sectors when planning for a more responsive health care system. Issues regarding education, housing, access to potable water, sanitation, employment and food must be addressed as well, as they affect the level of health outcomes. Implementing a universal health care program necessitates, as well, looking closely at improving access and availability of affordable quality essential medicines. Access points 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 and improvements in the countrys health infrastructure, such as public hospitals and health centers, and especially primary care units. Encourage the DILG and the DOH to work together on the formulation of firm policy guidelines and programs to ensure regular supply and availability of quality and affordable essential medicines in health facilities through LGUs. Stockouts must be minimized and essential health care services provided. Notwithstanding devolution, the national and local governments must find a mutually beneficial arrangement to coordinate 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 drug entitlement schemes, and generics promotion, among others. Such initiatives are laudable, although there is much room for improvements in implementation, an evident need 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, centralized purchasing, warehousing and distribution for government should be seriously considered. The private sector will be in a better position to provide such services more efficiently and promptly. Implement immediately the basic health package proposal which covers essential and front line drugs which, based on expert computations, will cost PhP 1,400.00 per person per year. Promote the principle of solidarity through a social health insurance program. All Filipinos should have access to health care, regardless of capacity to pay. Those who have more means to finance their health needs should contribute towards subsidizing the 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, 17

monitoring compliance and mobilization of resources. LGUs, under this structure, shall operationalize health programs and directly provide services to their respective constituents. Review the effectiveness of devolving health services to local governments and establish 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 a clear mechanism of accounting. The plan should also incorporate a health information, education and communications agenda. Develop innovative and non-traditional health financing schemes and savings mechanisms that will improve access of the poor and vulnerable to essential quality medicines. Promote public-private partnerships to address the problem. Relatedly, continuously assess the conditional cash transfer (CCT) program of the government. There must be a clearer delineation of roles and accountabilities between the national and local governments. Access of LGUs to CCT funds must continue to be dependent on ability to provide services, and LGU efforts to improve service delivery must be strongly supported. Many are advocating for CCT programs to 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. Health outcomes are also determined by lifestyle, genetics and environment. There must be a continuing and conscious effort to encourage healthy lifestyles. Current realities require the organization of an IT-based system for health. Many sectors are concerned, for example, that the Philippines does not even have reliable mapping of health professionals and facilities. The strengthening of the national regulatory agency (FDA) will have significant impact on the pharmaceuticals and healthcare markets. National self-reliance in drug manufacturing should be encouraged, but enforcing global GMP standards must be ensured. Micro-financing schemes will not be enough to solve the gargantuan problem of the lack of financial resources to access medicines and health care. But if they must be used, policy guidelines must be developed to ensure that micro-insurance programs actually 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 the delivery 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 health system will take time and realizing the full impact is expected only in the long term, but this must be promoted and started beginning immediately. There are many lessons to be learned from other country models. While no one scheme will address the problems of our current health system, each countrys situation being unique, the Philippines can choose to adopt specific best practices. 18

Global, regional and country experiences provide important policy guides for health system and financing reforms. The UK and Thai models, discussed during the MeTA Summit, present specific features that can be adopted in the Philippines. Although there are advantages to having a single health insurance provider controlled by the state, safety nets and safeguards are necessary to prevent the inefficiencies resulting from the monopoly. Private HMOs and providers should also be encouraged to complement health coverage efforts of Philhealth. Many stakeholder groups have strongly suggested that the government seriously review the possibility of imposing a health expenditures allocation for LGUs, similar to the 5% required for gender-related programs. Political Will and Governance The Philippines needs a very high-level champion who shall advocate and push strongly 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 taxes efficiently, but to direct revenues towards health. Innovations in reform are necessary to keep up with changing expectations and needs. Government must take advantage of donor funds directed towards improving the delivery of public health services and access to medicines. However, stronger standards for accountability and control need to be established. It is necessary to ensure 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 of counterfeit drugs, over-servicing and excessive claims in health insurance, physicians ordering unnecessary diagnostic or medical procedures, exorbitant procurement prices for medicines and services, etc. The development of a transparent and reliable procurement system in the public sector is 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 equally important to ensure the efficient and effective use of health resources. There are initiatives to increase resources for health. The government should look at earmarking revenues 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 sector efforts should supplement, rather than compete with or duplicate governments work. The private sector is taking a more proactive role than government in discussing the issues and involving all stakeholders. Public-private partnership is still not evident. Public sector agencies involved in providing health care services must not only learn to work together and innovate, but create synergy for better results and more efficient use of resources. There is fragmentation in policies and programs between the national and local governments, and between DOH and Philhealth. Government 19

strategies must be formulated with more firm planning and a clear articulation of desired outcomes. There are initiatives from enlightened groups and/or donor-assisted organizations. Their role and resources must be harnessed, instead of disregarded. Civil society is encouraged to take an even more active role in advocacy, monitoring and communication with other stakeholders. Non-government organizations (NGOs) have a 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 each other to promote healthy lifestyles. Efforts must be directed towards providing correct information to enable the public to make the right choices. In other areas, partnerships among key stakeholders must be strengthened. Civil society can be harnessed not only for mobilizing at the community-level, but also for information dissemination and lobbying 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 for instilling a culture of good governance, transparency and accountability. While there are pockets of success in some provinces and cities in the Philippines, there is great room 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. This practice has not succeeded in maximizing utilization of coverage. The use of the capitation fund intended to pay for services of health practitioners must be free from the influence of local government executives. There are inefficiencies and gaps in current Philhealth processes and systems which must be addressed. Benefits are not adequate to meet health care needs, especially those of the poor. Local governments are concerned about the reported plan of Philhealth to gradually decrease its share in the payment of premiums for the poor. There is a need to strengthen capacity for the management of health funds as well as for improvements in the quality of health services in primary facilities. Noting the important role that Philhealth will continue to play in the attainment of universal health care, more attention must be given to improving the quality and level of delivery of services to its members, as well as its systems and procedures. The public is concerned that Philhealth has shown a propensity for investing their funds in financial 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 benefits for accredited health professionals. While Philhealth should encourage increased enrollment, it must also seriously look into maximizing utilization. Specific programs should be directed to allow regular and effective utilization of benefits for actual health needs. Accredited health facilities must be equipped to provide services at the time members avail of these. Review the Philhealth law, and implement reforms where needed. Among the key factors 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. 20

Some sectors have suggested that DOH focus on regulations, policy and information programs, leaving service delivery as the responsibility and accountability of LGUs. For marked and immediate impact, develop a Philhealth outpatient drug benefit package as soon as possible covering chronic and non-communicable diseases as well. Ongoing efforts to improve benefits to members must be supported. Strong recommendations have been aired about the need for Philhealth to better communicate with and serve a more aware and discerning public. Medical Professionals Specific issues pertaining to the role and contribution of medical professionals in the delivery of health services still need to be addressed. There is an urgent need, for example, to look into the wide disparity in fees paid to General Practitioners (GPs) visa-vis medical specialists. Marketing to doctors contributes to high prices of medicines and is among the key causes of irrational use. Some sectors have suggested that government and/or private industry look into forms of regulation and monitoring of advertising, promotion and marketing practices of pharmaceutical companies to safeguard the interest of patients and consumers.

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