Universal Health Care Act

Republic Act No. 11223

MARIO C. VILLAVERDE, MD, MPH, MPM, CESO I

Undersecretary of Health | Health Policy and Systems Development Team

Department of Health, Philippines

Declaration of Principles

Integrated and comprehensive Health care model that

approach to ensure health literacy, provides comprehensive
healthy living, and protection from health services without
hazards and risks causing financial hardship

Whole-of-system, whole-of- People-oriented approach

government, whole-of-society centered on people’s needs
approach in the development of and well-being
health policies

Department of Health, Philippines

General Objectives

To progressively realize To ensure equitable access

universal health care to quality and affordable
through systemic approach health care and protection
and clear role delineation against financial risk
of stakeholders

Department of Health, Philippines

UHC Coverage

Population Coverage Service Coverage

Automatic inclusion of Immediate eligibility and
every Filipino citizen access to population-based
into the NHIP and individual-based health
services

Department of Health, Philippines

UHC Coverage
Financial Coverage

Population-based Individual-based
Health Services: Health Services:
• funded by National • funded primarily
Government through pre-payment
through DOH mechanisms (SHI,
• free at point of PHI, HMO)
service

Department of Health, Philippines

National Health Insurance Program

Simplification of NHIP membership:

• Direct contributors – those who Pooling funds to PhilHealth

have the capacity to pay premiums for all individual-based health
• Indirect contributors – those services
whose premiums are subsidized by
the National Government
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Department of Health, Philippines

National Health Insurance Program
 Immediate eligibility

 No co-payment in basic or ward accommodation

 Co-payment/co-insurance for amenities in public

Entitlement to hospitals
Benefits
 No reduction in current PhilHealth package

 Additional benefits for direct contributors

Department of Health, Philippines

National Health Insurance Program
Premium Contributions
Direct contributors Indirect contributors
Year Premium Rate Income Floor Income Ceiling
Gradually adjusted and
2019 2.75 % P10,000.00 P50,000.00 included in the GAA
2020 3.00 % P10,000.00 P60,000.00
2021 3.50 % P10,000.00 P70,000.00
2022 4.00 % P10,000.00 P80,000.00
2023 4.50 % P10,000.00 P90,000.00
2024 5.00 % P10,000.00 P100,000.00
2025 5.00 % P10,000.00 P100,000.00

Department of Health, Philippines

National Health Insurance Program

 Program Reserve Funds

 Administrative Expense
 PhilHealth Board of Directors
 President and Chief Executive Officer
 PhilHealth Personnel as Public Health Workers
 Additional Powers and Functions of PhilHealth

Department of Health, Philippines

Service Delivery
Population-based Health Services
DOH to contract province-wide and city-wide
health systems with the following minimum
components:

Primary care Epidemiologic Health promotion

provider surveillance programs and
network systems campaigns

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Department of Health, Philippines

Service Delivery
Individual-based Health Services
PhilHealth to contract public, private or
mixed health care provider networks that
would agree on:

Co-payment/
Service quality Data submission
co-insurance

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Department of Health, Philippines

Service Delivery
Individual-based Health Services

Incentives for health care Apex or end-referral hospitals

providers that form networks  to be determined by DOH
from DOH and PhilHealth  may be contracted by PhilHealth
as stand-alone providers

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Department of Health, Philippines

 Service Delivery
Individual-based Health Services

A shift to performance-driven, Development of differential Institution of strong

closed-end, prospective payment considering service surveillance and audit
payments based on DRGs, quality mechanisms
validated costing methods, and
no differentiation between facility
and professional fees

13

Department of Health, Philippines

 Organization of Local Health Systems
Integration of health Provincial/City Health Board
systems into:  oversee integration of health
 Province-wide services
 manage special health fund
 City-wide  exercise administrative and
technical supervision over
their health facilities and HRH
Department of Health, Philippines
Municipalities and cities
are entitled to have a
representative in the
Provincial/City Health
Board
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 Organization of Local Health Systems

Enabling income Income derived from Incentives through financial

retention for all public
providers through a
Special Health Fund
PhilHealth payments to and non-financial matching
accrue to the Special Health grants in accordance to local
Fund and credited as investment plans to improve
Annual Regular Income competitiveness of the Public
(ARI) of the LGU Health Service Delivery System

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Department of Health, Philippines

Human Resources for Health
National Health Human Resources
Master Plan to provide appropriate
policies and strategies for health
workforce based on population needs,
and for permanent employment and
competitive salaries
Department of Health, Philippines
National Health Workforce
Support System to support to
local public health systems in
addressing human health needs,
especially GIDAs
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 Human Resources for Health
Scholarship and Training Program

Expansion of health Regulation of enrollees Expansion of scholarship

related degree and based on health needs grants for undergraduate
training programs and graduate programs

Setting up of registry of Reorientation of health professional

medical and allied health education, certification and regulation
professionals for provision of primary care services

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Department of Health, Philippines

 Human Resources for Health
Return Service Agreement

Return service for at Provision of additional Establishment of

least three (3) years for incentives for those guidelines for non-
government-funded rendering additional compliance
scholars two (2) years of service

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Department of Health, Philippines

Regulation – Safety and Quality
Establishment of a rating
system in PhilHealth
under an incentive scheme
based on service quality,
efficiency and equity
PhilHealth to recognize
third party accreditation
mechanism as basis for
granting incentives
Department of Health, Philippines
Institutionalization of a
licensing and regulatory
system in DOH for stand alone
health facilities, ambulatory and
primary care providers
DOH to set standards for
clinical care through
development and use of
clinical practice guidelines
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Regulation – Affordability
Procurement of Drugs and Drug outlets to carry generic
Devices of DOH-owned equivalent of all drugs in
Health Care Providers Primary Care Formulary
 follow negotiated prices
 sell in prescribed maximum
mark-ups
 price listing of all drugs/ Mandating transparent pricing
devices procured and sold of health goods and services

Independent Price Negotiation Benefit complementation

Board to negotiate price on between DOH, PhilHealth, PHIs,
behalf of DOH and PhilHealth and HMOs

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Department of Health, Philippines

 Regulation - Equity
Preferential licensing
of health facilities and
contracting of health
services for
underserved areas
Department of Health, Philippines
Equitable distribution of
health services and benefits
prioritizing GIDA
Basic accommodation:
• at least 90% for
government hospitals
• at least 70% for
specialty hospitals
• at least 10% for private
hospitals
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Governance and Accountability

Creation of a Incorporation of DepEd schools to LGU to enact stricter

Health health promotion be designated as ordinances to promote
Promotion in school curricula healthy settings health literacy and
Bureau in the healthy lifestyle
DOH

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Department of Health, Philippines

Governance and Accountability
Health Impact Assessment as
requirement for all policies,
Evidence-informed Sectoral
programs and projects
Policy and Planning for UHC

Health Technology Assessment

Monitoring and Evaluation
 Establishment of Performance
Monitoring Division
Health Information System

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Department of Health, Philippines

Ethics in Public Health Policy and Practice

 Declaration and management of conflict of interest

 Collection and tracking of financial links of health

care providers to manufacturers of drugs, medical
devices and supplies under FDA

 Public Health Ethics Committee as an advisory

body to the Secretary of Health

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Department of Health, Philippines

Appropriations
Sources of Funding for UHC

 Total incremental sin tax collections

 50% of the National Government share from PAGCOR
 40% of the Charity Fund, net of Documentary Stamp Tax
Payments and mandatory contributions of PCSO
 Premium contributions of members
 Annual appropriations of the DOH
 National Government subsidy to PhilHealth
 Supplemental funding

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Department of Health, Philippines

Penal Provisions

Health care provider of PhilHealth member and

population-based health employer
services

Health care provider of Director, officer or employee

individual-based health of PhilHealth
services

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Department of Health, Philippines

Miscellaneous Provisions

Oversight Provision

 Creation of Joint Congressional Oversight

Committee on UHC
 Validation of UHC accomplishments by
NEDA, PSA, NIH and other academic
institutions
 DOH and PhilHealth to allocate adequate
funding for these studies
Establishment of Performance
Monitoring Division to monitor
and evaluate the implementation
of UHC
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Department of Health, Philippines

Miscellaneous Provisions
President of the Philippines to
appoint new members of the
Board and the PCEO of PhilHealth
within thirty (30) days
All officers and personnel of
PhilHealth, except for members of
the Board, to continuously
perform their duties and receive
their corresponding salaries and
benefits
Department of Health, Philippines
All affected officers and
personnel of the PCSO to be
absorbed by the agency without
demotion of rank or salary/benefits
National Government to provide
technical and financial support
to LGUs that commit to province-
wide integration in the first 6 years
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Miscellaneous Provisions
Managerial integration of
PhilHealth to outsource certain
province-wide and city-wide
functions to ensure operational
systems within the first 3 years;
efficiency and fulfillment of the Act
financial integration within the
in the first ten (10) years
next 3 years

Integration of all local health Philhealth and DOH to provide

systems through an Executive Order
upon positive recommendation of:
 independent study commissioned by
JCOC
 the Secretary of Health
financial and licensing incentives
to contracted health facilities to form
health care provider networks in the
first three (3) years

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Department of Health, Philippines

Miscellaneous Provisions
HTAC under the DOH to be
established within one (1)
year
PHIs and HMOs, together
with DOH and PhilHealth, to
develop a system of co-
payment that complements
PhilHealth benefit packages
within three (3) years
Department of Health, Philippines
Within ten (10) years, only those
certified by DOH and PRC as
capable of providing primary
care will be eligible as primary
care provider
For the first two (2) years, PCSO
to transfer at least fifty percent
(50%) of the forty percent (40%)
of the charity fund per year
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Summary - Financing
Clarifying roles: Simplifying
1.DOH and LGU for membership into two
population-based types: direct and indirect
services contributory members
2. PhilHealth for individual-
based services

Pooling funds to Contracting by network

PhilHealth for all based on adherence to
individual-based health quality and co-payment
services (e.g. Sin Tax, standards, and third
PAGCOR, PCSO) party accreditation

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Department of Health, Philippines

 Summary - Service Delivery
Consolidating fragmented
providers into province-
wide and city-wide service
delivery networks to
navigate and coordinate
Department of Health, Philippines
Institutionalizing primary care
provider networks,
epidemiologic surveillance
systems and health
promotion as minimum
components of population-
based health services
Enabling income
retention for all public
providers through a
Special Health Fund
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Summary - Regulation
Mandating transparent
pricing of health goods
and services
Basic and non-basic
accommodation bed
ratio of 90:10 for
government hospitals,
70:30 for specialty
hospitals, and 10:90 for
private hospitals
Department of Health, Philippines
Ensuring benefit
complementation between
PhilHealth and Private Health
Insurance (PHIs) and Health
Maintenance Organizations
(HMOs)
Expanding scholarship programs,
requiring 3 years return service
in underserved areas for
government scholars,
augmenting HRH through
national health workforce
support system, primary care-
oriented education, health
professionals registry
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Summary - Governance
Requiring submission of
health and financial data
by health care providers
and suppliers harmonized
to an interoperable system;
sharing of publicly-
funded data sets
Strengthening medicines
procurement, price
negotiation and
affordability
Department of Health, Philippines
Institutionalizing Health
Technology Assessment as
prerequisite for public financing
of goods and services, and
Health Impact Assessment
for various programs, policies,
and projects
Streamlining PhilHealth
Board from 17 to 13
members
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Presentation can be accessed at:
bit.ly/RA11223