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Financial protection from health spending in the Philippines: Policies and progress
Abstract
The objective of this article is to assess the progress of the Philippines health sector in providing financial protection to the population, as measured by estimates of health insurance coverage, out-of-pocket spending, catastrophic payments and impoverishing health expenditures. Data are drawn from eight household surveys between 2000 and 2013, including two Demographic and Health Surveys, one Family Health Survey and five Family Income and Expenditure Surveys. We find that out-of-pocket spending increased by 150% (real) from 2000 to 2012, with the sharpest increases occurring in recent years. The main driver of health spending is medicines, accounting for almost two-thirds of total health spending, and as much as three-quarters among the poor. The incidence of catastrophic payments has tripled since 2000, from 2.5% to 7.7%. The percentage of people impoverished by health spending has also increased and, in 2012, out-of-pocket spending on health added 1.5 percentage points to the poverty rate, pushing more than 1.5 million people into poverty. In light of these findings, recent policies to enhance financial risk protection-such as the expansion of government-subsidized health insurance from the poor to the near-poor, a policy of zero copayments for the poor, a deepening of the benefit package and provider payment reform aimed at cost-containment-are to be commended. Indeed, between 2008 and 2013, self-reported health insurance coverage increased across all quintiles and its distribution became more pro-poor. To speed progress toward financial protection goals, quick wins could include issuing health insurance cards to the poor to increase awareness of coverage and limiting out-of-pocket spending by clearly defining a clear copayment structure for non-poor members. An in-depth analysis of the pharmaceutical sector would help to shed light on why medicines impose such a large financial burden on households.
... incidences of borrowing, selling assets, or reduction in essential consumption). Excepting Malaysia and the Philippines, where OOPE have been continuously increasing over the past years [52,71,76,106], OOPE have overall decreased through the introduction of the HF schemes for which such data were available (Indonesia, Lao PDR, Thailand, Vietnam) ( Table 7). This generally coincided with declines in the incidence of catastrophic and impoverishing spending in these countries, subject to data availability [62,87,89,95,97,[107][108][109][110][111][112]. ...
... Additionally, shifts from uncovered/unregulated providers and from private to The share of OOPE on household capacity to pay, disposable income, per capita income and expenditure, and non-food expenditure has been increasing. Non-prescription drugs and medical products account for the largest share of OOPE in all income quintiles and are the main driver of CHE [76,106] a . ...
... This may be particularly difficult for IWs in lower-income groups who are both most in need of care and prone to forego treatment [21]. In the Philippines patients need to advance treatment costs and get reimbursed based on insurance claims submitted to PhilHealth [76,106], while in the remaining HF schemes, health services are provided without direct payment (besides co-payments if applicable). IWs, with often low and insecure incomes, may be unable to advance costs, and an average lower education level may also impact their ability to submit claims [135]. ...
Achieving universal health coverage (UHC) is a priority of most low- and middle-income countries, reflecting governments’ commitments to improved population health. However, high levels of informal employment in many countries create challenges to progress toward UHC, with governments struggling to extend access and financial protection to informal workers. One region characterized by a high prevalence of informal employment is Southeast Asia. Focusing on this region, we systematically reviewed and synthesized published evidence of health financing schemes implemented to extend UHC to informal workers. Following PRISMA guidelines, we systematically searched for both peer-reviewed articles and reports in the grey literature. We appraised study quality using the Joanna Briggs Institute checklists for systematic reviews. We synthesized extracted data using thematic analysis based on a common conceptual framework for analyzing health financing schemes, and we categorized the effect of these schemes on progress towards UHC along the dimensions of financial protection, population coverage, and service access. Findings suggest that countries have taken a variety of approaches to extend UHC to informal workers and implemented schemes with different revenue raising, pooling, and purchasing provisions. Population coverage rates differed across health financing schemes; those with explicit political commitments toward UHC that adopted universalist approaches reached the highest coverage of informal workers. Results for financial protection indicators were mixed, though indicated overall downward trends in out-of-pocket expenditures, catastrophic health expenditure, and impoverishment. Publications generally reported increased utilization rates through the introduced health financing schemes. Overall, this review supports the existing evidence base that predominant reliance on general revenues with full subsidies for and mandatory coverage of informal workers are promising directions for reform. Importantly, the paper extends existing research by offering countries committed to progressively realizing UHC around the world a relevant updated resource, mapping evidence-informed approaches toward accelerated progress on the UHC goals.
... Healthcare systems must do more than provide quality treatment: they must also protect patients from excessive financial burden. This is a significant problem in the Philippines, where one and a half million people, around 1% of the population, were pushed below the poverty threshold in 2012 as a result of outof-pocket (OOP) spending on healthcare (Bredenkamp and Buisman 2016). OOP payment has remained high in the Philippines for decades; in 2012, 57.2% of total healthcare was funded OOP. ...
... Consequently, rates of catastrophic expenditure (CE), and impoverishing expenditure (IE) show little sign of decline. 7.5% of Philippine households incurred CE in 2012, an increase from 2.5% of households in 2000 (Bredenkamp and Buisman 2016). ...
... In a similar vein, the extent of catastrophic expenditure incurred also rises with household income. The percentage of households incurring catastrophic expenditure in 2012 was 2.5% in the first quintile and 15% in the fifth quintile (Bredenkamp and Buisman 2016). Also, better support value is afforded to the poor than the relatively wealthy. ...
Throughout the last two decades, public health efforts in low-to-middle-income countries (LMIC) have been directed towards improving maternal health, reducing the burden of infectious diseases such as HIV, malaria and tuberculosis, and improving child mortality (UN-MDG 2015).These efforts, partly driven by the United Nations Millennium Development Goals, have led to significant successes as of 2015, including: a reduction by more than half of the global under-five mortality rate, the increase in accessibility and uptake of measles vaccines from 73% to 84% over a 13 year period, and a remarkable boost in the availability of anti-retroviral therapy for HIV infection from 800 000 people in 2003 up to 13.6 million in 2014 (UN-MDG 2015). These are but a few examples of recent achievements in public health; however, such targeted approaches have not been accompanied by equal changes in the healthcare infrastructure nor in the distribution and accessibility of healthcare services across socioeconomic backgrounds.
As the UN established new priorities in the Sustainable Development Goals (SDGs), which aim to provide Universal Health Coverage, it became apparent that a greater focus in managing non-communicable diseases was needed. Specifically, this should lead toward the goal of improving the provision of care and maintenance of good health. Evaluation of the accessibility, safety and affordability of surgical care falls necessarily within the remit of such plans, particularly as 11% of the global burden of disease (GBD) can be attributed to surgically treatable conditions. Interestingly, 11% appears to be a lower bound, with robust estimates by Shrime et. al reaching the 28-32% threshold (Kristiansson et al. 2009). Indeed, lack of surgical care, whether for financial or geographical reasons, contributes significantly towards reduced productivity in light of the disability burden borne by patients belonging to disadvantaged groups.
The Lancet Commission on Global Surgery (LCoGS) estimated that a total of 143 million additional surgical procedures ought to be performed to cater for the unmet needs of the worldwide population, with an average of 5000 procedures annually per 100 000 by 2030 as the minimal target. The LCoGS proposed a unified system to assess the quality of surgical care on national levels using suggested six indicators (Meara et al. 2015a).
In this report, our team analyses the Philippine surgical care system in accordance with the six indicators introduced by the LCoGS. We describe the challenges met upon data collection and data analysis, suggesting strategies to overcome some of these difficulties. In general, we highlight the need for a holistic, region-dictated, and socially-accountable approach to alleviating the burden of limited social access to surgical care in the Philippines. We conclude that this should include improving awareness of existing provisions within the system for affordable healthcare, increasing the incentives for rural surgeons, and investing in data-gathering to determine further areas in need of investment.
... According to the Philhealth database, 89.4 million individuals in a population of around 100 million were covered in 2015 (Bredenkamp et al. 2017). However, survey data consistently show a coverage rate that is lower by about 20 percentage points (Bredenkamp and Buisman 2016;Bredenkamp et al. 2017). 17 The gap in coverage is mainly because of low take-up of the voluntary program among those engaged in the informal economy. ...
... Coverage of outpatient services and primary care is more limited. Despite the breadth of population coverage, there are gaps in the financial protection against medical expenses (Bredenkamp and Buisman 2016). This is due to the limited coverage of ambulatory care and medication, and also the latitude of providers to charge in excess of reimbursement ceilings set by Philhealth -balanced billing. ...
... In principle, providers are prevented from charging indigent and sponsored program members (i.e., the poor and disadvantaged) in excess of the reimbursement ceiling. However, this prohibition does not appear to be well enforced (Bredenkamp and Buisman 2016). In sum, in addition to the uninsured, those insured through Philhealth are likely to be exposed to considerable medical expenditure risk. ...
Despite widespread exposure to substantial medical expenditure risk in low-income populations, health insurance enrollment is typically low. This is puzzling from the perspective of expected utility theory. To help explain it, this paper introduces a decomposition of the stated willingness to pay (WTP) for insurance into its fair price and three behavioral deviations from that price due to risk perception and risk attitude consistent with prospect theory, plus a residual. To apply this approach, we elicit WTP, subjective distributions of medical expenditures and risk attitude (utility curvature and probability weighting) from Filipino households in a nationwide survey. We find that the mean stated WTP of the uninsured is less than both the actuarially fair price and the subsidized price at which public insurance is offered. This is not explained by downwardly biased beliefs: both the mean and the median subjective expectation are greater than the subsidized price. Convex utility in the domain of losses pushes mean WTP below the fair price and the subsidized price, and the transformation of probabilities into decision weights depresses the mean further, at least using one of two specific decompositions. WTP is reduced further by factors other than risk perception and attitude.
... This paper contributed to the existing work in the area of resource allocation, disaster management, health care, and the like, particularly in the Philippines. Previous studies such as those conducted by Bredenkamp and Buisman (2016) and Obermann et al. (2018) focused on disaster preparedness and healthcare expenditure, both public and private. Furthermore, the motivation for this study came down to a lack of existing studies, past researches primarily focused on economic results, especially economic growth. ...
... The rates of diseases during natural disasters depend on the scale of disruption of health systems, therefore, decision-makers must allocate budget, plan logistics, and human resources for future disasters. Bredenkamp and Buisman (2016) assessed the progress of the Philippines in providing financial protection in the health sector, it was measured by the estimates of health insurance coverage, out-of-pocket spending, catastrophic payments, and impoverishing health expenditures. Results of the surveys conducted in 2000 and 2013 mainly focus on health spending across the respondents is medicines and there is an increase of 150% from year 2000 to 2012 on out-of-pocket spending which pushed more than 1.5 million Filipinos into poverty. ...
This study examines the relationship between the damages caused by natural disasters and the Philippine government's spending on disaster management and healthcare, especially that despite the country's exposure to natural disasters, the Philippine government significantly decreased its disaster funds for the 2020 national budget. Several studies have concluded that most of the local government units in the Philippines were evaluated as only 'partially prepared' when it comes to disaster preparedness. As part of the Pacific Ring of Fire, an average of 7.5 typhoons and increased exposure to earthquakes are experienced in the Philippines annually, which should make public spending on disaster management and healthcare a national priority. Results show that disaster management expenditure and economic losses are positively related, while no relationship exists between disaster management expenditure, and deaths and exposure. Meanwhile, healthcare spending and deaths are negatively related, healthcare spending and economic damages are positively related, and healthcare spending and exposure have no relationship.
... 13 With the exception of those qualified to avail of the "No Balance Billing" policy in government hospitals, patients are required to shoulder the remaining expenses no longer covered by the PhilHealth case rate. 14,15 A better understanding of the source of OOP for ESWL could potentially break the barrier to providing care for those who need it. A well-designed health policy is warranted to reduce OOP expenses of patients especially among those with limited resources. ...
... 17 The insufficient financial protection by PhilHealth especially in these locations could potentially push some families into poverty. 14 ...
Introduction: Extracorporeal shockwave lithotripsy (ESWL) remains to be a cost-effective strategy for treating patients with urolithiasis. In the Philippines, Philhealth shoulders a portion of medical expenses to minimize out-of-pocket (OOP) payments by its members. However, since the establishment of the case-based payment scheme in 2012, no studies have yet assessed its impact on OOP in ESWL. Objective: To determine the factors associated with out-of-pocket payment among Filipinos seeking treatment in ESWL centers located in the Philippines Methods: The study utilized a mixed method sequential explanatory design. Twelve ESWL facilities were purposively selected to represent each facility type and location. A total of 2241 patients who underwent ESWL from January to December 2017 in twelve facilities were included in the quantitative study. For the qualitative portion of the research, focus group discussions and key informant interviews were done. Results: It was found that 77% of the studied population had to pay OOP for ESWL with a median OOP expense to be Php37,769 ($750) after deductions by PhilHealth, private insurance, and other funding agencies. Factors affecting OOP payment differ by facility location. In Metro Manila, factors associated with OOP payment include facility type and private insurance membership. In Luzon, factors associated are facility type, professional fee, Philhealth membership, and private insurance membership. OOP payment was found to be associated with private insurance membership in Visayas, and professional fee in Mindanao. Conclusion:A high proportion of urolithiasis patients in the country require out-of-pocket (OOP) payment for ESWL despite the deductions from Philhealth, private insurance, and other supporting organizations. The large variation in ESWL charge by facility and location explains the high variability in OOP payment, especially in Visayas and Mindanao. Factors affecting OOP payment were also found to vary depending on the location of the facility.
... In the Philippines, out-ofpocket health expenditures increased by 150% (real) from 2000 to 2012 (Family Income and Expenditure Surveys 2012). The main driver of this increase is the cost of medicines, with the larger share of medicines in total health expenditures among the poor (76%) as compared to the rich (58%) (Bredenkamp and Buisman 2016). The high cost of medicines prevents indigents from seeking medical care even when they suspect it may be necessary and drives them to catastrophic spending. ...
... Third, the scarcity of medicines in health centers and their relatively high prices discourage indigents from seeking medical help in the event of illness, as discussed earlier in Subsection 2.2. The high cost of medicines not only discourages patients from utilizing appropriate care, but also drives patients to incur catastrophic payments and impoverishing health expenditures (Bredenkamp and Buisman 2016). Finally, the presence of very popular and less expensive traditional medicine practices makes healthcare centers less attractive for indigents seeking care and treatment. ...
Developing countries have spent a tremendous amount of time and money on social health insurance programs to give the low-income population free access to health care services. Standard economic theory predicts that people use care services more frequently and regularly when they are free. In this paper, we show that providing free access to health services might not be enough to enhance the utilization of health care by indigents.
... The lack of a (through private health maintenance organizations (HMOs). 6 Out-ofpocket health expenditure is defined as direct purchases by households of health services or goods, like medicines, hospital room charges, consultation fees and diagnostic tests. It excludes dental charges, food supplements, various alternative therapies and transportation for medical care. ...
... It excludes dental charges, food supplements, various alternative therapies and transportation for medical care. 6 Purchasing of health services is particularly relevant in the thrust of financial risk protection. 5 The focus of social health insurance in the Philippines has long been on expanding membership, but as coverage approached 80-90 percent of the population, this has shifted to increasing the reimbursement rate (or the so-called "support value"). ...
Objective: To determine the effectiveness of the Philippine Health Insurance Corporation (PhilHealth) case rate system in reducing out-of-pocket expenses among non-no balance billing (NBB) patients undergoing thyroidectomy under the Department of Otorhinolaryngology – Head and Neck Surgery of the Baguio General Hospital and Medical Center from February to September 2018.
Methods:
Design: Prospective Cross- Sectional
Setting: Tertiary Government Hospital
Participants: Sixty-four (64) randomly selected patients with PhilHealth who underwent thyroidectomy who agreed to participate and reveal their statements of accounts
Results: Among the study population, 20% belonged to the no balance billing (NBB) category, with zero out-of-pocket expenses during their confinement. Eighty percent (80%) belonged to the non-NBB category and also incurred zero hospital charges. In addition, there was no significant difference in the individual categories of the hospital expenses between the two groups except for the surgical procedures (p= .018, 95% CI). The accumulated total expenses also did not significantly differ between the two groups (p= .063, 95% CI). The minimum amount billed was PhP 1,984.95, while the maximum amount charged was PhP 38,898.65, with a median of PhP 18,703.28 and interquartile range of PhP 4,251.78 (XU: PhP 20,848.74, XL : PhP 16,596.96). There were no reported out-of-pocket expenses from non-NBB patients. The actual cost of thyroidectomy did not differ significantly from the case rate provided by PhilHealth among all the RVS categories.
Conclusion: The PhilHealth case rate system is effective in reducing out-of-pocket expenses among non-NBB patients who underwent thyroidectomy in our institution during the study period.
Keywords: out-of-pocket expenses; thyroidectomy; health care financing; health expenditures: universal health coverage
... Additionally, access to high cost facilities varied across the studies, since such facilities are only located in large cities. The incidence of catastrophic expenditures in 2013 found in our study were similar to that observed in the Philippines (7.7%) in the same year using the same WHO standard approach and the same threshold level of 40% [19]. In Indonesia and Thailand in 2013, the incidence of catastrophic health care expenditures was much lower (4.4 and 2.3%, respectively) based on the Sustainable Development Goal approach. ...
... [23]. One study in the Philippines also found that pharmaceutical costs are the main driver of health spending and is as high as two-thirds of the total health spending [19]. Wegner, Graves et al. 2011 also found that between 41 and 56% of households from lowand middle income countries make major OOPPs for pharmaceuticals [6]. ...
Background:
Around the world, millions of people are impoverished due to health care spending. The highest catastrophic health expenditures are found in countries in transition. Our study analyzes the extent of financial protection by estimating the incidence of catastrophic health care expenditure in Myanmar and its association with sociodemographic factors.
Methods:
We performed a secondary analysis of data from the household surveys conducted by the Livelihoods and Food Security Trust Fund (LIFT) in 2013 and 2015 in Myanmar. To estimate the magnitude of catastrophic health care expenditure, we applied the definition of catastrophic payment proposed by the World Health Organization (WHO); a household's out-of-pocket payment for health care is considered catastrophic if it exceeds 40% of the household capacity to pay. We also examined the changes in catastrophic payments at three different threshold levels (20, 30, 40%) with one equation allowing for a negative capacity to pay (modified WHO approach) and another equation with adjusted negative capacity to pay (standard WHO approach).
Results:
In 2013, the incidence of catastrophic expenditure was 21, 13, 7% (standard WHO approach) and 48, 43, 41% (modified WHO approach) at the 20, 30, 40% threshold level respectively, while in 2015, these estimates were 18, 8, 6% (standard WHO approach) and 47, 41, 39% (modified WHO approach) respectively. Geographical location, gender of the household head, total number of household members, number of children under 5, and number of disabled persons in the household were statistically significantly associated with catastrophic health care expenditures in both studied years 2013 and 2015. Education of household head was statistically significantly associated with catastrophic health expenditure in 2013. We found that the incidence of catastrophic expenditures varied by the approach used to estimate expenditures.
Conclusions:
Although the level of catastrophic health care expenditure varies depending on the approach and threshold used, the problem of catastrophic expenditures in Myanmar cannot be denied. The government of Myanmar needs to scale up the current Social Security Scheme (SSS) or establish a new financial protection mechanism for the population. Vulnerable groups, such as households with a household head with a low-level of education, households with children under the age of 5 years or disabled persons, and low-income households should be prioritized by policymakers to improve access to essential health care.
... Incidence of catastrophic health expenditure leapt from 2.5% to 7.7% from 2000 to 2012. 11 The Philippine Downloaded by [185.143.229.169] at 07: 15 14 December 2017 National Health Accounts show that out-of-pocket health spending as a proportion of total country health expenditure increased from 52.7% in 2010 to 55.8% in 2014. 12,13 In September 2015, senior officials in PHIC recognized its inefficiencies in decision making and requested that UNICEF-Philippines commission a consultancy to make priority setting for expanding service coverage more systematic. ...
... This is a reflection of global trends, where the NCD burden is steadily increasing and fertility rates are decreasing. 11 The rise of NCDs puts a greater strain on the health system, as chronic care is required. ...
Achievement of universal health coverage requires better allocative efficiency in health systems. Countries like the Philippines, however, do not have quality local data for these decisions. We present a method that applies existing global data, e.g., Global Burden of Disease and Disease Control Priorities project, into creating a local priority list of diseases and interventions that may be useful in providing a rational plan for expanding coverage of health services paid by public financing. In the context of the Philippines, this refers to the Department of Health for vertical programs like immunization and disease control, and the Philippine Health Insurance Corporation for inpatient and outpatient health services. We found that the top 48 (or 22%) of diseases account for 80% of total disability-adjusted life years (DALYs), reflecting a well-known concept in management, the Pareto principle. Due to its simplicity and widespread applicability, the Pareto principle facilitated interest in rational priority setting among high-level officials in the Philippine health sector. Priority setting must not be limited to disease burden and cost-effectiveness criteria. Our lists must be used pending further deliberation and stakeholder consultation. Priority setting is complex, value-laden process, and a purely utilitarian approach to prioritization may lead to further deterioration in the health status of vulnerable populations. We recommend that DOH and PHIC set up a joint, independent agency primarily responsible for implementing a sustainable, transparent, and participatory priority-setting process that will advise them on future service coverage expansions.
... The affordability of diagnostics during the pandemic was especially problematic. Our findings echo the well-documented dissociation between PhilHealth enrollment and catastrophic health expenditure [38][39][40]. ...
The COVID-19 pandemic directly increased mortality and morbidity globally. In addition, it has had extensive indirect ill effects on healthcare service delivery across health systems worldwide. We aimed to describe how patient access to diabetes care was affected by the pandemic in Manila, the Philippines. We used an explanatory, sequential mixed method approach including a cross-sectional survey (n = 150) and in-depth interviews of patients (n = 19), focus group discussions of healthcare workers (n = 22), and key informant interviews of health facility administrators (n = 3) from October 2021 to January 2022. Larger proportions of patients reported absence of livelihood (67.3%), being in the lowest average monthly household income group (17.3%), and disruptions in diabetes care (54.0%) during the pandemic. They identified the imposition of lockdowns, covidization of the healthcare system, and financial instability as contributors to the reduced availability, accessibility, and affordability of diabetes-related consultations, medications, and diagnostics. At least a quarter of the patients experienced catastrophic health expenditures across all areas of diabetes care during the pandemic. Most healthcare workers and administrators identified telemedicine as a potential but incomplete tool for reaching more patients, especially those deemed lost to follow-up. In the Philippines, the pandemic negatively impacted access to essential diabetes care.
... Because most households pay out-of-pocket for medicines, pharmaceutical prices are a major determinant of health care costs and have implications on access to healthcare and health outcomes, especially for poor households (Bredenkamp and Buisman, 2016). In 2012, the average Filipino household spent Php 5,158 on drugs and medicines which accounted for 61.7 percent of total out-of-pocket health spending (Ulep and Cruz, 2013). ...
This study examines the relationship between the entry of generic drugs, branded generic drugs and branded non-originator drugs, and whether their entry significantly reduced the price of prescription drugs in the market. Quarterly panel data from IQVIA for the anti-diabetes, anti-infectives, cholesterol, and hypertension therapeutic classes from 2000 to 2020 were used to conduct a panel data analysis. The outcomes of this research may inform regulatory policies in the pharmaceutical sector to ensure that prescription drugs are available and accessible to the public.
... However, Filipinos have been enduring the financial burden brought by the cost of medical services. In fact, expenditures on medicines caused a drastic increase in outof-pocket payments among Filipinos especially the indigents from 2000 to 2012 (Brendenkamp and Buisman, 2016). This implies a need to develop government-funded social health insurance particularly for poor and near-poor Filipinos. ...
... However, Filipinos have been enduring the financial burden brought by the cost of medical services. In fact, expenditures on medicines caused a drastic increase in outof-pocket payments among Filipinos especially the indigents from 2000 to 2012 (Brendenkamp and Buisman, 2016). This implies a need to develop government-funded social health insurance particularly for poor and near-poor Filipinos. ...
This paper is an empirical exercise to demonstrate how Philhealth indigent membership affects care utilization for both inpatient and outpatient services. We present theoretically that social health insurance coverage frees up more resources for household members to spend on health care. We use treatment effects methods to accurately measure the causal effect of Philhealth membership by estimating counterfactual outcomes for the treatment and control groups.
... 3 However, even with health financing schemes and patient benefit packages, catastrophic health expenditures continue to push Filipinos into poverty. 4,5 Self-care interventions are now being considered as a key strategy to achieving UHC, especially in lowresourced settings where the impacts of COVID-19 have been most felt. 6,7 Self-care empowers individuals to make health decisions for themselves and reduces unnecessary burden on the health system. ...
... The cost of healthcare is so prohibitive that hospitalization or a chronic illness can easily be catastrophic financially. Illness and the corresponding treatment had pushed 1.5 million Filipinos into poverty (3). This is aggravated by the high prices of medicine (4). ...
The World Health Organization espouses Universal Health Care (UHC) as a means to address health inequity and allow the poorest sections of the population to access health care. In the Philippines, government efforts to implement this have evolved over the last ten years, resulting in the passage of the Universal Health Care Act in 2019. The law relies heavily on health financing as the central driver of the healthcare system reforms. This article describes and analyzes key actors on the implementation of the UHC Act, particularly the insurance program it is anchored on, the agency that will be primarily tasked to implement it, and the overarching principle behind the law. These are burdened with problems that are anathema to the outcomes sought. Rather than a market based neoliberal capitalist direction in health development, a rights-based approach is posited to be a better framework and roadmap to achieve health for all.
... OOP payment increased by 150% from 2002 to 2012, accounting for 74% of the total household health spending in the country. 5 The gap between the cost of PCI and financial assistance provided by the national insurance contributes to the high-risk population's reluctance to seek health services. ...
... As with all PhilHealth programs, cover extends from the individual who becomes a member to their spouse, dependent children ( < 21 years old) and (in 2011) parents ( ≥ 65 years old) without any addition to the premium. In the period studied, the benefit package included a wide range of inpatient services at accredited public and private hospitals, some specific outpatient treatments and limited primary care ( Bredenkamp and Buisman, 2016 ). In addition to the lack of comprehensive coverage of all treatments, the scope for health care providers to charge in excess of the reimbursement ceilings imposed by the insurer limits the effective coverage against medical expenses (ibid). ...
Temporary incentives are offered in anticipation of persistent effects that are seldom estimated. We use a nationwide randomized experiment in the Philippines to estimate effects of two incentives for health insurance three years after their withdrawal. We find that both temporary incentives had persistent effects on enrollment. A premium subsidy had a small but highly persistent effect. Application assistance offered to those initially unresponsive to the subsidy had a much larger but less persistent effect. The subsidy persuaded those with higher initial stated willingness to pay to enroll and keep enrolling. The offer of application assistance to initial non-compliers with the subsidy achieved a larger immediate effect by drawing in those who stated they valued insurance less and were less likely to re-enroll when the incentives were withdrawn.
... It is likely that newly insured patients may be emboldened to seek services which are not fully covered, sometimes because healthcare providers seek profit by promoting 'off-plan' services, including those not covered by the scheme, including branded medicines, laboratory tests and consultation with specialist doctors without referral. [36][37][38] This 'gateway effect' has been seen in other countries embarking on scale-up of insurance, including China, Ghana, Kenya and India. 28 39-41 In addition, patients may prefer to pay OOP for outpatient services, in particular, since they are relatively affordable, perceived as higher quality, and less burdensome in terms of queuing and paperwork. ...
Objectives
To analyse the relationship between health need, insurance coverage, health service availability, service use, insurance claims and out-of-pocket spending on health across Indonesia.
Design
Secondary analysis of nationally representative quantitative data. We merged four national data sets: the National Socioeconomic Survey 2018, National Census of Villages 2018, Population Health Development Index 2018 and National Insurance Records to end 2017. Descriptive analysis and linear regression were performed.
Setting
Indonesia has one of the world’s largest single-payer national health insurance schemes. Data are individual and district level; all are representative for each of the country’s 514 districts.
Participants
Anonymised secondary data from 1 131 825 individual records in the National Socioeconomic Survey and 83 931 village records in the village census. Aggregate data for 220 million insured citizens.
Primary outcome measures
Health service use and out-of-pocket payments, by health need, insurance status and service availability. Secondary outcome: insurance claims.
Results
Self-reported national health insurance registration (60.6%) is about 10% lower compared with the insurer’s report (71.1%). Insurance coverage is highest in poorer areas, where service provision, and thus service use and health spending, are lowest. Inpatient use is higher among the insured than the uninsured (OR 2.35, 95% CI 2.27 to 2.42), controlling for health need and access), and poorer patients are most likely to report free inpatient care (53% in wealth quintile 1 vs 41% in Q5). Insured patients spend US$ 3.14 more on hospitalisation than the uninsured (95% CI 1.98 to 4.31), but the difference disappears when controlled for wealth. Lack of services is a major constraint on service use, insurance claims and out-of-pocket spending.
Conclusions
The Indonesian public insurance system protects many inpatients, especially the poorest, from excessive spending. However, others, especially in Eastern Indonesia cannot benefit because few services are available. To achieve health equity, the Indonesian government needs to address supply side constraints and reduce structural underfunding.
... Compared with the choice regarding the measure of household resources, the choice of the threshold has received much less consideration. In empirical studies, thresholds applied vary between 10% and 40%, with 10% and 25% thresholds commonly applied in the budget share approach and 40% commonly applied in the capacity-to-pay approach (Xu et al., 2003;Lu et al., 2012;Bredenkamp and Buisman, 2016;Prakongsai et al., 2009;World Health Organization and World Bank, 2015). Typically a single threshold is uniformly applied across the population; however Ataguba (2012) and Onoka et al. (2011) both examined changing application of a threshold to vary according to income to account for the diminishing marginal utility of income or the increasing opportunity cost of paying for health for poorer households. ...
Financial protection is a health system goal for all countries. Assessing progress on this relies on measuring the incidence of catastrophic health expenditures (proportion of the population whose out-of-pocket (OOP) payments for health surpass a certain threshold of household resources). Standard approaches rely on selective thresholds, however this masks varying intensities of financial hardship and poses a measurement challenge as incidence is sensitive to the choice of the threshold. We address this problem by applying the dominance approach, which tests differences in catastrophic incidence curves over a continuous range of thresholds.
Iran is an interesting country for empirical application of the dominance approach given its historically high reliance on OOP payments to finance its health system and its commitment to improving financial protection through several national health policies over the last two decades. Using data from annual Household Income and Expenditure Surveys from 2005 to 2017 (sample size: 26,851–39,088 households), incidence was analyzed following this novel approach. Distribution of incidence across socio-economic status was also analyzed by estimating concentration indices and across health services or products by estimating average shares of each item. Results showed that over time catastrophic health expenditures increased for thresholds lower than 25% and decreased for thresholds higher than 35%. Catastrophic health expenditures were more equally distributed across income levels at lower thresholds, becoming concentrated amongst the rich as the threshold rose. Medicines represented the largest share of catastrophic spending for the poorest; medicines, dentistry, inpatient and ancillary services for the richest.
This is the first study to apply dominance methods to analyze catastrophic health expenditures in a country over time. The analysis provides a nuanced picture of who incurs catastrophic health expenditures, to what extent hardship is experienced and what were the drivers of these expenditures – thus providing a better basis for policy responses.
... PFHIs have been promoted globally as a vehicle for UHC [38,124]. The evidence on effectiveness of PFHIs in ensuring nancial protection in LMICs has not been very convincing so far [37][38][39][125][126][127][128][129][130][131][132][133]. ...
Introduction: Out of Pocket Expenditure (OOPE) contributes to impoverishment and Catastrophic Health Expenditure (CHE) and restricts equitable access to healthcare in many Low and Medium Income Countries (LMICs), including India. Indian government has implemented different strategies to expand access and to reduce OOPE in public and private hospitals in its mixed healthcare system. The study aims to assess the long-term pattern of utilization, OOPE and CHE in public and private hospitals and to draw policy lessons for Universal Health Coverage in India.
Methods: Indian government conducts periodic household surveys called National Sample Survey (NSS). Unit data from the last four rounds of NSS (1996 to 2017) on healthcare utilization were analysed. Multivariate analysis was used to find out determinants of utilization, choice of provider, OOPE and CHE. Propensity Score Matching was applied to find effect of specific variables on OOPE and CHE.
Results: The share of public-sector in hospital-utilisation fell from 1996 to 2004 but grew consistently after 2004, reaching 51% of utilization in 2017. Socio-economically vulnerable sections were more likely to utilize public-sector. Mean OOPE per hospitalization in public-sector registered a decline from 2004 to 2017, while it increased substantially in private-sector. OOPE in private sector was around six times greater than public sector in 2017 and incidence of CHE was nine times. Utilising private-sector was an important determinant of incurring CHE. Coverage under publicly funded insurance was ineffective in reducing OOPE or CHE.
Discussion: Public sector provided effective protection to the poor from financial risk. While, the structural-adjustment policies of 1990s had resulted in reduction in public-sector utilisation, the supply-side strengthening of public sector after 2005 was more effective in improving access and financial-protection. For achieving UHC, Indian health-system needs increased public funding for strengthening public-sector, especially to provide services for NCDs and injuries. Persistently high OOPE in private-sector raises doubts whether public-funding or contracting can align provider incentives with goals of UHC. The debate on public-private provider mix and financing policies continues to hold relevance for health-systems performance across LMICs.
... [58][59][60] However, out-of-pocket expenditure on healthcare has increased between 2000 and 2012. 61 It has also been difficult to enrol low-income earners in PhilHealth, 60 and there is still a long way to reach universal health coverage. In fact, our participants also had significant financial burdens from the hospitalisation of their children, as they needed to pay for extra costs. ...
Background and objectives
Despite a substantial reduction in the mortality rate of children under 5 years in the past 25 years, pneumonia remains the single-largest infectious cause of child deaths worldwide. This study explored the chronological order of visited healthcare facilities and practitioners, and the factors affecting mothers’ intention to seek care before the hospitalisation of children with pneumonia.
Methods and analysis
A qualitative research design was employed using theory of planned behaviour as a framework for the analysis. Using purposive sampling technique, 11 mothers, whose children under 5 years old were hospitalised with severe pneumonia, were recruited for individual semi-structured interviews. Their socio-demographic information was analysed using descriptive statistics.
Results
Mothers brought their sick children to multiple facilities, and 1 to 19 days had passed before hospitalisation. We identified four major factors determining mothers’ intentions: (1) doing something useful for the sick child, (2) expecting the child to receive the necessary assessment and treatment, (3) accepting advice to visit a healthcare facility and be referred to a hospital and (4) considering issues and benefits associated with hospitalisation. Mothers noticed their children’s unusual symptoms and monitored them while applying home remedies. They also took their children to traditional healers despite knowing that the treatments were not necessarily effective. Mothers expected children to be checked by health professionals and listened to advice from family members regarding the facilities to visit, and from healthcare staff to be referred to a hospital. Financial issues and the double burden of housework and caring for the hospitalised child were mothers’ major concerns about hospitalisation.
Conclusion
Children were hospitalised after several days because they visited multiple healthcare facilities, including traditional healers. Improving care quality at healthcare facilities and reducing financial and mothers’ burden may reduce the hospitalisation delay for children with pneumonia.
... Paying for health services out-of-pocket (OOP) at the point of use is a major hinderance to access, stopping millions of people globally from accessing needed health care and pushing millions further into poverty [6,7]. Health systems that rely heavily on OOP payments as a major source of finance tend to provide little financial protection [8]. Despite this, OOP payments constitute a significant proportion of total health expenditure across LMICs. ...
Equity in health care financing has gained increased attention in low- and middle-income countries (LMICs) following the renewed global interest in universal health coverage (UHC), a key component of the sustainable development goals (SDGs). UHC requires that people have access to the health services they need without risking financial hardship. Health financing is central to UHC and many LMICs have initiated reforms to align their health financing systems with the goals of UHC. Evaluation of the equity impact of these reforms has become a growing area of research, especially in countries with large health inequalities where the pressure to move towards UHC is most intense and the need for evidence to inform policy most critical. However, current analytical tools for evaluating equity in health financing conspicuously exclude indicators of quality, an important dimension of UHC. The aim of this paper was to address this critical methodological gap by introducing quality scores into benefit incidence analysis (BIA), one of the key techniques for assessing equity in health financing. BIA measures the extent to which different socioeconomic groups benefit from public spending on health care through their use of health services. The benefit (public subsidy) is captured in monetary terms by multiplying the quantity of a particular health service consumed by the unit cost of that service and subtracting any out-of-pocket costs incurred while using the service. It does not account for variations in the quality of health services in the computation of the public subsidy.
... There also exists evidence that outpatient care expenses have the highest proportion in healthcare costs [28] and this can be attributed to the fact that social health insurance schemes in developing countries like India do not cover outpatient care [33]. There also exists enough empirical literature that suggests a positive relation between chronic illness and OOP health expenditure in LMICs [10,[34][35][36][37][38]. This is primarily because chronic care for NCDs is costly and place substantial burden on household budgets by increasing OOP payments and impoverishing households [39][40][41]. ...
Background
Medical care related catastrophe is generally identified by healthcare expenses crossing a certain percentage of household’s resources (Wagstaff and van Doorslaer, 2003). This paper attempts to examine medical care related ‘catastrophe’ by going beyond the threshold-oriented approach of catastrophic medical expenditure and include multiple indicators which seeks to explore the catastrophe from a multidimensional perspective.
Methods
Drawing from multidimensional vulnerability to poverty approach (Alkire and Forster, 2008), we provide a measure which incorporates multiple indicators that might put households in medical care related catastrophic situation. Our study uses data from a cross-sectional household survey conducted by the Society for Health and Demographic Surveillance (SHDS) of the Government of West Bengal in 2012. Using negative binomial and logistic regression, the study also attempts to find the correlates of healthcare utilization, incurring catastrophic health expenditure for both 10 per cent of household consumption expenditure and 40 per cent of non-food expenditure as well as resorting to distress financing and availing low quality/ no care despite chronic illness.
Results
Estimates show that illness, presence of elderly members, hospitalization and outpatient visits increases the risk of incurring catastrophic health expenditure and healthcare utilization counts. In addition, households belonging to backward socio-religious categories and having members engaged as casual labourers face higher odds of distressed financing and availing informal/ no healthcare. In contrast to Wagstaff and van Doorslaer’s measure of catastrophic medical expenses, the multidimensional measure shows a lower medical care catastrophe for the upper economic classes and forward caste groups and vice versa which is more realistic and convincing.
Conclusions
The evidence generated from the multidimensional analysis presents a more convincing and reliable picture of vulnerability imparted due to health shocks as compared to identifying households with catastrophic medical expenditure by Wagstaff and van Doorslaer’s method. However, this study has its limitations as it has given equal weightage to all the dimensions and restricted itself to headcount measures. However, extension and refinement of this approach can provide more insightful findings.
... Some studies show increases in financial protection and healthcare utilisation with enrolment [35,36], in some instances with pro-poor patterns [37]. Others have found that the expansion of health insurance did not necessarily lead to increased financial protection indicators or a decrease in out-of-pocket (OOP) expenditure [38,39]. The poor and people in remote areas with poorly staffed facilities tend to have less utilisation and financial protection [34,[40][41][42][43]. ...
Background:
Universal health coverage (UHC) has provided the impetus for the introduction of publicly funded health insurance (PFHI) schemes in the mixed health systems of India and many other low- and middle-income countries. There is a need for a holistic understanding of the pathways of impact of PFHI schemes, including their role in promoting equity of access.
Methods:
This paper applies an equity-oriented evaluation framework to assess the impacts of PFHI schemes in Chhattisgarh State by synthesising literature from various sources and highlighting knowledge gaps. Data were collected from an extensive review of publications on PFHI schemes in Chhattisgarh since 2009, including empirical studies from the first author's PhD and grey literature such as programme evaluation reports, media articles and civil society campaign documents. The framework was constructed using concepts and frameworks from the health policy and systems research literature on UHC, access and health system building blocks, and is underpinned by the values of equity, human rights and the right to health.
Results:
The analysis finds that evidence of equitable enrolment in Chhattisgarh's PFHI scheme may mask many other inequities. Firstly, equitable enrolment does not automatically lead to the acceptability of the scheme for the poor or to equity in utilisation. Utilisation, especially in the private sector, is skewed towards the areas that have the least health and social need. Secondly, related to this, resource allocation patterns under PFHI deepen the 'infrastructure inequality trap', with resources being effectively transferred from tribal and vulnerable to 'better-off' areas and from the public to the private sector. Thirdly, PFHI fails in its fundamental objective of effective financial protection. Technological innovations, such as the biometric smart card and billing systems, have not provided the necessary safeguards nor led to greater accountability.
Conclusion:
The study shows that development of PFHI schemes, within the context of wider neoliberal policies promoting private sector provisioning, has negative consequences for health equity and access. More research is needed on key knowledge gaps related to the impact of PFHI schemes on health systems. An over-reliance on and rapid expansion of PFHI schemes in India is unlikely to achieve UHC.
... Medicines take up 55 percent of total health expenditures among those who experience catastrophic payments. On the contrary, the poor who encounter catastrophic payments spend as much as 70 percent of health expenditures on medicines (Bredenkamp and Buisman, 2016). ...
This retrospective study aimed to assess whether Philippine local government units (LGUs) procure drugs within official benchmark prices set by the Department of Health (DOH) called the Drug Price Reference Index (DPRI). Drug procurement price data found in the purchase orders or obligation requests of 35 purposively selected LGUs and LGU‐owned and ‐operated hospitals were collected. A Laspeyres index was used to measure the percent difference of the total drug expenditure when the quantities procured were priced at DPRI prices instead of supplier prices. Indices higher (lower) than 1 would indicate that drugs bought were more expensive (cheaper) than the DPRI prices. Results show that out of the 10 study sites, 8 were found to be deviant from the DPRI and indices ranged from 0.35 to 212.70, which implies that majority of LGUs are not compliant with the benchmark. The DOH already has a policy that enforces the adherence of DPRI among LGUs in place, but the policy has yet to be properly implemented. Monitoring may be done through computing the Laspeyres index described in this study. Monitoring can be delegated to DOH Regional offices to de‐load the DOH Central Office.
... As with all PhilHealth programs, cover extends from the individual who becomes a member to their spouse, dependent children ( < 21 years old) and (in 2011) parents ( ≥ 65 years old) without any addition to the premium. In the period studied, the benefit package included a wide range of inpatient services at accredited public and private hospitals, some specific outpatient treatments and limited primary care ( Bredenkamp and Buisman, 2016 ). In addition to the lack of comprehensive coverage of all treatments, the scope for health care providers to charge in excess of the reimbursement ceilings imposed by the insurer limits the effective coverage against medical expenses (ibid). ...
... LMICs have however shown that social health insurance schemes do not comprehensively cover the costs for medicines 36 and that OOP costs, which are majorly contributed by medicines, are a hindrance to attainment of universal health coverage in many low resource settings. 37,38 Indeed, any reductions or removal of medicine costs is likely to increase access to DM health care services, but additional resources will be required to cover any concomitant increase in service utilization. ...
Objective:
To estimate the direct and indirect costs of diabetes mellitus care at five public health facilities in Kenya.
Methods:
We conducted a cross-sectional study in two counties where diabetes patients aged 18 years and above were interviewed. Data on care-seeking costs were obtained from 163 patients seeking diabetes care at five public facilities using the cost-of-illness approach. Medicines and user charges were classified as direct health care costs while expenses on transport, food, and accommodation were classified as direct non-health care costs. Productivity losses due to diabetes were classified as indirect costs. We computed annual direct and indirect costs borne by these patients.
Results:
More than half (57.7%) of sampled patients had hypertension comorbidity. Overall, the mean annual direct patient cost was KES 53 907 (95% CI, 43 625.4-64 188.6) (US 227.2 [95% CI, 205-249.4]). Patients reporting hypertension comorbidity incurred higher costs compared with diabetes-only patients. The incidence of catastrophic costs was 63.1% (95% CI, 55.7-70.7) and increased to 75.4% (95% CI, 68.3-82.1) when transport costs were included.
Conclusion:
There are substantial direct and indirect costs borne by diabetic patients in seeking care from public facilities in Kenya. High incidence of catastrophic costs suggests diabetes services are unaffordable to majority of diabetic patients and illustrate the urgent need to improve financial risk protection to ensure access to care.
... Globally, the evidence on financial risk protection through state-funded health insurance is mixed (Acharya et al., 2012). While many studies have found that insurance increases financial protection (Galárraga, Sosa-Rubí, Salinas-Rodríguez, & Sesma-Vázquez, 2010;Knaul et al., 2012;Spaan et al., 2012), in others insurance has not necessarily led to increased financial protection or a decrease in out of pocket expenditure (Ahmed, Szabo, & Nilsen, 2018;Bredenkamp & Buisman, 2016). Studies have also found that positive impacts of health insurance are unevenly distributed, with the poor benefitting less than the rich (Acharya et al., 2012;Barraza-Lloréns, Panopoulou, & Díaz, 2013;Grogger, Arnold, Leon, & Ome, 2014;King et al., 2009;Munge, Mulupi, Barasa, & Chuma, 2018). ...
This paper explores the dynamics of access under the state-funded universal health insurance scheme in Chhattisgarh, India, and specifically the relationship between choice, affordability and acceptability. A qualitative case study of patients from the slums of Raipur City incurring significant heath expenditure despite using insurance, was conducted, examining the way patients and their families sought to navigate and negotiate hospitalisation under the scheme. Eight purposefully selected (‘revelatory’) instances of patients (and their families) utilising private hospitals are presented. Patients and their family exercised their agency to the extent that they could. Negotiations on payments took place at every stage, from admission to post-hospitalisation. Once admitted, however, families rapidly lost the initiative, and faced mounting costs, and increasingly harsh interactions with providers. The paper analyses how these outcomes were produced by a combination of failures of key regulatory mechanisms (notably the ‘smart card’), dominant norms of care as a market transaction (rather than a right), and wider cultural acceptance of illegal informal healthcare payments. The unfavourable normative and cultural context of (especially) private sector provisioning in India needs to be recognised by policy makers seeking to ensure financial risk protection through publicly financed health insurance.
Article available here- https://www.tandfonline.com/doi/full/10.1080/17441692.2019.1651369
Accepted Manuscript version available here https://bit.ly/33IJYQo
... Consequently, PhilHealth's population coverage reportedly rose from 70 percent in 2010 to 90 percent in 2016. (Bredenkamp et al., 2017;Bredenkamp and Buisman, 2016;PhilHealth, 2016). ...
Like other developing countries, the Philippines commits to achieving universal health coverage. To identify the factors - including health care needs, financial and physical access, and opportunity costs - associated with delays in seeking outpatient (OP) and inpatient (IP) care among household members with illness, injury or advised by a
doctor, this paper estimates Cox and Weibull proportional hazard models using a nationally-representative sample of households surveyed in 2011, when the Philippine government just started implementing major health reforms. Our results indicate that the delays in seeking OP care tend to be shorter for the very young (5 years old or below), the elderly (65 years old or above), and those with prior poor health. Similarly, delays in seeking IP care tend to be shorter among the very young and those requiring maternity services. Moreover, having a college-educated head of household is associated with shorter delays in seeking OP and IP care. Delays in seeking
OP care are shorter in the National Capital Region than in other regions, but longer OP delays are associated with presence of a nearby public health facility. Deferrals in seeking IP care are shorter and delays in seeking OP care are longer when the sick or injured member is employed. When the spouse of the household head is employed, IP care is likewise postponed further. Relative to the poorest income quintile, the second- and third-income quintiles tarry longer. Last, insurance coverage and urban location are not found to be significant correlates. To enhance the effectiveness of recent reforms on utilization, these results suggest deepening the awareness of the covered population of their insurance benefits or to monitor the quality of local health facilities, especially that received grants. Labor policies that reduce the opportunity cost of seeking care among the employed may also be considered.
... By 2014, CHE incidence was the highest among Q5 households. This is similar to findings from other countries such as the Philippines, Mongolia and Vietnam (Van Minh et al. 2013;Bredenkamp and Buisman 2016;Dorjdagva et al. 2016). O'Donnell et al. (2005) ascribe this phenomenon to the fact that rich patients seek more expensive care, which in turn increases total household consumption, used in most studies as a proxy for income and socioeconomic quintile categorization (Wagstaff et al. 2018a). ...
Since the end of its internal conflict in 1998, Cambodia has experienced tremendous developments in the social, economic and health sectors, with the government embarking on substantial reforms in health financing. Health equity funds that have improved access to public health services for poor people have gradually been extended to the entire country. Using the World Health Organization's methods for the analysis of healthcare expenditure and household survey data from the 2004, 2009 and 2014 Cambodian SocioEconomic Survey, we assessed trends in reported illness , utilization of healthcare services and associated financial burden on households. The impact of out-of-pocket expenditures for health on catastrophic health expenditures, poverty headcount and depth over the same 10-year period are presented, disaggregated by consumption quintile and place of residence (rural, urban and capital). At the aggregated national level, evolution of these indicators was very positive and correlates with a substantial increase in the capacity-to-pay of households, which reduced the average financial burden on households. However, over time inequalities grew between rural and urban areas. By 2014, the national incidence of catastrophic health expenditure was 4.9%, but four times more likely among rural households than their peers in the capital. For rural households with members seeking medical care, catastrophic health expenditure incidence was 12.3%. The impoverishment rate due to health spending among the lowest consumption quintile was 15.3%; the highest rate in this analysis. These findings suggest that economic and health sector developments have indeed benefited many Cambodian people. However, these gains mainly benefited urban residents; especially those in the capital city. We argue that more resources should be allocated to rural health services to address inequalities and healthcare-related financial hardship, which traps vulnerable people into poverty.
... So far, no data is available to assess whether the goals of these commendable PhilHealth initiatives have been achieved. At a more general level, Bredenkamp and Buisman [20] report that OOP health spending in the Philippines increased by 150% (real) from 2000 to 2012, mainly due to spending on medicines. As a result, the percentage of people incurring catastrophic payments has tripled (from 2.5% in 2000 to 7.7% in 2012) and in 2012, OOP spending on health pushed more than 1.5 million people into poverty. ...
Background: Achieving Universal Health Coverage (UHC) has by now become a key health policy goal in many countries and some form of National Health Insurance (NHI) is often used for this. The Philippines has had more than 50 years’ experience with social health insurance and in 1995 established PhilHealth, the country’s national health insurer.
Objectives: Analyzing the role of the Philippine NHI scheme in moving towards UHC, identifying potential avenues for improvement as well as indicating challenges and areas for further development.
Methods: This paper is based on a mixed methods approach including extensive literature search, data from PhilHealth and other sources, and key informant interviews with staff at PhilHealth, health care providers, and policy experts at national and international level.
Results: Major achievements were the expansion of population coverage using an earmarked revenue source (‘Sin Tax’), the introduction of the no-balance-billing to prevent co-payments, and the Health Facilities Enhancement Program to improve quality. The share of PhilHealth in total health expenditures is still only 14%, managing quality and cost of providers remains insufficient, the benefit coverage does not reflect the country’s burden of disease, and financial protection for PhilHealth members is low. The UHC bill would provide a massive jump forward as all Filipinos would then be automatically enrolled in and thus entitled to the benefits of PhilHealth.
Conclusions: For expanding a contribution-based NHI beyond formal employment there needs to be a large increase in budget transfers to cover for citizens unable to contribute. The Philippine UHC bill shifts from the idea of contribution leading to entitlement to the idea of citizenship leading to entitlement and can thus be seen as a paradigmatic change in thinking about NHI. There are three areas that we believe are of key importance in developing further NHI: (i) governance, (ii) financial impact, and (iii) strategic purchasing.
... 1 Therefore, it is essential that governments in lower and middle-income countries, where there is not currently universal coverage, determine what is an equitable financial contribution for health service users. 2 To determine what an equitable contribution may be, it is important to know the current situation about inequality in financial protection and the factors, which determine this inequality. [3][4][5] Decomposition of health inequalities can provide useful information for identifying sources of inequalities and the impact of each of them to policy makers. ...
... 33 By contrast, expansion of health insurance coverage in Philippines was associated with a deepening of poverty among those who are already poor. 34 In conclusion, our findings show a dynamic prevalence of catastrophic and impoverishing health spending in relation to health care financing reforms in Indonesia. However, the health care financing system performance has shown positive evidence for financial protection offerings. ...
Our study examines the incidence and intensity of catastrophic and impoverishing health spending in Indonesia. A panel data set was used from 4 waves of the Indonesian Family Life Surveys 1993, 1997, 2000, and 2007. Catastrophic health expenditure was measured by calculating the ratio of out-of-pocket payments to household income. Then, we calculated poverty indicators as a measure of impoverishing spending in the health care financing system. Head count, overshoot, and mean positive overshoot for each given threshold in 2000 were lower than other surveyed periods; otherwise, fraction headcount in 2007 of households were the higher. Between 1993 and 2007, the percentage of households in poverty decreased, both in gross and net of health payments. However, in each year, the percentages of households in poverty using net health payments were higher than the gross. The estimates of poverty gap, normalized poverty gap, and normalized mean positive gap decreased across the survey periods. The health care financing system performance has shown positive evidence for financial protection offerings. A sound relationship between improvements of health care financing performance and the existing health reform demonstrated a mutual reinforcement, which should be maintained to promote equity and fairness in health care financing in Indonesia.
Objectives
PhilHealth’s present health benefit scheme is largely centered on in-patient services. This inadvertently incentivizes hospital admissions for increased access to benefit coverage. To address this problem, this study proposes a costing method to comprehensively finance outpatient care. The objective of this paper is to estimate an annual primary care benefit package (PCBP) cost based on experience analysis (actual benefit usage) on the first year of implementation at an urban pilot site.
Methods
A cost analysis was conducted to assess a disease-agnostic primary care benefit package for an urban outpatient government facility over the first year of implementation. Costing information was gathered through staff interviews, accounting documents, and usage data from the electronic health records system available on-site.
Results
The annual primary care cost was defined as the estimated financial coverage for eligible employees and their eligible dependents (n=15,051). The annual utilization rate for consultations was reported at 51%. Of patients who consulted, approximately 38% accessed free available diagnostic procedures and 48% availed of free available medicines. Based on these usage rates, the annual primary care cost for the first year was computed at PhP 403.22 per capita.
Conclusion
Our study shows that on the first year of coverage in a government run urban outpatient facility, an allocation of PhP 403.22 per capita can allow coverage for a disease-agnostic package (comprehensive); this amount excludes out-of-pocket expenses incurred by the target population of this study. This amount is feasible only when co-opted with opportunistic registration, reduction of untargeted check-ups, prior contextual community engagement, and streamlining of patient-transactions through an electronic health record (EHR).
Over the past decade, there have been vigorous efforts to document the financial burden of health care in the Philippines, charting the cost from both the demand side (e.g., patients’ out-of-pocket spending)1-3 and supply side (e.g., costing analysis)4,5, analyzing the cost-effectiveness of various interventions6, and measuring the impacts of various financial protection interventions7. With the passage of the Universal Health Care Law in 2019, the recent scholarship has been oriented towards informing case rates and per capita coverage.8
This study estimates Filipino’s catastrophic and impoverishing out-of-pocket (OOP) healthcare expenditures on a regional perspective to measure the effectiveness and progress of Philippines’ healthcare financing system in ensuring population protection from excessive and unequal healthcare costs. Observations are drawn from the most recent household-based survey in the Philippines, 2018 and 2021 Family Income and Expenditure Survey, and grouped by four major regions: National Capital Region, the rest of Luzon, Visayas, and Mindanao region. From 2018 to 2021, results showed that the distribution of catastrophic OOP healthcare expenditures decreases while depth of these payments increases across the four major regions. The highest incidences of these catastrophic payments were found in the rest of Luzon and Visayas regions, while the highest intensities were found in Mindanao region. Despite medicines and pharmaceuticals products dominance on OOP healthcare expenditures, payment on inpatient medical services drives the catastrophic expenditures of households. Aside, deepening poverty caused by healthcare payments were more evident in households residing in Mindanao regions, thus exposing this Filipino families to financial risk and poverty threats. Logistic regression analysis showed that aging households head, employment, and socio-economic status are significant and common factors affecting the likelihood of incurring excessive health expenditures across the regions. The risk of catastrophic and impoverishing effects of healthcare expenditures persists in the country. Low levels of catastrophic OOP healthcare expenditures may indicate that disadvantaged households focused on spending on basic necessities and struggle to afford healthcare due to high costs amid COVID 19, leading to foregone treatment. Thus, continuous implementation of fair and innovative ways of financing the healthcare system to reduce the financial burden of OOP payments on Filipino households is recommended.
Low insurance take‐up in low‐income populations is not easily explained by the standard single‐period expected utility model of insurance that overlooks the relevance of time preference when liquidity is constrained. We design field survey instruments to elicit quasi‐hyperbolic time preferences, as well as prospect theory risk preferences, and use them to examine whether time preferences explain health insurance behavior of low‐income Filipinos. Consistent with theory, those with stronger parameterized time preference are less likely to insure and the partial association is most pronounced at low wealth where liquidity is most likely to be constrained. Among those with better understanding of insurance, lower take‐up is also associated with present bias. We do not find that insurance is significantly associated with risk preferences.
Background
Financial risk protection (FRP), defined as households’ access to needed healthcare services without experiencing undue financial hardship, is a critical health systems target, particularly in low- and middle-income countries (LMICs). Given the remarkable growth in FRP literature in recent times, we conducted a scoping review of the literature on FRP from out-of-pocket (OOP) health spending in LMICs. The objective was to review current knowledge, identify evidence gaps and propose future research directions.
Methods
We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines to conduct this scoping review. We systematically searched PubMed, Scopus, ProQuest and Web of Science in July 2021 for literature published since 1 January 2015. We included empirical studies that used nationally representative data from household surveys to measure the incidence of at least one of the following indicators: catastrophic health expenditure (CHE), impoverishment, adoption of strategies to cope with OOP expenses, and forgone care for financial reasons. Our review covered 155 studies and analysed the geographical focus, data sources, methods and analytical rigour of the studies. We also examined the level of FRP by disease categories (all diseases, chronic illnesses, communicable diseases) and the effect of health insurance on FRP.
Results
The extant literature primarily focused on India and China as research settings. Notably, no FRP study was available on chronic illness in any low-income country (LIC) or on communicable diseases in an upper-middle-income country (UMIC). Only one study comprehensively measured FRP by examining all four indicators. Most studies assessed (lack of) FRP as CHE incidence alone (37.4%) or as CHE and impoverishment incidence (39.4%). However, the LMIC literature did not incorporate the recent methodological advances to measure CHE and impoverishment that address the limitations of conventional methods. There were also gaps in utilizing available panel data to determine the length of the lack of FRP (e.g. duration of poverty caused by OOP expenses). The current estimates of FRP varied substantially among the LMICs, with some of the poorest countries in the world experiencing similar or even lower rates of CHE and impoverishment compared with the UMICs. Also, health insurance in LMICs did not consistently offer a higher degree of FRP.
Conclusion
The literature to date is unable to provide a reliable representation of the actual level of protection enjoyed by the LMIC population because of the lack of comprehensive measurement of FRP indicators coupled with the use of dated methodologies. Future research in LMICs should address the shortcomings identified in this review.
Catastrophic expenditure occurs when a household allocates more than 40% of its effective, or non-subsistence, income for health expenditures.1,2 In general, low-income households, those with older persons or persons with disabilities, and families with members requiring healthcare for chronic illnesses are more likely to experience this phenomenon. 3 In the Philippine setting, it has also been suggested that disasters create catastrophic spending situations.4 As household incomes are generally fixed, incurring unexpected, large, and/or long-term expenditures typically means either reducing allocation for other expense items (e.g., diminution of the budget for food or shelter) or sourcing funding elsewhere (e.g., incurring substantial debt to bridge the shortfall), and may lead to the impoverishment of the family, particularly for those who are living remarkably close the knife’s edge of poverty. Hence, protecting individuals and families from such financial catastrophe has become an important policy objective at the global and domestic levels.5–7 Using the 40% non-subsistence income threshold, it has been estimated that the 0.78% (95% uncertainty interval: 0.71 – 0.85) of households in the Philippines experienced catastrophic health expenditure.1 Meanwhile, using a 25% total household budget as a cut-off point – as measured for the Sustainable Development Goals – would increase the proportion to 1.41% of households.8 These figures, however, seem to underestimate the actual situation, as shown by related data from the 2018 Family Income and Expenditure Survey and the Philippine National Health Accounts 2014-2019.9,10 First, households typically spend around 75% of their income, which translates to an average annual savings of about 75,000 pesos. Second, roughly two-thirds (63%) of expenses were allocated for food, shelter, and utilities. In comparison, only 2.7% went to health expenses (or about 6,500 pesos per year for the entire household, using as reference the 239,000 pesos total annual household expenses). Third, the per capita health expenditure in 2019 was estimated at Php 6,662.20 – the bulk of which went to curative care in hospitals – nearly half (47.9%) contributed directly from out-of-pocket. In short, regularly, households allocate only a small amount for health-related expenses but are forced to spend more when presented with conditions requiring more expensive treatment. A separate analysis showed that catastrophic health expenditures were, on average, more than 60,000 pesos annually; medicines and in-patient services accounted for two-thirds of this amount.11 Given that the net household savings are not substantial, the question arises as to where the difference in funding requirement comes from. Lasco et al.’s paper in this issue provides an answer in this respect and extends our insight into how individuals and families deal with health expenditures.12 Drawing on data gathered from 30 focus group discussions participated in by 250 individuals representing different socio-demographic and stakeholder groups, their results offer a human dimension to the processes that families go through as they initially forego help-seeking, owe money, and finally request institutional assistance to finance their health need. The low incidence of catastrophic health expenditure in the country currently documented by official sources may be attributed to either of two scenarios. The optimistic scenario is that institutional assistance and subsidized healthcare in government facilities can bridge the shortfall in health financing, averting financial catastrophe for the family. Our prior research, however, has shown that such institutional assistance is almost always not sufficient to cover the deficit unless a family is resourceful enough that they can tap multiple providers or donors.13,14 The alternative is that individuals or families do not go beyond the first stage of pagtitiis, so much so that no further treatment can be offered when the individual interfaces with a healthcare provider. An additional point must be thought-out when considering catastrophic health expenditure. Health needs are fraught with uncertainty, which biases an individual’s capacity to adequately prepare, financially or otherwise, for such occurrence. Uncertainty in this sense means that there is a dimension of indeterminacy of a future health state, such as when healthcare professionals discuss the risk of a person suffering complications from a chronic illness.15 Prior research has shown that accurate risk perceptions are vital in healthcare. 16 Yet, we are well aware that the concept of risk, or chance, is a rather abstract notion that distorts our decision-making processes, especially about things that are unknown, unobserved, or not yet experienced.17 The burden, therefore, of preparing for unexpected healthcare expenditure should be shifted from the individual or household through the strengthening of existing social safety nets and reducing the out-of-pocket share in total health expenditure. This will entail additional investments by the government and the social health insurance program and will be among the challenges that the new dispensation will have to consider as we collectively rise from the ravages of the pandemic. Carl Abelardo T. Antonio, MD, MPH Department of Health Policy and Administration College of Public Health University of the Philippines Manila, Manila, Philippines REFERENCES World Health Organization. Designing Health Financing Systems to Reduce Catastrophic Health Expenditure [Internet]. Geneva: World Health Organization; 2005 [cited 2022 Jun 06]. Available from https://apps.who.int/iris/handle/10665/70005. Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. Household Catastrophic Health Expenditure: A Multicountry Analysis. Lancet. 2003 Jul 12;362(9378):111-7. doi: 10.1016/S0140-6736(03)13861-5. Azzani M, Roslani AC, Su TT. Determinants of Household Catastrophic Health Expenditure: A Systematic Review. Malays J Med Sci. 2019 Jan;26(1):15-43. doi: 10.21315/mjms2019.26.1.3. Espallardo N, Geroy LS, Villanueva R, Gavino R, Nievera LA, Hall JL. A Snapshot of Catastrophic Post-disaster Health Expenses after Typhoon Haiyan. Western Pac Surveill Response J. 2015 Nov 6;6 Suppl 1(Suppl 1):76-81. doi: 10.5365/WPSAR.2015.6.2.HYN_017. World Health Organization. The World Health Report. Health Systems Financing: The Path to Universal Coverage [Internet]. Geneva: World Health Organization; 2010 [cited 2022 June 6]. Available from https://apps.who.int/iris/handle/10665/44371 United Nations. Transforming Our World: The 2030 Agenda for Sustainable Development [Internet]. [New York]: United Nations; 2015 [cited 2022 June 6]. Available from https://sdgs.un.org/publications/transforming-our-world-2030-agenda-sustainable-development-17981 Congress of the Philippines. Republic Act No. 11223, Universal Health Care Act [Internet]. 2019 [cited 2022 June 6]. Available from https://www.officialgazette.gov.ph/2019/02/20/republic-act-no-11223/ World Health Organization. Global Health Observatory [Internet].n.d. [cited 2022 June 6]. Available from https://www.who.int/data/gho/data/indicators/indicator-details/GHO/population-with-household-expenditures-on-health-greater-than-25-of-total-household-expenditure-or-income-(-sdg-indicator-3-8-2)-(-) Philippine Statistics Authority. 2018 Family Income and Expenditure Survey. Volume 1. National and regional estimates [Internet]. Quezon City: Philippine Statistics Authority; 2020 [cited 2022 June 6]. Available from https://psa.gov.ph/sites/default/files/FIES%202018%20Final%20Report.pdf Philippine Statistics Authority. Philippine National Health Accounts 2014-2019 [Internet]. Quezon City: Philippine Statistics Authority; 2020 [cited 2022 June 6]. Available from https://psa.gov.ph/sites/default/files/Publication%20PNHA%202019%20signed_0.pdf Bredenkamp C, Buisman LR. Financial Protection from Health Spending in the Philippines: Policies and Progress. Health Policy Plan. 2016 Sep;31(7):919-27. doi: 10.1093/heapol/czw011. Lasco G, Yu VG, David CC. The Lived Realities of Health Financing: A Qualitative Exploration of Catastrophic Health Expenditure in the Philippines. Acta Med Philipp. 2022; 56(11):11-21. doi.org/10.47895/amp.vi0.2389. Antonio CT, Bermudez AC, Cochon KL, Garcia FB, Gueverra JP, Manalo JA, Quizon RR, Salvino RP, Benedicto EG. Stakeholder Perceptions on the Challenges of Financing Debilitating Illnesses: The Case of Colorectal Cancer and Schizophrenia in the Philippines. Phil J Health Res Dev. 2017;21(2):17-19. Guevarra JP, Antonio CT, Cochon KL, Bermudez AC, Garcia FB, Manalo JA, Pagtiilan GT, Guevarra EM, Salvino RP, Benedicto EG. Financial Assistance for Treatment of Schizophrenia in the Philippines. Acta Med Philipp. 2022;56(5):75-81. doi: 10.47895/amp.vi0.3376. Han PK, Klein WM, Arora NK. Varieties of Uncertainty in Health Care: A Conceptual Taxonomy. Med Decis Making. 2011 Nov-Dec;31(6):828-38. doi: 10.1177/0272989x11393976. Ferrer R, Klein WM. Risk Perceptions and Health Behavior. Curr Opin Psychol. 2015 Oct 1;5:85-89. doi: 10.1016/j.copsyc.2015.03.012. Enke B. What You See is All There Is. Q J Econ. 2020; 135(3): 1363-98. doi: 10.1093/qje/qjaa012.
Background:
The United Nations set a goal for universal health coverage in all countries by 2030 and selected the catastrophic health expenditure (CHE) indicator as an assessment tool for this goal. Many countries have strived to reduce household CHE. However, no study has compared countries whose policies have had a remarkable effect on decreasing CHE. Therefore, the purpose of this systematic literature review is to find appropriate methods for measuring CHE that can help us to analyze the impact of health policies and identify countries whose health policies are most effective in reducing CHE.
Method:
PubMed and Web of Science were searched. Studies that measured the incidence or intensity of CHE in multiple years were included. Two independent reviewers screened the literature, extracted the data, and analyzed the studies selected. Thirty-eight studies met the inclusion criteria for the review. We classified the selected research papers to random sampling and quasi-experimental studies.
Results:
We graphically presented the results of CHE incidence and intensity rates reported in the collected papers as a time series data set. Since most studies did not use sample weights, it was not easy to confirm whether the time series changes of CHE are significant. Therefore, we could find only two countries that had policy effects. Both countries established policies that focus on the poor.
Conclusion:
There are so many studies that analyze CHE, but policies that are effective in reducing CHE are unknown. This study uses a systematic literature review methodology to determine effective policies by comparing CHE time series trends among countries. As a policy implication, it was found that because CHE is defined as the ratio of the ability to pay to medical expenses, a policy of differential medical expenses that is based on income level is effective.
The fraction of health-care costs financed from prepayment sources is a critical indicator of progress toward Universal Health Coverage. But it does not tell how prepayment varies with the level of health-care costs and between poorer and richer patients. This paper used survey data from the Philippines to estimate inpatient costs paid by the National Health Insurance Program (aka PhilHealth) in 2013–2017 when attempts were made to extend population, service and financial coverage. The mean fraction of the inpatient bill paid by PhilHealth increased by 21 percentage points. Expansions of population coverage do not appear to have been primarily responsible for this increase. Despite the introduction of a catastrophic cover benefit package, the fraction of inpatient costs that were prepaid increased more at lower costs than at higher costs. PhilHealth payments for inpatient care were pro-rich but became substantially less so, possibly because hospitals were no longer permitted to charge poor patients in excess of reimbursement ceilings. Overall, prepayment of inpatient costs increased and became more pro-poor, reflecting gains in insurance and equity.
This study was conducted to report the prevalence of financial hardship and identify associated factors among ethnic minority populations in Vietnam. In 2019, we conducted a cross-sectional study of 5,033 ethnic minority participants from 12 provinces located in four socioeconomic regions in Vietnam. Financial hardship was measured by asking the study respondents if they had to borrow money, sell household assets, or stop using health care services due to health care service fees. Among the health service users, 24.0% (95% CI: 22.3–25.8%) faced a health-related financial hardship. Participants with secondary education were more likely to experience financial hardship than illiterate participants. In contrast, those who were able to speak the Vietnamese language, had a religious affiliation, or had health insurance were likely to have lower financial hardship. Continuing to expand health insurance coverage and develop essential packages covered by health insurance is vital to reducing financial hardship
The National Objectives for Health (NOH) 2017-2022 serves as the medium-term roadmap of the Philippines towards achieving universal health care (UHC). It specifies the country's objectives, strategies and targets for health built along the health system pillars of financing, service delivery, regulation, governance, and performance accountability. The strategic thrusts are intended to lead to the three major goals that the Philippine Health Agenda aspires for, namely, better health outcomes with no major disparity among population groups; financial risk protection for all especially the poor and marginalized; and a responsive health system which makes Filipinos feel respected, valued and empowered. The document is intended to guide national government agencies, local government units, and other stakeholders in translating medium-term health policy directions, strategies and benchmarks into concrete programs and projects that will allow all Filipinos to readily access and use affordable quality care, and thereby boosting universal health care.
Aims:
Global governments have committed to achieve Universal Health Coverage (UHC), ensuring access to quality and affordable healthcare for all. This is fundamental for those with type 1 diabetes mellitus, who require daily access to both insulin and blood glucose test strips to survive. This group risks being left behind by global initiatives that fail to consider these particular needs.
Methods:
A questionnaire was distributed to key informants in 37 less-resourced countries. Seven high-income countries were also included for comparison. We drew on a WHO framework developed to assess progress towards UHC to create scales on three dimensions: population covered, services provided and direct costs. A fourth dimension, availability, was added. Results were grouped into six patterns and visually displayed with radar graphs.
Results:
65% of the less-resourced national health systems provided insulin, with medians of 67% for service provision (equating to Human Regular and NPH), 55% direct costs covered, and 75% availability. Test strips were only provided in 14% of the less-resourced systems, with medians 42% (less than two strips per day), 76%, and 88% respectively. Six patterns of provision were identified. Progress correlated with income level, yet some low-income countries are achieving provision for insulin and test strips for those enrolled in health insurance schemes.
Conclusion:
No less-resourced country had even near-complete coverage for insulin, and coverage was worse for test strips. This study demonstrates the utility of this framework which could be developed as a means of tracking progress in meeting the needs of people with diabetes.
Background: Southeast Asia consists of eleven countries-Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand, Timor-Leste and Vietnam, they are collectively known as the Association of Southeast Asian Nations (ASEAN). To sustain universal health coverage, and with the factors contributing to healthcare cost escalation, countries have to implement cost containment strategies to overcome these issues. The aim of this article is to do a descriptive analysis of the cost containment strategies implemented in each of Southeast Asia country.
This article provides an overview of health financing reforms across countries in the Western Pacific Region as progress is made towards universal health coverage (UHC). Moving towards UHC requires a strong health system with sustainable financing, which countries strive to achieve through various approaches appropriate to their country contexts. Great efforts have been made by financing reforms through resource mobilization, risk pooling, resource allocation, and strategic purchasing. Overall governance of health financing systems has improved within the context of service delivery and budget reforms. But there are still challenges and ongoing needs to continue expanding health financing mechanisms equitably and efficiently, improving stewardship and accountability, strengthening the transition to domestic financing, and enabling evidence-informed priority setting and benefits design processes. Asian countries are rapidly developing and moving to more pre-paid financing mechanisms with government subsidies to reduce relatively high out-of-pocket expenses, while facing implementation challenges in the governance and expansion of social health insurance. The Pacific island countries, on the other hand, face stagnating economic growth and rely on government financing, with some countries receiving significant external funding, making it important to have strong stewardship and public financing systems in place. The way forward calls for continuing to strengthen the evidence generation and monitoring function to assess country progress, reorienting primary health care as the foundation of the health sector to ensure continuity of care is affordable and accountable, and leveraging the private sector to contribute to an equitable and efficient health system.
Background: Southeast Asia consists of eleven countries-Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand, Timor-Leste and Vietnam, they are collectively known as the Association of Southeast Asian Nations (ASEAN). To sustain universal health coverage, and with the factors contributing to healthcare cost escalation, countries have to implement cost containment strategies to overcome these issues. The aim of this article is to do a descriptive analysis of the cost containment strategies implemented in each of Southeast Asia country.
This book shows how to implement a variety of analytic tools that allow health equity - along different dimensions and in different spheres - to be quantified. Questions that the techniques can help provide answers for include the following: Have gaps in health outcomes between the poor and the better-off grown in specific countries or in the developing world as a whole? Are they larger in one country than in another? Are health sector subsidies more equally distributed in some countries than in others? Is health care utilization equitably distributed in the sense that people in equal need receive similar amounts of health care irrespective of their income? Are health care payments more progressive in one health care financing system than in another? What are catastrophic payments? How can they be measured? How far do health care payments impoverish households? This volume has a simple aim: to provide researchers and analysts with a step-by-step practical guide to the measurement of a variety of aspects of health equity. Each chapter includes worked examples and computer code. The authors hope that these guides, and the easy-to-implement computer routines contained in them, will stimulate yet more analysis in the field of health equity, especially in developing countries. They hope this, in turn, will lead to more comprehensive monitoring of trends in health equity, a better understanding of the causes of these inequities, more extensive evaluation of the impacts of development programs on health equity, and more effective policies and programs to reduce inequities in the health sector.
We assess the economic risk of ill health for households in Indonesia and the role of informal coping strategies. Using household panel data from the Indonesian socio‐economic household survey (Susenas) for 2003 and 2004, and applying fixed effects Poisson models, we find evidence of economic risk from illness through medical expenses. For the poor and the informal sector, ill health events impact negatively on income from wage labour, whereas for the non‐poor and formal sector, it is income from self‐employed business activities which is negatively affected. However, only for the rural population and the poor does this lead to a decrease in consumption, whereas the non‐poor seem to be able to protect current household spending.
Borrowing and drawing on family network and buffers, such as savings and assets, seem to be key informal coping strategies for the poor, which may have negative long‐term effects.
While these results suggest scope for public intervention, the economic risk from income loss for the rural poor is beyond public health care financing reforms. Rather, formal sector employment seems to be a key instrument for financial protection from illness, by also reducing income risk. © 2015 The Authors. Health Economics Published by John Wiley & Sons, Ltd.
Drugs and medicines account for about half of the total medical out-of-pocket expenses of households. This share of drugs to total medical expenses is much higher for the poor than the rich. Thus, affordability of medicines is an important issue in poverty reduction. Recent efforts to improve affordability of medicines in the country were geared toward price mediation, advocacy campaigns for quality generic drugs, and creation of village drugstores (that is, the Botika ng Bayan and Botika ng Barangay), among others. This report shows how some of these efforts have gone as far as lowering the prices is concerned. It likewise examines the extent of establishment of DOH-initiated village drugstores in the effort to improve physical access to essential medicines. The goal is to identify areas with low access to affordable medicines by mapping out the geographic distribution of village drugstores.
The introduction of the New Cooperative Medical Scheme (NCMS) in rural China has been the most rapid and dramatic extension of health insurance coverage in the developing world in this millennium. The literature to date has mainly used the uneven rollout of NCMS across counties as a way of identifying its effects on access to care and financial protection. This study exploits the cross-county variation in NCMS generosity in 2006 and 2008 in the Ningxia and Shandong provinces to estimate the effect of coverage generosity on utilization and financial protection. Our results confirm earlier findings of NCMS being effective in increasing access to care but not in increasing financial protection. In addition, we find NCMS enrollees to be sensitive to the price incentives set in the NCMS design when choosing their provider and providers to respond by increasing prices and/or providing more expensive care. Copyright © 2013 John Wiley & Sons, Ltd.
We estimate the impact on health care utilization and out-of-pocket (OOP) expenditures of a major reform in Thailand that extended health insurance to one-quarter of the population to achieve universal coverage while keeping health spending below 4% of GDP. Identification is through comparison of changes in outcomes of groups to whom coverage was extended with those of public sector employees and their dependents whose coverage was not affected. The reform is estimated to have reduced the probability that a sick person goes without formal treatment by 3.2 percentage points (11%). It increased the probability of receiving public ambulatory care by 2.7 ppt (5%) and of admission to a public hospital by 1 ppt (18%). OOP expenditures were reduced by one-third on average, as was the probability of spending more than 10% of the household budget on health care, while spending at the very top of the OOP distribution was reduced by one-half representing substantial reductio ns in exposure to medical expenditure risk. Supply-side measures implemented with the coverage extension are likely to have helped realize these effects from an increased, but still very tight, budget.
The paper attempts to describe catastrophic health spending and its impact on poverty in the Philippine setting. It focuses on the role of out-of-pocket payments for health care as a springboard for measuring the magnitude and analysing the extent of damage of catastrophic health expenditures. It also explores the scope and trends of health spending in terms of different socioeconomic indicators. More important, it delves into trends over time and among different income groups. It also employs several quantifiable measures and tools in determining the extent and intensity of “catastrophic” incidence to determine its effects on poverty. Lastly it looks into the state of impoverishment after incurring these payments. The results indicate that, in general, households that belong to higher income groups are more vulnerable to catastrophic health spending, while households from lower-income groups are more prone to impoverishment.
In 2003, China launched a heavily subsidized voluntary health insurance program for rural residents. We combine differences-in-differences with matching methods to obtain impact estimates, using data collected from program administrators, health facilities and households. The scheme has increased outpatient and inpatient utilization, and has reduced the cost of deliveries. But it has not reduced out-of-pocket expenses per outpatient visit or inpatient spell. Out-of-pocket payments overall have not been reduced. We find heterogeneity across income groups and implementing counties. The program has increased ownership of expensive equipment among central township health centers but has had no impact on cost per case.
This paper has an empirical and overtly methodological goal. The authors propose and defend a method for estimating the effect of household economic status on educational outcomes without direct survey information on income or expenditures. They construct an index based on indicators of household assets, solving the vexing problem of choosing the appropriate weights by allowing them to be determined by the statistical procedure of principal components. While the data for India cannot be used to compare alternative approaches they use data from Indonesia, Nepal, and Pakistan which have both expenditures and asset variables for the same households. With these data the authors show that not only is there a correspondence between a classification of households based on the asset index and consumption expenditures but also that the evidence is consistent with the asset index being a better proxy for predicting enrollments--apparently less subject to measurement error for this purpose--than consumption expenditures. The relationship between household wealth and educational enrollment of children can be estimated without expenditure data. A method for doing so - which uses an index based on household asset ownership indicators- is proposed and defended in this paper. In India, children from the wealthiest households are over 30 percentage points more likely to be in school than those from the poorest households.
Using data from India, we estimate the relationship between household wealth and children's school enrollment. We proxy wealth by constructing a linear index from asset ownership indicators, using principal-components analysis to derive weights. In Indian data this index is robust to the assets included, and produces internally coherent results. State-level results correspond well to independent data on per capita output and poverty. To validate the method and to show that the asset index predicts enrollments as accurately as expenditures, or more so, we use data sets from Indonesia, Pakistan, and Nepal that contain information on both expenditures and assets. The results show large, variable wealth gaps in children's enrollment across Indian states. On average a "rich" child is 31 percentage points more likely to be enrolled than a "poor" child, but this gap varies from only 4.6 percentage points in Kerala to 38.2 in Uttar Pradesh and 42.6 in Bihar.
This paper presents and compares two threshold approaches to measuring the fairness of health care payments, one requiring that payments do not exceed a pre-specified proportion of pre-payment income, the other that they do not drive households into poverty. We develop indices for 'catastrophe' that capture the intensity of catastrophe as well as its incidence and also allow the analyst to capture the degree to which catastrophic payments occur disproportionately among poor households. Measures of poverty impact capturing both intensity and incidence are also developed. The arguments and methods are empirically illustrated with data on out-of-pocket payments from Vietnam in 1993 and 1998. This is not an uninteresting application given that 80% of health spending in that country was paid out-of-pocket in 1998. We find that the incidence and intensity of 'catastrophic' payments - both in terms of pre-payment income as well as ability to pay - were reduced between 1993 and 1998, and that both incidence and intensity of 'catastrophe' became less concentrated among the poor. We also find that the incidence and intensity of the poverty impact of out-of-pocket payments diminished over the period in question. Finally, we find that the poverty impact of out-of-pocket payments is primarily due to poor people becoming even poorer rather than the non-poor being made poor, and that it was not expenses associated with inpatient care that increased poverty but rather non-hospital expenditures.
Out-of-pocket (OOP) payments are the principal means of financing health care throughout much of Asia. We estimate the magnitude and distribution of OOP payments for health care in fourteen countries and territories accounting for 81% of the Asian population. We focus on payments that are catastrophic, in the sense of severely disrupting household living standards, and approximate such payments by those absorbing a large fraction of household resources. Bangladesh, China, India, Nepal and Vietnam rely most heavily on OOP financing and have the highest incidence of catastrophic payments. Sri Lanka, Thailand and Malaysia stand out as low to middle income countries that have constrained both the OOP share of health financing and the catastrophic impact of direct payments. In most low/middle-income countries, the better-off are more likely to spend a large fraction of total household resources on health care. This may reflect the inability of the poorest of the poor to divert resources from other basic needs and possibly the protection of the poor from user charges offered in some countries. But in China, Kyrgyz and Vietnam, where there are no exemptions of the poor from charges, they are as, or even more, likely to incur catastrophic payments.
This paper compares egalitarian concepts of fairness in health care payments (requiring that payments be linked to ability to pay or ATP) and minimum standards approaches (requiring that payments do not exceed a pre-specified proportion of pre-payment income, or do not drive households into poverty). We develop indices for both sets of approaches. In the first, we compare the "agnostic" approach (which does not pre-specify exactly how payments should be linked to ATP) with a recently proposed approach that requires payments to be proportional to ATP). We link the two using results from the income redistribution literature on taxes and deductions, arguing that ATP can be thought of as pre-payment income less deductions deemed necessary to ensure a household reaches a minimum standard of living or of food consumption. We show how both approaches can be enriched by distinguishing between vertical equity (or redistribution) and horizontal equity, and show how these can be quantified. We develop indices for "catastrophe " that capture the intensity of catastrophe as well as its incidence, and also allow the analyst to capture the degree to which catastrophic payments occur disproportionately among poor households. Our measures of poverty impact also capture intensity as well as incidence. Throughout we illustrate the arguments and methods with data on out-of-pocket payments from Vietnam in 1993 and 1998. This is a not uninteresting application given that 80% of health spending in that country was paid out-of-pocket in 1998. We find that out-of-pocket payments had a smaller disequalizing effect on the income distribution, whether income is measured as pre-payment income or ATP (i.e., pre-payment income less deductions). The latter is true irrespective of how the deductions ar...
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