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Citation: Bautista, M.C.G.;
Acacio-Claro, P.J.; Mendoza, N.B.;
Pulmano, C.; Estuar, M.R.J.; Dayrit,
M.M.; Festin, V.E.; Valera, M.; Sugon,
Q., Jr.; Villamor, D.A. The 2019
Philippine UHC Act, Pandemic
Management and Implementation
Implications in a Post-COVID-19
World: A Content Analysis. Int. J.
Environ. Res. Public Health 2022,19,
9567. https://doi.org/10.3390/
ijerph19159567
Academic Editor: Tomoko Kodama
Received: 2 June 2022
Accepted: 11 July 2022
Published: 4 August 2022
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International Journal of
Environmental Research
and Public Health
Article
The 2019 Philippine UHC Act, Pandemic Management and
Implementation Implications in a Post-COVID-19 World: A
Content Analysis
Maria Cristina G. Bautista 1, * , Paulyn Jean Acacio-Claro 1, * , Nori Benjamin Mendoza 1, Christian Pulmano 2,
Maria Regina Justina Estuar 2, Manuel M. Dayrit 3, Vincent Edward Festin 1, Madeleine Valera 1,
Quirino Sugon, Jr. 4and Dennis Andrew Villamor 2
1Graduate School of Business, Ateneo de Manila University, Makati 1200, Philippines
2Department of Information Systems and Computer Science, School of Science and Engineering,
Ateneo de Manila University, Quezon 1108, Philippines
3Ateneo School of Medicine and Public Health, Ateneo de Manila University, Pasig 1604, Philippines
4Department of Physics, School of Science and Engineering, Ateneo de Manila University,
Quezon 1108, Philippines
*Correspondence: mcbautista@ateneo.edu (M.C.G.B.); pclaro@ateneo.edu (P.J.A.-C.)
Abstract:
The 2019 Philippine Universal Health Care Act (Republic Act 11223) was set for implemen-
tation in January 2020 when disruptions brought on by the pandemic occurred. Will the provisions
of the new UHC Act for an improved health system enable agile responses to forthcoming shocks,
such as this COVID-19 pandemic? A content analysis of the 2019 Philippine UHC Act can identify
neglected and leverage areas for systems’ improvement in a post-pandemic world. While content or
document analysis is commonly undertaken as part of scoping or systematic reviews of a qualitative
nature, quantitative analyses using a two-way mixed effects, consistency, multiple raters type of intr-
aclass correlation coefficient (ICC) were applied to check for reliability and consistency of agreement
among the study participants in the manual tagging of UHC components in the legislation. The
intraclass correlation reflected the individuals’ consistency of agreement with significant reliability
(0.939, p< 0.001). The assessment highlighted a centralized approach to implementation, which can
set aside the crucial collaborations and partnerships demonstrated and developed during the pan-
demic. The financing for local governments was strengthened with a new ruling that could alter UHC
integration tendencies. A smarter allocation of tax-based financing sources, along with strengthened
information and communications systems, can confront issues of trust and accountability, amidst the
varying capacities of agents and systems.
Keywords:
UHC implementation; content analysis; intraclass correlation; partnerships; pandemic
response management; fiscal space
1. Introduction
The Philippines has taken great strides in moving towards universal health coverage.
In 2019, the Philippine Universal Health Care Act (UHC), or Republic Act 11223, was
signed and the planned implementation in January 2020 was disrupted by the COVID-19
pandemic [
1
]. This pause provides an opportunity to reflect on the provisions of the new
law, in the light of the country’s pandemic response and overall health-system reforms. This
study seeks to examine the UHC Act’s intentions and provisions, against the health-system
structures tested during the pandemic. The goal is to contribute to a post-pandemic health
system that is sufficiently agile to meet any new pandemic when it occurs. The 2019 Act
was crafted to meet the universal health coverage (UHC) goals of effectiveness, quality,
and affordability. The Act meets the goals and tenets of the global movement towards
universal health coverage pursued by the World Health Organization (WHO) since 2010 [
2
].
Int. J. Environ. Res. Public Health 2022,19, 9567. https://doi.org/10.3390/ijerph19159567 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022,19, 9567 2 of 13
Financial protection and equity are at the heart of the UHC Act. The overarching question
that the study raises is whether its provisions is still ‘fit for purpose’, given health-sector
performance since the pandemic began in 2020. At its core, the study seeks to examine
for intentionality, ‘neglected’, and leverage areas that proved critical to the pandemic
response management.
The content analysis approach is one widely used in political science to detect the
policy positions of parties [
3
] and is often used in health policy systematic reviews [
4
,
5
].
The commonly known pillars of health systems analysis espoused by WHO, as well as
the COVID-19 pandemic lessons’ frame, such as those identified by the British Academy
in a multi-disciplinary evidence review [
6
], can be viewed as a priori considerations that
serve as references for the legislation analysis. A scrutiny of a legislative product or law
allows a forward-looking view on the reform intentions and/or the neglected and leverage
areas critical in the law’s implementation. The authors are not aware of any similar work
in legislative analysis in health policy.
This section includes an overview of the Philippine health system and the country’s
pandemic performance, followed by the guiding framework.
1.1. Overview of the Philippine Health System
The Philippines is a middle-income economy in the southeast Asia region, with per
capita gross domestic product (GDP) of 3550 USD in 2021 [
7
]. It has an estimated population
of 111 million in 2021, with the median age of 25.7 years. Table 1shows some salient
features of the Philippine health-care system. Health expenditures comprised 5.6 percent
of its gross national product in 2020, from 4.7 percent the previous year 2019 [
8
]. The
Philippines national health accounts’ data showed that health expenditure by all sectors
rose to 12.6 percent in 2019–2020, the first year of the pandemic, from 10.2 percent in
the previous two years. Government schemes and compulsory contributory health care
financing schemes comprised 45.7 percent of the source of spending, with household out-of-
pocket payments at 44.7 percent, and the balance attributed to voluntary payment schemes.
The year 2020 saw government and contributory financing schemes overtake household
out-of-pocket payments, a welcome development for equity considerations [9].
Table 1. Philippine Health System: Overview of Basic Statistics.
Features Figures (as Indicated)
Current Health
Expenditures-CHE (NHA 2020
in [8])
5.6% of GDP
Growth Rate of (CHE)
2019–2020 12.6%
2018–2019 10.2%
Health financing (NHA: 2020 in
[8])-households (out of pocket) 44.7% Government and Compulsory
Schemes 45.7%
Distribution of Household Out
of pocket Expenses (NHA: 2020
in [8])
43.8% hospitals 28.2% drugs, pharmacies 9.0% preventive care
UHC Coverage Index (WHO
and World Bank data in [10]) 55%
HC Utilization by households
(DHS: 2017 in [11])
8% of household population sought
care past 30 days
59% sought from public medical
facilities
40% sought care from private
medical facilities
Health service delivery (Dayrit
et al., 2018 in [12])
1224 Hospital facilities, 64% private
and 35% public in 2016;
66% located in main island
2587 city/rural health centers,
20,216 village health stations
In 2016
Two-thirds are level 1 hospitals,
with 41 beds on average; 10% are
level 3, with 318 beds on average
Health Human Resources
(Philippine Statistical
Yearbook/PSY, 2018 in [13])
83% of health and medical
graduates in 2015–2016 were from
private schools (HIT, 2018)
3131 doctors in govt service; 1875
Dentists; 5975 Nurses 17,112 Midwives
Int. J. Environ. Res. Public Health 2022,19, 9567 3 of 13
Table 1. Cont.
Features Figures (as Indicated)
Public sector employs 61% of nurses
and 90% of midwives (HIT, 2018)
91% of Medical doctors and 74%
of nurses work in hospitals
(HiT,2018)
Health Governance
DOH as the overall policy setting of
population-based care, and
provision of regional hospital and
specialist services; PhilHealth, the
social insurance arm, as purchaser
of personal-based care
LGUs as facility owners,
managers and implementers of
health programs and services
Local Health Boards as advisers to
chief executives and local
legislatures, with DoH
representative
Abbreviations: DHS—Demographic Health Survey; DoH—Department of Health; NHA—National Health
Accounts; CHE—Current Health Expenditures; GDP—Gross Domestic Product.
Table 1highlights the household preference for public medical facilities, which under
the new UHC Act, must maintain 90% of beds as wards and 10% as private beds. The
reverse is mandated for private facilities to maintain at least 10% as ward beds of its total
bed capacity. The same Act requires no additional user charges be imposed on indigent
and other special groups in the ward facilities. While health human resources were largely
trained (86%) in fee-paying, private institutions, the new UHC Act expands public medical
and health services training, with a return-to-service clause for the scholars of public
universities and colleges. The public facilities had a larger share of nurses and midwives.
In general, the medical doctors and nurses are found in hospitals, as opposed to primary
care facilities.
Since the enactment, 60 operational guidelines and policies have been drawn up
to implement UHC, and in accord with its Implementing Rules and Regulations (IRR).
Fifty-five (55) are considered as finalized and issued. Thirty-three (33) implementation sites
are considered to be advanced implementation sites (AIS) [
14
]. The UHC implementation
process is presented by the DOH in various roadshows as being built around integration.
Below are the ways in which the implementation is described:
Structural integration—toward the creation of the city-wide and province-wide health
systems; this means bringing together the inter-local health zones (ILHZ) which group
municipalities into districts. This structural integration means having various service
delivery structures at province, municipal, and district levels work together more closely.
Primary health care, the lowest level of operations, will operate as the system gatekeeper,
channeling patients through diagnostic systems at secondary levels and specialist and
inpatient care through to tertiary and the apex, as needed;
Managerial integration—towards the strengthening of the Provincial Health Board and
the City Health Board; these boards are the policymaking instruments for UHC, as well as
the units that approve resource allocation and execute oversight of the implementation; this
will entail the bringing together of representatives from the various offices of the Province,
Municipalities, DOH, and the private sector, both for-profit and non-profit. This integration
will involve the strengthening of the Provincial Health Office as the technical arm of the
province in overseeing the hospitals (provincial hospitals, district hospitals), as well as the
public health facilities (rural health units, barangay health units). It is conceivable that the
private sector facilities will become part of the scope of the Provincial Health Office;
Financial integration—this means bringing together the resources from national gov-
ernment (internal revenues, PhilHealth remittances, etc.), resources from the province, and
resources from the municipality into one or two Special Health Funds (SHF) which will
be managed by the province and highly urbanized cities, respectively. From this Special
Health Fund, allocations and disbursements will be made.
This strategy for UHC implementation demonstrates a centralizing approach, as
presently the provinces and highly urbanized cities are the owners and the locus of the
health services delivery of the health system, responsible for planning, payroll, and budget
allocations to government health services and activities in their jurisdiction.
Int. J. Environ. Res. Public Health 2022,19, 9567 4 of 13
When the 2019 UHC Act joint legislative deliberations began in 2017, relatively strong
economic growth had been registered in prior years. Election promises and some reduction
in the poverty levels have created a wider receptivity to health sector advocacies. The Act
was discussed and drawn amidst much fiscal space, benefitting from payroll contributions
and new revenue sources in the form of sin taxes (so called taxes on cigarettes, alcohol,
and sugar content) and reforms that earmarked and increased the financial resources for
health. The allocation of roles and responsibilities, where the Philippine Health Insurance
Corporation (PhilHealth) is responsible for personal health services, while the Department
of Health (DOH) covers for the population health services, is a convenient way to divide
fiscal resources. The role of local government units (LGUs), who are the de jure owner of
the facilities below regional levels, such as provincial hospitals, city and rural health centers,
and barangay health stations, was not clearly specified. Many of the LGUs were not aware
of their roles, as voiced in the deliberations about its implementation rules. A separate
law, the Local Government Code (LGC) or Republic Act 7160 in 1991, governs LGUs.
The integrated local health systems (ILHS), established within the provincial and highly
urbanized cities, are tasked under the UHC Act to be responsible for both the planning and
managerial supervision of population-based and individual-based health services within
respective local jurisdictions (Sec. 19.8).
One area affecting national–local relationships is the health workforce. When local
governments took over the health functions in the 1991 decentralization, they had to
contend with paying health personnel with a higher pay structure, different from regular
government personnel, and mandated in another law, the Magna Carta for Public Health
Workers Act [
15
]. The differences in pay structure were justified in terms of hazards,
subsistence, longevity pay, laundry, and remote assignments, along with performance-
based allowances. The pay and benefit structures are not widely adopted in the private
health sector. A comprehensive policy review culled 134 policies consisting of 73 laws and
61 executive policy issuances of different government agencies affecting human resources
for health [
16
]. The payment for the health workforce is a contentious point for private
providers, particularly, if this will be part of the requirements for accreditation. The private
sector may not be able to pay its workers all of the benefit payments given to public health
care workers. The health workers paid from the local government funds are not receiving
the same amount as the national government-funded health workers, creating a contentious
area within the same workspace.
In a recent policy development, known as the Mandanas Ruling by the Supreme Court
in 2018 (and confirmed in 2019), the LGUs’ share of national funds or the Internal Revenue
Allocation (IRA) will increase by an estimated 30.7% under the new funding formula,
without earmarks. The increase was made possible as the allocations were expanded from
a broader set of taxes, including customs and excise taxes. The intention is to support
full devolution, assisting the LGUs with their service delivery functions, including health
services [
17
]. This puts the LGUs in a position of strength with respect to the two other
institutional custodians of UHC—the DOH and PhilHealth.
1.2. Pandemic Performance
By mid-February 2022, the 24th month since the pandemic was officially declared,
the Philippines had registered 3.6 million cases and 55 thousand people had died from
COVID-19. The active cases, tested via RT-PCR, at that point in time were 72.3 thousand.
An estimated 62% of the population were officially reported by then to have received at
least one dose of the vaccine [
18
]. There was no vaccination for children below 12 years old
at this point in time. The Philippines ranked bottom of the Bloomberg COVID-19 resilience
score in January 2022, due largely to the severity and duration of the lockdown periods,
vaccination rates, openness to travel via flights, and travel routes [19].
The fiscal space for UHC implementation has since shrunk with the pandemic; the
structure of service delivery and financing are challenged with the physical and human
resource requirements and coordination needs. In exploring complex systems, such as
Int. J. Environ. Res. Public Health 2022,19, 9567 5 of 13
health care, the country’s initial response during this pandemic can be characterized by
dysfunctional coordination platforms, inadequate and mismanagement of resources, as well
as limited information systems and capacities, as similarly indicated in systems thinking
analysis [
20
,
21
]. That the country was able eventually to track cases, continue to monitor
them, model, and anticipate trends was due to the coming on board of knowledge partners
from academia and the private sector. Vaccine orders were made in advance by the private
sector for their employees and eventually shared with the public sector, demonstrating
regulatory partnerships.
The pandemic also highlighted the crucial and effective role performance of the
LGUs, given weaknesses at the central level. Emergency funding was speedily approved
nationally, but distribution to lower levels were not as quick. International partners
(such as the Asian Development Bank) were also forthcoming with speedy support for
infrastructure, such as laboratories and expensive GenXpert machines. The LGUs looked to
the central authorities for guidance and support with materials. When these were unclear,
not forthcoming, or delayed, they proceeded within their own mandates through their
local legislative systems. Public–private partnerships were launched (Table 2). It is notable
that the public counterparts were local governments (provincial governments and one
highly urbanized city) and the University of the Philippines system. The imperatives of
responding to the pandemic have seen additional resources poured into the health sector
quite speedily, via legislation, private donations, and reallocation from other sectors. The
absorptive capacities of some of the LGUs remain a concern [
22
]. It is interesting to note
that these are hospital-based investments.
Table 2. List of Pipeline Public–Private Health Infrastructure Projects (as of February 2022).
Implementing Agency Investment (Php) J-Yen USD Status
Philippine General
Hospital-Diliman
University of
the Philippines 21.3 billion 47.9 trillion 414.92 million before ICC
for approval
Baguio General
Hospital and
Medical Center,
Renal Center
LGU and DOH 470 million 1 billion 8.0 million
Cagayan Valley
Medical Center
Hemodialysis Center
LGU and DOH 330 million 742 million 6.4 million
Philippine General
Hospital—PGH
Manila
Cancer Center
PGH 4.6 billion 10.3 billion 89.6 million before ICC
for approval
Mariveles Mental
Health and
Wellness Center
LGU and DOH
Makati Life
Medical Center LGU-Prv 5 billion 11 billion 97.2 million
LGU investments are in various stages of implementation. ICC refers to the Intergovernmental Coordinating
Council chaired by the President as final approval body for big ticket infrastructure investments. Source: Adapted
and updated from [23].
1.3. Framework
The WHO provides a framework where health systems’ performance is viewed in
terms of three goals, four functions, and six building blocks [
2
]. Adapting from such a
framework, this study’s view is one where healthcare is a complex system. It is composed
of people and processes where the agents are defined by their roles, and corresponding
scripts or actions (who does what) and processes facilitate relationships, so that each person
or group is able to achieve specific goals (how it is executed) [
24
]. The way the roles and
Int. J. Environ. Res. Public Health 2022,19, 9567 6 of 13
actions by the agents or actors in the system are undertaken is indicative of the type of
relationships that enable certain activities to be pursued or not, and thus is determinative
of the paths taken towards implementation and impact.
Figure 1shows the key agencies, namely, DOH, PhilHealth, LGUs, and other stake-
holders (private providers, insurers, community) at the center. Four health system building
blocks relate to health service delivery (supply side), population or health promotion
services, human resources, and stewardship. The functional component areas specific to
UHC relate to financial protection, benefit package, payments and incentives, and contracts.
Underpinning the reforms are the UHC values and goals of equity, efficiency, effectiveness,
quality, and responsiveness. These are not shown, to avoid complicating the diagram.
Ultimately, UHC intends to improve the health and well-being of Filipinos.
Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW 6 of 13
1.3. Framework
The WHO provides a framework where health systems’ performance is viewed in
terms of three goals, four functions, and six building blocks [2]. Adapting from such a
framework, this study’s view is one where healthcare is a complex system. It is composed
of people and processes where the agents are defined by their roles, and corresponding
scripts or actions (who does what) and processes facilitate relationships, so that each per-
son or group is able to achieve specific goals (how it is executed) [24]. The way the roles
and actions by the agents or actors in the system are undertaken is indicative of the type
of relationships that enable certain activities to be pursued or not, and thus is determina-
tive of the paths taken towards implementation and impact.
Figure 1 shows the key agencies, namely, DOH, PhilHealth, LGUs, and other stake-
holders (private providers, insurers, community) at the center. Four health system build-
ing blocks relate to health service delivery (supply side), population or health promotion
services, human resources, and stewardship. The functional component areas specific to
UHC relate to financial protection, benefit package, payments and incentives, and con-
tracts. Underpinning the reforms are the UHC values and goals of equity, efficiency, ef-
fectiveness, quality, and responsiveness. These are not shown, to avoid complicating the
diagram. Ultimately, UHC intends to improve the health and well-being of Filipinos.
Figure 1. Framework of the Content Study on the Philippine UHC Act.
To assess the UHC Act from the lens of the experience under the pandemic, studies
have identified interconnected areas that can be built on and are likely to endure for the
long term: the strength of engaging with local communities; protection of health workers
and other essential workers; effective national coordination; and transparent and con-
sistent information or messaging [6,25]. Having resources and platforms to secure sup-
plies and tools were necessary but not sufficient in the response. Examining whether the
UHC Act has considerations in these areas are under discussion in this study.
2. Materials and Methods
A team composed of seven individuals/raters conducted content analysis of the UHC
Act (RA 11223). These raters had legal, economics, physics, medical, public health, and
computer science backgrounds. They were chosen for their varying knowledge of the
UHC Act and general legislative processes to balance familiarity bias. One once served as
•Governance support:
HTA, HIA, accreditation,
research, M/E
• Contracts/Enforcement
• Benefits Demand
side (including
packages)
•Financial Protection
•Financing/Payments
/ Incentive
•Health Service
Delivery
(Supply)
•Population
Coverage &
Health
Promotion
•Health
Workforce
Department
of Health
(DOH)
Philippine
Health
Insurance
Corporation
(PhilHealth)
Private
sector and
communities'
engagement
Local
Government
units (LGUs)
Figure 1. Framework of the Content Study on the Philippine UHC Act.
To assess the UHC Act from the lens of the experience under the pandemic, studies
have identified interconnected areas that can be built on and are likely to endure for the
long term: the strength of engaging with local communities; protection of health workers
and other essential workers; effective national coordination; and transparent and consistent
information or messaging [
6
,
25
]. Having resources and platforms to secure supplies and
tools were necessary but not sufficient in the response. Examining whether the UHC Act
has considerations in these areas are under discussion in this study.
2. Materials and Methods
A team composed of seven individuals/raters conducted content analysis of the UHC
Act (RA 11223). These raters had legal, economics, physics, medical, public health, and
computer science backgrounds. They were chosen for their varying knowledge of the
UHC Act and general legislative processes to balance familiarity bias. One once served as
PhilHealth Vice President, three read the Act in full for the first time, and two were fully
acquainted with the Act but new to the given format. All of the team had graduate degrees.
The instruction was to ‘tag’ clauses to the actors, blocks, and functions as read and not to
go too deeply into ultimate ends or causes. The chapters and clauses of the law were put
as rows in an Excel spreadsheet. The first step in the manual tagging of each chapter and
clauses in the Act was made based on its directionality, or who it was being directed to.
The next step was to examine these clauses into the functions and building blocks, using
pre-determined components supporting the study’s framework (Figure 1). The taggers
Int. J. Environ. Res. Public Health 2022,19, 9567 7 of 13
separately submitted their sheets before a compiled sheet was made. The areas tagged
the most were examined for their implications. Items with the least tags were considered
indicative of the areas requiring some attention for their significance to implementation.
This ‘tagging’ of the Act’s clauses and provisions to the framework components were
further examined to check for reliability or consistency of the responses. The reliability or
homogeneity of the measurement of the tagging process on different components performed
by seven different raters was assessed through the intraclass correlation coefficient (ICC).
The ICC on individual and average ratings was estimated. The average ICC can be used
when the teams of raters are used to rate a target (called a component in this study). When
the unit of analysis is an average rating, the interpretation of the ICC pertains to average
ratings and not individual ratings.
Koo and Li [
26
] recommended selecting the correct form of ICC based on the model,
type (single rater/measurement or the mean of k raters/measurements), and the definition
of the relationship to be measured (consistency or absolute agreement). This study used
a two-way, mixed-effects model because the raters of interest were not independently
sampled. Thus, rater was considered a fixed effect, while targets/components were the
random effects. Since each rating by the multiple raters were used in the analysis, the
type of ICC referred to the “mean of k raters”. The relationship measured in this study
was the consistency-of-agreement, because it represents correlation when the rater is fixed.
Under consistency of agreement, the scores are considered consistent if the scores from
any two raters differ by the same constant value for all of the targets. This implies that
the raters give the same ranking to all of the targets. Researchers have pointed out that
the consistency of agreement is useful when comparative judgments are made about the
objects of measurement in the ICC [27].
The ICC estimates and their 95% confidence intervals (CI) were calculated using
STATA/SE version 15.1, based on a mean-rating (k = 7), consistency of agreement, and
two-way mixed-effects model.
Following a rule of thumb for the researchers to obtain at least 30 heterogeneous
samples and to involve at least three raters when conducting a reliability study, it was
suggested that ICC values less than 0.5 are indicative of poor reliability; values between 0.5
and 0.75 indicate moderate reliability; values between 0.75 and 0.9 indicate good reliability;
and values greater than 0.90 indicate excellent reliability [27].
3. Results
Each rater tagged the different statements per chapter in the UHC Act according to
the 14 components identified in the framework (Table 3). Each statement can have multiple
tags. A total of 195 clauses/statements within 11 chapters, with 46 sections spread across
them, were tagged.
Table 3below shows the top three components that were most evident, based on the
total tags by the raters. These components pertain to the DOH/National government,
PhilHealth and contracts/enforcement. It is noted that a high standard deviation for the
mean number of tags on contracts/enforcement implied that the frequency of tags by the
respondents was dispersed. The number of tags for this ranged from 11 to 70. The least
tagged component was Human Resource/Workforce Support Systems followed by the
LGU/DILG (Department of the Interior and Local Government), and Benefits Demand
Side (including health benefit plans).
Under a mixed-effects model, the individual ICC estimated was 0.69 (95% CI: 0.50–0.86),
showing a correlation between the individual tags, while the average ICC was 0.94 (95% CI:
0.87–0.98), showing a correlation between the average tags made on the same component.
The consistency of agreement of the seven raters for the individual tags on each component
implied a moderate reliability, while there was excellent reliability for the average tags made
per component. The estimated coefficients were statistically significant (F(13, 78) = 16.41,
p< 0.001), indicating that both the individual and average tags were randomly dependent
on the type of component and fixed on the corresponding rater making the measurements.
Int. J. Environ. Res. Public Health 2022,19, 9567 8 of 13
Table 3. Average number of tags for 14 components in the UHC Act by seven respondents.
Component Mean ±Std. Deviation Minimum–Maximum
Frequency
DOH/national government 55.9 ±8.5 42–68
PhilHealth 50.9 ±9.3 39–67
Contracts/Enforcement 46.5 ±23.2 11–70
Governance Support (HTA, HIA, accreditation, research, ME) * 42.7 ±11.6 21–60
Financing/Payments/Incentives 39 ±6.5 26–45
Community/Engagement 34.7 ±12.5 16–53
Supply: Service Delivery 29.9 ±8.8 22–48
Private Providers/Other Partners, (e.g., HMOs, Fund Managers) * 25.0 ±6.9 19–37
Population Coverage and Health Promotion 23.9 ±4.5 17–29
Financial Protection 23.6 ±10.8 9–38
Values/Principles/Ethics 18.4 ±6.4 11–29
Benefits Demand Side (Including packages) 16.6 ±9.9 3–28
LGU/DILG 13.4 ±4.0 8–19
Human Resource (HR)/Workforce Support Systems 4.4 ±2.9 1–8
* Abbreviations: HTA = health technology assessment; HIA = health impact assessment; ME = monitoring and
evaluation; HMO = health maintenance organization.
4. Discussion
The dominance of the DOH and PhilHealth is as expected, as the law can be viewed as
their mandate to access increased revenue resources and implement wide-ranging health
sector reforms to achieve or progress towards universal health coverage. Contracting, which
surfaced as the third most tagged, refers to an instrumentality or mechanism that will be
exercised by the primary agents to reach other agents. The least tagged, or what was viewed
as less attended to in the law, included health human resources, LGUs, and the demand side
of health services that involves health benefits. Three themes emerged as crucial in the UHC
implementation, particularly from the post-COVID-19 lens. These are the national–local
interactions, stakeholder engagement and contracting, and the capabilities and tools for
coordination. This section discusses the challenges and directions in these areas.
4.1. National-Local Interactions
The UHC implementation appears to have been envisioned as a strategy of re-centralization,
given the context of integration. At present, the provinces and highly urbanized cities
are the owners and locus of health services delivery of the health system; responsible for
planning, payroll, and budget allocations to government health services and activities in
their jurisdiction. The content assessment, that showed LGUs as having the least attribution
or responsibility, points to a critical neglect.
Under the implementing rules and regulations [
28
], the local health system refers to
“all health offices, facilities and services, human resources, and other operations relating
to health under the management of the LGUs to promote, restore or maintain health”
(Sec. 19.2). It is envisioned, under Rule 19.6, that the integration of the province and
city-wide health systems shall be undertaken “through a mechanism of cooperative under-
takings” (pursuant to Section 33 of the Republic Act 7160; The Local Government Code of
1991) [29].
DOH and PhilHealth, outside of headquarters, conduct their primary responsibilities
in a ‘cooperative’ arrangement. This arrangement has made for a mixed implementation of
the devolution enshrined in the local government code [
12
]. The new UHC Act, however,
has no compulsory power to enforce cooperation between the LGUs in their zones, even
as tasks, such as managerial and financial integration and the provision of the needed
resources and support mechanisms to make the integration possible and sustainable (Sec.
19.9), are indicated. This highlights the basic vulnerability of national–local relationships,
that as political administration changes, so can the strategies and priorities change. The
Mandanas ruling mentioned in Section 1.1 has given added leveraging power to LGUs
Int. J. Environ. Res. Public Health 2022,19, 9567 9 of 13
with the increased funding share of the internal revenue allocation (that is, their share
of the national taxes). These are not earmarked funds and it will require negotiations
with the primary UHC implementors. In terms of accountabilities, only PhilHealth has a
quasi-judicial authority on certain matters. The DOH has limited administrative remedies
with respect to decision-making in the interlocal health decision making by their boards.
The recent developments in public–private partnerships highlighted in Table 2above,
showed LGUs leading the partnerships in creating new facilities. The strengthening of the
financial position of LGUs can be viewed as re-devolution. The integration discussions
which strengthen the role of DOH in local matters will need re-calibration.
It has been indicated in the first part of this paper that one contentious area in national
and local relationships has to with the responsibilities and payment for the health work-
force. For the implementation of the UHC Act, more work needs to be completed in the
harmonization of various laws and policies, as they affect both the government workforces
and the private provision of care. The health workers paid from the local government funds
are not receiving the same amount as the national government-funded health workers,
creating a contentious area within the same workspace. The private providers may not
be able to pay its workers all of the benefit payments given to public health care workers,
and using this as a precondition for accreditation may put off private providers from UHC
implementation. In the midst of the pandemic, there were mounting complaints from the
private providers about unpaid accounts, an issue that has always been lodged against the
institution [
30
], and for which the new UHC Act has not provided greater compulsion for
PhilHealth, nor redress for the providers.
4.2. Other Stakeholders and Contracting
Our content analysis has shown that engagements with the private sector and commu-
nity groups were weakly ascribed in the Act, and contracting figured prominently as the
main instrument to relate with stakeholders. In the Act’s provisions on the private sector,
its participation in the integrated local health system, through a contractual arrangement
with the province-wide or city-wide health systems, is encouraged.
Since public (tax) and member funds are involved, services are not just purchased by
central authorities but will be underpinned by contracts, or formal agreements among gov-
ernment agencies and affected stakeholders, including public and private facility operators,
and the health workforce. Schuhmann and Bautista [
30
] observed that, while incentives are
mentioned 18
×
in the draft IRR, there are more than 40 counts of contracts or contracting
being mentioned in the implementation rules. With DOH and PhilHealth being hierarchical
or bureaucratic organizations, contracting has been viewed largely as transactional, and
the contracts are used to justify the transfers of resources. One of the biggest scandals
during the pandemic was related to the government procurement of personal protective
equipment (PPE), masks, and similar items [31].
The new UHC Act and its IRR view contracting as a “meeting of the minds”; however,
among a very diverse group of parties with equally varying interests and considerations,
this is not sufficient. It will be a challenge for the DOH, DILG, PhilHealth, and the LGUs
to develop a contract that will satisfy the varying interests of the diverse group of entities
sought to be brought together. The conceptual nuances of managing through contracts
has been discussed in more depth [
32
]. Much of the language of the Act and the rules
regarding contracts is directive, and for the individual-based health care provider networks,
it appears that there is a requirement to form a single entity under a network. This is seen in
the requirement of “networks exhibiting proof of legal personality” (Sec. 18.4.f). This clause
forms a likely disincentive to private sector providers who are normally in competition
with one another in small markets.
The DOH and PhilHealth have been given the task of providing general guidelines
for these contractual arrangements, hence the impression and concern that these contracts
will be very “top down” in nature is warranted. It is recommended that, to counteract this
possibility, the task ahead is to empower and strengthen the Provincial and City Health
Int. J. Environ. Res. Public Health 2022,19, 9567 10 of 13
Boards in order to provide nuanced, localized, and, consequently, responsive oversight and
management over the contracts that establish the ILHS and other networks.
The role of non-government organizations, patient, and community groups was high-
lighted during the pandemic. They were involved in community mobilization, contact
tracing, and coordinating the treatment of individuals in the community, even the provi-
sion of social assistance and support. They may continue to be partners post-pandemic.
Access to UHC funds is likely also to be through the contracting mechanism. Government
procurement systems are not user friendly to community groups and non-government
organizations. Membership in the health boards is one venue for participation.
4.3. Other Cross-Cutting Considerations
The top-down approach has created various anomalies in the light of limited tools
utilized to implement the new Act. Moving contracts from being mere transactions to
moving monies and paying vendors will require better provider payment systems, which
rests on improved information technology systems; with both, steering the system towards
health care quality. Financing and information systems form the backbone on which
the structure of the health system stands. The new UHC Act’s central feature divided
responsibilities by type of intervention; between DOH for population health activities and
PhilHealth for personal health care. Linkages on financing, particularly on payments to
providers, did not prominently figure in the content assessment.
Fair provider payment processes are critical to push for quality services from accred-
ited hospitals, using analytic and evidence-based approaches, rather than relying on its
quasi-judicial mandate and flexing its muscle on fraud detection and conflicting policies.
The funds from these two agencies will be pooled in provincial and highly urbanized
cities to form the special health fund that is managed by reconstituted local health boards.
Considering the slight majority of the private sector over government health in the facilities
count, there is no indication as to how the private sector will accept not being directly
in receipt of funds from the main insurer, PhilHealth. Instead, they will have to collect
against the Special Health Fund (SHF), which is managed by the local political bureaus.
Furthermore, the payment delays to hospitals, scandals over inappropriate payments, and
manipulation of the system through case creep (how one simple case diagnosis will be
upgraded to a more complicated case) have percolated into trust issues between PhilHealth
and the private providers [33].
While the UHC law improves on the governance of PhilHealth by tightening the
qualifications of PhilHealth board members, the financing reforms needed would require
more transformative leadership. The pandemic experience has shown how easy it is to
wipe out the financial reserves saved over the surplus years, erode agency credibility
with the scandals and untimely premium increases. Cost efficiency is gained by altering
the way payment is made to the providers, by moving from case payments to more cost
control systems, such as global budgeting [
34
]. The Act’s Chapter IV, Section 18-B mentions
performance-based, close-end, prospective payments based on diagnostic categories. This
will require capacities, technical skills, and information that may not be currently available.
Budget transfers, outside of premium revenues, by members will require better budget
cycle planning and financial reporting.
The information requirements and systems needed for efficiency and equity are vast.
While new regulatory agencies have been identified in the new UHC Act, such as the Health
Promotion Bureau and Health Technology Assessment, the availability and quality of the
data and information they will be working with for improved decision-making still need
to be constructed. As they generate the data, frequent analysis and updates on diagnostic
codes, weights, and costs will form part of the information technology systems that will
yield more transparent and robust internal evaluation, utilization processes, knowledge
exchange, and management for a nimbler health system.
As decentralized local delivery systems and a strong private health sector are the
contexts under which the centralizing approach of the new UHC will be undertaken,
Int. J. Environ. Res. Public Health 2022,19, 9567 11 of 13
incentives will be the main mechanism by which purchasing agencies, the DOH, and
PhilHealth, are going to relate with stakeholders. Under a strengthened central authority,
incentives need to evolve from simple ‘carrots’ or bargaining sticks to being part of a global
budget scheme, similar to how international agencies, such as the Global Fund, allocate
funds to countries. It is based on robust modeling and evaluation protocols. Only through
an interface with technology and evidence-based management can the financial flows in
the system be used to drive the strategic choices of users, be it as a provider, health center
staff, patients, managers, or decision makers. Only then will the system be efficiently and
equitably managed to ensure affordability and universal coverage. Without innovations,
adoption will be slow, if not resisted.
A key challenge for the information system sector is the provision in the UHC Act’s
implementing rules and regulations, stating that the Department of Health and the Philip-
pine Health Insurance Corporation will be funding the development and upgrading of the
information system software to be utilized by health care providers and insurers, at no cost
(Section 36.3) to them. Several initiatives have been undertaken through the Philippines’
eHealth Agenda framework of 2010. Some of the key players in the pandemic case reporting
systems were from the group. Central systems must be designed with local capacities and
interoperability in mind. Knowledge partnerships have been shown to be critical during
the pandemic, and can only be strengthened with less hierarchical systems.
5. Conclusions
This content assessment study set out to examine the provisions of the new UHC Act
for its intentions and directionality. While the ICC estimates obtained in this study implied
generally good reliability, these results may not be generalized to other populations of
raters, as the raters were not independently sampled but rather fixed in this mixed-effects
model. The educational and professional backgrounds of the raters may have influenced
the consistency of their ratings. While representativeness to the general population may
be unwieldy with the method chosen, the analyses are meant to draw insights into law
making in the health sector and for reflection on implementation design.
Drawing from various viewpoints and levels of technical expertise, a robust content
analysis uncovered tendencies towards centralization. Weak system links were identified
with respect to the health human workforce, financing and information systems, pointing
largely to basic governance issues. The key players in the system, such as local governments
and the private health providers and community groups, which played critical roles during
the pandemic, are cursorily treated. The harmonization of the critical laws affecting the
health workforce and the local government code is in order. The enhancement of devolution
through additional non-earmarked funding for local governments is expected to create
further tensions at implementation, in light of the centralizing tendencies of the new UHC
Act. Weak relationships with local government units, the private sector, and community
group engagements will need reexamination, given their importance in pandemic resilience
and in the networked systems envisioned for UHC. In particular, a re-examination of the
integration approach, in terms of the technical capacities for planning and evidence-based
management in the light of fresh resources, may be in order. Viewing the UHC Act from
the perspective of the pandemic also highlighted leverage areas to include innovations
in governance areas, such as public–private partnerships, improved financing through
provider payments’ reforms, and the smarter allocation of tax-based sources. Contracting
and allocation arrangements can improve the quality and efficiency of decision-making in
the UHC system. An alternative view of contracts and incentives beyond a mere transaction
exchange towards system steering can be examined more empirically and contribute to a
more equitable system.
Author Contributions:
Conceptualization, M.C.G.B. and M.R.J.E.; data curation, N.B.M. and C.P.;
methodology, P.J.A.-C., N.B.M., C.P., Q.S.J. and D.A.V.; formal analysis, M.C.G.B., P.J.A.-C. and
M.R.J.E.; writing—original draft preparation, M.C.G.B.; writing—review and editing, M.C.G.B.,
Int. J. Environ. Res. Public Health 2022,19, 9567 12 of 13
P.J.A.-C., M.R.J.E., V.E.F., M.M.D. and M.V.; funding acquisition, M.C.G.B. and M.R.J.E. All authors
have read and agreed to the published version of the manuscript.
Funding:
This research was funded by the University Research Council (URC), Grant Number
2020-05, of the Ateneo de Manila University.
Institutional Review Board Statement:
The study was conducted in accordance with the Declaration
of Helsinki, and approved by the University Research Ethics Office (UREO) of the Ateneo de Manila
University (December 2019).
Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement:
The data presented in this study are available on request from the
corresponding authors.
Conflicts of Interest: The authors declare no conflict of interest.
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