Pen Point 49

Various provider payment mechanisms will continue to exist in the country’s health care system. Emphasis is placed, however, on the current movement towards using performance-driven, prospective payments (e.g. Global Budget Payment) based on diagnosis-related groups (DRG). The shift to DRG-based GBP will not be easy. Mechanisms should be in place to avoid underprovision and ensure quality health care.

At the end of it all, “mixing” of provider payment mechanisms can be complementary or compensatory. It is promising how incentives will come into play when these mechanisms align themselves during the implementation of the UHC law.

Happy to know that PHIC is now working on this with various agencies. Very few hands on deck though.

NOBODY LEFT BEHIND: THE CHALLENGE OF ENSURING PHILHEALTH COVERAGE AMONG OFWS

EXECUTIVE SUMMARY

In order to reduce the financial uncertainties associated with future illnesses, Overseas Filipino Workers are encouraged to enroll themselves in the national health insurance program. However, not all OFWs are enrolled in the program or are actively paying their premiums. The reasons behind this include limited knowledge about Philhealth and its services. This, coupled with poor health-seeking behaviors, had economic and health consequences making it necessary for the government to intervene.

Philhealth is suffering from low premium collections brought about by a decline in membership among OFWs observed in previous years. Therefore, Philhealth is challenged to identify effective strategies that can improve OFWs’ health-seeking behaviors and access to health insurance.

Some strategies that can be considered include the following:

  • Expansion of the coverage of information, education, and communication campaign
  • Partnerships with government and private agencies to jointly promote public awareness
  • Inventory and system for reproducing, updating, and sharing of customized IEC materials
  • Digital platforms that remotely provide essential services and address learning needs

Investment in these strategies will be required to address information issues. Such investment, however, will require significant political will, support, and financial investment.

INTRODUCTION

The government plays a crucial role in ensuring that Overseas Filipino Workers (OFWs) and their dependents have access to quality health services without experiencing financial hardship. Through Philhealth, OFWs are guaranteed financial risk protection against the financial uncertainties associated with the need to use and pay for health care services.

The establishment of the National Health Insurance Program should have led to a steady increase of OFWs who are enrolled as members of Philhealth. Unfortunately, the opposite is true. In 2016, the premium payments of OFW Philhealth members amounted to only P823 million. This is below the P1.2 billion premium payments collected in the previous year. Such a decline has been attributed to a huge drop in membership among OFWs.1

Education, sex, civil status, income, among others, were identified as significant factors associated with OFWs’ health-seeking behavior, and membership in and access to social health insurance.2 In an attempt to address the problem of declining membership, Philhealth has conducted various strategies to increase awareness and understanding of OFWs on the promising contributions of Philhealth that ensure access to health care without the risk of financial catastrophe.

But even with these strategies, only 3.6 million out of approximately 10 million OFWs are Philhealth members. OFWs paid a total of P1 billion in premiums in 2019, significantly lower than the P1.7 billion in benefit claims that Philhealth paid out to them and their dependents in the same year.3 Therefore, there is an urgent need to look at other measures and/or improve current methods that can effectively deliver health messages and membership-related information to OFWs. Philhealth’s awareness campaign should go beyond the traditional and seek to use more effective strategies that can address the knowledge deficit in target audiences.

POLICY ISSUE

Philhealth is suffering from low premium collections brought about by a decline in membership among OFWs observed in previous years. Various factors have been looked at as possible barriers or facilitators to membership in and access to Philhealth.  In 2017, sociodemographic characteristics (i.e. age, sex, level of education, income, number of children, and having or not having a partner) were found to be associated with health-seeking behaviors and/or OFW membership in Philhealth.2

Information campaigns tend to have a one-size-fits-all design. Limited knowledge of Philheath membership and premiums and poor health-seeking behaviors were found in some subpopulations (e.g. women, individuals with low education, unmarried, young adults). Thus, increasing the need for audience-specific programs. This is challenging for Philhealth because of the range of migrant occupations and diversity of backgrounds of OFWs. These profiles are essential to consider when developing information, education, and communication (IEC) materials.4 

Information is disseminated through limited means. The majority of OFWs get information about Philhealth in pre-departure orientations usually organized by government agencies and private recruitment agencies. It remains unclear whether OFWs acquire the necessary information from these orientation seminars. There have been reports that some agencies do not provide the required seminar but still issue certificates to OFWs.4

Information dissemination lacks coordination among government agencies. In 2015, the POEA stopped collecting OFW Philhealth premium payments which forced Philhealth to market services on its own. Law has also mandated Philhealth to establish overseas satellite offices, or where it is not feasible, designate a focal person in every Philippine Consular Office in all countries where there are Filipino citizens. In 2010, there were only three Philhealth offices abroad.5

Despite efforts to increase awareness among OFWs, Philhealth still fails in effectively delivering its message to the target audience. Thus, membership and premium contributions continue to decline despite government effort to ensure that OFWs and their dependents equally enjoy the promise of universal health care, which is #HealthForAll.

POLICY ALTERNATIVES

To address the issue of declining membership, there is a need to analyze several policy alternatives to increase knowledge and understanding of OFWs of Philhealth programs and services. Some of these alternatives were inspired by the best practices of other government agencies in providing services to OFWs. The proposed alternatives are presented below.

  • Expand the coverage of information, education, and communication campaign with the help of tri-media

There may not be a need to extend the length of orientations. However, expanding coverage should mean including family members in pre-departure orientation seminars. Whether families remain behind or accompany OFWs, there are issues that might need to be addressed during these seminars. Moreover, pre-departure seminars are not the only means to reach OFWs. Print, broadcast (television and radio), and new media (digital and social media) can also be suitable channels for information dissemination. These platforms, however, are less participatory and more expensive.

  • Forge partnerships with government and private agencies to jointly promote public awareness on coverage and benefits for OFWs

Similar to the strategy of several agencies, Philhealth can establish a massive information campaign together with other government agencies that are directly involved in overseas employment. Some examples include the regional information caravans being conducted by OWWA6; comprehensive pre-employment and pre-departure orientation seminars jointly conducted by POEA, OWWA and the Insurance Commission7; and the placement of co-branded promotional displays in airports across the country in partnership with the Bureau of Immigration.8

  • Create an inventory and system for reproducing, updating, and sharing of customized IEC materials

Information campaigns for programs and services can be more effectively delivered when anchored to health risks and consequences. An inventory of customized materials produced by government agencies and NGOs, and a system of reproducing, updating or sharing these materials, can be established. Customized materials should address the learning gaps of target populations to achieve a more targeted approach to information dissemination.

  • Invest in digital platforms to remotely provide essential services and to address the learning needs of OFWs

Technology is evolving and so should the approach in changing how people live, behave, and decide for their health. Philhealth can develop a suite of digital tools that meets user needs and are free at the point of use. A Facebook or website bot that can provide answers to questions in a personal one-to-one way using mobile phones can be considered. Similarly, online learning systems, such as those being developed by the Department of Labor and Employment, can be vital in reaching OFWs with varying learning needs. Finally, a Philhealth member mobile app can be developed to view statements of accounts and pending payments, apply for reimbursements, upload important documents, and electronically pay for due premiums. Mobile apps can make transactions easier in the comfort of members’ homes. 

CONCLUSION AND RECOMMENDATIONS

Based on this analysis, it is recommended for Philhealth to address the policy issue using an integrated approach comprised of all the suggested alternatives. These alternatives are effective communication strategies ensuring better coverage and access to essential information related to Philhealth programs and services. These alternatives have been used by other agencies around the world and have been proven effective in changing the perception and behavior towards health.

To maximize the benefits of the use of these alternatives, it is recommended that Philhealth invests in studies seeking to enumerate other strategies that prospective members find useful and effective. The use of tri-media and technology can inform a larger audience while considering the unique needs of target subpopulations in most need of information. While Philhealth and the national government can appropriate funds for the implementation of these alternatives, local government units can shoulder some of the implementation costs as part of their health promotion activities.

Policy changes in information, education, and communication can have a synergistic effect in terms of increasing awareness or understanding of Philhealth’s programs and services, providing access to these services especially for those working overseas, and improving health-seeking behaviors. Using evidence-based strategies to address information needs, and thereby increase Philhealth membership, ensures that in our journey to universal health care nobody is left behind.

REFERENCES:

1 Why is there a steep decline in OFW contributions to PhilHealth? – The Manila Times. (2020). The Manila Times. Retrieved 28 May 2020, from https://www.manilatimes.net/2017/03/27/opinion/analysis/steep-decline-ofw-contributions-philhealth/319359/

2 Jabar, M. A. (2019). Factors influencing health-seeking behavior among overseas Filipino workers. International Journal of Healthcare Management, 1-13.

3 Yee, J. (2020). PhilHealth to hike premium rates starting next yearNewsinfo.inquirer.net. Retrieved 28 May 2020, from https://newsinfo.inquirer.net/1177046/philhealth-to-hike-premium-rates-starting-next-year

4 Asis, M., & Agunias, D. R. (2012). Strengthening pre-departure orientation programmes in Indonesia, Nepal and the Philippines. International Organization for Migration and Migration Policy Institute.

5 Philhealth Advisory No. 11-02-2010. Philhealth.gov.ph. Retrieved 28 May 2020, from https://www.philhealth.gov.ph/advisories/2010/adv11-02-2010.pdf

6 OWWA holds reintegration info caravan, membership campaign. (2019). Pia.gov.ph. Retrieved 28 May 2020, from https://pia.gov.ph/news/articles/1029385

7 Pre-departure awareness on insurance benefits for OFWs set | Department of Labor and Employment. (2017). Dole.gov.ph. Retrieved 28 May 2020, from https://www.dole.gov.ph/news/pre-departure-awareness-on-insurance-benefits-for-ofws-set/

8 Pag-IBIG and Bureau of Immigration join hands to promote OFW membership – ADFIAP. (2015). ADFIAP. Retrieved 28 May 2020, from http://www.adfiap.org/news/members-news/pag-ibig-and-bureau-of-immigration-join-hands-to-promote-ofw-membership/

Unpaved road to UHC

Almost every day I see patients (or their relatives) looking for stretcher beds as there are no longer available beds in the emergency room. This scenario, I suppose, will persist even when hospital renovations are finished this year. While increasing the hospital’s bed capacity potentially decreases waiting time for patients, no amount of beds will ever suffice. The neverending influx of patients in the Philippine General Hospital is a result of the increasing demand for health care among poor Filipinos amidst rising health care costs. The same is true, or even worse, for other government hospitals.

PGH is a microcosm of the Philippine health care system. Our experiences in this hospital mirror big challenges that the country will continue to face while implementing the universal health care law. First, poor gatekeeping at the primary care levels will allow patients to seek care at higher level facilities even when lower level facilities are capable of handling their medical conditions. This, coupled with patients’ poor confidence of primary care health workers, encourage them to flock in tertiary level facilities which results in overcrowding.

Second, chronic lack of manpower and other resources delay necessary care. Patient waiting time is high for common radiologic procedures (e.g. x-ray, ultrasound) because there are only few machines available for hundreds of patients. Nurses, faced with high patient workload, leave out essential care elements to meet only the urgent physiologic needs of their patients. Our study on nursing care rationing in PGH showed that 45% of nurses kept a patient who rung for a nurse waiting longer than five minutes. More than half of respondents disagree that there are enough nurses to get the job done or to provide quality care. More than half of nurses also reported a physician did not come or took a long time to arrive after a call.

These are few of the challenges that patients and health care workers in PGH continue to face. While we strive to be a model of health care delivery, our current set up is far from what we all have dreamed of – a hospital that transforms lives through excellent care, education and research. I cannot imagine how other hospitals and health workers deal with poorer work conditions.

The road to UHC is quite long. PGH is a reflection of the government’s failure to adequately lay concrete interventions that will make our journey smooth. Gatekeeping at the primary care level and provision of adequate human resources for health are two key elements that will drive the realization of universal health care.