scholarly journals Policy Analysis on Financing Roles for Population- and Individual-based Health Services in Light of the Universal Health Care Act

2020 ◽  
Vol 54 (6) ◽  
Author(s):  
Leonardo R. Estacio, Jr. ◽  
Christine Mae S. Avila ◽  
Ma-Ann M. Zarsuelo ◽  
Ma. Esmeralda C. Silva ◽  
Michael Antonio F. Mendoza ◽  
...  
Keyword(s):  
Systematic Review ◽  
Health Care ◽  
Health Services ◽  
Policy Issue ◽  
Population Based ◽  
The Philippines ◽  
Universal Health Care ◽  
Health Board ◽  
Health Maintenance ◽  
Universal Health

Objectives. The health financing scheme brought by the Universal Health Care Act has a significant change in the landscape of allocating funds for health services, as well as in the delineation of roles among the key actors. Consistent with the law, the protection from the health financial risks of Filipinos must be guaranteed. This study aimed to determine the roles of the government and other key agencies in financing population-based and individual-based health services in the Philippines. Methods. A systematic review of literature was done to generate evidence for the policy brief and proposed policy alternatives. The UP Manila Health Policy Development Hub organized a roundtable discussion in collaboration with the Department of Health participated by key stakeholders from various sectors involved in the policy issue. Systematic review and insights from the discussion were analyzed to produce consensus policy recommendations. Results. Given the current procurement and financing, the DOH should fund population-based services while PhilHealth, with the assistance of Health Maintenance Organizations (HMO) for premium holders, should fund individual-based services. Health programs with grey areas (i.e. with both individual- and population-based services) need further technical discussions. It is imperative to have clear-cut specific guidelines on the managerial and financial roles of the provincial health board and the scope of financing service delivery. Conclusion. Delineating the roles of DOH, PhilHealth, and HMOs in financing health services is not without risks. The utilization of the special health fund at the provincial level should be carefully implemented and monitored to minimize inefficiencies and fraud.

scholarly journals Policy Analysis on Establishing Criteria for Population versus Individual-based Health Services towards Achieving Universal Health Care

2020 ◽  
Vol 54 (6) ◽  
Author(s):  
Leonardo R. Estacio Jr. ◽  
Ma-Ann M. Zarsuelo ◽  
Christine Mae S. Avila ◽  
Ma. Esmeralda C. Silva ◽  
Michael Antonio F. Mendoza ◽  
...  
Keyword(s):  
Health Care ◽  
Health Services ◽  
Service Delivery ◽  
Policy Development ◽  
Supply And Demand ◽  
Policy Issue ◽  
Population Based ◽  
The Philippines ◽  
Universal Health Care ◽  
Universal Health

Background. The enactment of the Universal Health Care Act is anticipated to bring wider coverage and accessibility of quality healthcare services as stipulated in its objectives. With the integration of the healthcare system at the provincial level, determining population- and individual-based services is crucial in mapping the managerial and financial roles. Hence, this study aimed to establish the criteria for identifying population-based and individual-based health services in the Philippines. Methods. A systematic review of literature was conducted to generate evidence for the policy brief and discussion points on the roundtable discussion spearheaded by the UP Manila Health Policy Development Hub in collaboration with the Department of Health. Key stakeholders of the policy issue convened to share expertise and insights in determining criteria for population- and individual-based services, intending to generate consensus policy recommendations. Results. The general scope of individual-based health services stipulated in the Law are to be financed under the benefit packages of PHIC and HMOs. Meanwhile, population-based services are those that address public health issues such as health promotion and disease surveillance. Several services considered as ‘grey areas’ are those that fall in the overlap of the individual- and population-based services. These services may be examined through an outcome-based algorithm that examines fragmentation issues both in the supply and demand side of service delivery. Conclusion and Recommendation. Proposed criteria in identifying individual- and population-based services include the number of recipient/s, the effectivity of service delivery and utilization, and source of funding. Health programs that are in the grey areas can be examined through an outcome-based algorithm.

scholarly journals Policy Analysis on Identifying Copayment Services for the Shift in Financing Scheme of Health Care Services

2020 ◽  
Vol 54 (6) ◽  
Author(s):  
Hilton Y. Lam ◽  
Ma-Ann M. Zarsuelo ◽  
Katrina Loren R. Rey ◽  
Ma. Esmeralda C. Silva ◽  
Michael Antonio F. Mendoza ◽  
...  
Keyword(s):  
Systematic Review ◽  
Health Care ◽  
Health Services ◽  
Policy Development ◽  
Clinical Pathways ◽  
Policy Issue ◽  
The Philippines ◽  
Health Coverage ◽  
Review Of Literature ◽  
Universal Health

Background. As the Philippines moves toward universal health coverage, it is imperative to examine how to eliminate inefficiencies, particularly misuse, overutilization, and risks of fraudulent claims. This position statement aimed to identify health services requiring copayments for cost-efficient health financing for the Universal Health Care Act. Methods. A qualitative study was employed using a systematic review of literature, and thematic analysis of policy roundtable discussion (RTD) was conducted. The systematic review of literature generated evidence for the policy brief and critical points for discussion in the stakeholders’ RTD forum. The RTD was organized by the UP Manila Health Policy Development Hub (UPM HPDH) with the Department of Health (DOH) and was participated by key stakeholders of the policy issue to attain consensus recommendations and develop criteria for identifying services requiring copayments. Results. An algorithm is proposed by the UPM HPDH based on collective expertise as a guide for policymakers to assess each benefit package in terms of overutilization, the danger of depleting government funds, and the risk of fraud. The use of clinical pathways is suggested to assess the misuse and overutilization of health services. In addition to copayments, benefits packages prone to fraudulent activities should be subjected to fraud prevention processes. Copayment should be linked inversely to the preventability level of the disease or condition. Conclusion. There were gaps in the current policies to identify services requiring copayment services. Copayment schemes should be carefully determined to prevent misuse, overuse, and fraud of appropriate and necessary health services, while at the same time not limit access to needed care.

scholarly journals A Call for an Evidence-informed Criteria Selection to Guide Equitable Health Investments in the Era of Universal Health Care: Policy Analysis

2020 ◽  
Vol 54 (6) ◽  
Author(s):  
Ma. Esmeralda C. Silva ◽  
Ma-Ann M. Zarsuelo ◽  
Marianne Joy N. Naria-Maritana ◽  
Zenith D. Zordilla ◽  
Hilton Y. Lam ◽  
...  
Keyword(s):  
Health Care ◽  
Health Services ◽  
The Philippines ◽  
Population Characteristics ◽  
Integrated Analysis ◽  
Universal Health Care ◽  
Investment Planning ◽  
Geographic Population ◽  
Health Investments ◽  
Universal Health

Background. The passage of the Universal Health Care (UHC) Act in the Philippines in early 2019 intensified the need to ensure equitable health investments by the government. Exploring the different criteria and indicators that are used to determine areas that are most in need of health services can help local and national health authorities determine priorities for health investments given finite resources. Methods. A systematic review of literature on determinants of health equity and other indicators was conducted as pre-work to generate discussion points to the roundtable discussion participated by all major key stakeholders. Shared insights and expertise were thematically analyzed to produce a policy paper with consensus policy recommendations. Results. Based on the review of the literature and the discussion, indicators (mainly physical inaccessibility and socio-economic factors) for identifying Geographically Isolated and Disadvantaged Areas (GIDA) in DOH Administrative Order 185, s. 2004 is used to prioritize municipalities for health investments. Review of other policies and guidelines to determine the level of health needs and prioritizing investments yielded to four laddered domains: geographic, population characteristics (e.g., social and cultural determinants of access), health system (e.g., health service delivery), and health status. These domains may provide a more equitable set of metrics for health investment. The Local Investment Plan for Health (LIPH) is the current process used for health-related investments at the local level and may be revised to be more responsive to the requirements set by the UHC Act 2018. Hot spotting to concentrate health services by communities may be a more rapid approach to investment planning for health. Bed capacity as a specific metric in the UHC Act 2018 highlights the need for a review of the Hospital Licensure Act 2004. Conclusion and Recommendations. To aid in determining priorities for health investments, a comprehensive integrated analysis of resources, determinants, and indicators should be done to determine the need and the gaps in the available resources. Innovative strategies can also be best implemented such as mathematical models or formulas. Lastly, current strategies in the development, monitoring, and evaluation of investment planning for health at different levels should be strengthened, expanded, and harmonized with other existing development plans.

scholarly journals Identifying Possible Gaps and Gray Areas in the Draft Universal Health Care Act Implementing Rules and Regulations: a Thematic Analysis of a Roundtable Event on Local Health Systems

2020 ◽  
Vol 54 (6) ◽  
Author(s):  
Theo Prudencio Juhani Z. Capeding ◽  
Ma-Ann M. Zarsuelo ◽  
Michael Antonio F. Mendoza ◽  
Ma. Esmeralda C. Silva ◽  
Leonardo R. Estacio Jr.
Keyword(s):  
Health Care ◽  
Health Systems ◽  
Thematic Analysis ◽  
The Philippines ◽  
Universal Health Care ◽  
Health Board ◽  
Local Health ◽  
Department Of Health ◽  
Gray Areas ◽  
Universal Health

Background. The Universal Health Care (UHC) Act is a landmark legislation that seeks to improve provision ofcomprehensive health services through the integration of local health systems. The Department of Health (DOH)conducted a series of roundtable discussions to gather stakeholders' inputs and concerns to refine the initial draftof the Implementing Rules and Regulations (IRR) of UHC. Methods. On April 4, 2019, the Department of Health led a roundtable discussion on the Local Health Systemssections of the UHC IRR in collaboration with University of the Philippines Manila. A total of 65 stakeholders fromdifferent sectors participated in a semi-structured roundtable event. The proceedings were audio recorded andtranscribed. A thematic analysis was done using NVivo 12 software to document gaps and gray areas identifiedby the participants. Results. Concerns of the participants revolved around the following: role of the private sector in local health systems;the integration of different municipal and other component health systems into a province-wide health system;organizational design of the health systems; pooling and utilization of the Special Health Fund (SHF). Gaps andgray areas were concentrated on the transfer of personnel and other health resources to the province-wide system,the composition of the Provincial Health Board, and the utilization and management of the SHF. Conclusion. The roundtable event acquired various perspectives from stakeholders that could help the DOH identifypriority action points that could be resolved at the agency level. The identified themes from the study analysis couldbe of value to decision makers to clarify issues, address policy gaps, and to prioritize future research directions.

scholarly journals Policy Analysis on Determining Hospital Bed Capacity in Light of Universal Health Care

2020 ◽  
Vol 54 (6) ◽  
Author(s):  
Ma. Esmeralda C. Silva ◽  
Ma-Ann M. Zarsuelo ◽  
Marianne Joy N. Naria-Maritana ◽  
Zenith D. Zordilla ◽  
Hilton Y. Lam ◽  
...  
Keyword(s):  
Health Care ◽  
Health Service ◽  
Policy Issue ◽  
Health Service Delivery ◽  
The Philippines ◽  
Universal Health Care ◽  
Catchment Population ◽  
Hospital Bed ◽  
Bed Capacity ◽  
Universal Health

Background. Through the years of improving quality health service delivery, hospital bed capacity in the Philippines has remained to be a persistent challenge. In light of the aim of the Universal Health Care Act to protect and promote the right to health of every Filipino, one metric used to identify areas that are in most need or are under served, is the number of public hospital beds vis a vis the catchment population. Methods. The systematic review of literature was utilized to generate a policy brief presented to the invited stakeholders of the policy issue for the roundtable discussion participated by all key stakeholders of the policy issue. Evidence and insights were thematically analyzed to generate consensus policy recommendations. Results. With the current hospital bed availability and maldistribution, the Philippines still faces compounded issues in addressing healthcare demands. Currently, the request for increasing bed capacity is done through legislation. In context, this request is also parallel in expanding service capacity through the allocation of more funds and personnel. The ratio of private and charity beds must ensure to have equity among all patients of varying segments of the population. Enjoining private hospitals to share bed capacity for public service was also explored given appropriate subsidies. Conclusion and Recommendation. To ensure equity in health service delivery, it is imperative to assess, strategize, and conduct prioritization of the needs of government hospitals for increased bed capacity, considering the distribution, socio-demographic profile, and health needs of the catchment population.

scholarly journals Development on Third Party Accreditation of Healthcare Facilities in Light of the Universal Health Care Act: Policy Analysis

2020 ◽  
Vol 54 (6) ◽  
Author(s):  
Michael Antonio F. Mendoza ◽  
Ma-Ann M. Zarsuelo ◽  
Gabriel R. Borlongan ◽  
Ma. Esmeralda C. Silva ◽  
Hilton Y. Lam ◽  
...  
Keyword(s):  
Health Care ◽  
Literature Review ◽  
Policy Analysis ◽  
Policy Issue ◽  
National Health System ◽  
Development Program ◽  
The Philippines ◽  
Third Party ◽  
Universal Health Care ◽  
Universal Health

Background. The Universal Health Care (UHC) Act seeks to delineate the roles of key agencies and stakeholders towards equity in access to quality and affordable health care. Under the pillar of health regulation, the Philippine Health Insurance Corporation is mandated to recognize third party accreditation mechanisms as a basis for granting incentives to health facilities that provide better service quality, efficiency, and equity. Methods. A systematic review of literature was conducted to generate a policy brief that outlined the strengths and weaknesses of the current accreditation system, and how to address arising fragmentation issues in implementation based on international and local evidence. To generate recommendations from a multi-stakeholder approach, a roundtable discussion enjoined by all major stakeholders of the policy issue was conducted by the University of the Philippines Manila Health Policy Development Hub in collaboration with the Department of Health. Thematic analysis of the RTD and the literature review were utilized in crafting the position statement with the general aim of producing consensus policy recommendations, as inputs in the Implementing Rules and Regulations of the Act. Results. Policy analysis using results of literature review and policy discussion was crafted, with thematically arranged recommendations in the domains of leadership and governance, financing and sustainability, standards development, program development, and continuing quality improvement that could help the national health system in determining third party accreditation mechanisms set forth by the UHC Act. Significant issues raised was the composition and requirements of the third party accreditor and the risks in transition. Conclusion and Recommendation. With the PhilHealth Benchbook setting the standards and with the expressed commitment of stakeholders for third party accreditation, it is an opportune time for the UHC Act to institutionalize the accreditation mechanisms that will address existing challenges of PhilHealth accreditation. The literature review and discussion bring forth the proposed tool for the criteria in selecting third party accreditors.

BPJS Kesehatan Memberikan Jaminan Kesehatan Terhadap Pasien Atau Masyarakat

2021 ◽  
Vol 7 (2) ◽  
pp. 146-154
Author(s):  
Aidha Puteri Mustikasari
Keyword(s):  
Health Care ◽  
Health Insurance ◽  
Health Services ◽  
Social Security ◽  
The State ◽  
Universal Health Care ◽  
Universal Health Insurance ◽  
Universal Health ◽  
Provide Health Insurance

Abstrak. Kepesertaan BPJS Kesehatan pada tahun 2020 tidak akan mencakup 90% penduduk Indonesia, namun rencana Universal Health Care Implementation (UHC) telah direncanakan sejak tahun sebelumnya. Di masa pandemi Covid, sejumlah besar status kepesertaan BPJS Kesehatan  dicabut karena terlambat, padahal masyarakat membutuhkan layanan kesehatan dan asuransi dengan kondisi yang ada. Kajian ini bersifat norma deskriptif , dibahas dalam konteks kepesertaan BPJS kesehatan, dan cukup  menggunakan prinsip asuransi dengan hanya memberikan jaminan kepada peserta, tetapi negara mengikuti kewajiban UUD 1945 yaitu memberikan jaminan kesehatan dan pelayanan kepada warga negara. Untuk mendukung keberadaan jaminan kesehatan universal, Indonesia perlu menerapkan formulir kepesertaan dan  sanksi untuk ketentuan wajib  peserta jaminan sosial yang efektif dan efisien. Abstract. BPJS Health membership in 2020 will not cover 90% of Indonesia's population, but the Universal Health Care Implementation (UHC) plan has been planned since the previous year. During the Covid pandemic, a large number of BPJS Health membership statuses were revoked because they were late, even though people needed health services and insurance with the existing conditions. This study is descriptive in nature, discussed in the context of BPJS health participation, and it is sufficient to use the insurance principle by only providing guarantees to participants, but the state follows the obligations of the 1945 Constitution, namely to provide health insurance and services to citizens. To support the existence of universal health insurance, Indonesia needs to implement an effective and efficient membership form and sanctions for mandatory provisions for social security participants.

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