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Immunization is universally recognized as one of the most cost-effective public health interventions, yet low investment in immunization programs and variable vaccination coverage rates suggest that something else might be going on behind the scenes. Why is investment in immunization not as strong and sustainable as possible, even in settings where resources are generally available? As the world continues to grapple with the COVID-19 pandemic and to recover routine vaccination rates, policy solutions for sustaining immunization financing are more important and more pressing than ever.

Join ThinkWell for our second Counterpoint webinar “Sustainable Immunization Financing: Investing in Prevention to Secure Healthy Communities” on September 15 at 8:00 AM EST as we debate the issues that immunization programs face in securing and sustaining the resources they need to be able to deliver high-performing prevention services.

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We have invited an exciting group of experts to help explore and dig into the issues behind decisions that influence financing for immunization. Even in high and middle-income settings—immunization programs are not always prioritized by policymakers and those who advise them. Our debaters will reveal and discuss the hard truths about how and why sufficient public funding does not always materialize, despite generally widespread belief in the value of vaccines.

Moderator:

  • Margaret Cornelius, Senior Technical Advisor, Private Sector, ThinkWell

Panelists:

  • Stefan Swartling Peterson, MD, MPH, PhD, Professor of Global Transformations for Health, Karolinska Institutet, Sweden
  • Eduardo P. Banzon, Principal Health Specialist, Southeast Asia Regional Department, Asian Development Bank
  • Ulla Kou Griffiths, Senior Advisor, UNICEF USA and Honorary Associate Professor, London School of Hygiene & Tropical Medicine
  • Catherine Goode, Goode Strategies

We hope you will join our debate as we push the frontier of thinking and discuss creative ways that countries can secure the health of their citizens by investing in strong and sustainably financed immunization programs. We invite you to share your questions and thoughts prior to and during the webinar!

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ThinkWell seeks to improve sustainable immunization financing in countries across the globe. Whether public immunization programs 1) do not have the funding required to sustain and expand their immunization schedules to respond to public health needs or 2) do not have financing structures that optimize immunization outcomes, every country can work to improve immunization financing. This webinar is part of a project that is supported by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, New Jersey USA.

 

 

 

 

This piece originally appeared in P4H here. It was written by Christian Edward Nuevo, Maria Eufemia Yap, Matt Boxshall, and Nirmala Ravishankar. 

Primary health care (PHC), first introduced through the Alma Ata Declaration of 1978, emphasizes that addressing health needs should be people-centered and multi-sectoral in approach. The recently passed Universal Health Care (UHC) Law in the Philippines puts PHC center stage through reforms aimed to improve health system performance. While the vision is laudable, making it happen is challenging. This article offers early learnings from the implementation of the UHC Law drawn from ThinkWell Philippines’ program of technical assistance and policy research to support the Department of Health (DOH) and the Philippine Health Insurance Corporation (PhilHealth)¹. We identified key opportunities and challenges created by the UHC Law against the three main pillars of strengthening PHC [1]. The UHC vision will have to be progressively realized through paradigm shifts, communication interventions, and a clear and strategic roll out plan.

Philippine Health Sector Reform: The UHC Law

Health sector reform in the Philippines has been accelerated by the passage of Republic Act 11223, more commonly known as the UHC Law [2]. This landmark piece of legislation seeks to revitalize health care through a whole-of-system, whole-of-government, whole-of-society, people-centered approach. It recognizes that health systems are naturally complex, dynamic, and adaptive. The legislation acknowledges that improving health system performance requires sustainable, wholesale changes [3]. The pillars of PHC underpin the entire UHC reform [1][2].

PHC and the UHC Law

The 2030 Agenda for Sustainable Development as well as other landmark resolutions [4] all champion the crucial role of PHC in achieving responsive and resilient country health systems [5]. The UHC Law is anchored on the three main pillars of PHC [6] in the following way:

  • Primary care and essential public health functions as the core of integrated health services: The UHC Law seeks to re-integrate the Philippines’ highly devolved governance system into province-wide health systems. These integrated provincial health systems promise more efficient use of resources and delivery of comprehensive care. Providers are encouraged to consolidate into health care provider networks, capable of delivering a range of services, grounded on a strong primary care base. PhilHealth is expanding its currently limited primary care benefit to a new package called “Konsulta”², with expanded rates and service inclusions, accessible to all membership types. Health care provider networks will be contracted by PhilHealth as one entity, aligning their incentives and accountabilities, and promoting continuity of care.Regrettably, the law does not mandate this re-integration. Resistance to change, and politics of intervening laws such as the Local Government Code stand in the way. Municipal mayors stand to lose authority over their health spending, personnel, and resources, and will only influence these as a member of the health board. Adequacy and supply-side readiness of health facilities, as well as financial constraints and the sustainability of PhilHealth are still prevailing realities [7][8][9].
  • Empowered people and communities: With the UHC Law, all Filipinos are automatically members of PhilHealth, and are immediately entitled to benefits. Families and households are also given the freedom to choose the primary care provider they prefer and trust. Patient involvement in key decision areas is enhanced through representation in the Health Technology Assessment Committee that decides on benefit inclusions, and in the provincial health board that develops and monitors the province health plan.These opportunities for patients to directly influence matters concerning their own health contribute to a system that is truly responsive. However, patient knowledge is coming from a rather weak base. Data shows that for PhilHealth covered indigent families, only 53% knew of their entitlement for no balance billing, and around 39.6% are misinformed of their sponsorship [8]. This and other knowledge gaps present real challenges in affording people genuine participation even in institutionalized processes.
  • Multi-sectoral policy action: The UHC Law mandates the institutionalization of cooperative intergovernmental decision-making and implementation, particularly on areas such as health impact assessment, health professional education, and monitoring and evaluation of health system performance. The private sector is also enjoined to respond to service delivery needs as health care provider networks, and to generate evidence together with the academe through data sharing and commissioning of relevant health policy and systems studies.Through these more inclusive and regular stakeholder engagement processes, strategic complementation with partners within and outside government is encouraged. Still, differences in perspectives and interests are among the greatest hurdles that affect cooperation and resource allocation. For one, adequacy of PhilHealth benefit package rates are continuously criticized [10], particularly by for-profit private facilities that do not enjoy the government subsidy afforded to public facilities. Even between government units, changes in processes meant to improve efficiency of one agency, may result to negative effects for another. When the Department of Budget and Management (DBM) transitioned to a new budgeting mechanism, it resulted to a 28% decrease in DOH appropriation from 2018 to 2019 [11].

Key areas for priority action

One of the biggest prerequisites in this reform process is a shift in governance paradigms. The UHC reform requires provincial governments to be more accountable for care of their constituents and management of their health systems. They must reduce dependence on current national government support on personnel deployment, commodities, and infrastructure investments. Provincial governments must work to contextualize the benefits of integrating into province-wide health systems and health care provider networks, and rally support from people and providers within their jurisdiction. Central offices, on the other hand, should pivot back to their role of being technical stewards of the health sector, crafting strong policies, standards, and regulatory thrusts. These transitions from old to new ways need to be championed by the Department of Health, generating buy-in from other government agencies to ensure a genuine whole-of-government approach.

As new policies and guidelines are formulated, strong communication and promotion interventions must be pursued by both the national and local governments. Patients need to be informed of all their entitlements, and the merits of living healthy lifestyles. Likewise, health care providers must understand the need for instituting strong gatekeeping mechanisms and facilitating synergistic relationships between primary and specialty practitioners. By engaging various stakeholders and communicating a compelling value proposition, key players will better understand their respective roles, leading to greater alignment with the UHC agenda.

Finally, a clear, strategic, year-on-year rollout chronology towards achieving the vision for UHC should be laid out in a transparent manner. Sequencing of reforms should start with generating clear demand for primary care through patient empowerment and incentive schemes for providers. This can drive the necessary motivation for the public sector to build capacity, and similarly attract the private sector to participate and coordinate. By committing to a clear plan of action, the Philippines DOH can build confidence amongst all stakeholders, public and private, local and national, and across government. Clarity of vision will be essential to deliver on the promise of UHC in the Philippines.

¹ These activities are part of the Strategic Purchasing for Primary Health Care project supported by the Bill & Melinda Gates Foundation and implemented by ThinkWell. For more information, please visit our website. For questions, please write to us at sp4phc@thinkwell.global.

² An expanded primary care benefit package known as PhilHealth Konsulta (PhilHealth Konsultasyong Sulit at Tama) to cover all Filipinos and to ensure access to essential, preventive, promotive, and curative services.

References

  1. World Health Organization. 2019. Primary health care towards universal health coverage. In: Seventy-second World Health Assembly, 1 April 2019. Geneva: World Health Organization. Available from: https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_12-en.pdf [cited 2020 Feb 08].
  2. Republic of the Philippines. 2019. Republic Act 11223. An Act Instituting Universal Health Care for All Filipinos, Prescribing Reforms in the Health Care System, and Appropriating Funds Therefor.
  3. Fattore G, Tediosi F. 2013. The Importance of Values in Shaping How Health Systems Governance and Management Can Support Universal Health Coverage. Elsevier: Value in Health 16, S19-S23. http://dx.doi.org/10.1016/j.jval.2012.10.008
  4. 2012 UN Resolution on Universal Health Coverage, 2018 Declaration of Astana, 2019 World Health Assembly
  5. World Health Organization. 1978. Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR.
  6. Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, et al. 2018. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health. 11;6(11):e1196–252. http://dx.doi.org/10.1016/S2214-109X(18)30386-3 pmid: 30196093
  7. Bredenkamp C, Gomez V, Bales S. 2017. Pooling Health Risks to Protect People: An Assessment of Health Insurance Coverage in the Philippines.
  8. Dayrit MM, Lagrada LP, Picazo OF, Pons MC, Villaverde MC. 2018. The Philippines Health System Review. Vol. 8 No. 2. New Delhi: World Health Organization, Regional Office for SouthEast Asia. Available from: http://apps.searo.who.int/PDS_DOCS/B5438.pdf [cited 2020 Feb 10].
  9. Romualdez JR, Rosa J, Flavier J, Quimbo S, Hartigan-Go K, Lagrada L, et al. 2011. The Philippines Health System Review. Vol. 1 No. 2. Manila: World Health organization, Regional Office for the Western Pacific.
  10. Picazo OF et al. 2015. A Critical Analysis of Purchasing of Health Services in the Philippines: A Case Study of PhilHealth. Philippine Institute for Development Studies. Discussion Paper Series No 2015-54.
  11. Department of Health. 2019. Budget Briefer FY 2019. Health Policy Development and Planning Bureau. Available from: https://www.doh.gov.ph/publication/serials/2019-Budget-Briefer [cited 2020 Feb 10].

This piece originally appeared in P4H here. It was written by Dredge, R., Nuevo, C. E., and Paterno, A. R.

The Philippine Universal Health Care (UHC) Law of 2019 introduced system-level reforms on health financing, particularly for the provider payment mechanisms of the Philippine Health Insurance Corporation (PhilHealth). PhilHealth is the implementer of the National Health Insurance Program, with the goal of ensuring financial risk protection for all Filipinos when accessing the health care they need. The recently passed Philippine UHC Law aims to revitalize and strengthen PhilHealth as part of the overall agenda of health systems reform. In order to become the national strategic purchaser of health services, PhilHealth plans to shift its provider payment mechanism towards a blend of diagnosis-related groups (DRGs) and prospective global budget payments, supported by proper costing methodologies and explicit co-payment rules. Primary care is also a key area of focus – the development of a comprehensive outpatient benefit package will have gatekeeping and patient navigation features to integrate care across a contracted network of health care providers. Through these provider payment reforms, PhilHealth aims to improve cost-effective purchasing of health services that would lead to better health outcomes.

These complex and interlinked reforms require careful coordination across several policy strands and it is essential that they coordinate their research, data, technical and policies activities to facilitate true integrated care. Costing, DRGs, global budget payment, primary care, and co-payments all work together as distinct but complementary portfolios of the provider payment reform. This scale of policy reform has not been pursued in recent years by PhilHealth. In fact, previous reforms of provider payment (such as bundled payments for outpatient and catastrophic conditions, or the shift from fee-for-service to the case-based payments through the All Case Rates) were introduced separately and individually. Simultaneously setting into motion changes across different and interconnected facets of provider payment requires significant technical work, analysis, and policy development, as well as coordination with internal and external stakeholders. Understandably, this presents a formidable challenge for PhilHealth, and much help is needed to carry things forward.

At the same time as stewarding these reforms, PhilHealth has to contend with daily operational matters, including persisting issues of the prevailing payment system. PhilHealth has faced heavy criticism over the years for inefficient payment mechanisms, inadequate package rates, lack of transparency, and even poor technical capacity to fulfill its function. This has derailed the full materialization of its mandate to ensure financial risk protection. In 2019, the share of PhilHealth in the current health expenditure (CHE) of the country remains low at only 18.8%, while out-of-pocket spending continues to be the primary source of financing at 47.9% of CHE. While the UHC Law provides the policy direction to revitalize PhilHealth’s financing mechanisms, this will not happen immediately. The current system must still be developed, and its challenges and shortfalls demand attention.

ThinkWell provided support to PhilHealth in the form of learning sessions that allowed technical teams and senior figures from many stakeholders to be introduced to global best practices, and to discuss ongoing work with subject matter experts. These one-and-a-half hour learning sessions were either of two platforms: 1) conceptual discussion with PhilHealth on provider payment and global best practices which would aid the reforms; or 2) a policy consultation for PhilHealth where they present and solicit feedback on ongoing analytics and draft policies on the provider payment reforms. Though the nature and subject of each session varied, the main objective remains the same: to provide a platform for technical discourse to allow PhilHealth to benchmark and review their current courses of action and policy directions with that of global best practices. A total of around 60 technical staff at the central and regional offices, as well as representatives from senior management (Senior Managers; Regional and Senior Vice Presidents) participated in the sessions that resulted in holistic discussions touching on high-level policy questions, as well as operational and implementation considerations.

The learning sessions served as an avenue to brainstorm and assess policy and implementation options for provider payment, and were documented through technical briefs that are later on summarized in a monograph. All technical insights which arose from the discussions were documented and developed into post-session technical briefs and disseminated to all participants. A monograph that assembles all key concepts, discussion points, and learning insights was also put together as the final product, intended to be a resource containing key concepts on health financing, specifically in the context of the Philippine health care system. The full monograph can be accessed here. This monograph will allow PhilHealth to have a continuing reference for all future actions and policies on provider payment reforms.
The learning sessions resulted in positive outcomes and concrete actions adopted by PhilHealth through their official activities and policy drafts. These include (1) conduct of stakeholder consultation and results dissemination with pilot health care provider on the costing framework and methodology, (2) early linking of the anticipated costing results with the development of the DRGs and co-payments, (3) implementation of facility-based global budget payment as an interim strategy prior to full contracting of health care provider networks, (4) blended payments as either interim or final payment designs, and (5) designing of global budget mechanism supported by clear end-goals and governance mechanisms to facilitate the transition. These actions taken by PhilHealth highlight the immediate value and impact of the insights generated during the learning sessions.

References

  1. Cabalfin MR. 2016. “Health Financing for the Poor in the Philippines: Final Report,” Discussion Papers DP 2016-37, Philippine Institute for Development Studies.

  2. Congress of the Philippines. 1995. Republic Act No. 7875. An Act Instituting A National Health Insurance Program For All Filipinos And Establishing the Philippine Health Insurance Corporation for the Purpose.

  3. Congress of the Philippines. 2012. Republic Act No. 10606. An Act Amending Republic Act No. 7875, Otherwise Known as the “National Health Insurance Act of 1995”, As Amended, And For Other Purposes.

  4. Congress of the Philippines. 2019. Republic Act No. 11223. An Act Instituting Universal Health Care for All Filipinos, Prescribing Reforms in the Health Care System, and Appropriating Funds Therefor.

  5. Picazo OF, Ulep VGT, Pantig IM, and Ho BL. 2015. A Critical Analysis of Purchasing of Health Services in the Philippines: A Case Study of PhilHealth. Philippine Institute for Development Studies.

  6. Philippine Statistics Authority. 2020. Health Spending Grew by 10.9 Percent in 2019. https://psa.gov.ph/pnha-press-release/node/163258. Accessed Apr 2021.

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