The Philippines: Strategic purchasing strategies and early results

THE PHILIPPINES COUNTRY TEAM JANUARY 2020 PROJECT OVERVIEW

•An investment by the Bill & Melinda Gates Foundation (BMGF) implemented by ThinkWell SP4PHC with country learning partners •Project duration from 2017 to 2022

•Leverage strategic purchasing to improve primary healthcare (PHC) delivery in 5 countries, with a focus on family planning (FP) and maternal, newborn and child health (MNCH) Our Goal •Facilitate learning on strategic purchasing for PHC, FP and MNCH -- and the application of that learning to policy and practice -- at the national and global levels

Burkina Faso The Philippines Indonesia Uganda

Kenya

2 PROJECT INCEPTION TO IMPLEMENTATION

EXPLORING LANDSCAPE DESIGN STRATEGIES COUNTY-LED In each country, We developed project IMPLEMENTATION ThinkWell conducted a strategies based on an We commenced rapid review of the understanding of implementation landscape, meeting with current challenges and following agreement a range of stakeholders critical opportunities with country and partners to with respect to strategic stakeholders and BMGF. understand the context. purchasing for PHC, FP and MNCH.

3 OUR APPROACH TO IMPLEMENTING THE SP4PHC PROJECT

Country-based support

Build local teams to Analytics support purchasing reforms Engage local research Policy dialogue organizations to Facilitate discussions Testing solutions undertake targeted between key Where appropriate, analytics Co-design, test, and embed technical stakeholders to advocate for adoption experts within key identify current of evidenced-based purchasing challenges and Track performance approaches to institutions at through M&E explore potential solutions strengthen national and local activities purchasing schemes level

Network policy Partner with other makers, researchers, BMGF grantees and practitioners and development other stakeholders at agencies the national and global levels

4 DECK OBJECTIVES

1 Review the context in the Philippines in terms of strategic purchasing for PHC, FP and MNCH 2 Summarize key SP4PHC strategies

3 Showcase key results and findings to date

5 SECTION 2 SUBHEAD IN HERE IF REQUIRED

The Philippines: Country Context ABOUT THE PHILIPPINES Indicator Value (2018) Total population (million) 106.7 Population growth (annual %) 1.4 Population ages 0-14 (% of total) 31.0 Population ages 15-64 (% of total) 63.9 Population ages 65 and above (% of total) 5.1

GDP growth (annual %) 6.2 GDP per capita, PPP (current international 9546.5 $) Poverty headcount ratio at national 21.6 poverty lines (% of population) (2015)*

Source: World Bank Open Data, *Philippine Statistics Authority 7 COUNTRY HEALTH EXPENDITURE (CHE)

Total Health Expenditure (2018): PhP 799.1B (15.6B USD)

CHE Distribution among Health Care Providers Government Others hospitals 16% 21%

Retailers 27% Private hospitals 22%

Government Private clinics health centers 9% 5% Source: 2018 National Health Accounts

8 ORGANIZATION OF SERVICE DELIVERY IN THE PHILIPPINES

. The Department of Health (DOH) is responsible for policy development, regulation of services, setting standards and guidelines for health, and providing highly specialized and tertiary-level hospital services . Local Government Units – provincial, city and municipal governments – are responsible for managing and implementing local health programs and services.

Organizational structure showing the health offices Health facilities, 2016 devolved to local government units Government Private hospitals, 434 hospitals, 790

Rural health units, 2,587

Barangay health stations, 20,216

Source: Dayrit et. al 2018 9 PURCHASING LANDSCAPE IN THE PHILIPPINES

. PhilHealth, the social health insurance program run by the government, accounts for approximately 13% of health spending in the Philippines, covering 92% of the population. . PhilHealth purchases comprehensive hospital-level services and an expanding package of PHC benefits.

Current health expenditure by financing scheme, 2018

…select PHC services from public sector Voluntary health facilities through capitation care payment arrangement. schemes 12%

Government PhilHealth schemes and Household out- purchases…. compulsory of-pocket contributory payment health financing 54% …a comprehensive set of FP, maternity, schemes delivery and postnatal services from 34% public and private facilities (case-based payment).

10 Source: Philippines NHA 2018 A UNIQUE OPPORTUNITY: PHILIPPINE UHC LAW 2019 (RA 11223) ISSUES UHC LAW GOALS of UHC

Confusing membership Guaranteed PhilHealth Every schemes Membership for all Filipino… Effective & well-resourced Poor prioritization of public …is prevented from health programs public health programs being sick. Overburdened RHUs, doing Primary Care Provider Health Promotion both primary care & PH for each Filipino

Lack & misdistribution of HC Enough, competent …is managed well Professionals Health Professionals if sick, which means: Few resources & incentives Good, adequate facilities to improve facilities • Seen by an HCP • Seen at a facility Sustainable supply of Procurement failures, • Treated sufficiently High prices of medicines quality Medicines • Provided meds Unreliable, disconnected Reliable referral network Responsiveness referral networks that is easy to navigate Devolved health systems Effective planning, …with Good health have limited resources & leadership & technical know-how outcomes monitoring So much money, weak purchasing power Government as strategic …and protected purchaser of affordable, financially from High out of pocket despite quality services High health expenditures being poor

11 A UNIQUE OPPORTUNITY: PHILIPPINE UHC LAW 2019 (RA 11223) INTEGRATION UHC LAW GOALS of UHC

ConfusingSIMPLIFIED membership Guaranteed PhilHealth Every Membershipschemes Types Membership for all Filipino… Effective & well-resourced ProvincialPoor prioritization Synergy of publicin the …is prevented from health programs public health programs Delivery of PH Services being sick. PUBLIC HEALTH Overburdened RHUs, doing Primary Care Provider INTEGRATION Health Promotion both primary care & PH for each Filipino

Lack & misdistribution of HC Province-wide Health Enough, competent …is managed well Professionals Health Professionals Care Provider Networks if sick, which means: open to private sector Few resources & incentives Good, adequate facilities to improveparticipation facilities • Seen by an HCP • Seen at a facility CLINICAL INTEGRATION Sustainable supply of Procurement failures, • Treated sufficiently High prices of medicines quality Medicines • Provided meds Provincialize health Unreliable, disconnected Reliable referral network Responsiveness systemsreferral leadership networks and administration that is easy to navigate DevolvedMANAGERIAL health systems Effective planning, …with Good health haveINTEGRATION limited resources & leadership & technical know-how outcomes monitoring PoolingSo much of money money, into a weak purchasing power Government as strategic …and protected Special Health Fund purchaser of affordable, financially from FINANCIALHigh out of pocketINTEGRATION despite quality services High health expenditures being poor

12 FAMILY PLANNING IN THE PHILIPPINES: OUTCOMES SHOW INEQUITIES AND LAG BEHIND ASIAN COUNTRIES

. Use of modern contraceptive methods among married women increased between 1993 and 2018. . The modern contraceptive prevalence rate (mCPR) in the Philippines is lower than the average for Asia in 2018. . Total fertility rate declines as women’s education and wealth increases.

Total fertility rate 4.3 3.2 2.6 2.1 1.7 Number Number childrenof Lowest Second Middle Fourth Highest Poorest → Wealthiest

Source: Philippines DHS 2017 Source: FP2020 Annual Report 2016 – 2017, “The Way Ahead” 13 FAMILY PLANNING IN THE PHILIPPINES: SERVICE DELIVERY IS HEAVILY PUBLIC AND SARC-ORIENTED . The Philippines has a relatively imbalanced method mix, with a preference for short acting reversible contraceptives. . More than half of the modern methods are provided through an overburdened public sector. . Barangay health stations are the most common public sector sources for contraception with 25% of users obtaining their method from this source, primarily injectable. . Pharmacies are the main private providers of contraceptives, serving 30% of users, primarily with pills and condoms.

Method mix (modern methods), 2017

Sterilization (female) 7.4%

IUD 3.5%

Injection 5.0%

Pill 20.9%

Condom (male) 1.7%

Implant 1.1%

Other modern method 0.6%

Source: Philippines DHS 2017 Source: Philippines DHS 2017 14 FAMILY PLANNING IN THE PHILIPPINES: LIMITED FP OPTIONS FOR POOR WOMEN • PhilHealth’s FP packages open access for poor women to Service Case Rate Approved Location Approved Provider

long-acting and permanent contraception (LARCs) Bilateral tubal ligation 4,000 PhP ($77 USD) Hospitals and Physicians ambulatory surgical • Offered as an adjunct service package for eligible birthing clinics (ASCs)

homes already accredited by PhilHealth’s Maternal Care No-scalpel vasectomy 4,000 PHP Hospitals and ASCs Physicians Package (MCP) Intrauterine devices 2,000 PhP ($39 USD) Hospitals, ASCs, Rural Physicians, midwives, Health Units (RHUs), and nurses • However, only 18.5% (355 out of 3159) of birthing homes Birthing Homes, Free- (both public and private) are accredited by PhilHealth to Standing FP Clinics

provide FP services (that is one PhilHealth accredited facility Subdermal implants 3,000 PhP ($58 USD) Hospitals, ASCs, RHUs, Physicians, midwives, and nurses to offer FP for every 20,000 women of reproductive age). Birthing Homes, Free- Standing FP Clinics

Few FP-accredited public facilities + Limited private sector complementation = Little options for poor women to access effective and quality FP services at little or no cost

15 FAMILY PLANNING IN THE PHILIPPINES: CHALLENGES AND OPPORTUNITIES

CHALLENGES OPPORTUNITIES

Improve the supply and accessibility of quality The Philippines lag behind other Asian and affordable services to meet growing countries in terms of FP outcomes demand through HCPNs

There is dependence on short acting Improve mCPR and expand options by improving contraceptives and narrow method-mix access to injectables and subdermal implants

Delivery of FP services is concentrated on an Only 7% of private providers contribute to the overburdened public sector where delivery of FP services across all methods – commodities are usually procured and private sector involvement can contribute to provided by government at no cost to patients service delivery

16 MATERNAL NEONATAL AND CHILD HEALTH (MNCH) IN THE PHILIPPINES: OUTCOMES REVEAL INEQUITIES . While there are small differences between urban and rural areas, there is considerable variation across regions and wealth quintiles for almost all key MNCH coverage indicators, except for ANC from a skilled provider for which the coverage rates are uniformly high. . Though 78% of women who had a baby in the past five years delivered at a health facility, there is a significant urban-rural gap in facility births (85% vs. 72%). . 84% of live births were delivered by a skilled provider; mainly by a doctor or midwife.

Coverage of key MNCH indicators, 2017 Place of delivery, 2017

2.6% 3.1% 2.2% Newborn's first postnatal check-up in the first two days after 85.7% 83.8% 12.1% birth 19.6% 88.0% 25.6%

86.1% Women with a postnatal check-up in the two days after birth 83.8% 30.1% 88.9% 22.6% 16.8%

84.4% Deliveries by a skilled provider 78.7% 91.6%

93.8% Women receiving antenatal care from a skilled provider 93.6% 94.0% 55.1% 54.7% 55.4%

86.5% ANC 4+ visits 84.9% 88.4% Percentage Total Urban Rural 17 Total Rural Urban Public facility Private facility Home Other Source: Philippines DHS 2017 MATERNAL NEONATAL AND CHILD HEALTH (MNCH) IN THE PHILIPPINES: NO SIGNIFICANT IMPROVEMENTS IN MNCH MORTALITY RATES

. Despite improvements in coverage of key maternal and newborn services, the maternal mortality rate and neonatal mortality rate have not gone down significantly in the last decades. . Improved access does not translate to better outcomes; quality emerges as a rate-limiting variable

152 54 48 127 129 122 124 114 40 34 35 34 31 29 27 25 23 21 18 18 17 16 13 14

1993 NDS 1998 NDHS 2003 NDHS 2008 NDHS 2013 NDHS 2017 NDHS 1990 1995 2000 2005 2010 2015

Neonatal mortality Infant mortality Under 5 mortality Maternal mortality

18 Source: Philippines DHS 2017 Source: WHO and Population Division 2015 MATERNAL NEONATAL AND CHILD HEALTH (MNCH) IN THE PHILIPPINES: CHALLENGES AND OPPORTUNITIES

CHALLENGES OPPORTUNITIES

The ePCB under UHC Law includes coverage of Variations across regions and wealth quintiles MNCH services to be delivered by HCPNs that for most key MNCH coverage indicators include private sector providers

The ePCB under UHC Law includes coverage of Notable urban-rural gap in facility births MNCH services to be delivered by HCPNs that include private sector providers

Despite improvements in access, MMR and The UHC sets the stage for PhilHealth to IMR have not gone down significantly in the purchase for quality through performance- last decades; Quality as a rate-limiting based payments on providers variable

19 SECTION 2 SUBHEAD IN HERE IF REQUIRED

SP4PHC strategies in the Philippines SP4PHC IN THE PHILIPPINES: KEY STRATEGIES

Design and operationalize HCPNs Strategy 1 that promote PHC delivery

Support the government to better engage Strategy 2 private providers of FP and MNCH services Learningagenda

Support PhilHealth expand the PHC benefit Strategy 3 package to improve access to quality FP and

MNCH services 21 STRATEGY 1: DESIGN AND OPERATIONALIZE HCPNS THAT PROMOTE PHC DELIVERY

The challenge/opportunity

• Fragmented health service delivery in a devolved setting that do not deliver coordinated and appropriate care including those for FP and MNCH • Lack of clear and definite referral linkages • Poor quality of care at the primary care level leading to poor health seeking behavior • Poor accountability • Progressive realization of UHC Law guarantees towards local health systems integration through UHC Integration Sites

Our work

• Providing technical support to the DOH in crafting policies and guidelines in setting up and managing Health Care Provider Networks (or Service Delivery Networks) as a key integration component in the roll out of the UHC Law provisions; • Assisting the DOH in the progressive rollout of UHC Law provisions through: • Overseeing the roll out of two UHC-IS provinces: and (located in Region 6) and providing technical assistance; • Documenting lessons learned and providing feedback to DOH in order to integrate these learning in policy formulation 22 STRATEGY 1: KEY RESULTS KEY INTERVENTIONS KEY LEARNING AREAS — Provide technical support to the DOH as it crafts policies for the UIS Improved quality of primary care — Conduct a scoping review of HCPN (done) services In what way do HCPNs facilitate rationalization of resource — Participate in discussions and contribute to the allocation and service delivery in the policies to be used for UIS. provinces? How did it affect FP and — Oversee the roll out of at least one UIS site MNCH services? — Assist UI Sites in developing and rolling out a Operationalization of HCPN How workplan in terms of integration and the UHC Law can HCPNs exist in a decentralized — Monitor, Evaluate and document key learnings from system? What institutional, the UIS especially in terms of impact to FP and management and incentive systems MNCH services can national agencies put in place to support HCPNs in a decentralized system? What institutional, management and incentive systems can national agencies put in place to support HCPNs in a decentralized system?

23 STRATEGY 1: LOW LYING HARVESTS Current Output — Participation in the IRR Discussion on Governance of the UHC Law — Contributed towards sections on the province-wide and city- wide network — Scoping Review of HCPN Shared with the UIS DOH TWG — Inputs were used in some of the discussions of DOH in the thinking about HCPN — Assistance in the planning process of Guimaras and Antique — Creation of a tool to assist provinces in planning for integration as part of their Local Investment Plan for Health (LIPH-UHC Integration) Lessons Learned — UHC roll out in the provinces requires some adaptation to local settings that are varied and uneven in terms of readiness — The process of integration poses many opportunities and challenges to the strengthening of health systems for primary health care — Shaping the network (including planning and financial management processes) is important to ensure that it is responsive to the goals of 24 strategic purchasing SIGNING OF UHC INTEGRATION SITES MEMORANDUM OF UNDERSTANDING

— The Department of Health chose 33 provinces and cities, called UHC Integration Sites, for the first-year implementation of the UHC Law to demonstrate approaches to and mechanisms of its regulations, Governor (third from left) and representatives financing, and governance from the province of Guimaras — MOUs were signed between Department of Health and the UHC Integration Sites, including Guimaras and Antique, on Dec 17, 2019 — On January 2020, Guimaras and Antique will begin with the rollout of UHC in their localities, with ThinkWell Philippines as their Health System Development Partner

Governor Rhodora Cadiao (third from right) and representatives from the province of Antique

25 STRATEGIC DECISION SUPPORT FOR LOCAL INVESTMENT PLAN FOR HEALTH (LIPH) ALIGNMENT WITH UHC

— The Local Investment Plan for Health (LIPH) provides a framework for the development of a medium-term public investment plan in health for cities. It serves as a guide for local government unit (LGU) action and DOH support to the LGU — ThinkWell Philippines created a tool that aims to guide LGUs in incorporating the UHC Theory of Change into their planning processes. This tool was first presented to Guimaras last Nov 7 and to the DOH Stakeholders’ Meeting last Nov 25. It also served as an internal guide of the team in giving quick assessments in the plans of the PHO as was done for Antique last Dec 10-12 and for Guimaras last Dec 13.

26 COSTING TOOL

— Guimaras and Antique have raised queries about how much resources are expected from PhilHealth given the UHC reforms, and how much the local government should counterpart. — To assist ThinkWell Integration Sites, a costing tool was developed to fully understand their financial landscape and needs. — The first costing tool focuses on financing and expenditures of rural health units. Data from RHUs in Guimaras was collected last December 2019, and analysis is currently ongoing. Data from Antique RHUs shall be collected this January 2020. — The results of the analysis will be linked with the work on primary care, particularly the potential capitation amount PhilHealth may pay the provinces. — A costing tool is also being developed for public hospitals by the ThinkWell Philippine team.

27 STRATEGY 2: SUPPORT THE GOVERNMENT TO BETTER ENGAGE PRIVATE PROVIDERS OF FP AND MNCH SERVICES

The challenge/opportunity • Unattractive value proposition offered by PhilHealth packages to private providers limits the potential of private sector complementation to contribute to accelerating improvements in FP and MNCH outcomes in the Philippines

• Bottlenecks in processes and mechanisms of contracting private providers to deliver PhilHealth packages for FP and MNCH services further discourage participation • Example: Cost-prohibitive licensing requirements and arduous processes, delays in claims reimbursement

• Concerned government agencies struggle at aligning goals and strategies, and creating an enabling policy environment for private sector participation in improving FP and MNCH outcomes.

Our work • Collect insights and data from private providers towards gaining a comprehensive understanding of current barriers/ bottlenecks and drivers of private provider engagement on primary care, especially FP and MNCH

• Liaise and work closely with key stakeholders -- DOH, PhilHealth, Commission on Population & Development (NEDA) and private sector organizations--towards [1] identifying, [2] establishing, [3] monitoring and [4] achieving goals and targets for engaging private providers of primary care services, with a special focus on FP and MNCH services. 28 STRATEGY 2: KEY RESULTS KEY INTERVENTIONS KEY LEARNING AREAS — Scope into the challenges encountered by private providers in delivering PhilHealth packages for Long- Greater participation of the private acting Reversible contraceptives (LARCs) sector in reaching FP and MNCH targets What are processes, facilitators and — Completed in July 2019; undergoing dissemination barriers to engagement of private to key stakeholders for utilization in policy making midwives for FP and MNCH? and program development. — Engage and provide technical support to key government agencies, local and international partners. Increased value proposition of — National Agencies (DOH, PhilHealth, CPD): convene PhilHealth to private providers What governing bodies towards clarifying goals, setting institutional, management and complementary strategies, and creating an enabling incentive systems would increase the policy environment for private sector engagement. participation of private midwives to provide services under PhilHealth? — Professional organizations (IMAP, PNA): engage and support capacity-building initiatives that will enable private providers to maximize opportunities from PhilHealth and UHC. — Local and International Partners (UNFPA, FP2020, Likhaan, etc): regular interfacing to align strategies, share resources, and synergize efforts. 29 STRATEGY 2: LOW LYING HARVESTS Current Outputs — September 2019: Publication of a scoping study on challenges and opportunities for engaging private providers of FP in the Philippines — Dissemination of learning outputs to key stakeholders — October 8, 2019: Roundtable discussion attended by DOH, PhilHealth, CPD, UNFPA, professional organizations — October 16, 2019: Presentation of study results in a national midwifery conference (IMAP) attended by 3,500 midwives all over the Philippines — November 2019: Study presented by DOH in the 25th ICPD summit in Nairobi — Ongoing Planning for a High-Level Meeting for SRH in UHC — Collaboration with UNFPA-Philippines — Objective is to convene heads of agencies to synergize targets and strategies towards situating SRH as a trailblazer in maximizing opportunities provided by the Universal Health Care Law Lessons Learned — The roles and interests of the private sector interest must be considered as [1] necessary and [2] strategic in public policy and political economy — Building trust across agencies/ stakeholders require aligning [1] information, [2] interests, and [2] institutional mandates and processes. — ThinkWell-PH fills in a unique, urgent yet unmet role as an [1] independent knowledge broker, [2] convener, and [3] navigator-organizer for providers and 30 professional organizations LONG ACTING AND REVERSIBLE CONTRACEPTIVE (LARC) CLAIMS, PHILHEALTH 2019

20000

15000

10000

5000

0 2014 2015 2016 2017 2018 Implant claims (paid & in-process) IUD claims (paid & in-process)

Source: Analysis of PhilHealth claims data, received July 2019, ThinkWell Philippines 31 WHAT ARE THE FACTORS THAT HINDER PRIVATE PROVIDERS IN PROVIDING PHILHEALTH’S FAMILY PLANNING (FP) PACKAGES? RESULTS OF A THINKWELL-PH SCOPING REVIEW

Process and Low Arduous Documents Implement’n and Policy Profitability Contracting Fidelity review rocesses Analysis of Packages P

FGDs and Key Quantitative Delays in Informant Professional Analyses Payment Interviews Identity of Claims

Research Methods Key Results 32 PROVISION OF FP SERVICES THROUGH PHILHEALTH Low PROPOSES LOW ABSOLUTE AND RELATIVE Profitability PROFITABILITY FOR PRIVATE PROVIDERS.

Private sector rates in PHP (USD equivalent) Family planning PhilHealth Case Rates in PHP (USD service equivalent) Commodity Price Insertion Fee Ancillary Costs Total

IUD Insertion 2,000 (40 USD) 800-4,000 500-1,500 1,100-1,500 48-140 (16-80 USD) (10-30 USD) (22-30 USD) USD

Subdermal 1750-5,000 1,000-2,000 500 -1,000 65 – 160 3,000 (60 USD) Implant Insertion (35-100 USD) (20-40 USD) (10-20 USD) USD

• PhilHealth case rates were costed with the assumption that FP commodities will be distributed for free by government and/or procured by providers at low negotiated prices. • However, private providers procure FP commodities from the market at a wide range and variability of prices. • PhilHealth case rates also fail to account removal fees and other ancillary costs. • Given limited time and in the interest of productivity, busy service providers generally prefer providing the MCP package (than the FP package) which is deemed relatively more profitable for the time and resources invested (NO CARROT) 33 REDUNDANT, COSTLY, AND ARDUOUS Arduous CONTRACTING PROCESSES AND REQUIREMENTS Licensing DISINCENTIVIZE PRIVATE PROVIDERS FROM BEING Processes ENGAGED TO PROVIDE PHILHEALTH FP PACKAGES

• NO CARROT: Most Private Providers do not find value in undergoing the requisite contracting processes because the underlying costs are not commensurate to the profitability of offering PhilHealth packages • NO STICK: Because regulatory bodies do not routinely monitor compliance with licensing requirements, providers may freely operate (and maintain profitability) without the benefit of a license to operate (LTO) 34 PRIVATE SECTOR MIDWIVES TEND TO VIEW THEIR Professional PROFESSIONAL ROLE AS CENTERED ON ATTENDING Identity DELIVERIES RATHER THAN PROVIDING FAMILY PLANNING SERVICES.

• This perspective may limit not just their willingness to pursue PhilHealth accreditation but also their intentions to provide family planning services at all. • Midwives voiced that their training prepared them to deliver babies rather than to prevent them. • Others voiced they felt more much more familiar with the business of running a birthing facility but, because of limited exposure, would not feel inclined to operate a business centered on providing family planning services. • Many private providers know that rural health units (RHU) provide these services for free as part of the government’s FP advocacy. They consider it the rural health unit’s role, rather than theirs, to provide FP services and further the government’s agenda.

“I am a midwife; I was meant to facilitate birth, not prevent it.

Giving birth is our bread and butter” 35 STRATEGY 3: SUPPORT PHILHEALTH EXPAND THE PHC BENEFIT PACKAGE TO IMPROVE ACCESS TO QUALITY FP AND MNCH SERVICES

The challenge/opportunity

• Fragmented financing system that do not incentivize coordinated and appropriate care • Blurred incentives that drive more hospitalizations and less primary care delivery • Poor accountability to the disadvantage of primary care facility management

• Limited investments on primary care (<20% of total health expenditure)

• Selective benefit coverage for primary care services (approximately 7 primary care conditions with PhilHealth coverage)

Our work • Develop financing strategies and provider payment mechanisms that drive coordinated care • Performance-based, prospective payment to leverage strategic purchasing • Contracting of health care provider networks to provide comprehensive care

• Strengthening primary care service delivery • Development of a comprehensive primary care benefit (disease agnostic) with increased capitation rates • Integration of outpatient specialist services to the comprehensive primary care benefit 36 • Engagement strategies with private providers to expand access points STRATEGY 3: KEY RESULTS KEY INTERVENTIONS KEY LEARNING AREAS — Design key benefit / service packages — Expanded Primary Care Benefit Package: interim Higher prioritization of primary care PC benefit that provides a higher capitation rate to especially for FP and MNCH What incentivize participation of more private providers was the experience of expanding the primary care benefit especially in the — Comprehensive Primary Care Benefit Package: first year of implementation? How envisioned PC benefit that is disease-agnostic and did it affect FP and MNCH services? strong in gatekeeping How can it be improved? — Global Budget Payment: prospective payment for provision of services from primary to tertiary that Stronger purchasing role for promote comprehensive and coordinated care PhilHealth What are processes, — Develop mechanisms that promote strategic purchasing facilitators and barriers to the and drive financial integration development and implementation of — Network-based Contracting: grouping of providers policies on health financing in the to provide primary to tertiary services, with country? What are global best payments based on network-agreed performance practices in terms of prospective and targets and priority indicators network-based payment? Which ones can be adopted in the Provincial Special Health Fund: integration of — Philippine context? fragmented financing at the provincial level to drive spending efficiency and shared accountability 37 STRATEGY 3: LOW LYING HARVESTS Current Output — Participation in the IRR Discussion on Service Delivery of the UHC Law and Primary Care TWG discussion — Contributed towards delineation of individual vs population- based services — AO on Primary Care drafted — Early technical work on “Transition of Commodities” — Provision of technical support towards the design of the KONSULTA Benefit Package — Currently approved by the board of PhilHealth — Operational Policy is currently being designed — Early Technical Work on the benefits of PhilHealth for Network — Preparation of technical materials for discussion Lessons — “Strategy” is important in strategic purchasing — Internal and external system readiness is important as well as having the “package” 38 Streamlining and expansion of services and access to primary care benefit through…

Beneficiaries Payment Mechanism Benefit Inclusions Providers •All eligible • Capitation and •Initial and follow up •All accredited OPD and registered to a primary performance based consultation with a primary care facilities care provider of choice Primary Care Provider (public and private) Target for payment •Targeted health risk Benefit Package Amount release screening and assessment (addresses 80% of the • PhP500.00 per capita •40% upon registration for public facilities common OP consults) Recording and Reporting •60% upon performance • PhP750.00 per capita + •11 diagnostics • Primary Care EMR Co-payment for private •19 molecules (drugs and facilities medicines)

Philippine Health Insurance Corporation P ROPOSED D IFFERENTIAL Proposed Payment for Public vs Private P AYMENT

Private Public Differential Rate Single Rate 750 per capita 500 per capita rate rate PhP1500 for private PhP 1500 for all facility facilities + PhP500 types PHIC maximum co-payment (to nd be paid on the 2 visit) Revenue Fees PhP1000 for public facilities PHIC LGU Budget Appropriation Public facilities are Easier communication subsidized; Revenue Fees DOH Subsidy rationalized government Lessen incentive for LGUs funding (PhilHealth, DOH, to contribute to budget for LGUs) health Private Public

Philippine Health Insurance Corporation Additional Considerations: Integration of the MDG/SDG Benefits to KONSULTA*

DOH Antenatal Tuberculosis Funding Care Actual Cost Php 2200 Php 15,000 per case PhilHealth Benefit Package

PHIC Php 1500 per case Php 4000 per case Reimbursement (Net: ~1B) (Net: 140M)

DOH Funding 180 M ~784 M

With SDG and MDG benefits

Philippine Health Insurance Corporation *subject to further costing, policy proposal and other considerations SIMULATION OF KONSULTA ROLLOUT (BEST SCENARIO)

Private Hospitals Public Hospitals Private Infirmaries ASSUMPTIONS  Only 50% of RHUs are ready in Public Infirmaries Private Primary Care Facilities RHUS terms of service capacity for KONSULTA for 2020 (based on WB/KDI readiness assessment study) +34% of the 2597  Accreditation for 2020 will be private will be processed until 2nd quarter late majority  After 2022, hospitals and infirmaries will only be accredited 2,078 2,337 2,597 +34% of the 1,299 in areas with no access private will be 3013  Providers are IT enabled, PHIC has early majority enhanced the system support 1,431 2,456 13.5% accredited 314 649 314 3,013 private hosp. and 318 318 3,013 IMPLICATIONS 407 infirmaries as 430 157 430 244  Support for massive 159 244 early adapters 833 215 833 244 accreditation is needed in 2020 417 244 40 5 40 1510  Public Primary care facilities TOTAL 1ST Q 2020 2ND Q 2020 1ST Q 2021 1ST Q 2022 1 Q 2023 need to be supported in Total Projected Accredited 2,004 4,625 5,796 6,067 5,610 terms of capacity 40M 92M 110.2M 110.2M 112.89 M  Hospitals need to be Est Max Assigned Population accredited for primary care 59B 70B 71B 72B until 2022 Net Capita Payout (per year)  Communications to beneficiaries is needed to encourage 108.8M 110.20M 110.20M 112.89M Projected Population (PSA) registration to primary care provider 5,439 5,510 5,510 5,645 Required Number of Facility STRATEGY 3: LONG RUNNING TASKS (IN THE PIPELINE) Key work items and current outputs (on-going) • Global Budget Payment • Analysis of claims data and generated historical trends and reimbursements as basis for global budget • Development of policies: PhilHealth Global Budget Program, Joint Memorandum Circular with Commission on Audit • Development of progression plan for roll out of Global Budget Program (transition plan from All Case Rates to Global Budget) • Technical resource person / moderator in consultations, planning workshops, and information dissemination • Key supporting policies (technical support in ongoing policy development) • PhilHealth / DOH Co-payment Policies • PhilHealth Costing Methodology and Framework • PhilHealth Updating of All Case Rates • PhilHealth Contracting of Healthcare Provider Networks 43 STRATEGY 3: LONG RUNNING TASKS (IN THE PIPELINE) Key work items and current outputs • Special Health Fund • Development of policy: Special Health Fund Guidelines • Technical resource person / moderator in consultations and technical planning workshops Lessons • Big reforms must be strategically phased in • “Bite size/Manageable Bites” movements toward vision • Introduce nudges that bring relevant stakeholders towards vision • Set clear progression plan with learning agenda for all stakeholders • Constant and consistent correspondence helps build champions, especially at top levels

44 https://thinkwell.global/projects/sp4phc/

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