Approaching healthcare through national health insurance

The Philippine Health Insurance Corp. (PhilHealth) says it reaches full population coverage in 2025 as it celebrates its 31st year, with 106.24 million beneficiaries enrolled in the National Health Insurance Program (NHIP).

The state insurer reports paying more than P300.45 billion in benefits nationwide in 2025, nearly double the P165.34 billion it released in 2024.

In the first half of 2025 alone, PhilHealth processes 9.4 million claims with a 96.8% efficiency rate and an average turnaround time of 25 days, according to data from the Department of Information and Communications Technology-PhilHealth Transparency Portal. The figures place the agency above its 95% efficiency target and within its benchmark of completing claims processing in less than 30 days.

Providing access since inception

PhilHealth traces its roots to reforms that began decades before its creation.

In 1969, lawmakers enact Republic Act 6111, also known as the Philippine Medical Care Act. The law takes effect in 1971 and places the national medical care program under the Philippine Medical Care Commission. The program ran for nearly 25 years and laid the groundwork for broader health insurance reform.

In 1995, the Congress passed Republic Act 7875, or the National Health Insurance Act. The measure created PhilHealth and has set the goal of providing social health insurance coverage to all Filipinos.

By October 1997, the state insurer assumes administration of the Medicare program for government employees from the Government Service Insurance System. It has took over private sector Medicare accounts from the Social Security System in April 1998 and then absorbed the program for overseas workers from the Overseas Workers Welfare Administration in March 2005.

Under its charter, PhilHealth administers the NHIP, formulates policies, sets standards for quality and utilization, manages the National Health Insurance Fund and accredits healthcare providers. It operates as a tax-exempt government corporation attached to the Department of Health for policy coordination and guidance.

The agency also maintains affiliations with the International Social Security Association, the ASEAN Social Security Association and the Philippine Social Security Association.

Billions of benefits delivered

For the first semester of 2025, PhilHealth collects P100.51 billion in premium contributions. Direct contributors from the private sector, government and informal economy account for nearly all collections.

The agency pays P68.72 billion in benefit expenses as claims during the same period. Total processed claims reach P139.31 billion, covering 9,396,020 claims with an average value of P14,826.50 each.

The benefits-to-revenue ratio stands at 68.4%, which PhilHealth cites as a measure of benefit delivery relative to collections.

At the same time, the state insurer reports P152.57 billion in total healthcare investments and P4.39 billion in operating expenses. It posts an operating margin of negative 47%, which it attributes to higher benefit payouts tied to expanded coverage.

Across the country, PhilHealth accredits 13,646 facilities and works with 58,700 healthcare professionals. Of these, 1,902 institutions hold full accreditation, including 799 government-owned and 1,103 private hospitals. Another 11,744 facilities operate under public and private ownership. The network includes 2,156 hospitals and 54,805 accredited health professionals, most of whom are physicians.

This year, the National Budget allocates nearly P130 billion to PhilHealth, including P60 billion restored by order of the Supreme Court. The broader health sector receives P448.125 billion to support the Universal Health Care Act, with P1 billion earmarked for the Zero Balance Billing Program to cover in-patient services in basic accommodations in local government hospitals.

Push for primary care

Recently, PhilHealth has started rolling out RISE30 as a corporate strategy that sets internal improvement targets every 30 days. The program focuses on streamlining administrative processes and upgrading systems to improve service delivery.

At the same time, PhilHealth advances the Yaman ng Kalusugan Program, or YAKAP, a primary care initiative that connects members to designated providers for preventive and continuous care. Under the program, members receive free consultations, laboratory tests, medicines and cancer screening.

The program registers 31,789,799 members and covers 90% of municipalities nationwide. It also accredits 3,476 providers to deliver primary care services.

YAKAP benefits now expanded to dental checkups and procedures. The package covers routine consultations, fluoride treatments, cleaning sessions, sealants and emergency dental interventions.

Members receive P600 annually for preventive dental checkups and P200 per tooth for sealant applications. The package also allows two dental fillings and one cleaning per year. PhilHealth says 129 accredited dental clinics currently provide these services.

The agency also introduces the Guaranteed and Accessible Medications for Outpatient Treatment program, or GAMOT, in YAKAP clinics, offering 21 essential medicines for outpatient care. These medicines include amoxicillin, co-amoxiclav, cotrimoxazole, nitrofurantoin, ciprofloxacin, clarithromycin, oral rehydration salts, prednisone, salbutamol, fluticasone with salmeterol, paracetamol, gliclazide, metformin, simvastatin, enalapril, metoprolol, amlodipine, hydrochlorothiazide, losartan, aspirin and chlorphenamine.

PhilHealth President and Chief Executive Officer Edwin M. Mercado said members may obtain these medicines from their chosen YAKAP clinics as the agency upgrades benefits under YAKAP and Gamot.

“We are striving to improve and deliver quality services through coordinating with YAKAP providers, giving Filipinos, who depend on PhilHealth, peace of mind and comfort,” Mr. Mercado said in a statement.

The state insurer also expands benefits for middle-income direct contributors, including those who pay premiums through salaries or business income. The move follows the directive of President Ferdinand R. Marcos, Jr. to provide upgraded hospital accommodations and improved benefits for direct contributors.

In addition, the agency coordinates with the Overseas Workers Welfare Administration to strengthen health service access for overseas Filipino workers.

“Ito ang aming mandato: Sa Bagong Pilipinas, mayroon tayong Mabilis, Patas at Mapagkakatiwalaang PhilHealth (This is our mandate: In the New Philippines, we have a PhilHealth that is fast, fair, and trustworthy),” Mr. Mercado said. — Mhicole A. Moral