By Maria C.G. Bautista
THE ENACTMENT of the Universal Health Care (UHC) Law marks a watershed in the Philippine health sector. It is a culmination of reforms in health care financing, spanning 26 years under the old Medicare, 16 years under the national health insurance program (NHIP) and eight years under a so-called universal coverage or Kalahatang Pangkalusugan. Can we expect a transformation of the way we pay, access treatment and deliver health care? Expectations are huge and require veering away from path dependency, with decisions and systems design bound to traditional frameworks, capacities and systems.
Changing models of health care under the new law seeks to strengthen prevention over treatment and primary care over hospital care. In the run-up to the crafting of the Implementing Rules and Regulations (IRR) of the new law, there will be much role clarification among agencies in the health care sector due to administrative artefacts of provider-financier-policy setting splits in the system. Even with the best of laws, there are aspects of the Philippine health system that can challenge even the best of intentions and competent individuals in government.
Implementation of the new law will be under the context of the Local Government Code of 1991 which has given to the provinces and mayors the “ownership” of health services, and the planning and monitoring at local levels to Local Health Boards. How much do we know of the performance of these local officials and boards? Health is not high in the priorities and competence of local officials. The new law envisions some complex systems and with the Department of Health’s limited influence in local health systems, it will take more than financial incentives to coordinate and/or bypass territorial boundaries and political loyalties.
The new UHC law will work with resources much more than what the health sector had before, underpinned by premium contribution monies supplemented by tax revenues from “sin” sources. If it were to build on what PhilHealth has been doing, where it has struggled to get to a population coverage rate in the 90 percentiles, to raise its support value to members’ treatment bills, or to expand coverage for informal and overseas workers, the new law has put in time targets for which measures must be in place. Basic insurance tasks hinge on viable information systems, which we hope the national ID system can speed up. We hear less of delays in reimbursing facilities, though much more needs to be done to strengthen trust, embrace technological developments and pursue transparent and evidence-based decision making.
The undeniable entrepreneurial qualities of the practice of medicine in the country do not make an easy system for governance and regulation. The nature of institutional investments that will drive the implementation of the new law will be massive and disruptive. These investments include health technology assessments for products and intervention systems that will be considered for safety and benefit package considerations, diagnostic related groups as basis for reimbursements, and networks for service delivery, among others. The demand for accountabilities will not be left to the professionals but to whole of government and systems. While most Filipinos are excited by the “no enrolment” that comes with universality; what happens after they register with their primary care provider, or if there are enough primary care providers, will matter most. It is concerning to read words like “progressively” and “endeavor to” in the new law; but still hopeful for the joint monitoring bodies to be established for oversight.
For UHC to live to its promise of universal, affordable, fair and quality care will require more than just a discussion of roles and responsibilities of the primary institutions. The usual transactive approach of agencies to craft guidelines and expect buy-in will not work smoothly, given the complex environment of change. It will require strong coordination and stakeholder engagement, better management of technical imperatives and relationships, not just across government agencies but also civil society, academic institutions and the private sector. The first order of IRR discussions will require an enabling environment where experimentation can be supported for new models to emerge, one which is driven not solely by financial incentives but also capture shared values that will bring us to the stage where we see and feel the improvements in health security the UHC law envisions.
Dr. Maria C. G. Bautista is a professor at the Ateneo Graduate School of Business.