Universal Health Care Act
Republic Act No. 11223
MARIO C. VILLAVERDE, MD, MPH, MPM, CESO I
Undersecretary of Health | Health Policy and Systems Development Team
Department of Health, Philippines
Declaration of Principles
• Integrated and comprehensive approach to ensure health
literacy, healthy living, and protection from hazards and risks
• Health care model that provides comprehensive health
services without causing financial hardship
• Whole-of-system, whole-of-government, whole-of-
society approach in the development of health policies
• People-oriented approach centered on people’s needs and
well-being
Department of Health, Philippines
General Objectives
• To progressively realize universal health care through
systemic approach and clear role delineation of
stakeholders
• To ensure equitable access to quality and affordable
health care and protection against financial risk
Department of Health, Philippines
Universal Health Care
Population Coverage – automatic inclusion of every Filipino
citizen into the NHIP
Service Coverage
• immediate eligibility and access to population-based and
individual-based health services
• comprehensive outpatient benefit package
• provision of primary care provider
Department of Health, Philippines
Universal Health Care
Financial Coverage
Population-based health services
• funded by National Government through DOH
• free at point of service
Individual-based health services
• primarily through pre-payment mechanisms (SHI, PHI,
HMO)
Department of Health, Philippines
National Health Insurance Program
Membership
• Direct contributors – those who have the capacity to
pay premiums
• Indirect contributors – those whose premiums are
subsidized by the national government
Department of Health, Philippines
National Health Insurance Program
Entitlement to Benefits
• immediate eligibility
• no co-payment in basic or ward accommodation
• co-payment and co-insurance for amenities in public
hospitals regulated by DOH and PhilHealth
• no reduction in current PhilHealth package
• additional benefits for direct contributors, where applicable
Department of Health, Philippines
National Health Insurance Program
Premium Contributions
For direct contributors
Year Premium Rate Income Floor Income Ceiling
2019 2.75 % P10,000.00 P50,000.00
2020 3.00 % P10,000.00 P60,000.00
2021 3.50 % P10,000.00 P70,000.00
2022 4.00 % P10,000.00 P80,000.00
2023 4.50 % P10,000.00 P90,000.00
2024 5.00 % P10,000.00 P100,000.00
2025 5.00 % P10,000.00 P100,000.00
For indirect contributors – to be gradually adjusted and included in the GAA
Department of Health, Philippines
National Health Insurance Program
• Program Reserve Funds
• Administrative Expense
• PhilHealth Board of Directors
• President and Chief Executive Officer
• PhilHealth Personnel as Public Health Workers
• Additional Powers and Functions of PhilHealth
Department of Health, Philippines
Health Services Delivery
Population-based Health Services
• DOH to contract province-wide and city-wide health
systems
• Minimum components:
• primary care provider network
• epidemiologic surveillance systems
• health promotion programs/campaigns
Department of Health, Philippines
Health Services Delivery
Individual-based Health Services
• Philhealth to contract public, private or mixed health care
provider networks
• service quality
• co-payment/co-insurance
• data submission
• PhilHealth and DOH to incentivize health care providers
that form networks
Department of Health, Philippines
Health Services Delivery
Individual-based Health Services
• DOH to determine apex or end-referral hospitals; may be
contracted by PhilHealth as stand-alone providers
• PhilHealth to:
• shift to performance-driven, close-end, prospective payments
based on DRGs, validated costing methods, and no
differentiation between facility and professional fees
• develop differential payment considering service quality
• institute strong surveillance and audit mechanisms
Department of Health, Philippines
Organization of Local Health Systems
Integration into Province-wide and City-wide Health
Systems
• Provincial/City Health Board to:
• oversee integration of health services
• manage the special health fund
• exercise administrative and technical supervision over health
facilities and HRH within their jurisdiction
• Municipalities and cities to be represented in the Board
Department of Health, Philippines
Organization of Local Health Systems
Special Health Fund
• Province-wide and City-wide Health System shall pool
and manage all resources in order to finance population-
based and individual-based health services
• DOH, in consultation with DBM and LGUs, shall develop
guidelines for Special Health Fund
Department of Health, Philippines
Organization of Local Health Systems
Income derived from PhilHealth payments
• PhilHealth payments shall accrue to the Special Health Fund
and credited as Annual Regular Income (ARI) of the LGU
Incentives for improving competitiveness of the Public
Health Service Delivery System
• National Government to provide financial and non-financial
matching grants in accordance with province-wide and city-
wide investment plans
Department of Health, Philippines
Human Resources for Health
National Health Human Resources Master Plan
• Provision of policies and strategies for appropriate health
workforce based on population needs, and for guaranteed
permanent employment and competitive salaries
National Health Workforce (NHW) Support System
• Support to local public health systems in addressing human
health needs, especially for GIDAs
Department of Health, Philippines
Human Resources for Health
Scholarship and Training Program
• expansion of existing and new health related degree and
training programs
• regulation of the number of enrollees based on health needs
• expansion of scholarship grants for undergraduate and
graduate programs
• setting-up of registry of medical and allied health professionals
• reorientation of health professional education, certification and
regulation towards provision of primary care services
Department of Health, Philippines
Human Resources for Health
Return Service Agreement
• return service for at least three (3) years for recipients of
government-funded scholarship programs
• provision of additional incentives for those rendering additional
two (2) years of service
• establishment of guidelines for non-compliance
Department of Health, Philippines
Regulation
Safety and Quality
PhilHealth to:
• establish a rating system under an incentive scheme
based on service quality, efficiency and equity
• recognize third party accreditation mechanism
Department of Health, Philippines
Regulation
Safety and Quality
DOH to:
• institute a licensing and regulatory system for stand-
alone health facilities, ambulatory and primary care
providers
• set standards for clinical care through development and
use of clinical practice guidelines
Department of Health, Philippines
Regulation
Affordability
• Procurement of Drugs and Devices of DOH-owned Health Care
Providers
• follow centrally negotiated prices
• sell in prescribed maximum mark-ups
• submit a price list of all drugs/devices procured and sold
• Independent Price Negotiation Board
• negotiate prices on behalf of DOH and PhilHealth
Department of Health, Philippines
Regulation
Affordability
• health care providers to make price information of health
goods and services readily accessible
• drug outlets to carry the generic equivalent of all drugs in
the Primary Care Formulary
• DOH, PhilHealth, HMOs and PHIs to develop policies and
plans for complementation of health benefits
Department of Health, Philippines
Regulation
Equity
• preferential licensing of health facilities and contracting of health
services for underserved areas
• equitable distribution of health services and benefits prioritizing
GIDA
• all government hospitals to operate not less than 90% of bed
capacity as basic accommodation; specialty hospitals not less
than 70%; private hospitals not less than 10%
Department of Health, Philippines
Governance and Accountability
Health Promotion
Transformation of HPCS to Health Promotion Bureau
• formulation of strategy for increasing health literacy
• implementation of health promotion programs and activities
across social determinants of health
• policy coordination across government instrumentalities
• provision of technical support to local research and
development
Department of Health, Philippines
Governance and Accountability
Health Promotion
• at least one percent (1%) of total DOH budget earmarked
for health promotion programs
• DepEd schools to be designated as healthy settings
• incorporation of health promotion in school curricula
• LGU to enact stricter ordinances to promote health
literacy and healthy lifestyle
Department of Health, Philippines
Governance and Accountability
Evidence-Informed Sectoral Policy and Planning for UHC
• all health-related entities to submit health data to PhilHealth
• DOH and DOST to develop cadre of policy systems
researchers, experts and managers through training grants
• administrative and survey data generated using public funds
considered as public records and made accessible to the public
• action researches on health promotion and social mobilization
as part of the national health research agenda
Department of Health, Philippines
Governance and Accountability
Monitoring and Evaluation
• PSA to conduct relevant modules of household surveys annually
for the first ten (10) years of implementation
• DOH to publish annual provincial burden of disease estimates
Health Impact Assessment
• HIA as requirement for all policies, programs and projects
Department of Health, Philippines
Governance and Accountability
Health Technology Assessment
• institutionalizaton of HTA process to inform policies and
decisions of DOH and PhilHealth
• creation of HTAC within DOH
• within five (5) years after establishment, HTAC to be an
independent entity separate from DOH, attached to DOST
Department of Health, Philippines
Governance and Accountability
Ethics in Public Health Policy and Practice
• declaration and management of conflict of interest
• collection and tracking of financial relationships with health
care professionals/providers for all manufacturers of drugs,
medical devices, and medical supplies registered by FDA
• Public health ethics committee as an advisory body to the
Secretary of Health
Department of Health, Philippines
Governance and Accountability
Health Information System
• health service providers and insurers to maintain a health
information system to be electronically uploaded on a
regular basis through interoperable system
• enterprise resource planning
• human resource information
• electronic health records
• electronic prescription log
Department of Health, Philippines
Appropriations
Source of Funding for UHC
• Total incremental sin tax collections
• 50% of the National Government share from PAGCOR
• 40% of the Charity Fund, net of Documentary Stamp Tax Payments
and mandatory contributions of PCSO
• Premium contributions of members
• Annual appropriations of the DOH
• National Government subsidy to PhilHealth
• Supplemental funding
Department of Health, Philippines
Penal Provisions
Penalties and sanctions cover the following:
• health care provider of population-based health services
• health care provider of individual-based health services
• PhilHealth member
• employer
• Director, officer or employee of PhilHealth
Department of Health, Philippines
Miscellaneous Provisions
Oversight Provision
• Creation of Joint Congressional Oversight Committee on
UHC
• NEDA, PSA, NIH and other academic institution to validate
and evaluate UHC accomplishments
• DOH and PhilHealth to allocate adequate funding for these
studies
Department of Health, Philippines
Miscellaneous Provisions
Performance Monitoring Division
• Establishment of Performance Monitoring Division to
monitor and evaluate the implementation of UHC
• Office-in-charge of field implementation performance to
comprise the core personnel of the office
Department of Health, Philippines
Miscellaneous Provisions
Transitory Provision
• President of the Philippines to appoint new members of the
Board and the PCEO of PhilHealth within thirty (30) days
• All officers and personnel of PhilHealth, except for the members
of the Board, to continuously perform their duties and receive
their corresponding salaries and benefits
• All affected officers and personnel of the PCSO to be absorbed
by the agency without demotion of rank or salary/benefits
Department of Health, Philippines
Miscellaneous Provisions
• National Government to provide technical and financial support
to LGUs that commit to province-wide integration in the first 6
years
• managerial integration of province-wide and city-wide systems
within the first 3 years; financial integration within the next 3
years
• upon positive recommendation by an independent study and by
the Secretary of Health all local health systems shall be
integrated through issuance of an E.O. by the President
Department of Health, Philippines
Miscellaneous Provisions
• PhilHealth to outsource certain functions to ensure
operational efficiency and fulfillment of the Act in the first
ten (10) years
• Philhealth and DOH to provide reasonable financial and
licensing incentives to contracted health facilities to form
health care provider networks in the first three (3) years
Department of Health, Philippines
Miscellaneous Provisions
• HTAC under the DOH to be established within one (1) year
• PHIs and HMOs, together with DOH and PhilHealth, to develop a
system of co-payment that complements PhilHealth benefit
packages within three (3) years
• Within ten (10) years, only those certified by DOH and PRC as
capable of providing primary care will be eligible as primary care
provider
• For the first two (2) years, PCSO to transfer at least fifty percent
(50%) of the forty percent (40%) of the charity fund per year
Department of Health, Philippines
Summary - Financing
Clarifying roles: Simplifying membership
1.DOH and LGU for into two types: Direct
population-based services and Indirect Contributory
2. PhilHealth for individual-
based services
Pooling funds to Contracting by network
PhilHealth for all based on adherence to
individual-based health quality and co-payment
services (e.g. Sin Tax, standards + third party
PAGCOR, PCSO) accreditation
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Department of Health, Philippines
Summary - Service Delivery
Institutionalizing primary Consolidating fragmented providers Enabling income retention
care as a prerequisite to into province-wide and city-wide for all public providers through
access higher level of care service delivery networks to a Special Health Fund
and contracting by network navigate and coordinate
40
Department of Health, Philippines
Summary - Regulation
Mandating transparent Ensuring benefit complementation
pricing of health goods between PhilHealth and Private Health
and services Insurance (PHIs) and Health Maintenance
Organizations (HMOs)
Expanding scholarship programs, requiring
Basic and non-basic 3 years return service in underserved
accommodation bed areas for government scholars,
ratio of 90:10 for augmenting HRH through national health
government hospitals, workforce support system, primary
70:30 for specialty care-oriented education, health
hospitals, and 10:90 for professionals registry
private hospitals
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Department of Health, Philippines
Summary - Governance
Requiring submission of health and
Strengthening Health
financial data by healthcare providers
Promotion and medicines
and suppliers harmonized to an
interoperable system; sharing of procurement
publicly-funded data sets
Institutionalizing Streamlining
Health Technology Assessment as PhilHealth Board
prerequisite for public financing of from 17 to 13
goods/services, and Health Impact members
Assessment for various programs,
policies, and projects
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Department of Health, Philippines
Maraming salamat po!
