The onset of COVID-19 pandemic

After an initial denial about the COVID-19 ominous threat and persistent oversimplification of the disease in early February 2020 confidently saying that “there is nothing really to be extra scared of that coronavirus thing” and that the virus will “die a natural death,” President Rodrigo Duterte belatedly declared a public health emergency on March 9, 2020 [1]. (Next slide) Proclamation No. 922 was issued putting the country in a state of calamity and pursuant to RA 11332 or the Law on Reporting Communicable Diseases enacted on April 26, 2019. Duterte proclaimed that the novel coronavirus “constitutes an emergency that threatens national security which requires a whole-of-government response” [2]. On March 7, 2020, the first case of local transmission happened and additional more cases recorded [3]. Subsequent to the declaration of a public health emergency and a Luzon-wide enhanced community quarantine (ECQ) or lockdown, various of social protection measures to address the impact of COVID-19 on the public was announced and immediately enacted [4]. Fiscal measures for households, businesses, and the financial sectors under RA No. 11469 or the “Bayanihan to Heal as One Act” [5]. Granted the President emergency powers to respond to the needs during the COVID- 19 outbreak. This is the salient point and the onset of the paper which aims to rationalize the Universal Health Care Act for the financial risk protection for all Filipinos during the COVID-19 situation. It reviews the National Health Insurance Program and other fiscal policies which will respond the financial risk and management for testing, hospitalization, and vaccination, in reference to the mandate of Universal Health Care Act.

A Review of National Health Insurance Program and Universal Health Care Act

The Philippines is known to have a privatized system of providing health care following the US health care system. A majority of health care providers are thus in the private sector. National expenditure on healthcare rose in the early 1990s, but then declined rapidly and is yet to fully recover. Of the total health expenditure, private out-of-pocket expenses formed a large percentage; private insurance and HMOs also have minimal, yet, accommodating percentage share; the remainder comes from the government budget or social insurance. While more than half of the health expenditure in the Philippines is out of pocket in 2007,[6] social insurance plans have existed for more than 25 years under the National Health Insurance Act of 1995, the government is committed to their fiduciary responsibility to have equitable, accessible, and affordable health care in the country [7]. The Philippine Health Insurance Corporation (Phil Health) took over the health insurance functions of social security schemes for public and private sector employees in and administers a unified health insurance program providing inpatient and outpatient care. In reality, the scheme has little relevance for majority of the population, who remain outside its coverage for various reasons, most notably because of the existence of a large informal sector. However, in 2013, RA No. 7875 was amended and ratified the National Health Insurance Program, the enrollment of the general population in the program addresses to cover the indigents in pursuant of mandatory coverage of the same law [8]. In 2019, the Philippine government enacted Republic Act 11223, or known as Universal Health Care (UHC) Act, that guarantees “equitable access to quality and affordable healthcare” [9]. Under the UHC Act, all Filipino citizens are automatically covered under the National Health Insurance Program (NHIP). Premium contributions of direct contributor are paid to the NHIP in proportion to the paying member’s income, while subsidies for indirect contributors are funded by the national government through its general appropriations [10]. All Filipinos are required by law to register with a primary care provider who will act as the navigator and coordinator of health care for each individual. Because the UHC Act are funded through different mechanisms, including sin taxes, share of government incomes from public corporations, NHIP premium contributions, and other unobligated government incomes, the incidence burden of financing UHC depends on who contributes to each of these mechanisms. Among direct contributors, the burden is expected to be larger among richer households. Some 43% of the sin tax is given to the Philippine Health Insurance System to cover non-contributory members. (Next slide).

COVID-19: Financial Risk Protection

The government increased its budget allocation and safety nets for health [11] to respond to COVID-19 pandemic and to help achieve the goals of health agenda Healthy Philippines 2022, which advocates the UHC call for improving the three coverage dimensions population, services, and financial [12]. Despite reforms, financial health protection remains limited. Out-of-pocket spending continues to dominate as source for health care financing [13]. While others forgo medication. At the start of the pandemic, Phil Health announced that it would be paying all the expenses of COVID-19 patients [14] however, starting 15 April 2020, beneficiaries will be covered by case rate packages categories based on the severity of illness. Patients admitted before the said date will still have their hospital bills fully compensated by the insurance program [15]. According to the 4 month study conducted in University of the Philippines. Philippine General Hospital, Tabuñar and Dominado estimated 12% average out of pocket payment per patient of the total hospital expenses, with those aged less than 60 years paying from PHP 25,899 to Php 44,428.63 (from USD 511 to USD 876), which is higher compared to those older than 60 years old, from PHP 4,005.60 to PHP 32,920.20 (from USD 79 to USD 649). This could also be due to the additional senior citizen discount for this age group. The 19-30 age groups has the most OOP charges amounting to PHP 44,428.63 (USD 876), and while the 61-70 age range logged the greatest number of admissions, it did not record a higher out of pocket payment [16]. COVID-19 patients generate massive demands for health system resources in the form of hospital beds, intensive care unit (ICU) beds, ventilators, frontline health workers, personal protective equipment (PPE). Moreover, as stated, the Philippine Health Insurance Corporation (Phil Health), the national health insurance corporation of the country with a central role of funding Universal Health Care, proposed case rates to cover medical charges for hospitalization of COVID-19 cases, SARS CoV-2 testing using RT-PCR and cartridge-based PCR, community isolation, home isolation and vaccine injury compensation. Here are the following Phil Health packages according to hospitalization, isolation, and vaccination case rates:

Table 1: For inpatient care of probable and confirmed COVID-19 developing severe illness/outcomes [17].

Table 2: For SARS-CoV-2 testing by RT-PCR [18].

Table 3: For SARS-CoV-2 testing by cartridge-based PCR [19].

Table 4: For community isolation [20].

Table 5: For Home Isolation [21].

Table 6: For Vaccine Injury Compensation [22].

Healthcare is inexpensive, especially in times of pandemics with medical services which usually cause unpredictable out of pocket (OOP) expenses even for minor problems. Medical emergencies can cause a severe financial burden. Because of this, considering the concurrent COVID-19 situation, patients will delay or refuse to seek medical attention until the illness is already far advanced and it is too late for preventive measures. Furthermore, the National Health Insurance Program has system that refunds individuals on a fee-for-service up to a specified amount based on the severity of the illness, classification of hospitals, and price ceiling for health care services relating to COVID-19. The Department of Budget and Management has allotted and released PHP 45.717-B (USD 902-M) to DOH for its COVID-19 response. The Philippine Health Insurance Corp. (Phil Health) will cover all COVID-19 cases and allocated PHP 30-B (USD 59-M) for its response payment to boost the liquidity of hospitals. This amount will be charged to future claims based on the new COVID- 19 benefit package and recomputed case rates [23]. The SARS-CoV-2 virus has not only inured global health care systems but has also negatively impacted economies, in micro and macro level, that might push the world into recession. Universal health care coverage is pushed to the border due to the increasing hospitalization expenditure as the disease progresses with increased transmission of the virus [24]. Although the level of financial protection provided remains limited, Phil Health has claimed success in terms of population coverage: estimated at 86% in 2010, coverage increased to 92% in 2016, and to a ‘universal’ coverage, at 100%, in 2019 due to the implementation of RA no. 11223, known as Universal Health Care Act. It has also been claimed that Phil Health has successfully increased access to primary health care services through various packages and ensured quality of services through its accreditation system [25]. However, it should be noted that a real universal health could be attained through a restructured health financing system that emphasizes government and shared risk sourcing of funds and minimizes reliance on out of pocket payments at the point of service [26].

1. Tomacruz S. “Trust us, Duterte urges Filipinos amid coronavirus threat,” Rappler 2020.
2. Declaring a State of Public Health Emergency throughout the Philippines, Proc. No. 922 OG, 2020.
3. Department of Health, “DOH confirms local transmission of COVID-19 in PH; Reports 6th Case,” DOH Press Release, 2020.
4. Talabong R. “Metro Manila to be placed on lockdown due to coronavirus outbreak,” Rappler 2020
5. An Act Providing For COVID-19 Response and Recovery Interventions and Providing Mechanisms to Accelerate the Recovery and Bolster the Resiliency of the Philippine Economy, Providing Funds Therefor, and for other purposes, Rep. Act No. 11494, O.G. 2020.
6. Romualdez A, Lasco PG, Lim BA. “Universal Health Care in the Philippines,” Journal of the ASEAN Federation of Endocrine Societies 27, 2021; 182: 2.
7. An Act Instituting a National Health Insurance Program for all Filipinos and Establishing the Philippine Health Insurance Corporation for the purpose, Rep. Act No. 7875, Sec. 2(i), Phil Health, 1995.
8. An Act Amending Republic Act No. 7875, Otherwise Known as the “National Health Insurance Act of 1995”, As Amended, and for other purpose, Rep. Act No. 10606, Sec. 5, O.G, 2013.
9. An Act Instituting Universal Health Care for All Filipinos, Prescribing Reforms in the Health Care System, and Approriating Funds Thereof, Rep. Act No. 11223, Sec. 3(b), O.G, 2018.
10. An Act Instituting Universal Health Care for All Filipinos, Prescribing Reforms in the Health Care System, and Approriating Funds Thereof, Rep. Act No. 11223, Sec. 10, O.G, 2018.
11. Department of Budget and Management (DBM), 2021 National Budget, Reset, Rebound, and Recover: Investing for Resiliency and Sustainability 2021.
12. See World Health Organization (WHO), Universal Coverage Three Dimensions 2020.
13. Dayrit M, Lagrada L, Picazo O, Pons M, Villaverde M. The Philippines Health System Review. World Health Organization: Regional Office for South-East Asia. 2018.
14. Full financial risk protection for Filipino health workers and patients against coronavirus disease (COVID-19), Phil Health Circ. No. 2020-0011, 2020.
15. Aguilar K. Phil Health sets new case rate benefits for COVID-19 patients starting April 15. Inquirer. 2020.
16. Tabuñar SM, Dominado TM. Hospitalization Expenditure of COVID-19 Patients at the University of the Philippines-Philippine General Hospital (UP-PGH) with Phil Health Coverage. Acta Medica Philippina. 2021; 216-223.
17. Benefit packages for inpatient care of probable and confirmed COVID-19 developing severe illness/outcomes, Phil Health Circ. No. 2020-0009
18. Benefit package for SARS-CoV-2 Testing using RT-PCR (Revision 2), Phil Health Circ. No. 2021-0001.
19. Benefit Package for SARS-CoV-2 Testing Using Cartridge-based PCR, Phil Health Circ. No. 2021-0003.
20. Guidelines on the COVID-19 Community Isolation Benefit Package (CCIBP) (Revision 1), Phil Health Circ. No. 2020- 0018.
21. COVID-19 Home Isolation Benefit Package (CHIBP), Phil Health Circ. No. 2021-0014.
22. Implementing Guidelines on the Coverage of COVID-19 Vaccine Injury due to Serious Adverse Effects (SAEs) Following Immunization Resulting to Hospitalization, Permanent Disability, or Death under the COVID-19 National Vaccine Indemnity Fund (The COVID-19 Vaccine Injury Compensation Package), Phil Health Circ. No. 2021-0007.
23. Philippine Health Insurance Corp. (Phil Health) Advisory No. 2020-022.
24. Tabuñar and Dominado, “Hospitalization Expenditure of COVID-19,” 217.
25. Philippine Health Insurance Corp., “Population Coverage,” Stats and Charts, 2020
26. Romualdez, “Universal Health Care in the Philippines,” 183.