Commentary of an Academic
(Copyright @ 2010 by Chester B Cabalza. All Rights Reserved).
By Chester Cabalza
NATIONAL HEALTH INSURANCE ACT OF 1995
“An Act Instituting A National Health Insurance Program for all Filipinos and Establishing the Philippine Health Insurance Corporation for the Purpose”
“The poor are being left out, that means, around 60 percent of the population, while only 40 percent is being served by the health system at present, in the Philippines…”
The National Insurance Act of 1995 was approved by then President Fidel V. Ramos on February 14, 1995 with 13 Articles consisting of guiding principles, definition of terms, the national health insurance program, the Philippine health insurance corporation, local health insurance office, the national health insurance fund, financing, health care providers, grievance and appeal, penalties, appropriations, transitory provisions, and miscellaneous provisions.
Based from the study of Llaneta (2010) on “Universal Health Care for Filipinos,” she found out that eight out of 10 Filipinos deem that they wanted our country to have better health services.
The bleak health care conditions prevailing today, in terms of average life expectancy at birth, infant mortality rate, maternal mortality ratio and all other indicators, well-off urban communities such as those in Metro Manila, Cebu and Davao have numbers comparable to those developed countries, while poor rural and urban communities have indicators dipping below the national average.
Important provisions in Republic Act No. 7875 include Section 2 on Declaration of Principles and Policies, which in Section 11, Article XIII, 1987 Constitution, declares that, “the State shall adopt an integrated and comprehensive approach to health development which shall endeavor to make essential goods, health and other social services available to all the people at affordable cost. Priority for the needs of the underprivileged, sick, elderly, disabled, women, and children shall be recognized. Likewise, it shall be the policy of the State to provide free medical care to paupers.”
Definition of Terms are found therewith in Section 4, Article II, RA 7875 that thoroughly enumerates terms with corresponding legal definitions of (a) Beneficiary, (b) Benefit Package, (c) Capitation, (d) Contribution, (e) Coverage, (f) Dependent, (g) Diagnostic Procedure, (h) Emergency, (i) Employee; (j) Employer; (k) Enrollment; (l) Fee for Service; (m) Global Budget; (n) Government Service Insurance System; (o) Health Care Provider; (p) Health Insurance Identification Card; (q) Indigent; (r) Inpatient Education Package; (s) Member; (t) Means Test; (u) Medicare; (v) National health Insurance Program; (w) Pensioner; (x) Personal Health Services; (y) Philippine Medical Care Commission; (z) Philippine National Drug Formulary; (aa) Portability; (bb) Prescription Drug; (cc) Public Health Services; (dd) Quality Assurance; (ee) Residence; (ff) Retiree; (gg) Self-employed; (hh) Social Security System; (ii) Treatment Procedure; and (jj) Utilization Review.
Whereas, Article III, is focused on “The National Health Insurance Program.” Sections 5 to 13 cover significant provisions which guarantees that it will, “ensure affordable, acceptable, available and accessible health case services for all citizens of the country, in accordance with policies and specific provisions of this Act.”
But as a critique, Dr. Galvez Tan cites problems within the components of the Philippine health case system that have contributed to inequity. For instance, total government expenditure for health, which is around 3.3 percent of the Gross Domestic Product (GDP), falls short of the World Health Organization’s recommended five (5) percent.
Section 10, provides for the Benefit Package, subject to the limitations specified in this Act as may be determined by the Corporation, the following categories of personal health services granted to the member or his dependents as medically necessary or appropriate, shall include:
a)In patient hospital care:
1)room and board;
2)services of health care professionals;
3)diagnostic, laboratory, and other medical examination services;
4)use of surgical or medical equipment and facilities;
5)prescription drugs and biologicals; subject to the limitations stated in Section 37 of this Act;
6)inpatient education packages
1)services of health care professionals;
2)diagnostic, laboratory, and other medical examination services;
3)personal preventive services; and
4)prescription drugs and biological, subject to the limitations described in Section 37 of this Act;
c) Emergency and transfer services.
Article IV covers “The Philippine Health Insurance Corporation” creation and nature of the Philippine Health Insurance Corporation, which in Section 14, shall have the status of a tax-exempt government corporation attached to the Department of Health (DOH) for policy coordination and guidance.
In this Article, it covers exemptions from taxes and duties, powers and functions of the Corporation. Whereas, Article V examines the “Local Health Insurance Office” which mandates that in every province or chartered city, it must bring its services closer to members of the program. The following functions are enumerated in Section 23, Article V, RA 7876.
As a comment to this Act, PhilHealth was established through the passage of the National Health Insurance Act of 1995 (RA 7875), which states that the national health insurance program should, “provide all citizens with the mechanism to gain financial access to health services,” and “provide for uniform basic benefits based on a person’s health needs rather than his ability to pay,” and “enhance risk-sharing among income groups, age groups and persons of different health status and residing in different geographic areas.” Hence, health sector has been prodding PhilHealth to expand its coverage.
Article VI provides the funding for the National Health Insurance, consisting of: (a) contributions from Program members; (b) current balances of the health Insurance Fund of the SSS and GSIS collected under the Philippine Medical Care Act of 1969, as amended, including arrearages of the Government of the Philippines with the GSIS for the said Fund; (c) other appropriations earmarked by the national and local governments purposely for the implementation of the program; (d) subsequent appropriations provided for under Sections 46 and 47 of this Act; (e) donations and grants-in-aid; and (f) all accruals thereof.
Furthermore as a comment, experts point out that the Philippine Amusement and Gaming Corporation (PAGCOR) and the Philippine Charity Sweepstakes Office (PCSO) can be earmarked as possible alternative funding sources.
The group has recommended that to make this Act effective, nonetheless, the government should gauge more programs based on the following:
1.Establish a “core package” of health services to be guaranteed by the government, starting with the most essential, cost-effective, and evidence-based health services. The initial package includes immunization and dental services for infants and children; reproductive services including contraceptives, self-breast examination education and mammography, cervical cancer and prostate cancer screening; prenatal check-ups, health worker-assisted deliveries, post-natal care, and breastfeeding counseling; screening and treatment of hypertension and diabetes, and pneumonia and influenza immunization for the elderly; a program of lifestyle modification, including smoking cessation, proper diet, exercise and personal and community hygiene and sanitation; and control of tuberculosis, HIV/AIDS, malaria and emerging infectious diseases;
2.Substantially improve the implementation of the National Health Insurance Act of 1995 by refocusing commitment to the social mandate of universal insurance coverage and guaranteed access for the poor through the Philippine Health Insurance Corporation (PhilHealth);
3.Work closely with local government units to assist them in meeting their responsibilities for health care delivery, including ensuring universal PhilHealth coverage in their localities, improving access to hospital services, implementing holistic socio-economic and environmental programs covering nutrition, food and health services, and establishing floating clinics to reach far-flung islands;
4.Introduce programs to improve health human resource development to meet the needs of the local health system. Such measures could include a special labor/migration policy for the health care workforce going abroad; incentives such as realistic salary scales, non-wage benefits and full implementation of the Magna Carta for Health Workers; and a return¬-of-service contract for graduates of state colleges and universities, among other things;
5.Ensure universal access to essential medicines, particularly the 25—or at least the 12—most critical and lifesaving generic drugs, by making these available in all health facilities and barangays. In addition, compliance with the Cheaper Medicines Act of 2008 and the Generics Law of 1988 must be ensured.