UHC Forward: Towards Universal Health Coverage

The EHIF covers a broad range of services, including family physicians services, in- and out-patient care, long-term care, rehabilitation, and prescription drugs. Children through 19 years of age are also eligible for free dental care, including preventive and curative services. Meanwhile, adults receive partial reimbursement for dental care.
Patients are free to choose the doctors and hospitals they prefer, since the EHIF contracts with most providers. The primary constraint in the system is the waiting list that a highly preferred doctor or facility may have.

All Estonians register on a family doctor’s practice list. Doctors can refuse to add a patient if the patient lives outside the practice region or when the practice list is full. In 2005 only 13% of patients changed doctors and these cases were primarily due to a change in residence. Family doctors are required to hold a minimum of 20 visiting hours per week and the practice must remain open at least eight hours per day. Patients must get access to their doctor within one day for acute problems and within three days for chronic conditions.

If certain services are not available in Estonia, patients can seek care abroad. In non-urgent situations, patients must seek approval from the EHIF. The service must be medically justifiable and must be proven efficacious with a probability of success of at least 50%.

In order to add new benefits to be covered under EHIF, the managerial board conducts an evaluation process and recommends services to the supervisory board, which then proposes them to the Ministry of Social Affairs where they are reviewed and sent to the government for approval once per year. There are four criteria for including or excluding services from the benefits package:

• Medical efficacy
• Cost effectiveness
• Appropriateness and compliance with national health policy
• Availability of financial resources

The Explicit Health Guarantee (GES) laws contain provisions for basic primary care, emergency care, and targeted health problems. Primary care coverage includes preventative and curative services provided by a physician and a family medicine team. Acute illnesses, preventative health care, health screenings, special programs for mental and cardiovascular health, specialist referrals, and home visits are all part of the primary care menu. Emergency care is guaranteed through a network of facilities covering the entire country. Emergency services provided include pre-hospital care, transportation, diagnostic care, stabilization, and treatment of life-threatening situations. ISAPREs must offer the same benefits covered under the GES. Beyond this, they are free to provide additional coverage to those who wish to purchase it. As of 2008, there were over 10,000 plans available.

Coverage for targeted health problems is assured through the AUGE plan for both FONASA and ISAPRE enrollees. Table 2 outlines the health problems that are included in the plan.

Table 2: AUGE health problems

Source: Bitran, R., Urcullo, G., 105

There are also special FONASA programs such as the Catastrophic Insurance program and the Seniors program. Catastrophic Insurance covers complex and high cost diseases such as cancer, cystic fibrosis, and brain tumors. Meanwhile, the Seniors program is designed to increase the coverage of pathologies that affect seniors over the age of 65 for the Institutional Modality and seniors over 55 for the Free Election Modality. This program is free to those enrolled. Among the benefits included are prosthetics, high-cost procedures, and expedited wait-listing for certain surgeries.

PhilHealth beneficiaries have access to a nearly comprehensive package of services, including inpatient care, catastrophic coverage, ambulatory surgeries, deliveries, and outpatient treatment for malaria and tuberculosis. Those identified as indigent and OFW are also entitled to outpatient primary care.

More specifically, services included range from:

• Inpatient care: a.) room and board; b.) drugs and medicines; c.) diagnostics and other services; d.) professional fees and; e.) operating room services.
  • These benefits are subject to some limits, which differ based on the level of the health facility/hospital (level 1 to 4 hospitals and the Ambulatory surgical centers equivalent to level 2 hospitals) and the severity of the cause of admission (case-type A, B, C and D)
  • Catastrophic coverage also subject to limits discussed above
• Ambulatory surgeries including ambulatory dialysis
• Deliveries
• Outpatient malaria and TB-DOTS care

Except for the outpatient primary care that the poor and OFW are entitled to via public providers, there is free choice of providers for beneficiaries, both public and private.

Annual or lifetime coverage limits do exist. These limits are expressed in terms of volumes of services (e.g., days) rather than a peso coverage limit. For example, member households are eligible for 45 days of inpatient admission, sharing 45 days among all household members. Each day of ambulatory surgery counts as a day of admission.

While there is no formal system that sets fixed deductibles or co-payments, health care providers are allowed to charge the patient the balance between the total cost of care and what PhilHealth pay (i.e., balance billing).

There are some waiting periods before beneficiaries can access care; waiting periods differ by population category:

• Formal sector: 3 months
• Poor: none
• Retirees: none
• Non-poor, OFWs, and others not eligible for other three categories: 9 months for elective procedures and deliveries, 3 months for the rest