UHC Forward: Towards Universal Health Coverage

Jamkesmas offers a comprehensive benefits package, including both inpatient and outpatient care, as well as maternal and preventive care. In terms of medication, enrollees are only entitled to coverage for drugs from specific formularies and must opt for generic drugs when filling prescriptions. Exclusions from the Jamkesmas benefits package include cosmetic surgery, annual physical check-ups, alternative medicine, dental prosthesis and fertility treatment. Cancer treatment and treatment for heart related problems are also limited.

Overall, free access to many providers—both private and public—and a comprehensive benefits package make Jamkesmas more attractive to the majority of the population—even those covered under Askes and Jamsostek. A recent survey in early 2008 entitled “Study on Benefit Package Based on Community’s Preference” conducted by Center for Health Financing Policy and Health Insurance Management at the University of Gadjah Mada has shown that 79.8 % of people who were already enrolled with health insurance schemes, such as Askes and Jamsostek, preferred to be entitled with Jamkesmas benefits as they felt the coverage provided under Jamkesmas was superior to that provided under their existing plan.

The basic benefits package is fairly extensive and purports to cover 95% of all health problems reported in Ghanaian health care facilities, though there is a noticeable emphasis on female reproductive health. Expensive, highly specialized care such as dialysis and organ transplants are not covered by the NHIS. ARVs for the treatment of HIV/AIDS are also not covered as these drugs are supplied by a separate government program.

The health services covered by the NHIS are laid out in the minimum basic benefits package. The list also delineates prescribed medicines. Benefits for maternity care include antenatal care, caesarean sections, and postnatal care for up to six months after birth. Treatment for breast and cervical cancer are included in the package, although treatment for other cancers is not.

NHIS Benefits Package

Outpatient services

• General and specialist consultation services
• General and specialist diagnostic testing, including laboratory investigation, X-rays, ultrasound scanning
• Medicines on the NHIS medicines list
• Surgical operations such as hernia repair
• Physiotherapy

Inpatient services

• General and specialist inpatient care
• Diagnostic tests
• Medication - prescribed medicines on the NHIS medicines list, blood and blood products
• Surgical operations
• Inpatient physiotherapy
• Accommodation in the general ward
• Feeding (where available)

Oral health

• Pain relief (tooth extraction, temporary incision and drainage)
• Dental restoration (simple amalgam filling, temporary dressing)

Maternity care

• Antenatal care
• Deliveries (normal and assisted)
• Caesarean section
• Postnatal care

Emergencies

• Medical emergencies
• Surgical emergencies
• Pediatric emergencies
• Obstetric and gynecological emergencies
• Road traffic accident

Exclusions list

• Appliance and prostheses including optical aids, heart aids, orthopedic aids, dentures, etc.
• Cosmetic surgeries and aesthetic treatment
• HIV retroviral drugs
• Assisted reproduction (e.g., artificial insemination) and gynecological hormone replacement therapy
• Echocardiography
• Photography and angiography
• Dialysis for chronic renal failure
• Organ transplantation
• All drugs not listed on the NHIS list
• Heart and brain surgery other than those resulting from accidents
• Cancer treatment other than breast and cervical
• Mortuary services
• Diagnosis and treatment abroad
• Medical examinations for purposes other than treatment in accredited health facilities
• VIP ward accommodation

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