UHC Forward: Towards Universal Health Coverage

The Mutuelle system is still voluntary, and thus steps must be taken to bring about large-scale enrollment of the people. Thus, the “national strategy to extend health coverage through Mutuelles” contains solutions for the slow pace at which Mutuelles grew in the past, for the poor capacities of the players involved in promoting the Mutuelle movement, the management of Mutuelle movement organizations, and the lack of information and awareness about the Mutuelle movement on the national level. It was found that the principal actors were not enlisted sufficiently at the local level in the past. Health care workers, the ASACOs, and the territorial governments were only marginally involved in promoting the Mutuelle movement. By organizing Mutuelles at the commune level, the strategy seeks to have the mayors and local elected officials play an active role in mobilizing the population. The main challenge in promoting the Mutuelle movement for large-scale enrollment thus continues to be implementing a major information and awareness campaign for Mutuelles at the national scale. This is part of the national strategy and advocacy activities that also include local and national leaders .

Since the AMO is mandatory, beneficiaries are enrolled automatically by withdrawing dues from their wages. Benefit eligibility begins on May 1, 2011 for those who have paid dues for six months.

With regard to identifying the indigent for RAMED, the social services in each commune routinely conduct a social survey to assess the situation after interested parties submit an application. The social services or other persons may also prepare an application on behalf of someone else who has not taken the initiative to do so for several reasons. Based on the social survey, the communal authorities issue an indigent card that serves as physical evidence to enroll the member and to obtain the card from the National Medical Assistance Agency (ANAM – the management agency for RAMED) and to obtain care (including the beneficiaries whose applications are submitted to ANAM staff). The status of indigence is always considered temporary, so that the insured member’s card is annual.

PhilHealth coverage is theoretically available to the entire population. The enrollment process differs based on the population group. For example, all formal sector workers must enroll at the start of employment. The poor are identified and enrolled by the local government.

The population is tagged to one of the four major population categorizations:

• Formal sector
• Indigents that are financed by central and local governments
• Retirees (non-paying members) who have already paid 120 months of membership
• The individual paying program (IPP) for those not eligible for the other three categories

The benefits package is essentially the same for each population group. The exception is for indigents and the Overseas Filipino Workers (OFW) who have additional outpatient primary care benefits (with the providers paid by capitation) however these benefits are available only through public providers.

However, the enrollment process for each population category differs. For the formal sector, employees are enrolled upon the start of employment. It is mandatory that all employees enroll in health insurance. No exceptions are allowed for the size of the company. For the poor, the local government determines “poorness” and enrolls those who are determined poor. For the rest of the population there is open enrollment—one can walk into a local enrollment office anytime to enroll.

While enrollment is mandatory only for the formal sector, for the remainder of the population, it is “construed” as voluntary although the law can be interpreted as being mandatory. There is an ongoing debate on the issue of mandated versus voluntary enrollment.

Enrollment in PhilHealth is by family so the premium paid covers the member, the spouse, eligible children (those less than 21 years of age), and eligible parents (those 60 years and above and who depend financially on the member). Given that enrollment is by family, documentation of proof of marriage and birth(s) are required before spouses and children are enrolled. This is a problem for indigenous population as they usually do not have marriage and birth certificates.

While the country has achieved significant strides in moving towards universal enrollment, covering the poor and informal sectors remains a challenge, with methods to enroll these populations through organized groups gaining very little traction. There is much ongoing discussion regarding the need for the central government to finance and/or subsidize the enrollment of the nation’s entire poor population. Leaving financial responsibility for insuring the poorest to local governments, coupled with a refusal to outright declare insurance as mandatory for all populations, makes it nearly impossible for the government to reach universal health coverage. It also forces PhilHealth to invest heavily in marketing campaigns for the program to local governments.

Enrollment in the SP takes place on a per-family basis. A family is composed of the father and/or mother, children and adopted children younger than eighteen or minors younger than eighteen who are dependents and live in the same household, those older than sixty-four years of age who live in the same household, single student children up to age twenty-five, and disabled children. Upon enrollment, families receive a pamphlet with their rights and duties that outlines the health interventions and services to which they are entitled. The SP was intended to be rolled out at the health center level. Regions were permitted to enroll individuals only if they had sufficient facilities and human resources to provide adequate care under the program. Enrollment took place at the municipal level, which meant that many municipalities without adequate facilities were not initially able to accommodate large-scale enrollment. State ministries of health are responsible for promotion of the SP program. Voluntary affiliation takes place on a quarterly basis, but enrollees must wait until the following trimester to begin receiving services. Due to the voluntary nature of the program, enrollees must choose to re-enroll annually.

At the start of the program, the primary strategies for enrollment focused on large-scale affiliation campaigns for vulnerable families. Strategies that have been used to aid in the enrollment and re-enrollment process have included the following: coordinating enrollment activities with other programs targeted to poor populations; promoting enrollment in public gathering places like markets and health clinics; communicating with state and local governments to help identify priority populations; collaborating with local governments to speed the processing of official documentation; re-enrollment invitations through mass-mailings to current enrollees; using mass-marketing campaigns to motivate re-enrollment; and launching special brigades for special enrollment campaigns in localities with low levels of enrollment or re-enrollment. However, due to the fact that there were annual quotas on the number of new enrollees, certain states limited the size of their communication campaigns.

During the first years of the SP targeted populations were given priority affiliation. These included those living in rural regions, those who belonged to poverty alleviating programs such as Oportunidades, and indigenous populations. As of 2009, special targeted populations included newborns and pregnant women. Moreover, the last few years have seen the growth of unemployment leading many families to lose their rights to public services such as IMSS or ISSSTE, which has led to an expansion of the enrollment goals for SP beyond what had previously been established.

During the two years of the pilot program between 2001 and 2003, 614,000 families were affiliated. By the end of 2006, this number had increased to 4 million families. In terms of percentages, in 2005 the SPSS covered approximately 14% of the previously uninsured population. By 2009, this number had reached in excess of 90% of the uninsured.

Table 1: Affiliation Coverage per State, 2009

Source: Secretaria de Salud