A community Health insurance scheme in the Philippines: extension of a community based integrated project
Item
- Title
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A community Health
insurance scheme in the
Philippines:
extension of a
community based
integrated project
- extracted text
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«Macroeconomics,
Health and
Development® Series
Number 19
World Health Organization
Geneva, April 1996
A community health
insurance scheme in the
Philippines:
extension of a
community based
integrated project
by
Aviva Ron
Division of Intensified Cooperation
with Countries
World Health Organization
Geneva
and
Avi Kupferman
J
Organization for Education Resources^F
and Training (ORT) - Philippines J
International Cooperation J
World ORT U lion
J
London
J
j
ACKNOWLEDGEMENTS
The development of this scheme was made possible by the willingness to adopt the concept
and carry out the necessary tasks among the staff of the ORT Mother and Child Community
Based Integrated Project in La Union Province in the Philippines. The authors are especially
grateful to the Manager of the ORT Multi-Purpose Cooperative, Mrs Cynthia Lao and the
Primary Health Care Team, headed by Dr Salvacion Nabua. for their cooperation and hard work.
The support provided by the International Cooperation Division of the World ORT Union
Headquarters in launching the scheme is much appreciated.
The authors are indebted to Michel Jancloes and Guy Carrin of WHO for their useful
comments and suggestions.
1C
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document may not be reviewed, abstracted , quoted, reproduced or translated, in part or in whole, without the prior permission of
WHO.
No part of this document may be stored in a retrieval system or transmitted in any form or by any means - electronic,
mechanical or other - without the prior written permission of WHO.
The views expressed in documents by named authors are solely the responsibility of these authors.
Printed in 1996 by WHO
Printed in Switzerland
TABLE OF CONTENTS
Page
1.
INTRODUCTION
1
2.
FRAMEWORK FOR THE COMMUNITY
HEALTH INSURANCE SCHEME
2
3.
DESIGN OF THE ORT HEALTH PLUS SCHEME (OHPS)
3.1
3.2
3.3
3.4
3.5
4.
Target population
Benefits
Financing
Administration
Information system
5
5
6
8
9
IMPLEMENTATION OF OHPS
4.1 Registration
4.2 The provision of health care benefits
10
11
4.3 Financing
4.4 Information system
12
14
5.
DISCUSSION OF PROGRESS TO DATE
15
6.
CONCLUSIONS
19
Annexes
1. REFERENCES
2. INFORMATION SYSTEM
22
23
1. INTRODUCTION
In poor rural communities, access to basic health care is often severely limited by
inadequate supply, mainly of sparsely distributed government health centres and
hospitals. Access may be further hampered when government funding for health care is
reduced and new public financing policies lead to the introduction of user charges in
these public health care facilities (1, 2). The financial barriers to access may become
even greater when private for-profit services located in nearby towns are the major or
only source of care.
National policies may introduce social health insurance, as part of a broad social
security system or as a separate programme. However, such schemes are usually
implemented in stages, with salaried workers covered first. In many developing
countries, the vast majority of the population will not fit into that group, even when the
schemes cover both public and private sector employees and when family members are
included. Private for-profit health insurance is not likely to cover more than a very small
proportion of the population, as the premiums and costs in these schemes are usually far
above the average per capita expenditure on health care in the country.
Community initiatives to generate health care financing through voluntary
prepayment schemes are an option, but may require a complex process. An underlying
assumption is that direct responsibility for the financial stability of the personal health
care services of a community has advantages recognized by the local consumers.
Another assumption is that if the local community members will themselves contribute
on a regular basis to create this financing mechanism, the government will not decrease
its current level of funding and will continue to guarantee and improve the provision of
public health services. These assumptions are not generally in the forefront in the
process of obtaining health care in poor rural communities.
This situation reflects some of the problems in access to basic health care in poor
rural areas in the Philippines. Government community health centres are the basic unit
for primary health care, including preventive services, but have not yet been established
in many rural communities. Recent devolution of health services has led to decisions
allowing government health care facilities in the Provinces to apply user charges (3).
Regional hospitals, serving as tertiary care centres for a number of Provinces, still
provide most basic services free of charge, but recently introduced user charges, starting
with fees for diagnostic x-ray and laboratory services for both in-patients and out
patients. Over the past two decades, the growth of small private for-profit hospitals has
1
spread to many provincial capitals and towns in the Philippines. Neither the government
nor private hospitals can undertake the primary health care function for dispersed rural
populations.
Some protection exists for salaried workers through Medicare, the health insurance
branch of the Social Security System (SSS) for the private sector and the General State
Insurance System (GSIS) for the public sector in the Philippines. The health care
benefits currently only include limited reimbursement for in-patient care for workers and
their dependents. The Medicare Programme does allow for the self-employed to join,
but affiliation has been slow. This is mainly because of the requirement to enrol in the
overall social security scheme, including pension, invalidity, maternity and funeral grant
benefit branches. The contribution is therefore far more than most of the self-employed
are willing or able to pay. Commercial for-profit health insurance has been growing in
the Philippines, but is concentrated in urban areas, in some schemes through health
maintenance organizations (HMOs) and covers less than 2 percent of the population.
The National Health Insurance Law passed in February' 1995 is aimed at providing
universal coverage for a more comprehensive range of health care benefits (4).
However, universal coverage, to include all rural communities, is likely to take at least
10 years. In the meantime, community projects to develop health insurance schemes,
within the basic guidelines of the Health Insurance Law, are encouraged. Both the Law
and the Implementing Rules and Regulations refer to a process by which such community
schemes will be accredited within the national health insurance system. This paper
describes a voluntary health insurance scheme for residents of poor rural communities
in the Philippines, based on an existing cooperative of a community based integrated
project and designed to gain such accreditation.
2. FRAMEWORK FOR THE COMMUNITY HEALTH INSURANCE SCHEME
The ORT Mother and Child Care Community Based Integrated Project (MCC) in
La Union Province in the Philippines follows the basic model of integrated development
projects implemented by the Organization for Education Resources and Training (ORT)
in a number of countries. ORT is an international non-profit NGO based in London,
currently involved in training and integrated human development projects in around 40
countries.
The main components in the ORT MCC Projects are infrastructure, pre-school
education and basic health services following recruitment and training of local women
2
for the required pre-school day-care tasks, community organizing and livelihood
activities. In the Philippines as in six other countries, the beneficiaries are residents of
selected poor areas, with very limited access to adequate education and health services,
and limited employment opportunities to supplement income from subsistence farming.
Project funding comes from external donors and ORT. At the end of the first
phase, responsibility for the day-care educational function is transferred to local
government. In the second phase the external funding and technical assistance are
directed mainly to developing livelihood activities through training, infrastructure and
marketing activities. In this phase, the Project management also puts emphasis on
increasing the capacity of a multi-purpose cooperative to take on the long-term
responsibilities of all the components.
The ORT MCC Project was implemented in La Union Province in the Philippines
in 1991. By the time of transfer of the educational components to the Provincial
Government in 1994, the Project had a Central Unit and 13 satellites serving 36
communities (barangays), providing pre-school education and basic health and nutrition
services. These health services, provided by a team of paediatrician and 2 nurses, and
the health promoters in each satellite, include prevention (immunization materials
provided by the local government), growth and development monitoring, supplemental
feeding and regular deworming for around 1,000 children enrolled each year in the day
care centres. In addition, health, hygiene and nutrition education are provided to the
parents. The primary health care team are salaried staff, at levels slightly above public
health services salaries.
Over time, the regular visits of the health care team became an important, and in
some communities the only, source of medical consultation for other members of the
family. The severity of illness often seen reflected the difficulties which members of
these communities face in seeking health care and indicated the need for a regular source
of primary health care in the community.
Following a process of community organization, the ORT Multi-Purpose
Cooperative was established with the staff and parents to increase household income in
general and to ensure long-term sustainability of the day-care centres. In accordance
with the charter of this cooperative, 20% of the profits are channelled to sustain the pre
school education activities at the original MCC Project standard.
The livelihood activities range from home-based production of handicrafts using
indigenous materials, satellite (day-care centre) based production of secondary foods, to
3
a bakery and workshops for weaving, carpentry and welding, as well as plantations.
spawn and mushroom production and bee-keeping. The cooperative administration in
the Central Unit manages the construction of workshops, training, purchase of raw
materials, marketing and transport of products, as well as general administration and
accounting. The extension and diversity of the livelihood projects has broadened
participation to all the satellite communities, and increased the Cooperative's capacity
in handling a wide range of management issues.
The idea of adding a health insurance scheme for the ORT Project's beneficiaries
was first raised during an informal visit by a World Health Organization staff member
to the ORT MCC Project in La Union. Preliminary enquiries and calculations were
made by the Project team to determine whether such a scheme could be self-sustaining,
under five conditions and following basic principles linked to the development of such
schemes (5,6):
- the family contribution would be affordable for the majority of the target
population,
- the existing cooperative would handle the administration of the scheme, including
financial control,
- the health care benefits would include both ambulatory and in-patient care, with
a strong primary health care base,
- primary health care would be provided in the day-care centres through a salaried
team, without disrupting the MCC Project health component, and
- hospital based care would be provided through a capitation contract with a
hospital in the area.
Following the positive outcome of the basic calculations and informal enquiries on
the acceptability of such a scheme, the proposal was put to the Assembly of the ORT
Multi-Purpose Cooperative in March 1994. From the beginning, the response was
positive, and endorsement was then obtained from ORT, as the non-governmental
organization responsible for the MCC Project. Planning for the scheme, termed the ORT
Health Plus Scheme, or OHPS, began immediately, with the assistance of the WHO
consultant. The following sections describe the initial design and implementation of
OHPS.
4
3. DESIGN OF THE ORT HEALTH PLUS SCHEME (OHPS)
3.1 Target population:
Three population groups were defined as potential members of the Scheme:
a)
The families of children attending the 13 ORT day-care centres: expected
population of around 1,000 households.
b)
Members of the ORT Cooperative, including ORT staff already enrolled in
the Medicare Programme of the Social Security System of the Philippines,
which has insurance for hospital in-patient care. For this population of
around 110 families, the contribution level was adjusted to cover only
ambulatory care.
c)
The general population of the communities in which the day-care centres are
located.
The total expected coverage for the first stage (3 years) could therefore reach 2,500
households. To limit adverse selection, it was decided from the outset that the family
would constitute the membership unit, and that individual family members could not be
registered. This population has an average of 5 members per family, with dependents
of the household head defined as spouse, children under 18 years of age and dependent
parents residing permanently in the same household.
However, the real potential registration in the first year was considered to be less
than 300 families, taking into account the lack of familiarity with such schemes.
Eventual extension of coverage would also take into consideration the need for physical
expansion of the day-care centre facilities for the delivery of health care, without
compromising the educational components of the ORT MCC Project.
3.2 Benefits
The benefit package was designed to include ambulatory and in-patient care,
prescribed drugs and basic ancillary services included in specific lists. The design opted
for the direct delivery of primary health care, with salaried doctors and nurses providing
services in the existing pre-school day-care centres, termed satellites of the MCC Project.
A grant from the Australian Embassy enabled adaptation of the Central Unit and day care
centre health rooms to store drugs and assure privacy during the consultations.
5
The ORT MCC Project primary health care team, then consisting of a paediatrician
and two nurses was strengthened by adding two part-time doctors, and the roles of the
health promoters and nurses in the satellites were redefined. The emphasis on primary
health care was strengthened by the referral system, which requires consultation with the
OHPS doctor for referral to hospital out-patient or in-patient services. Dental care was
not included in the first stage.
According to the design, hospital based diagnostic and therapeutic services on an
out-patient or in-patient basis would be limited to a provider with which a capitation
contract would be reached. An agreement was negotiated with a private non-profit
hospital in the Provincial capital to provide hospital based care, with in-patient care to
be covered following a two-month qualifying period for each OHPS member on a
capitation basis. For the OHPS members covered by Medicare, referrals could also be
made to the government Ilocos Regional Hospital in the area, which has full secondary
and some tertiary care services. Most services are provided free of charge in this
hospital, but user charges have recently been imposed for some diagnostic tests.
Drug benefits were defined as prescribed drugs within an Essential Drug list
(generic) to be developed from the WHO Essential Drug List adapted for the Philippines,
and covering the most commonly used drugs in primary health care. Non-prescribed
drugs could be sold in the satellites, at cost plus 20%, which is far below the cost in
private pharmacies in town. For the non-insured residents of the communities, drugs
could be purchased at cost plus 50%.
3.3 Financing
Revenues were planned to come mainly from family contributions paid regularly
to the OHPS fund, managed by the ORT Multi-Purpose Cooperative. It was decided to
enable contribution payment on a monthly, quarterly, bi-annual or annual basis, taking
into account income flow patterns in the target population. Contributions were calculated
for two types of membership: with and without membership affiliation with the Medicare
Programme. Three contribution levels were set:
a) Single (18 years old and above) .
b) Standard family, with up to 6 members, including parents, dependent children
(up to 18 years) and dependent parents.
c) Large family, with over 6 members, including dependent children and dependent
6
parents.
The monthly contribution for the single person was set at P 50 per month, for the
standard family was at P 100 and for the large family at P 130 per month. The monthly
contribution for the families with hospital coverage through the Medicare Program of the
Social Security System was set at P 25 per month for the Single Person, P 70 for a
standard family and P 95 for the Large Family. The exchange rate since the launching
of the scheme has remained at around 25 pesos to one US dollar.
It is difficult to define these amounts in terms of percent of household income in
the area, as data were not collected. The amounts above did not result from actuarial
calculations, but from proposals and then discussions within the Cooperative Assembly
regarding levels which were considered affordable for the majority of the population.
The amounts were considered less than half the amount most families spent each month
on basic health care, excluding in-patient admissions. This monthly contribution was
favourable compared to the probability of having to seek loans to pay for an in-patient
admission, which has been reported to be the usual way of dealing with such
contingencies among the rural poor in the Philippines (7). For those with in-patient care
coverage through Medicare, the out-patient benefits, particularly the primary health care
services in the community, were very attractive for a monthly prepayment of P 70 per
month.
For the initial period, it was decided that the ORT MCC Project would continue
to pay the salaries of the paediatrician and the two nurses who would continue their
work, including health care, training and supervision, in the pre-school day-care centres.
On the assumption that the minimum target registration could be achieved in the
first year, this figure was then used to develop the expenditures budget and determine the
per capita amount to be offered as payment for hospital services. The scheme has no co
payment or deductible elements.
Other sources of revenue were expected to come from the sale of non-prescription
drugs, on a cost plus 20% basis for OHPS members, and charges to non-insured
individuals in the communities for consultations, set at P 50 per consultation, and for
drugs at cost plus 50%.
7
The expenditures budget was based on the following allocation:
Hospital based care through contracts
Primary health care team salaries
Essential drugs and medical supplies
Health promotion activities
Transport and other supplies
Ancillary services
Contingency fund
Administration
30%
25%
25%
2%
5%
5%
4%
4%
Total
100%
3.4 Administration
The scheme was planned to be administered by the ORT Multi-Purpose
Cooperative, through its management located in the Central Unit. This management was
given responsibility for all financial transactions, such as the banking of revenues
(collected mainly through the health promoters in the satellite day-care centres), payment
of salaries to the primary health care team, quarterly capitation payment to the hospital
and the purchase of drugs and medical supplies.
An essential drug list was defined, based on the Primary Health Care Essential
Drug List of the national level Department of Health and the experience of the ORT
MCC Project, and drug stocks for the Central Unit and satellites were planned to be
purchased by competitive bid.
The ORT paediatrician serves as leader of the primary health care team and is
responsible for the hiring of staff and work schedules of visits to the satellites. Schedules
were developed for a primary health care doctor and nurse to visit each satellite once or
twice a week, according to the number of members, but also taking into account the
travel time and distance to the satellites. Consultations were planned at the Central Unit
five days a week. The OHPS doctors were asked to follow-up patients referred for
hospital services, as a quality assurance measure in the new capitation environment, and
to provide continuity of care.
8
3.5 Information System
An information system was defined to serve the management and health information
purposes of OHPS, including membership registration, contribution payment, utilization
of specific services, drug orders, purchases and sales and financial accounting. Through
the grant from the Australian Embassy, a computer was purchased and installed in the
Central Unit for this purpose.
A household and individual membership number was defined for each contributing
unit (household), and a single OHPS membership card was designed for each household,
to list all family members, allowing for recording of twelve months' contribution.
Recording is registered on the card by affixing a specially printed stamp for each
calendar month for which payment is made. The data base could then generate lists of
insured families and the number of individuals by community, to facilitate capitation
payment to providers and to plan primary health care activities in the satellites.
At satellite level, patient care recording was planned at satellite and individual
patient level. Log-sheets were planned to record each contact (visit and/or purchase of
drugs), with aggregate data to be transferred from each satellite to the Central Unit on
a monthly basis. Family folders were designed to keep medical records in each satellite.
OHPS referral and response forms were designed for referral of patients for hospital out
patient and in-patient services, and thereby to monitor the use of services provided
outside OHPS. Forms were also designed for the monitoring of high-risk individuals,
defined as pregnant women, and individuals with active tuberculosis, hypertension and
diabetes. A leaflet on the basic features of OHPS, including contribution rates, benefits,
referral and other conditions, was printed in English and Tagalog, and distributed in the
target communities.
Examples of the leaflet, registration card, the computer screen for data entry to
create the membership data base and the various forms are shown in Annex 2 of this
paper.
9
4. IMPLEMENTATION OF OHPS
4.1 Registration
OHPS was implemented in July 1994. through a registration campaign conducted
in the Central Unit and all the satellite communities. At first there was steady growth,
beginning with registration of the majority of the ORT Cooperative members. The
number of members then decreased over the Christmas period, indicating the change in
priorities over that time. In the initial stage, that is, during a period of familiarization
with the health insurance concept, it was considered important to encourage registration
at any time during the year, and to offer monthly, quarterly or semi-annual payment
options. This flexibility was weighed against more rigid registration and contribution
payment options, such as annual or semi-annual bases, which could have simplified
administration and reduced the priority dilemma regarding household expenditure around
the Christmas period. However, few families in these communities are considered able
to pay in advance for a year or even 6 months membership.
To deal with the drop-out problem in the first year, a Christmas campaign was
launched and donors were found to sponsor a number of families for limited periods.
This was important in maintaining the minimum number of members, until the ORT
Cooperative staff undertook to campaign in all the communities, using a competition
approach among the MCC day-care centre staff and volunteers to register the highest
number of new members.
In January 1996, that is, 18 months after the initial registration, 292 families were
registered, increased from around 220 families after the first year. These families
included 148 families with only OHPS coverage and 144 with Medicare membership (for
in-patient care), most of the latter being members of the ORT Cooperative. The total
number of individuals covered in both groups was 1,301. Membership by satellite
appeared to grow with experience of the families in not having to face a financial
problem in paying for hospital in-patient care. Peak registration was 320 families,
following a membership drive with incentives to health promoters. However, some
families dropped out (failed to pay contributions for two months) in November and
December of 1995, again indicating priorities around Christmas.
10
4.2 The provision of health care benefits
From the beginning of implementation, the OHPS primary health care team began
regular weekly or bi-weekly visits to the 13 satellites and daily attendance at the Central
Unit. Over the first year, schedules were adjusted several times to make appropriate
recognition of travel time to the satellites, and the changes in demand as membership
grew. Although only two or three families registered in the first months in some
satellites, regular visits were continued.
Negotiations were conducted with the pharmaceutical suppliers to obtain favourable
prices for the drugs on the Essential Drug list. As the Project site is at least 5 hours
travel time from Manila, and local suppliers requested high prices, it was decided to
begin with a two-month drugs stock, and maintain a two week supply. The Essential
Drug list was reviewed and modified every 6 months, based on actual experience with
the need for each drug. The ORT Cooperative funds were used to create the initial stock
of drugs and medical supplies in the Central Unit and satellites.
The availability of non-prescribed drugs at community level turned out to be an
important advantage in the scheme. The charge of cost plus 20% for the non-prescribed
drugs is far below the price in private pharmacies, where the average cost to the patient
is four to ten times the OHPS charge. The sale of drugs in the satellites was also
recognized as a source of revenue which could in fact overcome initial problems in
balancing revenues from contributions and fixed expenditures in the first period.
However, the first financial review (after 6 months) showed that credit was frequently
extended to those who did not have the cash to buy the drugs. The decision to stop credit
for drugs in the Central Unit and satellites was difficult to implement, reflecting some
lack of understanding of the necessary financial controls in such a community health care
system.
In addition, it appeared that drugs stocks at the satellite level needed to be
improved to avoid having to reimburse for prescribed drugs purchased from private
pharmacies. After the first year of implementation, responsibility for the drug
procurement, distribution and monthly inventory was given to the OHPS nurse. The list
of drugs, ordering and distributions system were revised and members were informed
that costs of drugs purchased outside OHPS would not be covered.
It was also
necessary to reinforce the concept among both OHPS staff and members that the scheme
is not a reimbursing mechanism. As a result of the modifications in the Essential Drug
list and in the procurement and satellite distribution system, no reimbursements were
made for prescribed drugs bought in private pharmacies in the last quarter of 1995.
11
Following conclusion of the agreement with the non-profit private hospital in the
provincial capital, hospital services began in September 1994. The number of patients
referred and admitted to hospital in the first year was lower than expected (estimated for
the purpose of calculating the hospital per capita payment). Patients reported their
satisfaction with the hospital stays, a factor which contributed to the popularity of OHPS.
However, major problems arose with the hospital in treating the first patient requiring
a surgical procedure, in this case, a Caesarean section. When the hospital submitted an
itemized bill amounting to over P 20,000 for this case, OHPS refused payment, in
accordance with the contract. The ensuing discussions around the case led to a better
understanding of the capitation arrangements by the hospital, and some adjustments in
OHPS benefits.
Although the hospital is a non-profit institution linked to a religious organization
and receives financial support from abroad, it turned out that most of the medical care
was provided by "private" physicians with attending out-patient and in-patient privileges,
who expected to be paid at conventional private practice charges. To deal with this
problem, the OHPS physicians not only had to follow but serve as attending physician
for OHPS patients when hospitalized. It became necessary to allow referrals to a limited
number of specialists for ambulatory care. In these cases, OHPS now pays a fixed
amount directly to several specialists on a limited list. The hospital recognized the
inclusion of all ambulatory diagnostic tests, mainly x-ray and laboratory, through the
capitation agreement.
Investigation also revealed that the maternity benefits were a strong incentive to
membership. It was suspected that this might be temporary membership, mainly to use
the pregnancy-related benefits. Changes were then introduced in eligibility for maternity
benefits. Hospital delivery benefits were only approved if the family had been a member
of OHPS for at least 12 months, and if the pregnant woman followed a pre-natal protocol
of visits to the OHPS primary health care team. This was done to facilitate timely
referral to an obstetrician in the hospital of women defined as having high risk
pregnancies.
4.3
Financing
At the end of 1995, accounting was made of all revenues and expenditures, with
emphasis on current monthly operating figures. On the revenues side, it appears that
revenue from the sale of non-prescription drugs was higher than expected. This should
be seen as a positive factor, as it basically reflects the importance of availability of these
basic drugs in the community. On the expenditures side, the allocations did not follow
12
the plan, but the general principles were kept. Some of the start up but essentially
current cost items were covered by the ORT Cooperative, such as the initial two month
drug supply. An additional and unplanned expenditure was the payment to specialists for
consultations not provided by the hospital.
Based on the last six months of 1995, an appraisal of the average monthly operating
budget is given below (in Philippine Pesos):
Revenues
Contributions
Drug sales
Consultations to
non-members
Total
Expenditures
P 23,000
P 10,500
P 1,000
P 34,500
Salaries
Drug purchases
Payment to hospital
Payment to specialists
Transport, forms
Miscellaneous
P
P
P
P
8,000
14,000
6,000
1,400
P
2,000
Total
P
31,000
The figures above should not be seen as a surplus in the monthly or annual budget,
as the OHPS primary health care salary component is still partly funded by the ORT
Cooperative (which currently pays the salary of one doctor and the two nurses). In the
initial period, health promotion activities were funded through the MCC Project activities
and transport was also assisted by the Cooperative vehicles. However, the above
appraisal does indicate that the scheme could be financially viable with an increase of
membership. Not all costs would increase proportionately, as the three doctors could
well handle a larger patient load than the current number of around 1,300 individuals.
It is currently estimated that around 500 families would allow for a balanced
budget, taking into account additional monthly expenditure allocations of P 1,000 for
membership promotion (including incentives to promoters), and P 1,000 for health
education to the members and training for the OHPS staff.
At this point, no increase in the contribution rate is contemplated, as this could
deter an increase in membership. However, an increase in salary or increment through
incentive payment linked to the load of insured persons may be considered for the OHPS
primary health care team as membership grows. On the other hand, analysis of drug
prescribing in the daily log sheets in the satellites shows some room for a decrease in
13
expenditure on antibiotics, possibly through health education on rational drug use for
both members and the OHPS primary health care team.
4.4 Information system
Following purchase of the computer, the ORT Cooperative clerk underwent
training and began to set up parts of the system, beginning with orders and accounts for
the drug supply, schedules for the primary health care team and other management
functions. The membership data base is now being created, as the registration form
information, with basic demographic data on the households, is now entered into the
computer. The software selected for the membership data base components was Excel
5 in the Windows environment, and the team are now undergoing training in Access to
facilitate the generation of reports.
Over time, the primary health care team, and the health promoters in the satellites
became used to the daily contact log, to register patients and record their chief
complaints, drugs prescribed or sold and referrals. These forms are now used on a
regular basis and will become an extremely useful source of information on utilization
patterns in the second year.
The separate register of high risk patients revealed what appeared to be an
excessive prevalence of adults and children with active tuberculosis. The number of
cases as a percentage of total insured population, and the diagnostic measures used were
discussed with the WHO Regional Advisor on tuberculosis. It was observed that the data
could represent a significant proportion of false positives, due to the diagnostic methods
used. As a result, updated information on the diagnosis and treatment of tuberculosis has
been given to the OHPS primary health care team. With the Regional health authorities,
a plan is now being developed to diagnose, treat and monitor all tuberculosis patients in
the target population.
The information on patients recorded by the OHPS primary health care team on
tuberculosis could perhaps be considered indicative of the need for continuing medical
education among health care providers in rural areas. The potential to provide such
education through the development of a community health care financing scheme was
clearly recognized. As noted in the section on financing above (4.3) a monthly allotment
for staff training was budgeted from March 1996.
14
5. DISCUSSION OF PROGRESS TO DATE
Although the experience of less than 18 months of operation is insufficient to reach
major conclusions, an initial appraisal shows that OHPS has made health care affordable
and accessible to the target population, composed mainly of low and often unstable
income families in rural areas. The experience is insufficient to provide an in-depth
evaluation of the impact of the scheme, but does allow for several conclusions to be
drawn regarding the operation of the scheme to date.
The fluctuations in membership due to drop-outs at the end of 1994 and 1995 do
not always indicate a severe lack of funds in the member families. It is likely that some
drop-out resulted from a change in household expenditure priorities in the holiday
season, and the lack of familiarity with the insurance or prepayment concept.
Membership by satellite shows that interest and registration increased after an in-patient
admission of an insured resident of the community. At the same time, the situation at
the beginning of 1996 shows that registration is lowest in the communities in which
livelihood projects are at an early stage, that is, where household income has not yet
increased in a significant number of families.
The OHPS management, through the health promoters in the satellites, have been
fairly accurate in their identification of the real cases of inability to pay contributions.
Sources of sponsorship of part of the contributions for some of these families have been
found, but the mechanism of subsidized contributions for specific families over a limited
period of 3 to 6 months may not be the best way to sustain membership. Some families
were unable to continue to pay their own contributions after several months of subsidy
and therefore dropped out. Knowledge about possible subsidies also generated some
negative competition among families to acquire this assistance, leading to unnecessary
pressure on the health promoters. It may be more appropriate to use any donations to
reduce or maintain the same contribution rate for all members. Current efforts to
identify new sources of funding for this purpose should be kept up.
Recent months have shown a more rapid increase in registration following
promotion campaigns at community level and spreading of the word on positive
experiences, mainly of not having to pay for hospital services at the time of hospital
admission or discharge. Several small business in the provincial capital, where the
Central Unit is located, have begun to register their workers for OHPS membership to
cover ambulatory care. The Cooperative Manager has been appointed Ombudsman and
the marketing staff of the ORT Cooperative have been asked to increase assistance in a
membership promotion drive, and will propose methods and registration incentives, with
15
500 families set as the target for mid-1996.
In January 1996 a community outreach project of the Ilocos Regional Hospital
requested OHPS affiliation for residents of communities "adopted" by the hospital.
Following several months of negotiations and surveys in the communities, a contract
between OHPS and the Ilocos Regional Hospital was signed early in April, to be
implemented in June 1996. According to this agreement, residents of communities
adopted by the Ilocos Regional Hospital and residing in the vicinity of the ORT MCC
day-care centres will be able to register. In a later stage, and depending on interest, the
OHPS team could be expanded to provide primary health care in government health care
centres in additional communities. This is extremely important, as many of the existing
government health care centres in the area are not served regularly by primary health
care doctors and do not dispense drugs.
According to the agreement, the Ilocos Regional Hospital will provide all the
hospital-based services through the capitation agreement under favourable conditions for
the OHPS members. Attention will be given to waiting time for out-patient and in
patient care, and in-patient care conditions will be equivalent to those for members of
Medicare. This implies patient rooms with fewer beds and more comfort amenities than
for the general public. The OHPS doctors will follow hospitalized patients but not take
on responsibilities as attending physicians, as under the current practice with the private
hospital.
In addition, a membership campaign has been undertaken to register members in
a network of women home-based workers, assisted by an International Labour
Organization Project supported by DANIDA in rural areas in Thailand, Indonesia and
the Philippines. The Philippines network has two chapters with around 100 families in
the ORT MCC Project area. The possibility to join OHPS fits well into the objective of
attaining social protection for these homeworkers.
The initial accounting exercise does allow for two basic conclusions regarding the
budget. First, the current contribution level can be maintained. Throughout the period
of implementation, modifications have been made in eligibility requirements and the
provision of some benefits, such as maternity benefits and the list of prescribed drugs.
However, it would be difficult to ask for higher contribution rates at a time of major
effort in spreading the insurance concept to register new members. The challenge now
will be to maintain the same contribution level by controlling costs through reduced
expenditure on antibiotics and to extend benefits in the areas of counselling and health
promotion, to cover for example, family planning, substance abuse, nutrition and hygiene
education.
Second, the capitation payment to the hospital does not need to be increased. The
actual use of in-patient care, including the small number of "higher-cost" patients has
demonstrated the financial and administrative advantages of the capitation payment to the
hospital. The failure of the hospital to provide all the physician services covered in the
contract within the capitation arrangement led to some excess expenditure for out-patient
consultations. This will require adjustment in the budget in the future, depending on the
decision on how best to cover specialist consultations.
A considerable increase in membership could allow for "retainer" contracts with
a limited number of specialists, such as a surgeon and obstetrician-gynaecologist. At the
same time, the agreement with the Ilocos Regional Hospital to extend OHPS coverage
in its "adopted" communities should allow for a more favourable arrangement for out
patient services in all the major specialties. It will also provide an alternative for in
patient care through the Regional Hospital, which is the government tertiary care hospital
located in the centre of the geographical area covered.
The hospital capitation payment system is one of the mechanisms to reduce
financial risk. The other is the fixed cost component for primary health care, through
the direct delivery system using salaried doctors and nurses. At this point, some
economies of scale are lost as the three doctors could probably handle a larger patient
load in each of the satellites. However, the ability to plan this expenditure through
salaries has been more useful than any possible savings which may have occurred if the
health care providers had been paid on a fee-for-service basis. The experience of setting
up the scheme in this way avoided potential problems of provider generated demand
linked to a payment mechanism.
The budget appraisal for the second full year should provide a better indication of
the financial viability, at the present contribution level, as current revenues and
expenditures can be taken into account for a full twelve months period. During the
second year, some initial confusion regarding recording of drug revenues (from sales),
expenditures for purchase and some reimbursement should disappear, so that a proper
analysis of the financing of prescribed and non-prescribed drugs can be done.
The major factor in the successful launching and operation of the scheme is
probably the sound administrative structure provided by the ORT Multi-Purpose
Cooperative. The positive approach and performance was no doubt dependent on the
financial and moral backing of the ORT Philippines Country Office responsible for the
17
ORT MCC Project, as part of the World ORT Union. The challenge for non
governmental organizations to take on a role in health care financing has been noted in
reviews of the realities of government and household expenditure on health in developing
countries (8), and this scheme is an example of such a development.
The ORT MCC Project and its Cooperative management team was clearly
interested in achieving success in the scheme, and understood the basic underlying
objectives of enabling access to health care in the target population. The team was
guided to see the scheme not only as a viable and equitable financing mechanism, but
also as a community based health care delivery system, with a significant role in
improving the health care and health status of the target population. As the livelihood
projects enable increased household income in this population, OHPS is seen as a way
to provide access to health care and to enable more rational household expenditure on
health through an affordable prepayment mechanism.
The Cooperative was able to allocate staff time and funds as required in the set-up
period, and apply experience gained in both community organizing and the management
of the livelihood activities to the various tasks required for OHPS. Savings were
obviously made by having the ORT Cooperative transport system to help the primary
health care team reach the satellites and to distribute drugs and other supplies on a
regular basis.
Over time, the commitment of the ORT Cooperative management team and the
primary health care team have led to greater interest in the objectives and operational
aspects of community health care financing. The recruitment of the part-time doctors has
not presented problems, despite the need to work in different locations during the
working week, and often inconvenient transport, due to distance and weather factors.
As one of the nurses was given responsibility for drugs, the other has been given
responsibility for all non-clinical management.
In February 1996, this nurse
administrator was sent to the national headquarters of the Medicare Program of the Social
Security System for a specially designed course. The main focus of the training was on
administration, such as the membership data base, monitoring of contribution collection,
the computer department, quality assurance and membership assistance. However, the
course also provided the opportunity first to observe the major elements of the national
compulsory social security health insurance system, and compare these with OHPS as a
community voluntary health care financing scheme. As membership grows, training in
the relevant areas will need to be broadened to include health insurance management
aspects as well as clinical and public health issues.
18
Sustainability is obviously dependent to a large extent on the continued
development and particular commitment of the ORT Cooperative. In this context,
membership growth will probably be a major factor in long-term sustainability. This is
important not only for purposes of reaching financial viability, but to prevent stagnation
in interest and activity among those responsible for the day-to-day implementation. The
outlook for membership growth is currently optimistic, but the need for constant
monitoring and review of trends should not be underestimated.
In addition to continued financial monitoring, periodic attention will need to be
given to staff incentives and membership campaigns, as well as to adjusting and
extending benefits to deal with the changing needs and preferences of the insured
population. It is certainly likely that contributions will also need to be adjusted at
reasonable intervals to reflect changes in benefits, changes in health costs and inflation.
The cooperative mechanisms of review and approval through its assembly should be
more favourable than a one-sided decision by a health care financing scheme without
member or community participation.
6. CONCLUSION
The establishment of OHPS as part of the implementation of the Philippine
Government national policy on health insurance is in itself an incentive to achieve
success, to be measured in membership growth, financial viability, satisfaction and
among the insured population and the health care providers and improved health status.
The cooperative framework, with its built-in member participation mechanisms, appears
to be a major factor in finding the optimal administrative base for such voluntary health
insurance schemes.
There is considerable interest in finding social protection mechanisms based on
community participation in financing and management for low income and disadvantaged
populations (9,10). It may be tempting to look at such experiences in order to develop
models for community health care prepayment or insurance schemes. At this stage,
several points of caution are indicated.
First, we should not attempt to provide the elements of such schemes as models
with transferable knowledge and techniques, but emphasise that any serious appraisal
requires monitoring over a longer period, with a larger insured population and a sound
analysis of the factors for success and failure. There is a tendency to superficially
summarize such schemes as mini health maintenance organizations (HMOs) without due
19
appraisal of the various elements involved.
Second, the development of such schemes should take into account the specific
characteristics of each community, the factors indicating potential success or failure in
the communities, and the conformity of this kind of community effort in the local and
regional health care financing policies. Even if we begin with the assumption that
understanding of the insurance concept needs to be developed, we should have an
appraisal of the approach to solidarity in the target populations. The scheme reported
here was planned on the basis of principles rather than data from local studies. Reliable
data on health care costs and expenditure, utilization patterns and morbidity in the target
population would undoubtedly assist the planning process. With this knowledge, and
insight into community leadership patterns, appropriate promotion and marketing
strategies to implement the scheme can also be developed.
Cooperatives created through livelihood projects may be an important base in
establishing such schemes. However, other organizational structures may be needed to
cover other urban or rural populations. These may be mutual associations created by
various types of affiliation, in which case the relevant knowledge and skills developed
in cooperatives may need to be added to basic accountability and member participation.
Other options may be through health care providers, in which case the for-profit issue
will need to be dealt with.
The third aspect of caution relates to national policy on health care financing in
developing countries, particularly for those populations currently left out of existing
social security systems for the salaried sector and private commercial insurance. The
concept of community prepayment schemes may be attractive, but whether it can be
advanced as the optimal method at national level involves many other issues. One crucial
issue is whether indeed a multitude of independent community schemes should be
encouraged.
Many such schemes may be successful, but there are implications regarding limited
possibilities for the pooling of resources and spreading of risks on the one hand, and the
loss of opportunities for cross-subsidization by populations with higher and more stable
incomes on the other. The issue of who will pay for the very low income and noneconomically active populations in these communities needs to be addressed. In addition,
the administrative capacity to plan, launch, operate and monitor a multitude of small
schemes may be questionable.
At the very least, the proliferation of such schemes could benefit from national
20
guidelines, a formal accreditation process, and an umbrella organization to provide
assistance in design, training and information services. The nature of such an umbrella
organization, that is, as a government, quasi-government or non-government body, will
determine the application of the results of monitoring and evaluation.
The development of a sound national policy will no doubt be assisted by such
experiences as the one described. The continued monitoring of such schemes will also
facilitate the eventual development of national guidelines, covering such elements as
minimum benefit packages and provider relations, the development of training,
monitoring and research facilities and the creation of the optimal umbrella organization.
The involvement of government, non-government and the country's academic institutions
at regional and national level should be an integral part of the development process.
Opportunities to review and compare community health insurance schemes at national
and international level, with objective discussion of the factors related to success and
failure, should enable increased access to health care through a stable financing
mechanism.
ANNEX 1
REFERENCES
1. Abel-Smith, B. and Dua A.: Community Financing in Developing Countries: The
potential for the health sector, Health Policy and Planning, Vol.3, No. 2, 1988.
2. Waddington, C.J. and Enyimayew, K.A.: A Price to Pay, Part 2: The Impact of User
Charges in the Volta Region of Ghana, International Journal of Health Planning and
Management, Vol. 5, 1990.
3. Nanagas, J.R. et al: The Management of Philippine Hospital Services Post
Devolution, Department of Health, Republic of the Philippines, Manila, 1995.
4. Republic of the Philippines: An Act Instituting a National Health Insurance Program
for all Filipinos and Establishing the Philippines Health Insurance Corporation for the
Purpose, Republic Act No 7875, Congress of the Republic of the Philippines, Manila,
Official Gazette April 17, 1995.
5. Ron, A. Planning and Implementing Health Insurance in Developing Countries:
Guidelines and Case Studies, Macroeconomics, Health and Development Series, No. 7,
World Health Organization, Geneva, 1993.
6. Ron, A. Abel-Smith, B. and Tamburi, G.: Health Insurance in Developing Countries:
The Social Security Approach, ILO Publication, Geneva, 1990.
7. Costello, M. and Palabrica-Costello, M.: Health Care Financing for the Rural Poor:
A Comparison of three Policy Options, Regional Conference on Health Sector Reform
in Asia, Asian Development Bank, Manila, Philippines, May, 1995.
8. Evlo, K. and Carrin, G.: Finance for Health Care: part of a broad canvas, World
Health Forum Vol. 13, 1992.
9. Moens, F.: Design, Implementation and Evaluation of a Community Financing
Scheme for Hospital Care in Developing Countries: A Pre-paid Health Plan in the
Bwamanda Health Zone, Zaire, Social Science and Medicine, Vol. 30, No. 12, 1990.
10. Arhin, D. Rural Health Insurance: A Viable Alternative to User Fees? Department
of Public Health and Policy, Health Policy Unit, PHP Departmental Publication No. 19,
London School of Hygiene and Tropical Medicine, London, 1995.
22
ANNEX 2
INFORMATION SYSTEM
Page
1.
Leaflet for community residents
25
2.
Registration Card
27
3.
Membership data-base Computer Screen
28
4.
Table of OHPS Membership by month
29
5.
Graph of OHPS Membership by Month
30
23
World Health Organization
"Macroeconomics, Health
and Development Series"
WHO/ICO/MESD.19
Add.l
A community health insurance scheme in the Philippines:
extension of a community based integrated project
You have recently received a copy of the document
WHO/ICO/MESD.19.
Please insert the attached pages after page 23 of the document.
Sorry for the inconvenience caused.
6.
SERVICES TO THE NON-INSURED
services,
including
nurse
and
doctor
consultations and drugs, maybe provided to
non-insured residents in the barangays in the
ORT MCC satellites and Central Unit al defined
charges, which will be higher than lhe monthly
contribution rate.
These services will no!
include hospital care. Prescribed drugs could
be sold to them at cost plus 50%
7.
Maternity benefits will only be provided
after 6 months contribution. Palienls should be
seen by the OHPS Physician al least (i tunes prior
to expected dale of delivery
Services will be provided Io new bom
children on registration of their names on the
family membership card, without a qualifying
period
World ORT Union Philippines
Guerrero Road, San Fernando, La Union
Tel. 41-50-80/41-48-50 loc. 46
LIMITATIONS - al this stage the following
services will not be covered:
dental care.
cosmetic surgery, and specialist care that is
not provided by [lelhuiy Hospital, such as
organ transplant and open heart surgery
Medications tor chronic illnesses (Diabetes
mellilus. Tuberculosis. Hypertension, etc.) are
not included but will be sold (it available) at
affordable prices In-patient hospital care will
be covered up to 15 days
bo
V.
QUALIFYING PERIOD
Primary health care benefits will be given
after payment of one month's contribution and in
patient benefits will be piovioed after 2 months'
contribution
Benefits will not be given if lhe
monthly contributions have not been made for two
(2) consecutive months and more than one (1)
interruption of one month over a twelve (12) month
period
New members will have to pay initially 3
months coniribulion then monthly, quarterly or
bi-annually depending on their preference.
thereafter
ORT HEALTH PLUS
SCHEME
I.
PRINCIPLE
ORT Health Plus Scheme is a self-help
program to provide health care among
the
members through a community prepayment scheme
to create a fund to finance the program
C.
Joining and Collection Frequency
Joining can be done every 1st week of the
month First payment will be done within one week
of joining
SUBSEQUENT PAYMENTS:
II.
1 Monthly
ro
III.
CONTRIBUTIONS TO THE SCHEME
A.
Rate if Non-SSS/GSIS member
1
Single (18 years old and above)
P50 00/monlh
Standard Family (G members and
below)
PlOOOO/month
Large Family (more than G members)
PlOOOO/month
2.
3.
IV.
1.
2
3
I
2
3
PREVENTIVE CARE -
5.
HOSPITAL CARE - In-patient hospital
- 1st week of every month
Quarterly - 1st week of every calendar quarter
(March. June. September. December)
Semiannually - 1st week of January and July of
every year
BENEFITS
CONSULTATIONS - nurse and doctors
consultations in the ORT MCC satellites and
Central Unit on a regular weekday basis
On weekends, only
consullalions at Bethany Hospital
2.
B.
4.
MEMBERSHIP
This is open to all members of the ORT
Multi-Purpose Cooperative, family members of the
children attending ORT Day Care Center and the
general population of the barangays in which the
centers are located.
CD
Hospital (free of charge), by arrangement
with the ORT Health Plus Scheme Patients
will be sent lo this provider, as the ORT
Health Plus Scheme may not be able lu
transfer specimens in the first stage
emergency
DRUGS - dispensing of essential drugs
prescribed by OHPS doctor or nurse-free of
charge - through the ORT MCC satellite and
Central Unit.
Drugs prescribe for use
following discharge from the hospital will be
dispensed by the ORT Health Plus Scheme
(OHPS) Non-prescription drugs will be sold
to members al defined prices
Rate if SSS/GS1S member
Single (18 years old and above)
P25 00/inonlfi
Standard Family (G members and
below) P70 00/monlh
large Family (more than b members)
P95 00/month
3.
ANCILLARY SERVICES
-
diagnostic
services which can be done in the satellite
facilities will be done by the nurses and
doctors Ollier tests will be done by Bethany
iinmumzatioii.
prenatal and well-baby care will be provided
in collaboration with the Rural Health Care
Units
care will be provided to NON-SSS/GSIS
members and out-patient services, including
x-ray
and
laboratory
lest
(except
Ultrasound) will be provided lo all members
al Bethany Hospital in San Fernando The
in-patient
services include.
room and
board, medical examinations and procedures
including
surgery,
drugs,
x-ray and
laboratory services. These services will be
provided free of charge by Bethany Hospital
only on referral from the OHPS nurses or
doctors, and on presentation of a valid OHPS
membership Card
OHPS will not cover
services provided by Bethany Hospital without
referral or approval except emergencies, or
for special accommodation services (private
room, telephone, and TV m patient room)
For GSIS/SSS members, only out
patient sei vices are covered by OHPS
OHPS will not reimburse payment
for services provided by other hospitals
BARANGAY:
|
.
ORT HEALTH PLUS SCHEME
Central Office: ORT World Union
Guerrero Road, SFLU
Tel. No. 41-50-80
MEMBERSHIP CARD
1.
This card is for exclusive use of the
member whose signature appears here
on.
2.
Present this card when availing of the
services covered by the agreement.
3.
Report loss of this card immediately.
Signature ot Member
27
ORT HEALTH PLUS SCHEME (OHPS>
lliMd
REGISTRATION FORM
.
BMJnw IlName’
PRINCIPAL
Nssmc .
(Meneses
Axkfaws:
D«Uef Dtthi/
OccupOttofE
jjlnes
Im
|No. Cariatan SFLU
j.................... ..... -V;67
(Govem me n t E m ploy
TERMS OF PAYMENT:
28
O«tK
Tuesday. MyW
OHPS MEMBERSHIP::NO. OF REGISTERED FAMILIES
BY SATELLITE. TYPE AMD MONTH
1995
LEGEND
(-) - NON-SSS7GS1S
(+>- SSS/GSIS
SATELLITE
September
August
July
-
Octoter
+
-
-
■+
-
Nivember
Decemtier
+
+
-
-
12
Barlquir
12
13
15
17
15
14
15
15
13
12
12
Baroro
4
0
4
0
5
0
5
0
4
0
4 ________ 0
Bulala
13
1
38
5
39
5
39
5
39
2
7
2
7
2
7
2
7
33
4
Carcarmay
7
2
7
Central Unit
17
15
19
15
19
15
19
16
■0
16
20
Gonzales
14
15
15
21
15
24
15
24
15
21
13 _______21
Lloren
4
3
5
4
6
4
6
4
6
4
6
3
Macalva
6
2
6
3
5
3
5
3
5
*
5
6
Nadsaag
10
3
10
3
11
3
12
2
12
1
12 ________ 0
Pangaoaoan
4
4
4
4
4
4
4
y
4
6
4
7
Pudoc
12
21
12
22
11
22
11
18
11
18
11
15
4L
16
SanJuan
6
1
a
1
6
2
8
2
8
2
8
Sta. Rita
4
5
4
5
4
4
4
4
4
5
4 ________5
Santiago
9
24
13
42
15
38
16
40
16
-10
14 _______ 37
TOTAL
122
109
159
144
163
140
165
142
1>4
13-1
153
No. of Nm Families
16
46
38
35
6
4
2
11
3
4
No. of New Individual
88
201
143
160
25
19
9
36
8
8
0 _______ £7
No. of Dropped Famlts
7
8
1
0
2
8
0
9
4
14
11 _______ 14
No. of Dropped Indlv+uaJs
28
39
1
0
2
44
0
34
!2
70
Total No. of Individual
S9S
524
738
684
761
659
no
661
7S6
599
130
0 ________ 5
41 _______ 60
715
S56
TOTAL NO. OF REGISTERED FAMILIES
(1896)
1995
TOTAL NO. OF REGISTERED FAMILIES
- Media
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