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KaSAPI Extending PhilHealth’s Coverage to Workers in the Informal Economy Philippines Annie A. Asanza, MD 1 Context 2 Population 36.7m (1970) 85.2m (2005) Life expectancy 58.1 (1970) 70.0 (2005) GDP PPP $ 1,345 (1975) 5,300 (2005) Income Gini 46.1 (1957) 51.1 (1964) 46.6 (2003) Tax revenues (as % GDP) Poverty level Governance Growth rate = 2.3% 10.1% (1990) 16.3% (2004) 36.8% Local Government Code 1991 Labour Force Wage Earners 49.8%(2000) 22% (2000) 50.5% (2006) Own-account Workers 50.2%(2000) 78% (2000) 49.5% (2006) Country Context 3 55% from private sources 37.5% from government 8% from SHI 4 EDSA Revolution Local Government Code Growth of community-base health financing schemes 5 6 KaSAPI 7 Year 2003 low coverage of informal economy workers through the Individually Paying Program PhilHealth embarked on a tie-up with small credit cooperatives for enrollment of their members Tested with 11 cooperatives in 2 regions Cooperatives were evaluated based on financial indicators used for cooperatives by the Department of Finance allowing them to perform functions i.e. marketing, collection based on their classification Cooperatives gets an incentive for every new member and amount remitted to PhilHealth PhilHealth Organized Group Interface (POGI) 8 Cooperatives used loans to pay for PhilHealth premiums high default rate High administrative cost for partner organization groups Not attractive enough high out of pocket spending due to expensive medicines & unregulated practice of health care providers Low awareness on health insurance increase advocacy on its advatages and benefits Strengthen PhilHealth’s administrative capacity ILO-GTZ-WHO Evaluation of POGI March 2005 9 Only 77% of IPP members are actively paying. 1500000 Approximately only 19% of informal economy workers are covered by PhilHealth. 1000000 500000 Own Account Workers 0 Registered IPP Members Paying IPP MANDATE FOR UNIVERSAL COVERAGE 10 Problems on demand-side De facto voluntary decision for household. As a result, low coverage levels – approx 14% of the target group enrolled. Premium $20 per annum for family; generally acceptable but people want to pay weekly/monthly given uncertain income. Many remote communities, with little health infra. Irregular contributions / coverage: only two-third of members registered in PhilHealth’s voluntary ‘individual paying programme’ pay regularly Adverse selection creates financial instability: Estimated that programme targeting informal sector made 121% loss in 2005 174% increase in number of paid claims (IPP 2002-05) Utilization Rate 5.2 1.9 Year Claim Value 12% increase in average claim value (IPP 2002-05) Year Problems on supply-side Large public sector bureaucracy has limitations in: Marketing and selling health insurance Developing flexible payment systems which meet demands of target group PhilHealth ideally wants annual premium payments (to stabilise irregular payments), but target population want the opposite Chasing individual households administratively expensive and highly inefficient Response to unstable coverage / contributions Rather than targeting individual households directly, target groups, and mirror employeremployee relationship (admin efficiency gains, limit adverse selection). Piggy-back on collection systems of microfinance / cooperative organisations who collect very regularly from clients (greater flexibility for client). This partnership allows PhilHealth to respond to household’s demand to pay small amounts regularly, whilst the organisation remits annual/semi-annual/quarterly payments to PhilHealth. Up to each partner how to organise internally. Response to adverse selection Promote mandatory enrolment within microfinance organisation (efficient risksharing). Strong demand for health insurance by MFI/Coop management for their members. Set minimum group size. Currently set at 70% (counter adverse selection). How to enforce? Offer discounted premium. Similar approach to private health insurance approaching companies. Should also help to limit coverage instability – partner loses income (through discounted premium) if enrolment drops below 70%. Kalusugang Sigurado at Abot-Kaya sa PhilHealth Insurance 17 5,000,000 4,000,000 3,000,000 2,000,000 APPROXIMATELY, ONLY 56% OF WAGE EARNERS AND SALARIED WORKERS ARE COVERED. 1,000,000 - Wage Earners & Salaried Workers Mandate for universal coverage 18 X… X VII I… II - N… PhilHealth has extended 1,000,000.00 sponsorship to more families than it should. 500,000.00 Families Living Below the Poverty Line Sponsored Families MANDATE FOR UNIVERSAL COVERAGE 19 Protection from financial implications of illness “Increased” benefits for KaSAPI members Flexibility of payment Time and hassle savings Lower premium Informal Economy Workers Increased and sustained coverage Improved financial stability of the NHIP Fulfilment of social mission – reduce members’ vulnerability Financial stability Administrative efficiency PhilHealth Microfinance Institution Stable health insurance organization 20 National Health Insurance Act ◦ Universal coverage by 2015 ◦ Partnership with community based health care organizations, health management organizations, local government units KaSAPI is a partnership ◦ Microfinance institutions ◦ Cooperatives ◦ Rural Banks Mandate for Universal Coverage 21 PhilHealth Board Resolution 719 approved September 2004 KaSAPI launched on September 2005 in 7 pilot regions At present, 15 partners …. And counting KaSAPI 22 Organized Groups and PhilHealth Partners in implementing NHIP (Conceptual framework) Members of Organized Groups ORGANIZED GROUPS PhilHealth • Recruitment/enrollment • Capability building (IEC) • Conduct of IEC/Advocacy • ID Generation • Collection & remittance of members’ contribution • Benefit Payment • Group Premium Rate • Submission of reports 23 Mode of Payment ANNUAL PERCENT OF GROUP SIZE MEMBERS BAND ENROLLED 85% 8A 4000 & up 70% 7A 85% 6A 3000-3999 70% 5A 85% 4A 2000-2999 70% 3A 85% 2A 1000-1999 70% 1A ONE-YEAR 1,083 1,089 1,094 1,100 1,106 1,112 1,117 1,123 GROUP PREMIUM Three Annual Quarters 1,083 812 1,089 816 1,094 821 1,100 825 1,106 829 1,112 834 1,117 838 1,123 842 Mode of Payment SEMI-ANNUAL GROUP PREMIUM PERCENT OF GROUP SIZE MEMBERS BAND ONE-YEAR Semi-Annual ENROLLED 85% 8S 1,094 547 4000 & up 70% 7S 1,100 550 85% 6S 1,106 553 3000-3999 70% 5S 1,112 556 85% 4S 1,117 559 2000-2999 70% 3S 1,123 562 85% 2S 1,129 565 1000-1999 70% 1S 1,135 567 Mode of Payment QUARTERLY PERCENT OF GROUP SIZE MEMBERS BAND ENROLLED 85% 8Q 4000 & up 70% 7Q 85% 6Q 3000-3999 70% 5Q 85% 4Q 2000-2999 70% 3Q 85% 2Q 1000-1999 70% 1Q Two Quarters 541 544 547 550 553 556 559 562 One Quarter 271 272 274 275 276 278 279 281 One Quarter 274 275 276 278 279 281 282 284 GROUP PREMIUM ONE-YEAR Quarterly 1,105 1,111 1,117 1,123 1,129 1,135 1,141 1,147 276 278 279 281 282 284 285 287 24 25 26 Conference on Extending Social Health Insurance to Informal Economy Workers – Manila, October 2006 Involvement of other partners in the program DOF, DOLE, NEDA, DBP, RBAP, MFC, NATCCO, PinoyME, labour groups http://www.gtzhealth-philippines.org 27 PhilHealth ◦ Immersion to different types of organized groups ◦ Training of trainers on “Social Health Insurance Advocates and Champions (SHIAC) for Organized Groups” Organized Groups ◦ SHIAC ◦ Understanding PhilHealth Process Review ◦ In preparation of a national roll out by 2008 Capacity Development 28 PhilHealth needed data to support claim the illness is bad for business among MFIs Findings ◦ Illness is perceived to be a cause of loan default and drop outs from OGs ◦ Illness, by client or family member, is among causes of loan default by members ◦ Illness will affect clients more than MFIs Study: Illness as a Cause of Loan Default 29 Out of a potential 600,000 members from the 14 OG(s), we have enrolled 4,500 as of September 2007 ◦ Partners were also in a pilot mode, limiting enrollment to certain areas ◦ Program is voluntary in almost all partners Only NGO-MFIs have reached at least the minimum 700 enrollees ◦ Frequent contacts with members increase awareness, facilitates easier collection and monitoring What have we achieved so far? 30 Feedback mechanism on the type and quality of care given by accredited health providers ◦ Members found a venue to voice out their concerns through the OGs Membership to PhilHealth by people from “geographically isolated areas” are facilitated What have we achieved so far? 31 High drop out rate especially among those opting to pay on a quarterly basis ◦ Premiums are tied to loans particularly with MFIs ◦ Partners are now considering financing through savings, dividends or outright payment Administratively taxing for OGs and PhilHealth ◦ Social marketing activities ◦ Administrative work – seamless integration of IT system not yet fully there What are our current challenges? 32 Lack of public documents that would qualify dependents as beneficiaries Exclusion of groups that do not qualify the evaluation criteria ◦ Workers’ associations ◦ smaller groups like cooperatives that do not reach minimum number of members = 1000 Creating a consortium to reach 1000 members is very difficult What are our current challenges? 33 34 Premium financing • Small, frequent payments; sources of financing premiums other than loans Access to adequate quality health care • • • • Accredited health facilities and professionals Planned implementation of a quality standards Feedback mechanisms Improvement of PhilHealth’s current benefit package Universality • Extension to informal economy workers • Equitable scheme Performance (design and implementation of sound management information system) Inclusion in national strategies, legal framework Social marketing • Developing marketing messages for members, leaders of community organizations…PhilHealth officials Checklist 35 http://www.gtzhealth-philippines.org 36
