This study investigated the social health insurance (SHI) scheme in the Philippines in terms of equity and access. A review of policy documents of PhilHealth, ...
Equity and access to health care and social health insurance in the Philippines: A policy review Celso Jr Pagatpatana and Samantha Meyerb a Ateneo Center for Health Evidence, Action, and Leadership (A-HEALS), Ateneo De Manila University, Philippines b School of Public
Health and Health Systems, University of Waterloo, Canada
ABSTRACT This study investigated the social health insurance (SHI) scheme in the Philippines in terms of equity and access. A review of policy documents of PhilHealth, a SHI institution in the Philippines, was conducted using a framework that views access as empowerment and as a multi-dimensional concept arising from the interaction of the clients and health system. This review showed that PhilHealth recognizes the multi-dimensionality of access as it strives for financial risk protection and quality of health care. Social solidarity as an inherent principle in SHI indicates community spirit but does not necessarily imply empowerment. PhilHealth policies that use the SHI scheme confirm a supply-side and provider-focus in health financing. It is recommended that the demand-side factors of access should emphasize not only the enhancement of purchasing power but also the freedom to use health services, as improving people’s willingness and capabilities are essential preconditions for the utilization of health care.
Introduction Many governments articulate in their policy documents the intention to provide equitable and accessible healthcare services to its citizens by improving health service delivery and providing financial risk protection. Although these objectives are stated in terms of policies, some may not be translated into actionable terms while others may only be partially implemented. Thiede (2005) explains that most of these efforts are focused on the supplyside improvement of the health system, while limited efforts focus on the demand-side aspects. This imbalance poses some problems because it undermines the willingness and preferences of the consumers of health services as an essential factor in achieving access. Supply-side aspects refer to the qualities of the health system such as location, cost, and appropriateness of health services, while the demand-side aspects may include the characteristics of the population in relation to their capacity, willingness, or ability to use health services. This paper is an investigation driven by the widening health and health care inequities in the Philippine health system (Son, 2009). Another influence for this review is the statement by the former health secretary (minister) who described the system as having a “firmly entrenched top-down approach to policy formulation, planning, and management and is dominantly supply-side driven and provider-oriented” that contributed to the fading out of participatory processes in health decision-making and policy formulation (Romualdez, 2010).
1
The aim of this study was to analyze the evidence of equity and access within policies and related documents of PhilHealth. It sought to answer the question: how and to what extent does the Social Health Insurance scheme in the Philippines utilize evidence specifically on addressing the supply- and demand-side factors in its policies in order to achieve equity and access to health care? It ultimately sought to determine how enabling PhilHealth policies are in terms of outlining actionable items and focusing on achieving equity and access to health care. The supply- and demand-side factors Difficulties with access to health care are multiple and complex and can be categorized as resulting from either supply- or demand-side factors. O'Donnell (2007) suggests that the demand-side aspects are comprised of the constraints and preferences of health care consumers. For example, household income, charges for health care, and costs to reach health care services are determinants of constraints that limit a consumer’s ability to utilize health services. Preferences are influenced by cultural factors (e.g. preference for traditional therapies), knowledge of the potential benefit of health care, and the quality of services available. Preferences influence the “consumption” of health care services. This suggests that demand-side interventions that only improve the purchasing power of the individuals are inadequate; it must also address the willingness of the individuals to utilize healthcare services. Consequently, these interventions should address the three implications of access to health care as identified by Gulliford et al. (2002): an individual’s recognition and acceptance of their needs for services; consent to his/her role as service user; and acknowledgment of socially-generated resources he/she wanted to utilize. This emphasizes the importance of empowerment and participatory processes to enable access and improve utilization of individuals and families to effective preventive and treatment health care services. One of the important indications for emphasizing these processes includes the incorporation of people’s views and values into policies as an evidence of the extent to which demand-side factors are taken into account. The supply-side aspects, on the other hand, may relate to the health system characteristics that pertain to the volume and distribution of health resources and the organization of the processes in providing health services (Aday & Andersen, 1974). O'Donnell (2007) cited examples of supply-side problems such as available resources not being allocated to the most effective interventions, being geographically concentrated in large cities, of inadequate quality, and lacking economic resources to support the provisions of essential services. Health system problems in terms of resources and organizations of health services may result in specific problems such as poor quality, long travel time, and long waiting list. Supply-side related interventions, in this sense, should address the availability and quality of services provided.
2
Social Health Insurance schemes To improve equity in the provision of health care and access to risk protection in poor households, low- and middle income countries (LMICs) are increasingly moving towards Social Health Insurance (SHI) schemes (Jehu-Appiah et al., 2011). SHI is one of the most common health care financing schemes where the health risks of its members are pooled on one hand, and the contributions from the institution, household, and government pooled on the other (Carrin & James, 2005). An essential characteristic of SHI is the compulsory membership of the formal sectors. This includes payment of contribution to the social health insurance fund by employees and workers from the private and government institutions, by the self-employed, and by the owners of enterprises. The contributions of employees are usually based on their salaries; for self-employed, it is usually a flat rate. The accumulated social health insurance fund would then be used for cross-subsidization of those SHI members who are in need of health services. Part of these funds is also used to subsidize the informal sectors, particularly the unemployed and indigent sections of the society. The government usually provides the other partial subsidies for the financial requirements of the indigent groups. However, SHI as a form of financing health care is criticized as being non-progressive because it enforces a triple taxation to the formal sectors in the form of automatic deducted income tax, automatically deducted SHI premiums as payroll tax, and indirect tax such as value added tax (Paterno & Herrera, 2010). For the informal sectors, many LMICs consider financing them as challenging especially in ensuring their continued enrollment as subsidy comes from the local government units where scarce sources of funding is a common problem and issues of political patronage remain in relation to the selection of subsidized members. Despite the difficulties of many LMICs in the implementation of SHI (e.g. fiscal capacity and administrative capabilities), reports of success have been documented in countries like Costa Rica, Colombia, South Korea (Carrin & James, 2005), and Thailand (Tangcharoensathien et al., 2013) showing evidence of improving equity and access to health care. Equity and access to health care A fair and just distribution of health care services are central to equity in access to health care (Gulliford, 2003). Equity relates to the idea that the distribution of services should be based on health care need and not on the ability to pay. The most common interpretation of equity in the literature is “equal use for equal need” which implies that those who have equal need for health care make equal use of health care. However, there is no utilization (and expenditure) that can be equalized because consumers’ preferences are very relevant and different social groupings have different preferences for health care that lead to differences in services (Mooney, Hall, Donaldson, & Gerard, 1991; Thiede, 2008). Arguing that “utilization” is a problematic interpretation for equity, “equal access for equal need” was contended as a more superior criterion (Mooney et al., 1991; Oliver & Mossialos, 3
2004). This provides the opportunity for consumers to use health services, recognizes the variation of patterns of use (and expenditures) for equal need, and respects patients’ preferences to comply with treatment in various ways (Mooney et al., 1991). Mooney (2009) further explains that an informed preference or citizens construct should determine the principle of access and operationalization of equity and that access per se is a superior equity criterion. These differences in the concept of equity and access to health care imply disagreements in which aspect to focus on – the demand side or the supply side. The objective of the research informing this paper was to examine the Philippine SHI scheme to identify evidence of equity and access that informs its policies. Driven by the literature, the review is focused on understanding the demand-side aspect of access to health care in the Philippines. This is in-line with the perspective that access rather than utilization of health services is a better measure of equity (Mooney et al., 1991) Context The passage of the National Health Insurance Act [NHIA] of 1995, otherwise known as Republic Act 7875, created the Philippine Health Insurance Corporation [PHIC or PhilHealth] to implement a national health insurance program [NHIP] through a SHI scheme (Congress of the Philippines, 1995). PhilHealth has played an important role in the implementation of a wide-ranging health reform agenda in the country since 1999. This reform emphasizes the role of PhilHealth noted by Busse and Schwartz (1997) as goals quite similar with other contexts, which is “to obtain greater equity by improving the access to health care, both in socio-economic and regional aspects.” The NHIP went through continuous development summarized as follows. In 2004, the NHIA was amended to accommodate further developments of the program. Later, in consonance with the Millennium Development Goals (WHO, 2005), an implementation framework of health reform called Fourmula One for Health was used that aims for better health outcomes and equitable health financing. The ascension to power of the Aquino government in 2010 called for scaling up of PhilHealth enrolment and delivery of health services aiming to achieve Universal Health Care by 2016.
Method Data were gathered by searching relevant PhilHealth policy documents through Google and Google Scholar search engines, and the websites of the Department of Health and PhilHealth. These policy documents are limited to those posted and published online from 1995 to 2012. Search terms included “PhilHealth” OR “social health insurance” OR “health financing” AND “access to health care” OR “equity” AND “policy” OR “law” AND “Philippines.” The retrieved policy documents are classified as grey literature. For the purpose of this review, the documents were assessed based on Tyndall’s criteria for evaluating grey literature: authority, accuracy, objectivity, coverage, date, and significance (Tyndall, 2010). In particular, these grey literature documents were promulgated by 4
PhilHealth, the Department of Health, and the Philippine Congress who are authorities on social health insurance in the country. Credible sources and representatives of health financing work in the Philippines were also evident and thus, suggest accuracy and objectivity. Coverage and date were also clear as they indicated relevance and the particular population group they serve. The documents also manifested significance as these provide important contributions to health care financing and argument towards the attainment of Universal Health Care in the country. Access framework This study used a framework that views access as empowerment and as a multidimensional concept based on the interaction (or “degree of fit”) of the health system and clients (individuals, households, and communities). This framework highlights that policies aimed at increasing access to health care cannot be evaluated by the effect of health service utilization. Instead, access should be evaluated directly and should “view access that represents empowerment of an individual to use health care and reflects an individual’s capacity to benefit from services within the clients’ circumstances and experiences in relation to the health system” (McIntyre, Thiede, & Birch, 2009). In this framework, information and communication facilitate a good “fit” between the health system and the client and see how professional status of health care providers generates power relations. McIntyre et al.’s (2009) view of access as a multi-dimensional concept includes availability (physical access), affordability (financial access), and acceptability (cultural access). Availability is concerned with whether or not the appropriate health care providers or services are supplied in the right place and at the right time to meet the prevailing needs of the population. The “degree of fit” between the full costs to the individual of using the service and the individual’s ability to pay is the concern of affordability. Acceptability is described as the compatibility of provider-patient attitude towards expectation of each other. McIntyre et al. (2009) argue that access could be understood in a comprehensive manner by determining the interactions of these dimensions. Using these principles of access framework, each of the policy documents retrieved were carefully read, focusing on the identification of salient points as evidence of equity and access. In particular, these salient points were reviewed to determine the extent to which they addressed the supply- or demand-side aspects and whether or not these are related to the affordability, availability, or accessibility dimensions of access. No ethics approval was necessary for this study as it involved collection of data or records that are readily accessible online and contained non-identifiable materials, which present negligible risk (NHMRC, 2007).
5
Results Seven major policy documents of PhilHealth were retrieved from various sources. These documents pertained to the establishment of PhilHealth as the main health care financing scheme in the Philippines. The other documents related to the aim of achieving Universal Health Coverage in the country as well as documents that specifically dealt with improving access to health care. Table 1 is a summary of the policy documents with the salient points relevant to equity and access. Table 1: Equity and access evidence in PhilHealth policy documents
Policy documents
Salient points relevant to equity and access
Demand side (DS) or Supply side (SS)
1. National Health Guiding principles Insurance Act of 1995 Equity defined as provision of uniform basic (Republic Act No. 7857) benefits; access to care as a function of person’s health needs rather than ability to pay
SS/DS
Affordability, Acceptability, and Availability
Availability/ Acceptability
Social solidarity guided by community spirit; must enhance risk sharing among income groups, age groups, and persons of differing health status
DS
Affordability
Maximum community participation – builds on existing community initiatives for its organization and human requirements
SS/DS
Availability
Compulsory coverage requires all citizens to enroll in NHIP in order to avoid adverse selection and social inequity
SS
Affordability
Encourages members to choose from among accredited health care providers, selecting the appropriate and most suitable provider, shall be given in clear and simple Filipino and in the local languages that is comprehensible to the member
DS
Acceptability
Care for the indigent: provision of basic package of needed personal health services to indigents through premium subsidy
SS
Availability
Sets standard rules and regulations necessary to ensure quality of care
SS
Acceptability
Negotiates and enters into contracts with health care institutions regarding the pricing, payment mechanisms, design, and implementation of administrative and operating systems and procedures, financing, and delivery of health services.
SS
Availability/
PHIC or PhilHealth
6
Affordability
Local health insurance Supervision of means testing or targeting the indigent undertaken by the local chief executive in coordination of social welfare and community-based health care organizations
DS
Affordability
Tap community-based volunteer health workers and village officials, if necessary, for member recruitment and similar activities
SS/DS
Affordability
Beneficiaries’ freedom to choose from accredited health facility, medical, and dental practitioner
DS
Acceptability
Participation in programs of quality assurance, utilization review, and technology assessment Payment of Indigent Contributions
SS
Acceptability
DS
Affordability
DS
Acceptability
DS/SS
Acceptability/
Health care providers
2. Amendment to RA 7875 (RA 9241), 2004
The local government unit shall subsidize contributions for indigent members partially where the member resides. Accreditation Eligibility Health care providers, operating for at least three (3) years may apply for accreditation; others who have not operated less than three (3) years may apply and qualify for accreditation if it complies with all the other accreditation and further meets some specific conditions Oversight Provision Congress shall conduct regular review of the National Health Insurance Program, which shall entail a systematic evaluation of the programs performance, impact or accomplishments with respect to its objectives or goals.
3. Implementing Rules and Regulation (RA 9241), 2004
Affordability/ Availability
Clinical practice guidelines: systematically developed statements based on best evidence to assist practitioners in making decisions about appropriate management of specific clinical conditions
SS
Acceptability
Peer-review: quality of care provided to members or the performance of health care providers are reviewed by professional colleagues with comparable training and experience.
SS
Acceptability
SS/DS
Affordability
Develop mechanism for the participation of community based health organization, cooperatives, and other organized groups to the program, primarily on mobilizing funds for enrollment 7
4. Benchmark on Performance Improvement of Health Services, 2004
5. Aquino Health Agenda: Achieving Universal Health Care For All Filipinos, 2010 6. Universal Health Executive Plan and Implementation Arrangements, 2011
7. Creation of Health Technology Assessment Unit, 2004
Accreditation of institutional and independent health care providers Lays out basic concepts of quality assurance in health care and how the accreditation process supports continuous quality improvement
SS
Acceptability
SS
Acceptability
Serves as an instrument of PhilHealth to provide equitable access to the highest feasible quality of health services for as many Filipinos as possible Stated means to attain UHC goal: spirit of solidarity and equitable access to affordable health care Major guidelines: improved access to quality hospitals and health care facilities by upgrading these facilities Rapid expansion of enrollment and benefit delivery using national subsidies for the poorest families
SS
Acceptability
SS
Affordability
SS
Availability
DS
Affordability
DS
Availability
SS
Acceptability
Attainment of the health-related MDGs by applying additional efforts and resources in localities with high concentration of families who are unable to receive critical public health services Health technology assessment committee of PhilHealth to develop reimbursement policies on medical claims based on the costeffectiveness of tests and treatments
Availability of health care providers and facilities In response to the inadequacy and inefficiency of health facilities and human resources for health in the country especially in the countryside, the accreditation of professional and institutional providers is instituted where qualifications and capabilities are verified in accordance with the guidelines, standards, and procedures set by PhilHealth. Moreover, the Aquino Health Agenda (Department of Health, 2010) aims to upgrade and expand the capacity of government-owned and -operated health facilities and further improve services provided for traumatic injuries and other types of emergencies, as well as management of non-communicable diseases and their complications. However, the perennial problem of uneven distribution of human resources for health in the country where the rural areas are often understaffed (Domingo, 2010; Kanchanachitra et al., 2011) is not clearly addressed in the PhilHealth policy documents in order to facilitate equity and access to health care. Similarly, modern health technologies and other health facilities remain concentrated in Metro Manila (Palaganas, 2003) despite the initiatives to improve provincial and regional hospitals. Despite intentions or realized action to ensure quality of health providers, upgrade health facilities, and improve geographic distribution of services provision, the availability of health care providers and facilities still poses barriers.
8
Affordability and financial protection The provision of a mechanism to gain financial access to health services has been the main goal of PhilHealth and lately revitalized through the Aquino Health Agenda (Department of Health, 2010). This indicates that financial risk protection through scaled up expansion in enrollment and benefit delivery are among the essential strategies in the attainment of Universal Health Care for all Filipinos. Mandatory enrollment, which is an inherent characteristic of SHI, facilitates expansion of enrollment among the formal sectors. This encourages greater pooling of risk that will eventually result to better cross-subsidization especially for the poor. PhilHealth, through its financial risk protection policy, has contributed to addressing the challenges to achieving Universal Health Coverage as identified by the WHO. These challenges include: the breadth of coverage or the expansion of social health protection that progressively encompasses the uninsured; the depth of coverage or expansion of range of essential services; and the height of coverage that refers to the expansion of coverage of health care cost through pooling of risk and prepayment mechanism that eventually diminishes out-of-pocket payments (Busse & Schletter, 2007; WHO, 2008). PhilHealth’s principle of provision of care based on need rather than ability to pay is understood as the health condition of an individual and basis of care rather than his economic health status. It is assumed that access to health care is every citizen’s right and this ought not to be influenced by income and wealth. Consistently, Akazili et al. (2011), point out that the ability to pay is an important element of financial risk protection in a fair distribution of health care financing. However, addressing the demand-side aspect through affordability approach alone does not improve consumer’s perception of the barriers of access, subjective choice sets, and the cultural consideration of access related problems. Acceptability and quality care Hsiao and Shaw (2007) argue that SHI should purchase health care for its insured prudently in order to gain sustained public support. To ensure safety and quality of services rendered, Benchbook (dela Pena, 2004) provide guidelines on PhilHealth quality standards for health care providers. It sets a framework that focuses on the assessment of dimensions of quality care (safety, effectiveness, appropriateness, consumer participation, and efficiency) and six cross-dimensional issues (competence, information management, continuity of care, evidence-based medicine, education and training, and accreditation). This serves as the basis for PhilHealth to assess if appropriate quality of care exists by determining health care providers’ adequate performance in the dimensions of quality care and rate on the crossdimensional aspect. Further, PhilHealth’s adherence to health technology assessment that ensures quality of drugs and treatment received by the patient is another quality assurance initiative. However, in a realist review Michielsen et al. (2011) point out that, apart from improving health services and infrastructure, other mechanisms to ensure quality of care should include not only technical quality but also proper attitude of health care providers. 9
Further, Segal (1998) points out that healthcare providers are expected to encourage and support the consumers to make decisions about their own health and encourage them to access health information on available services. This, however, can only be realized when there are adequate training of health professionals on patient participation and empowerment supported by adequate health funding and appropriate health delivery arrangement. As such, patients’ right such as freedom to choose and patients’ right to know their conditions are better promoted because it improves their willingness and preferences as important aspect of demand-side reforms. Empowerment and community participation The principle of solidarity as inherent in SHI schemes is assumed by Akazili and Mooney (2011) to be akin to the communitarian spirit wherein there is an emphasis on social protection in which individuals are part of a wider society or community and so are willing to pay for some social good. An expression of social solidarity in PhilHealth could also be understood in terms of community participation as stipulated in its policy documents. In fact, maximum community participation is considered an important principle in the NHIA [RA 7857] while consumer participation is one of the six dimensions of quality care in Benchbook (dela Pena, 2004). Likewise, IRR [RA 9241] encourages participation of community-based associations, cooperatives, and non-profit organizations to mobilize funds for enrolment. Though there are explicit articulations of community participation in PhilHealth documents, it does not necessarily imply empowerment. As Adams (2008) noted in strongly provider-led service provision context, there could be a tension between the relatively powerful professional and relatively powerless service user that makes the latter feel more disempowered. Moreover, participation-related initiatives of PhilHealth such as mobilizing community leaders in the expansion and enrolment of membership are not considered to address the demand-side problems, as it does not directly enhance people’s willingness and preferences; rather, it is intended mainly to strengthen the supply-side aspect. Addressing the power relations generated from professional status of providers is likewise not explicit in the documents.
Discussion The multi-dimensional view of access is evident in the policy documents of the SHI scheme in the Philippines. This shows recognition that the cost of health care is not the only barrier to health care access as there is a wide-range of affordability, availability, and acceptability barriers, which affect lower income groups most severely. However, in addressing these specific dimensions of access, the interactions between the health care system and the clients should necessarily result to the empowerment of the latter (McIntyre et al., 2009). In particular, interventions that address the supply-side and demand-side aspects of access
10
should enhance the compatibility of the characteristics of the providers of care and health services to the characteristics and expectations of the consumers of care. The limited attention and evidence from PhilHealth policies that directly relate to empowerment is consistent with Romualdez’s (2010) argument that the Philippine health care system (that includes PhilHealth) focuses mainly on the supply-side approach to health care. Several demand-side interventions may have been implemented but these mainly relate to enhancing of the purchasing power of families, which is inadequate to improve people’s capabilities. More concretely, health communication strategies are essential in improving access as Thiede (2005) argues that adequate information broadens the individual choice set and increases freedom to use health services. His emphasis on the interactive process of information exchange highlights the argument that the effectiveness of information increases if the transfer of information is not unidirectional but a process that promotes empowerment of individuals and families in understanding better and taking control of their conditions. Segal (1998), for instance, cites several initiatives that promote empowerment of consumers of health care that have contributed to the efficacy of various health programs. These suggest that every health system reform should emphasize the demandside reforms that focus on empowerment of consumers of health services. In aiming for better involvement of individuals and communities in accessing health care such as consultation of consumer groups in devising access related policies and programs will most likely to be successful when consumers of health care are adequately empowered. Participation without adequate enhancement of people’s capacity is tokenistic. This may not address the demand-side problems but may even result to a more supply-side driven health system that undermines empowerment and participatory processes. Consistently, Sengupta (2013) asserts that communities should be involved as active participants rather than passive beneficiaries in any Universal Health Care program. Amartya Sen’s capability approach Evaluating the notion of access in SHI scheme documents through the lens of empowerment framework merits reflection on Sen’s capability-based analysis. Sen has been advocating that people’s well-being and standing in the society should be evaluated on the basis of their capability to achieve valuable functionings. In this approach, functionings refer to the achievement of a person, what he/she manages to do or to be, and things that he/she values. Capabilities represent the extent of freedom that a person has in order to achieve different functionings (Alexander, 2008). Building on the notion of access as empowerment, a need for clients to be aware of the possibility to use and being empowered to choose is necessary. The description of access by Thiede (2005) as freedom to use health services underlining information and communication are essential in enhancing peoples’ capabilities and important elements to provide freedom 11
of choice. Thiede further argues that the focus of equity debate should lie on empowering people to make choices in health care as a fundamental policy objective in a democratic society. Empowerment in seeking health care access is increasing peoples’ capabilities to achieve a particular functioning; that is, the capability to use quality health care towards a better health. Parallel-tracking of bottom-up and top down approach The improvements of the demand side as well as the supply side factors of access to health care are both essential; deficiency of one aspect is a limitation of the entire health care system. Laverack’s (2009) idea of empowerment and public health programming that combines bottom-up and top-to-bottom approach could be one basis in improving access to health care. His notion of parallel-tracking that mobilizes financial, material, and human resources to be systematically available to the community in a more empowering way, could complimentarily provide a dialectical perspective to the supply-side and demand-side factors of health care financing. In this way community empowerment (or bottom-up approach) is intentionally developed rather than viewed as an unexpected benefit of the planning design. In this approach, health care practitioners and health financing managers must be knowledgeable and must internalize the importance of people’s involvement along with processes of top-down approach to health care financing.
Conclusion Adequate and concurrent attention to both the supply-side and demand-side aspects are necessary in achieving substantial improvement in access to health care (De Brouwere, Richard, & Witter, 2010). This policy analysis of PhilHeath’s documents indicates a need for a more substantial effort for the demand side aspects particularly in addressing issues that relate to the “preferences” of individuals and families as well as problems on “constraints” in order to enhance both their willingness to access health care and their purchasing capacity. Health policy that recognizes the multi-dimensional interpretation of access may provide comprehensive and quality health services that address the supply-side aspect. However, this could be unsustainable and inadequate if no significant effort to improve the demand-side aspect, that is, to empower the people not only in their purchasing capacity but more so to develop their freedom to use health services. It is the responsibility of those institutions aiming for accessibility of health care to provide this opportunity to consumers of health care and develop what they are capable to do towards the achievement of access and equity of health care. In a broader sense, Martha Nussbaum (Sen’s contemporary) emphasized that “in order to achieve real equality and promote meaningful economic and social development, policy makers must determine what people are able to do and to be” (cited in Alexander, 2008). Social health insurance schemes have the potential to achieve equity and access to health care. Its inherent principles of social solidarity and mandatory enrollment as SHI’s essential 12
characteristics are important capital and basis to attain such goals. However, seeking equitable access in health care financing necessitates clear articulation in policies and programs not only on the aim for financial risk protection and quality of health care but also on allowing people to realize their capabilities and freedom to choose. It should also be clear that providing spaces for people, especially the marginalized sectors, to participate in decision-making should be accompanied with improving people’s capabilities. The supplyside and the demand-side aspects are both important to be addressed as there is a need for the appropriate combination of the top-down and bottom-up approach in health governance. Achieving equity and access to health care services greatly depends on the realization of the appropriate articulation in health policies of the demand-side reforms. This requires adequate preparation of health financing managers and implementers as well as health practitioners in the execution of their tasks to address the demand-side problems where empowerment and participatory principles are emphasized. The creation of appropriate organizational arrangements and sustained investment and support also enables inclusive and equitable access to health care.
References Adams, R. (2008). Empowerment, participation and social work (4th ed.). Hamsphire, England: Palgrave Macmillan. Aday, L. A., & Andersen, R. (1974). A framework for the study of access to medical care. Health Services Research, 9(3), 208-220. Akazili, J., & Mooney, G. (2011). Social health insurance: to each according to his needs; from each according to his means--but what might that mean? International journal of health services : planning, administration, evaluation, 41(4), 679-690. Alexander, J. (2008). Capabilities and social justice: the political philosophy of Amartya Sen and Martha Nussbaum. Hampshire, England: Ashgate Publishing. Busse, R., & Schlette, S. (2007). Focus on prevention, health and aging and health professions. Health Policy Developments, 7(8). Busse, R., & Schwartz, F. W. (1997). The Philippines' National Health Insurance Act: A German perspective. International Journal of Health Planning and Management, 12(2), 131-148. Carrin, G., & James, C. (2005). Key performance indicators for the implementation of social health insurance. Applied health economics and health policy, 4(1), 15-22. Congress of the Philippines. (1995). An act instituting a national health insurance program for all Filipinos and establishing the Philippine health insurance corporation for the purpose. Manila, Philippines: Philippine Government. De Brouwere, V., Richard, F., & Witter, S. (2010). Access to maternal and perinatal health services: lessons from successful and less successful examples of improving access to safe delivery and care of the newborn Tropical Medicine and International Health, 15(8), 901-909. dela Pena, W. e. (2004). Benchbook on performance of health services. Manila, Philippines: Philippine Health Insurance Corporation. Department of Health. (2010). Aquino health agenda: achieving universal care for all Filipinos. Manila, Philippines. Domingo, E. (2010). Reforms in the health human resource sector in the context of universal health care. Acta Medica Philippina, 44(4), 43-55.
13
Gulliford, M. (2003). Equity and access to health care. In M. G. M. Morgan (Ed.), Access to health care (pp. 36-60). London: Routledge. Gulliford, M., Figueroa-Munoz, J., Morgan, M., Hughes, D., Gibson, B., Beech, R., & Hudson, M. (2002). What does `access to health care’ mean? Journal of Health Services Research & Policy, 7(3), 186-188. Hsiao, W., & Shaw, R. (Eds.). (2007). Social health insurance for developing nations. Washington: The World Bank. Jehu-Appiah, C., Aryeetey, G., Spaan, E., de Hoop, T., Agyepong, I., & Baltussen, R. (2011). Equity aspects of the National Health Insurance Scheme in Ghana: Who is enrolling, who is not and why? Social Science & Medicine, 72, 157-165. Kanchanachitra, C., Lindelow, M., Johnston, T., Hanvoravongchai, P., Lorenzo, F. M., Huong, N. L., . . . Dela Rosa, J. F. (2011). Human resources for health in southeast Asia: Shortages, distributional challenges, and international trade in health services. The Lancet, 377(9767), 769-781. Laverack, G. (2009). Public health: power, empowerment and professional practice (2nd ed.). Hampshire, England: Palgrave Macmillan. McIntyre, D., Thiede, M., & Birch, S. (2009). Access as a policy-relevant concept in low- and middleincome countries. Health Economics Policy and Law, 4(2), 179-193. Michielsen, J., Criel, B., Devadasan, N., Soors, W., Wouters, E., & Meulemans, H. (2011). Can health insurance improve access to quality care for the Indian poor? International Journal for Quality in Health Care, 23(4), 471-486. Mooney, G. (2009). Is it not time for health economists to rethink equity and access? Health Economics, Policy and Law, 4(2), 209-221. Mooney, G., Hall, J., Donaldson, C., & Gerard, K. (1991). Utilization as a measure of equity: weighing heat? Journal of Health Economics, 10, 475-480. NHMRC. (2007). National statement on ethical conduct in human research. Canberra: Australian Government. O'Donnell, O. (2007). Access to health care in developing countries: Breaking down demand side barriers. Cadernos de Saude Publica, 23(12), 2820-2834. Oliver, A., & Mossialos, E. (2004). Equity of access to health care: Outlining the foundations for action. Journal of Epidemiology and Community Health, 58(8), 655-658. Palaganas, E. (2003). Health care practice in the community (First ed.). Manila, Philippines: Educational Publishing House. Paterno, R., & Herrera, C. (2010). Health Financing. Acta Medica Philippina, 44(4), 58-68. Romualdez, A. (2010). Governance. Acta Medica Philippina, 44(4), 22-28. Segal, L. (1998). The importance of patient empowerment in health system reform. Health Policy, 44(1), 31-44. Sengupta, A. (2013). Universal health care in India: making it public making it a reality. Municipal Services Project, Delhi. Son, H. H. (2009) Equity in health and health care in the Philippines. Vol. 171. ADB Economics Working Paper Series (pp. 1-38). Tangcharoensathien, V., Pitayarangsarit, S., Patcharanarumol, W., Prakongsai, P., Sumalee, H., Tosanguan, J., & Mills, A. (2013). Promoting universal financial protection: how the Thai universal coverage scheme was designed to ensure equity. Health research policy and systems / BioMed Central, 11. Thiede, M. (2005). Information and access to health care: Is there a role for trust? Social Science and Medicine, 61(7), 1452-1462. Thiede, M. (2008). Access as freedom to use: A comment on Gavin Mooney's, 'equity in health care: Some concepts for debate'. Critical Public Health, 18(1), 103-105.
14
Tyndall, J. (2010). AACODS checklist for evaluation and critical appraisal of grey literatures. Retrieved December 12, 2012, from http://dspace.flinders.edu.au/jspui/bitstream/2328/3326/4/AACODS_Checklist.pd WHO. (2005). Health and the Millenium Development Goals. Geneva, Switzerland: World Health Organization. WHO. (2008). The World Health Report 2008. Primary Health Care. World Health Organization, Geneva.
15
