impact of shi for the poor on fbd in the philippines

Impact of extending Social Health Insurance for the poor on facility-based

deliveries in the Philippines

카를로파레데스Karlo Paolo P. [email protected]

서울대학교보건대학원Seoul National University | Graduate School of Public Health

August 2015

COHRED | Global Forum on Research and Innovation for Health

Contents

• Introduction and Background of the Study

•Philippines’ Health System

• The UHC/KP policy

•Objectives

•Methods

•Key Messages

보건대학원 | Graduate School of Public Health

Background

• Channeling increased funding flows through the National Health Insurance schemes offers the best avenue to improve (1) the supply of services, (2) access to health services and (3) delivering quality health care, especially in low-income countries (WHO, 2005)

• Strong calls for Universal Health Coverage has prompted countries to institute / expand health insurance and prioritize health (WHO, 2008, 2010, 2013)

• However, recent studies have no consensus on the impact of health insurance especially among the poor, with no strong evidence of an impact on utilization, financial risks and health status (Acharya et al., 2013)


Background

• Philippines – premium sharing for the poor (National and Local) has not increased coverage under Philhealth (Before UHC/KP policy) (Chakraborty 2013)


Extension of SHI for

the poor

Voluntary

Free

Discounted Fees

• Strategy in the Philippines has shifted from a premium sharing scheme for the identified poor by LGUs (Pre-policy) to Full National Government subsidy to the proxy-tested poor in 2011 (post-policy) (DOH 2011, Philhealth revised IRR, 2013).

• Since then, there has been a marked increase in the number of SHI indigent members from 22% in 2010 to 46% in 2014 (More than the employed members at 40% in 2014) (Philhealth, 2010, 2014)

Strategies in expanding SHI for the poor

Philippines’ Health System

• 1991 – Health System was Devolved• Local Chief Executives (LCEs) role critical in Local Health

development after Devolution

• DOH – Remained (National Health Agency)

• DOH Regional Agency – Center for Health Development Offices

• DOH Retained Hospitals / Specialty centers

• 1995 – Creation of the National Health Insurance

• 1999 – Health Sector Reform Agenda

• 2005 – FOURmula 1 for Health (Financing, Service Delivery, Regulation & Governance)

• 2011 – UHC (Kalusugang Pangkalahatan)Levels of Health Service Delivery

Source: Melgar, J. D. (2010). Organizing Health Services towards Universal Health Care. Acta

Medica Philippina, Volume 44 No. 4(Universal Health Care for Filipinos: A Proposal), 36-42.


UHC/KP policy in the Philippines

• Enrollment of 5.2 Million Poor Filipinos to the National Health Insurance (Philhealth)

• Training and Mobilization of Community Health Teams (CHTs) to increase utilization of health services / use of Philhealth

• Reduction of unmet needs for Maternal and Child Health

• Health Facilities Enhancement Program – to Improve capacities of Health Facilities


3 Thrusts of UHC in the PhilippinesSource: Kalusugan Pangkalahatan Execution Plan and Implementation Arrangements (2011).

Aquino Health Agenda – Universal health Care (2010)

KalusuganPangkalahatan

(UHC) Framework for Implementation

UHC/KP policy in the Philippines


National Household Targeting System for Poverty Reduction

(NHTS-PR)

Proxy Means Test (PMT); Identification of the poorest of the poor Filipinos (5.2 M)

DOH / PhilhealthEnrollment to SHI

(Sponsored category)

Poor household: How were they enrolled under the UHC/KP?


Health Insurance Theories

Theories of Health

Insurance

Demand for Health

insurance

Moral Hazard

Risk-Sharing

Adverse Selection

Ex-ante

Post-ante

Informal vs. Health

Insurance

Economic Model of

Demand; (Besley 1989)

“The sick pays more for

health”

Demand for Health -> demand for

health care -> demand for health

insurance

Change in lifestyle of the insured

individuals exist

Increased consumption/use of

health services

Are the increase beneficial?

(Nyman, 1999)

Reliance on informal risk-sharing;

Lack of trust to institutions

Arrow (1963);

Pauly (1968)

*Figure based on author’s illustration


Value of Health Insurance

Nyman (1999): Value of Health Insurance

Health

Insurance

Risk Aversion Value

Access Value

The access value of health insurance is related to the

value of the consumer of medical care that the person

would not otherwise be able to afford.

“If the insurance is the only way to gain access to

expensive health care, then the value of insurance for that

care is the expected consumer surplus from health care

that would otherwise be inaccessible”

Moral Hazard as otherwise implied, is not necessarily

inefficient if the increase in health service use was brought

by the access value of insurance to necessary services

that were previously inaccessible.

In the context of low-income countries, where levels of

unmet needs tends to be substantial, increased in

consumption are not necessarily problematic (Jowett,

2004)


Related studies

Studies measuring SHI impact to the poor (targeted)

Country Study objectives Results

Colombia(Trujillo, Portillo, &

Vernon, 2005)

Measurement of the impact of the subsidized

health insurance for the poor in Colombia (PSM

and IV Estimations)

The subsidized health insurance program greatly

increased medical care utilization among the poor

Colombia(Miller, Pinto, and

Vera-Hernandez,

2009)

Determination of how the SR enrollment is

associated with financial risk protection and

efficiency in health service use (IV estimation)

The SR has been successful in financially protecting

the poor from financial risk associated with medical

costs of unexpected illnesses; Increase in utilization of

the previously underutilized preventive services.

Vietnam(Wagstaff, 2010)

Measuring the impact of VHCFP on health

service use and financial risk protection using

VHLS surveys (Difference-in-differences)

VHCFP had no impact on use of health services. ATT

of health insurance did not show statistically significant

results for out-patient or in-patient visits; VHCFP

substantially reduced OOP spending.


Related studies

Studies measuring SHI impact to the poor (targeted)

Country Study objectives Results

Vietnam(Axelson et al, 2009)

Evaluation of the short-term impacts of VHCFP

on utilization and out of pocket expenditure using

VHLS survey (PSM and double differencing)

Small, positive impact on overall healthcare

utilization; statistically significant result in out-patient

strong negative impact on out-of-pocket expenditure;

the insured had lower OOP expenditure for in-patient care

Georgia(Bauhoff, Hotchkiss,

and Smith, 2011)

Measuring the impact of the medical insurance

for the poor using a dedicated survey of 3500

households (RDD estimation)

There was no impact seen on utilization; lower

expenditure was only seen on the elderly group, all others

with no robust evidence. Lower expenditure among the

insured for inpatient care.

Georgia(Zoidze, Rukhazde,

Chkhatarashvili, and

Gotsadze, 2013)

Mix-method study of Georgia’s health insurance

for the poor, using secondary data analysis and

health expenditure and utilization surveys of

2007-2010 (DID)

MIP has positive impact in terms of reduced

expenditure for IP services; Consequently, the MIP had

almost no significant effect on health services

utilization.

Did health insurance made health services more accessible to the poor?



Methods3.1 Research Design SHI Impact and Health

Service Utilization

I. Quasi-Experimental

- Impact of extending

SHI for the poor

Data Source Description Percentage of Insured HH (Income

quintile 1&2)

NDHS 2013 (Post-policy) NHDS survey data conducted in the Philippines after the

UHC/KP policy in 201144.24% of total households covered

NDHS 2008 (Pre-policy) NDHS survey data conducted in the Philippines before the

initiation of the UHC/KP policy in 201115.75% of total households covered

Department of Health /

Philhealth / National

Statistical Board

Information about regional/provincial community-level variables

to be used in the analysisWealth Index: Samples are categorized

using an index which is equal to 1 for the

poorest to 5 for the richest


Methods

Why NDHS?

DHS Year Total Households

Covered

Total population

(Women, Children,

Household Members)

Total Women

Respondents

Total number of

Children <5

% of Poor and next

poor samples (Q1 &

2)

2013 14,804

(43% in Q1&2)

70,100

(45% in Q1&2)

16,155

(40% in Q1&2)

7,216

(54% in Q1&2)

40% of total sample

2008 12,469

(45% in Q1&2)

60,901

(45% in Q1&2)

13,594

(40% in Q1&2)

6,572

(55% in Q1&2)

40% of total sample


Methods

Measuring impact of sponsored SHI on health service use (Facility-based delivery)

Impact of Health insurance to

Service Utilization

Level 2: Community-level

characteristics

(1) Women (Q1&2) who

delivered in the last 24 months

(NDHS 2013)

Insured under UHC/KP

(treatment)

Uninsured (control)


Methods

Determination of the impact of SHI for the poor

will be determined controlling both for

individual and community factors.

Variable Name Coding Definition

Dependent Variable

fbd - Women who last delivered

in a facility (Facility-Based

Delivery)

0, 1 Identified women who delivered in a health facility (government / private)

Dependent variable in a binary form

Facility Delivery (Q1 & Q2)

Year

2008 2013

Yes 290 (24%) 679 (51%)

No 928 (76%) 651 (49%)


MethodsModel: DID under Linear Probability Model

(LPM), with cluster-robust standard errors

Interaction terms in the DID model using a

Non-linear model will not be able to show

the ATT of the interaction variable (A &

Norton, 2003; Athey & Imbens, 2006)

Difference-in-Differences Estimation


MethodsModel: DDD under Linear Probability Model

(LPM), with cluster-robust standard errors

Identification of post-policy effect of SHI on

utilization with consideration of urban/rural

community types

Assumption: individuals from urban

community types have more access to

health facilitiesTriple Differences Estimation


ResultsMLR HLM

Interaction variables Model 1 Model 2 Model 3 Model 4 Model 5 Model 6 Model 7 Model 8 Model 9 Model 10

Interaction (DD) -0.07 -0.01 -.09 -0.02 -0.07 -0.01 -0.01 -0.09 -0.03 -0.03

Interaction (DDD) 0.05 0.01 0.08 0.04 0.04

Insured 0.06 0.06 0.07* 0.06 0.05 0.05 0.05 0.06 0.05 0.05

Post-policy 0.29* .26 * 0.31* 0.28 0.30* 0.27* 0.26* 0.33* 0.30* .30 *

Insured*postpolicy -0.07 -0.01 -.09* -0.02 -0.07 -0.01 -0.01 -0.09 -0.03 -0.03

Community Type 0.14* 0.08 .13* .08* .08*

Community Type * Post policy -.10* -0.08 -0.13* 0-.12* -.13*

Insured*Community Type 0.02 0.04 0.00 0.02 0.03

Independent Variables (x)

Education 0.08* .08 * 0.08 0.08 0.08* 0.08*

Number of HH Members -0.01* -.01 * -0.01 -0.01* -0.01 -0.01*

Head of HH Sex -0.04 -0.04 -0.04 -0.04 -0.04 -0.04

Head of HH Age 0.00* 0.00 * .002301 * 0.00* 0.00* .00*

Wealth Index Decile (5 decimals) 1.45e-06*

1.36e-06 * 0.00 1.20e-06*

1.21e-06 *

1.17e-06 *

Total number of Children -0.01* -.01 * -0.01 -.01 * -0.01 -0.01

Union Status -0.04 -0.03 -0.02 -0.02 -0.02 -0.02

Partners' Educational Attainment .06* 0.06 0.05 .05* 0.05* 0.05

Age group 0.00 0.00 0.00 0.00 0.00 0.00

Level 2 Variables (Regions)

MD to Population Ratio 0.00 0.00

RN to Population Ratio 0.00 0.00

MW to Population Ratio 0.00 0.00

Number of Government Hospitals -0.01* -0.01*

Number of Private Hospitals -0.01* -0.01*

Number of RHUs / Lying-in 0.00 0.00

Number of Philhealth Accredited Hospitals 0.01 .01 *

n=2,257

• The models yielded insignificantresults.

• This suggests that despite the fact that FBDs increased (2008-2013), there is no significant evidence to say that the increase was brought by the “insured” status of the poor (from UHC/KP policy).


Key Messages

1. Measuring the impact of the recent policy change in the Philippines, insuring

the poor does not seem to have an immediate effect of increasing use of

health services.

2. Further studies to explore other barriers to health use despite the

“insured” status of the poor should be further investigated which may be

related to the following:

• Availability of health facilities (for delivery) where the poor is located

• Awareness of the nationally sponsored poor of their health insurance benefits

• Ease of Use (of insurance benefits) in facilities

• OOP payments above insurance coverage (from patient experience), etc.


Key Messages

3. Many countries now are using subsidies to achieve UHC – it is important

therefore to note that while health insurance is important to enable the

poor to access services, other supply- / demand-side barriers beyond

financing services should be considered.

4. Medium- and long-term evaluation is recommended for thorough policy

evaluation and future health policy development.


Thank You!

Maraming Salamat!

감사합니다!

Karlo Paredes

[email protected]

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Bauhoff, S., Hotchkiss, D. R., & Smith, O. (2011). The impact of medical insurance for the poor in Georgia: a regression discontinuity approach. Health economics, 20(11), 1362-1378. doi: 10.1002/hec.1673

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Babitsch, B., Gohl, D., & von Lengerke, T. (2012). Re-revisiting Andersen’s Behavioral Model of Health Services Use: a systematic review of studies from 1998–2011. GMS Psycho-Social-Medicine, 9, Doc11. doi: 10.3205/psm000089

Bauhoff, S., Hotchkiss, D. R., & Smith, O. (2011). The impact of medical insurance for the poor in Georgia: a regression discontinuity approach. Health economics, 20(11), 1362-1378. doi: 10.1002/hec.1673

Besley, T. (1989). The Demand for Health Care and Health Insurance. Oxford Review of Economic Policy, 5(1), 21-33.

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Culyer, A. J., & Wagstaff, A. (1993). Equity and equality in health and health care. Journal of Health Economics, 12(4), 431-457. doi: http://dx.doi.org/10.1016/0167-6296(93)90004-X

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Duan, N., Manning, W. G., Morris, C. N., & Newhouse, J. P. (1984). Choosing Between the Sample-Selection Model and the Multi-Part Model. Journal of Business & Economic Statistics, 2(3), 283-289. doi: 10.1080/07350015.1984.10509396

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Melgar, J. D. (2010). Organizing Health Services towards Universal Health Care. Acta Medica Philippina, Volume 44 No. 4(Universal Health Care for Filipinos: A Proposal), 36-42.

Miller, G., Pinto, D., & Vera-Hernandez, M. (2009). High-powered Incentives in Developing Country Health Insurance: Evidence from Colombia's Regimen Subsidiado. NATIONAL BUREAU OF ECONOMIC RESEARCH(NBER Working Paper Series).

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impact of shi for the poor on fbd in the philippines

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