Universal Health Care Act

Case Overview and Summary

Summary of Republic Act No. 11223 (Universal Health Care Act)

General Provisions
- Declares the policy of the State to protect and promote the right to health of all Filipinos. (Section 2)
- Aims to progressively realize universal health care and ensure equitable access to quality and affordable health care goods and services. (Section 3)
- Defines key terms used in the Act, such as "direct contributors," "indirect contributors," "health care provider," "health care provider network," "Health Maintenance Organization (HMO)," "Health Technology Assessment (HTA)," and "primary care provider." (Section 4)

Universal Health Care (UHC)
- Every Filipino citizen shall be automatically included in the National Health Insurance Program (NHIP). (Section 5)
- Every Filipino shall be granted immediate eligibility and access to preventive, promotive, curative, rehabilitative, and palliative care for medical, dental, mental and emergency health services. (Section 6)
- Population-based health services shall be financed by the National Government and provided free of charge. (Section 7)
- Individual-based health services shall be financed primarily through prepayment mechanisms such as social health insurance, private health insurance, and HMO plans. (Section 7)

National Health Insurance Program
- Membership in the Program shall be simplified into two types: direct contributors and indirect contributors. (Section 8)
- Every member shall be granted immediate eligibility for health benefit package under the Program, without requiring a PhilHealth Identification Card. (Section 9)
- No co-payment shall be charged for services rendered in basic or ward accommodation. (Section 9)
- Premium rates for direct contributors are specified, with a monthly income floor and ceiling. (Section 10)
- PhilHealth shall set aside a portion of its accumulated revenues as reserve funds, subject to a ceiling equivalent to two years' projected Program expenditures. (Section 11)
- No more than 7.5% of the actual total premium collected shall be allotted for administrative cost of implementing the Program. (Section 12)
- The PhilHealth Board of Directors is reconstituted with a maximum of 13 members, including ex officio members, expert panel members, and sectoral panel members. (Section 13)
- The President and CEO of PhilHealth shall be appointed by the President of the Philippines from the Board's non-ex officio members. (Section 14)
- All PhilHealth personnel shall be classified as public health workers. (Section 15)
- Additional powers and functions of PhilHealth are specified, including fixing compensation, establishing organizational structure, maintaining a Provident Fund, and adopting budgets. (Section 16)

Health Services Delivery
- The DOH shall endeavor to contract province-wide and city-wide health systems for the delivery of population-based health services. (Section 17)
- PhilHealth shall endeavor to contract public, private, or mixed health care provider networks for the delivery of individual-based health services. (Section 18)
- PhilHealth shall endeavor to shift to paying providers using performance-driven, prospective payments based on disease or diagnosis related groupings. (Section 18)

Organization of Local Health Systems
- The DOH, DILG, PhilHealth and the LGUs shall endeavor to integrate health systems into province-wide and city-wide health systems. (Section 19)
- The province-wide or city-wide health system shall pool and manage a special health fund to finance health services, operating costs, capital investments, and remuneration of health workers. (Section 20)
- All income derived from PhilHealth payments shall accrue to the Special Health Fund and be allocated by the LGUs for improving the LGU health system. (Section 21)
- The National Government shall make available financial and non-financial matching grants to improve the functionality of province-wide and city-wide health systems. (Section 22)

Human Resources for Health
- The DOH, together with stakeholders, shall ensure the formulation and implementation of a National Health Human Resource Master Plan. (Section 23)
- A national health workforce support system shall be created to support local public health systems in addressing their human resource needs. (Section 24)
- The CHED, TESDA, PRC and the DOH shall develop and plan the expansion of allied and health-related degree and training programs, and expand scholarship grants. (Section 25)
- All graduates of allied and health-related courses who are recipients of government-funded scholarship programs shall be required to serve in priority areas in the public sector for at least three full years. (Section 26)

Regulation
- PhilHealth shall establish a rating system under an incentive scheme to acknowledge and reward health facilities that provide better service quality, efficiency and equity. (Section 27)
- The DOH shall institute a licensing and regulatory system for stand-alone health facilities, and set standards for clinical care. (Section 27)
- DOH-owned health care providers shall procure drugs and devices guided by price reference indices and centrally negotiated prices. (Section 28)
- An independent price negotiation board shall be constituted to negotiate prices on behalf of the DOH and PhilHealth. (Section 28)
- Health care providers and facilities shall make accessible information regarding the prices of health services and goods. (Section 28)
- The DOH shall annually update its list of underserved areas, which shall be the basis for preferential licensing of health facilities and contracting of health services. (Section 29)
- All government hospitals are required to operate not less than 90% of their bed capacity as basic or ward accommodation. (Section 29)

Governance and Accountability
- The DOH shall strengthen national efforts in providing a comprehensive and coordinated approach to health development with emphasis on scaling up health promotion and preventive care. (Section 30)
- The DOH shall transform its existing Health Promotion and Communication Service into a full-fledged Health Promotion Bureau. (Section 30)
- All public and private, national and local health-related entities shall be required to submit health and health-related data to PhilHealth. (Section 31)
- The DOH and DOST shall develop a cadre of policy systems researchers, technical experts and managers by providing training grants. (Section 31)
- The PSA shall conduct relevant modules of household surveys annually during the first ten years of implementation. (Section 32)
- The DOH shall publish annual provincial burden of disease estimates. (Section 32)
- Health Impact Assessment (HIA) shall be required for policies, programs, and projects that are crucial in attaining better health outcomes or those that may have an impact on the health sector. (Section 33)
- The Health Technology Assessment (HTA) process shall be institutionalized as a fair and transparent priority setting mechanism. (Section 34)
- The Health Technology Assessment Council (HTAC) shall be created within the DOH to facilitate provision of financing and coverage recommendations on health technologies. (Section 34)
- Conflict of interest declaration and management shall be routine in all policy-determining activities. (Section 35)
- All health service providers and insurers shall maintain a health information system consisting of enterprise resource planning, human resource information, electronic health records, and an electronic prescription log. (Section 36)

Appropriations
- The amount necessary to implement this Act shall be sourced from: (1) total incremental sin tax collections, (2) 50% of the National Government share from the income of PAGCOR, (3) 40% of the Charity Fund and mandatory contributions of PCSO, (4) premium contributions of members, (5) annual appropriations of the DOH, and (6) National Government subsidy to PhilHealth. (Section 37)

Penal Provisions
- Penalties are specified for violations committed by health care providers, members, employers, and PhilHealth directors, officers or employees, including fines, suspension of contract or accreditation, imprisonment, and misappropriation of funds. (Section 38)

Miscellaneous Provisions
- A Joint Congressional Oversight Committee on Universal Health Care is created to conduct a regular review of the implementation of this Act. (Section 39)
- The DOH shall establish a Performance Monitoring Division to monitor and evaluate the proper and effective implementation of the provisions of this Act. (Section 40)
- Transitory provisions are specified, including the appointment of new members of the PhilHealth Board and President, absorption of affected PCSO officers and personnel, and timelines for the implementation of various provisions. (Section 41)
- All doubts in the implementation and interpretation of this Act shall be resolved in favor of upholding the rights and interests of every Filipino to quality, accessible and affordable health care. (Section 42)
- The DOH and PhilHealth shall promulgate the necessary rules and regulations for the effective implementation of this Act no later than 180 days upon the effectivity of this Act. (Section 43)
- Separability clause and repealing clause are included. (Sections 44 and 45)
- The Act shall take effect 15 days after its publication in the Official Gazette or in any newspaper of general circulation. (Section 46)