|Author(s)||Raoul Bermejo1, Beverly Lorraine Ho2, Wim Van Damme3
|Affiliation(s)||1Department of Public Health, Institute of Tropical Medicine -Antwerp, Manila, Philippines, 2Health Unit, Philippine Institute of Development Studies, Manila, Philippines, 3Department of Public Health, Institute of Tropical Medicine -Antwerp, Antwerp, Belgium.|
|Country - ies of focus||Philippines|
|Relevant to the conference tracks||Governance and Policies|
|Summary||In response to rising non-communicable disease prevalence and access to medicines challenges for the worst-off, the national government has launched three medicines access programs. Data were collected from informant interviews, site visits and document reviews. These were analyzed by first creating a chronology of events. Then, using a health policy framework, strategies and actions used along with the results were examined. Findings revealed that the rapid roll out of the NCD access programs exhibited strong political commitment towards UHC. However, weak policy processes have failed to ensure equitable access to quality and cost-effective medicines and implementation success.|
|Background||As more Filipinos continue to be exposed to non-communicable disease risk factors such as tobacco and alcohol use, unhealthy diets and physical inactivity, prevalence for hypertension and diabetes mellitus have risen to 21% and 7.7 % respectively in 2008, and are expected to increase further. Cardiovascular disease and diabetes, along with cancer and chronic respiratory disease account for 57% of total deaths during the same year. According to the National Health Accounts, 52.7% of health expenditures are out-of-pocket. Of these, pharmaceuticals – accounting for 65.75% of household spending – are the single largest item of health care expenditures for households. Republic Act 9502, a law providing for cheaper and quality medicines was enacted in 2009.The Department of Health’s National Center for Pharmaceutical Access and Management launched three medicine access programs, namely DOH Complete Treatment Pack (ComPack), Valsartan (VAP) and Insulin Access Programs (IAP). ComPack provides complete (monthly) treatment regimens at no cost to the poorest families identified under the NHTS who are diagnosed to have diabetes and hypertension. VAP and IAP make available patent-protected Valsartan and Insulin at 60% lower cost than market prices.|
|Objectives||The paper aims to document the policy process of three NCD medicine acces programs in the Philippines using a health policy analytical framework. Specifically, the paper seeks to understand the interaction of strategies that were employed and the factors that contributed greatly to policy advancement.|
|Methodology||A qualitative, case study methodology using an in-depth longitudinal, prospective examination of events was employed for each of the three programs. Primary and secondary data were collected from (1) interviews with key policy and programme stakeholders; (2) visits to programme implementation sites; and (3) review of government documents, development partner reports, meeting records, conference proceedings and media clips. Representatives from government, academic institutions, nongovernment organizations, multilateral and bilateral agencies were interviewed. The interview guide reflected the three themes of emergence, formulation and implementation as described in the analytical framework by Lemieux (2002). A chronology of events was developed and process tracing was conducted. Triangulation of multiple data sources and discussion/verification with key actors supported interpretation and minimized bias.|
|Results||Emergence: Our analysis shows that the following were critical in moving the access programs forward: (1) political commitment to achieve Universal Health Coverage by 2016, (2) availability of national health budget, (3) strong NCD policy community and access to medicines alliances, (4) increasing focus for the worst-off population and (5) strong industry lobbying.Formulation: The policy unit responsible for the programs was operational for less than 3 years when the policies were conceptualized and launched, and did not receive full technical support as was required. A relatively participative process was undertaken to define the contents but there was minimal integration into the health system.Implementation: Full subsidy of $15 million/annum and $400,000 are allocated for the ComPack and VAP. IAP has no subsidy since it is procured on a supply now-pay later (or consignment scheme). Information activities, implementation and evaluation support were constrained for all three programs largely due to funding limitations. The non-uniformity of information across health workers and patients resulted in a varied application of the policy in different implementation sites. Implementation was compromised by immediate national roll-out and devolved set-up for ComPack and the limited access sites for IAP and VAP. Availability of an efficient means for monitoring and responding to stock-outs remained a major challenge. To date, no plans for program evaluation have been articulated. IAP and VAP were also unable to address access challenges especially for the worst-off.|
|Conclusion||The rapid roll out of the NCD access programs exhibit strong political commitment towards UHC. However, weak policy processes have failed to ensure equitable access to quality and cost-effective medicines and implementation success. Findings indicate that that rapid rollout of access to medicines programs is possible only if strategies employed are purposeful and contextually sensitive. Favorable conditions for the emergence of a policy may not always exist but can be created.|
|Author(s)||Raoul Bermejo1, Pura Angela Wee2, Wim Van Damme3.
|Affiliation(s)||1Department of Public Health, Institute of Tropical Medicine -Antwerp, Manila, Philippines, 2Zuellig Center for Asian Business Transformation, Asian Institute of Management, Manila, Philippines, 3Department of Public Health, Institute of Tropical Medicine -Antwerp, Antwerp, Belgium.|
|Country - ies of focus||Philippines|
|Relevant to the conference tracks||Governance and Policies|
|Summary||There is increasing global attention on Non-Communicable Diseases (NCDs). In the Philippines, the burden of NCDs is growing but government response remains weak. The study is a policy research that looks at the development of a new benefit package for non-communicable diseases within the Philippine social health insurance program (Philhealth). We investigated how the interaction between the context, actors and processes contributed in shaping the policy. The push for Universal Healthcare, the increasing fiscal space, the growing burden of NCDs, and the increasing demand for access to quality medicines are important contextual discourses that help push the development of the benefit.|
|Background||There has been increasing attention to non-communicable disease (NCDs) globally since the run-up to the high-level summit at the United Nations in September 2011 (Beaglehole 2011). In the Philippines, the burden of NCDs is growing (Shaw 2010). Although the government has started to develop policies and programs to address NCDs, there is still poor financing especially for prevention activities and comprehensive primary care services, lack of health human resource and weak political support (Higuchi 2010; Dans 2011). At the community level, the implementation of NCD programs, comprising mainly of healthy lifestyle clubs and occasional screening activities, remain weak (Lorenzo 2011). Overall, there is an inadequate response considering increasing burden of disease (Bermejo 2011; Van Olmen 2011).The improvement of the health financing mechanisms and particularly of the national health insurance agency, PhilHealth, is seen as a key in decreasing inequities and improving access (Romualdez 2011). One of the new Philhealth benefit packages that is ready to be piloted is the “Outpatient Medicines Benefit Package For Hypertension, Diabetes And Dyslipidemia” also known as the "Primary Care Benefit 2" (PCB2).|
|Objectives||The study is essentially a policy research which looks at the development of a new benefit package for non-communicable diseases within the Philippines social health insurance program (Philhealth). We investigated how the interaction between the context, actors and processes contributed to shaping the policy. The study will also identify different streams in the discourse around PCB2 and analyze how and why this specific policy window emerged.Philhealth is emerging to be one of largest purchasers of healthcare services in the Philippines. It is an agency attached to the Department of Health and is increasingly seen as one of the institutions that shape the healthcare landscape in the country. This research will help to gain insight into its policy making processes, what and who these affect and how these are influenced. This study will help us identify opportunities for improvement of the policy processes at Philhealth and develop recommendations to inform current health policy.|
A case study methodology was done using both qualitative and quantitative methodologies. Documents and issuances related to the development of PCB2 including Administrative Orders, Philhealth Circulars, other legal issuances, and reports of key meetings and events were reviewed. Key informant interviews were conducted among an initial list of actors involved in the development of this new benefit package to gain insight into the key decision made, why these decisions were made and how such decisions were arrived at. The snowballing technique was employed to identify other potential interviewees. The study aimed for theoretical saturation. A trend analysis on quantitative data from the Philhealth database on inpatient claims for NCDs was performed to enrich the contextual description of the case.Sampling
A total of 28 key informant Interviews were conducted with actors involved in the development of PCB2, including:
1. Philhealth decision-makers (e.g. the former and current president of Philhealth, technical personnel within the Primary Care Benefit Team);
2. Program managers and decision-makers at the Department of Health specifically those who are concerned with primary care, NCDs, access to medicines and local health systems development;
3. Members of the academe and researchers consulted on PCB2;
4. Representatives of advocacy groups on Universal Health Care and NCDs;
5. Health officers and representatives of local governments selected as pilot sites;
6. Representatives of the private pharmaceutical sector in the Philippines.Analysis
The policy triangle (Walt and Gilson 1994) and Kingdon’s policy window theory (Kingdon 1995; Guldbrandsson 2009) was applied to analyze the case. The researchers reconstructed the story of the development of PCB2 and identified key strategic decision-making points in the development process. We analyzed how the policy was shaped by the interaction between the context, actors and process. We enriched the contextual description with the time trend analyses of Philhealth population coverage, NCD-related inpatient claims, and reserve funds. The study also identified different streams in the discourse around PCB2, including the discussions on Universal Health Care, NCDs, primary care, strengthening local health systems, and analysed how and why this specific policy window emerged. The research approach was iterative. Each set of data analyzed were used to construct and test the theory.
|Results||We identified four key elements in the new outpatient benefit package of Philhealth: 1) only for sponsored program members or the bottom poor enrolled into the program by the national and local governments, 2) use of the WHO Package of Essential Noncommunicable (PEN) Disease Intervention guidelines for screening and risk scoring, 3) access to full monthly regiments of 8 firstline NCD medications which were 4) made available through contracted private pharmacies.The focus on the bottom poor is consistent with the overall poverty reduction strategy of the government. The strategy is to concentrate poverty alleviation interventions (e.g. Conditional Cash Transfers, enrolment in social health insurance) among the bottom poor (20% of the population) identified through a national household targeting system for poverty reduction.The use of the PEN guideline for screening and risk scoring was a result of consultation with the World Health Organization (WHO) and with the health managers of the City of Pateros where the guidelines were being piloted. Setting risk scores was seen by the insurance managers as a good way to have control over the cost exposure of Philhealth on this new benefit package. This was further validated by expert consultants in Medicine.The first line generic medications included in the list covered by the benefit package was arrived at with the technical team validating the evidence around NCD drugs included in the Philippine National Drug Formulary. By law, all government agencies, including Philhealth, can only pay or procure medicines that are included in the formulary. The position of Philhalth is to promote rational drug use and is directed at the common practice of many physicians who prefer originator drugs. Representatives of pharmaceutical companies, public health centers and specialist doctors actively raised the issue of the "very limited" list of medicines covered by the package.
The decision to make the NCD medicines available through contracted pharmacies is to be consistent with the Pharmacy Law but also largely depoliticizes access to drugs and link it as a clear benefit of being a Philhealth member. Access to medcines made available through public primary care facilities are often politicized.
The push for Universal Healthcare, the increasing fiscal space, the growing burden of NCDs, and the increasing demand for access to quality medicines are important contextual discourses that help push the development of the benefit.
|Conclusion||Health policies, programs and and agendas do not exist in separate silos from each other. PhilHealth’s “Outpatient Medicines Benefit Package For Hypertension, Diabetes And Dyslipidemia" or "Primary Care Benefit Package 2" (PCB2) is one such policy whose development was shaped by policy development processes, actors pushing for their specific agenda and by the context. The actual policy is a product of the dynamic interplay of these factors.|