QuestionsQuestions (Republic Act No. 11223)
RA 11223 is the “Universal Health Care Act.” It aims to institute universal health care for all Filipinos, prescribe reforms in the health care system, and appropriate funds for its implementation.
The State adopts an integrated and comprehensive approach to health literacy and protection from health hazards; a health care model that provides access to quality, cost-effective promotive, preventive, curative, rehabilitative, and palliative services without financial hardship; a whole-of-system/government/society framework; and a people-oriented delivery approach centered on needs and well-being.
Primary Care is initial-contact, accessible, continuous, comprehensive and coordinated care available at the time of need, including coordination of referrals. A Primary Care Provider is a health worker with defined competencies certified in primary care as determined by DOH or a DOH-licensed/certified health institution.
Population-based services are interventions like health promotion, disease surveillance, and vector control with population groups as recipients. Individual-based services are services traceable to one recipient with limited population-level effect, such as ambulatory/inpatient care, medicines, diagnostics, and procedures.
Every Filipino citizen is automatically included in the National Health Insurance Program (NHIP) called the Program.
Every member has immediate eligibility/access to a health benefit package covering preventive, promotive, curative, rehabilitative, palliative, medical, dental, mental, and emergency services, determined through a fair and transparent Health Technology Assessment (HTA) process. A PhilHealth ID is not required to avail services; no co-payment for basic/ward accommodation.
Within two (2) years from effectivity, PhilHealth must implement a comprehensive outpatient benefit, including outpatient drug benefits and emergency medical services, based on HTAC recommendations.
Co-payments and co-insurance for amenities in public hospitals shall be regulated by DOH and PhilHealth.
Membership is simplified into two types: direct contributors and indirect contributors, as defined in Section 4 of the Act.
Population-based services are financed by the National Government through DOH and provided free of charge at the point of service to all Filipinos.
They are financed primarily through prepayment mechanisms such as social health insurance, private health insurance, and HMO plans to ensure predictability of health expenditures.
PhilHealth Identification Card shall not be required in the availment of any health service.
No more than seven and one-half percent (7.5%) of the actual total premium collected from direct and indirect contributory members during the immediately preceding year may be allotted for administrative cost.
It has a maximum of thirteen (13) members: five (5) ex-officio members (Secretaries of Health, DSWD, DBM, Finance, and Labor and Employment); three (3) expert panel members; and five (5) sectoral panel members representing direct contributors, indirect contributors, employers group, health care providers, and elected local chief executives.
PhilHealth shall endeavor to contract public, private, or mixed provider networks, subject to agreements on service quality, co-payment/co-insurance, and data submission standards, and with a requirement that member access to services shall not be compromised.
A province-wide or city-wide health system pools resources through a Special Health Fund for population-based/individual-based services, system operating costs, capital investments, and additional health workers/incentives. All income derived from PhilHealth payments accrues to the Special Health Fund to be allocated exclusively for improving the LGU health system, and PhilHealth payments shall be credited to the LGU’s annual regular income.
HTA is the fair and transparent priority-setting mechanism recommendatory to DOH and PhilHealth for policies, programs, regulation, and determination of a range of entitlements (e.g., drugs, devices, procedures, and services). Investments/benefit packages must be based on positive HTA recommendations but remain subject to periodic review as new evidence emerges.
The Act lists criteria including: responsiveness to magnitude/severity/equity; safety and effectiveness (with available Phase IV trials and systematic reviews/meta-analyses); household financial impact (reducing out-of-pocket expenses); cost-effectiveness; and affordability/viability for financing agents.
Committing an unethical act, abusing authority, or performing a fraudulent act may lead to fines, suspension of contract or accreditation, and in certain cases constitutes a criminal violation punishable by imprisonment (as discretion of the court), without prejudice to other legal liabilities.