Universal Health Care Act of the Philippines

Declaration of principles and objectives

Section 2 requires an integrated and comprehensive approach to ensure health literacy, healthy living conditions, and protection from health hazards and risks.
Section 2 mandates a health care model providing access to a comprehensive set of quality and cost-effective promotive, preventive, curative, rehabilitative, and palliative services without causing financial hardship, prioritizing people who cannot afford services.
Section 2 establishes a whole-of-system, whole-of-government, and whole-of-society framework for developing, implementing, monitoring, and evaluating health policies, programs, and plans.
Section 2 requires a people-oriented delivery approach centered on people’s needs and well-being, cognizant of culture, values, and beliefs.
Section 3 seeks to progressively realize universal health care through a systemic approach and clear agency/stakeholder roles, and to ensure equitable access and protection against financial risk.

Core statutory definitions

Section 4(a) defines “Abuse of authority” as an act beyond authorization by this Act and Republic Act No. 7875, otherwise known as “National Health Insurance Act of 1995,” as amended, or its IRR, and inimical to the public.
Section 4(b) defines “Amenities” as features providing comfort or convenience (e.g., private accommodation, air conditioning, telephone, television, choice of meals).
Section 4(c) defines “Basic or ward accommodation” as regular meal, bed in shared room, fan ventilation, and shared toilet and bath.
Section 4(d) defines “Co-insurance” as a percentage of a medical charge paid by the insured, with the rest paid by the health insurance plan.
Section 4(e) defines “Co-payment” as a flat fee or predetermined rate paid at point of service.
Section 4(f) defines “Direct contributors” as those who can pay premiums, gainfully employed with employer-employee relationship, self-earning professional practitioners, migrant workers (including qualified dependents), and lifetime members.
Section 4(g) defines “Emergency” based on objective findings of a prudent medical officer on duty, with danger of loss of life/permanent disability (or permanent injury/loss of unborn child for pregnant women) where delay in initial support/treatment may cause harm, or a non-institutional delivery.
Section 4(h) defines “Entitlement” as any singular or package of health services for Filipinos to improve health.
Section 4(i) defines the “Essential health benefit package” as a set of individual-based entitlements under the NHIP including primary care; medicines, diagnostics and laboratory; and preventive, curative, and rehabilitative services.
Section 4(j) defines “Fraudulent act” as misrepresentation/deception for undue benefit or advantage, deviating from normal procedure for personal gain, resulting in damage and prejudice capable of pecuniary estimation.
Section 4(k) defines “Health care provider” as: (1) public or private health facility for health promotion/prevention/diagnosis/treatment/rehabilitation/palliation and care for illness/disease/injury/disability/deformity or obstetrical/medical and nursing care; (2) licensed health professional (doctor of medicine, nurse, midwife, dentist, or other allied professional/practitioner); (3) community-based health care organization; or (4) pharmacies or drug outlets, laboratories and diagnostic clinics.
Section 4(l) defines “Health care provider network” as primary to tertiary providers (public or private) offering people-centered and comprehensive integrated and coordinated care, with primary care provider acting as navigator and coordinator.
Section 4(m) defines “Health Maintenance Organization (HMO)” as an entity providing/offering/covers designated health services for plan holders/members for a fixed prepaid premium.
Section 4(n) defines “Health Technology Assessment (HTA)” as systematic evaluation of properties, effects, or impacts of health-related technologies, devices, medicines, vaccines, procedures and other systems, using multidisciplinary process for social, economic, organizational, and ethical issues.
Section 4(o) defines “Indirect contributors” as all others not direct contributors (and their qualified dependents) whose premium is subsidized by the national government, including those subsidized by special laws.
Section 4(p) defines “Individual-based health services” as services traceable to one (1) recipient, with limited population-level effect, not altering the underlying cause of illness (e.g., ambulatory/inpatient care, medicines, laboratory tests and procedures).
Section 4(q) defines “Population-based health services” as interventions (e.g., health promotion, disease surveillance, vector control) with population groups as recipients.
Section 4(r) defines “Primary care” as initial-contact, accessible, continuous, comprehensive and coordinated care, accessible when needed, and capable of coordinating referrals.
Section 4(s) defines “Primary care provider” as a health care worker with defined competencies, certified in primary care as determined by DOH or a DOH-licensed and certified institution.
Section 4(t) defines “Private health insurance” as coverage of a defined set of health services financed through private premium payments.
Section 4(u) defines “Unethical act” as actions/schemes contrary to NHIP, including overtoiling, upcasing, harboring ghost patients/recruitment practice, acts contrary to a responsible professional’s Code of Ethics, or similar acts that put or tend to put disrepute the NHIP’s integrity and effective implementation.

Universal coverage: who is covered

Section 5 provides that every Filipino citizen is automatically included in the NHIP, referred to in the Act as the Program.
Section 6(a) grants every Filipino immediate eligibility and access to preventive, promotive, curative, rehabilitative, and palliative care for medical, dental, mental, and emergency health services, delivered as population-based or individual-based health services.
Section 6(a) requires the goods and services included to be determined through a fair and transparent HTA process.

Service coverage and access rules

Section 6(b) requires that within two (2) years from the Act’s effectivity, PhilHealth implement a comprehensive outpatient benefit, including outpatient drug benefit and emergency medical services, in accordance with recommendations of the Health Technology Assessment Council (HTAC) created under Section 34.
Section 6(c) directs DOH and LGUs to provide a health care delivery system affording every Filipino a primary care provider as navigator, coordinator, and initial and continuing point of contact.
Section 6(c) requires higher-level access to be coordinated by the primary care provider except in emergency or serious cases and when proximity is a concern.
Section 6(d) requires every Filipino to register with a public or private primary care provider of choice.
Section 6(d) empowers DOH to promulgate guidelines on licensing of primary care providers and registration of every Filipino to a primary care provider.

Financial coverage and financing structure

Section 7(a) provides that population-based health services are financed by the National Government through DOH and are free of charge at point of service for all Filipinos.
Section 7(a) requires the National Government to support LGUs in financing capital investments and provision of population-based interventions.
Section 7(b) provides that individual-based health services are financed primarily through prepayment mechanisms such as social health insurance, private health insurance, and HMO plans for predictability of health expenditures.

National Health Insurance Program membership and benefits

Section 8 provides that Program membership is simplified into two (2) types: direct contributors and indirect contributors as defined in Section 4.
Section 9 provides immediate eligibility for every member to the health benefit package under the Program.
Section 9 prohibits requiring a PhilHealth Identification Card for availing any health service.
Section 9 prohibits charging co-payment for services rendered in basic or ward accommodation.
Section 9 directs that co-payments and co-insurance for amenities in public hospitals are regulated by DOH and PhilHealth.
Section 9 prohibits reduction of the current PhilHealth package for members.
Section 9 requires PhilHealth to provide additional Program benefits for direct contributors, where applicable.
Section 9 prohibits failure to pay premiums from preventing enjoyment of any Program benefits.
Section 9 requires employers and self-employed direct contributors to pay missed contributions with interest compounded monthly of at least three percent (3%) for employers and not exceeding one and one-half percent (1.5%) for self-earning, professional practitioners, and migrant workers.

Premium schedule and subsidy mechanics

Section 10 provides premium rates for direct contributors using a schedule by year, with monthly income floor and income ceiling:
- 2019: 2.75%; floor PHP 10,000.00; ceiling PHP 50,000.00
- 2020: 3.00%; floor PHP 10,000.00; ceiling PHP 60,000.00
- 2021: 3.50%; floor PHP 10,000.00; ceiling PHP 70,000.00
- 2022: 4.00%; floor PHP 10,000.00; ceiling PHP 80,000.00
- 2023: 3.50%; floor PHP 10,000.00; ceiling PHP 90,000.00
- 2024: 5.00%; floor PHP 10,000.00; ceiling PHP 100,000.00
- 2025: 5.00%; floor PHP 10,000.00; ceiling PHP 100,000.00
Section 10 requires that for indirect contributors, premium subsidy be gradually adjusted and included annually in the General Appropriations Act (GAA).
Section 10 requires release of funds to PhilHealth.
Section 10 authorizes DOH, in coordination with PhilHealth, to request Congress to appropriate supplemental funding to meet targeted milestones of the Act.
Section 10 requires that for every increase in direct contributors’ rate and premium subsidy of indirect contributors, PhilHealth provides a corresponding increase in benefits.

Program reserve limits and investments

Section 11 requires PhilHealth to set aside reserves from accumulated revenues not needed for the current year’s expenditures.
Section 11 limits total reserves to a ceiling equivalent to the actuarially estimated amount for two (2) years’ projected Program expenditures.
Section 11 directs that if actual reserves exceed the required ceiling at the end of the fiscal year, the excess reserve fund shall be used to increase Program benefits and decrease members’ contributions.
Section 11 requires that any unused reserve portion not needed for current obligations or for the stated programs be placed into investments to earn an average annual income at prevailing interest rates, called the Investment Reserve Fund.
Section 11 mandates that Investment Reserve Fund investments be placed in allowable instruments, including:
- At least fifty percent (50%) in interest-bearing bonds, securities, or other government evidences of indebtedness, subject to government credit requirements.
- Not more than thirty percent (30%) in debt securities and corporate bonds of prime/solvent corporations (with non-default on interest payments and issuer quality requirements).
- Investment in interest-bearing deposits and loans to, or securities in, any domestic bank in the Philippines designated by the Monetary Board, subject to limits tied to unimpaired capital and surplus or total private deposits.
- Investments in preferred stocks and common stocks of solvent Philippine corporations/institutions listed in stock exchange meeting specified track record/earnings criteria.
- Investments in bonds/securities/promissory notes or evidences of indebtedness of accredited financially sound medical institutions exclusively for hospital construction/improvement/maintenance, subject to Republic guarantee or issuing institution guarantee, triple ‘A’ rating requirement, and a not exceeding ten percent (10%) cap of total reserve fund.
- Investments in debt instruments/other securities traded in secondary markets with intrinsic quality similar to the earlier categories, subject to PhilHealth Board approval.
Section 11 bars any portion of the reserve fund or income from accruing to the general fund of the National Government or any of its agencies/instrumentalities, including GOCCs.
Section 11 authorizes PhilHealth to hire external local fund managers with valid trust licenses through public bidding; it requires an annual report on investment performance by the fund manager to PhilHealth.
Section 11 requires PhilHealth to set up separate funds:
- a fund for benefit payouts before becoming lifetime members;
- a fund for lifetime member payouts; and
- a fund for optional supplemental benefits subject to additional contributions.
Section 11 requires liquid portions of each fund identified as current, and such portions must not be treated as invested assets.
Section 11 requires allocation of a portion of contributions to the lifetime members’ fund based on an actuarial determination using a predetermined percentage, the members’ current average age, and current life expectancy and morbidity curve.
Section 11 requires actuarially sound management of supplemental benefits and lifetime members’ fund, including minimum requirements to secure supplemental benefit payments.

Administrative expense ceiling

Section 12 caps administrative expenses: PhilHealth shall allot 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 for Program administrative cost.

PhilHealth governance and leadership

Section 13 reconstitutes the PhilHealth Board of Directors with a maximum of thirteen (13) members:
- Five (5) ex-officio members: the Secretary of Health, Secretary of Social Welfare and Development, Secretary of Budget and Management, Secretary of Finance, and Secretary of Labor and Employment;
- Three (3) expert panel members in public health, management, finance, and health economics; and
- Five (5) sectoral panel members representing direct contributors, indirect contributors, employers group, health care providers (endorsed by national associations), and representative of elected local chief executives (endorsed by the League of Provinces of the Philippines, League of Cities of the Philippines, and League of Municipalities of the Philippines).
Section 13 requires at least one (1) expert panel member and at least two (2) sectoral panel members to be women.
Section 13 requires sectoral and expert panel members to be Filipino citizens of good moral character.
Section 13 imposes qualification requirements on expert panel members, including seven (7) years active practice and recognition of probity/independence, and bars appointment within one (1) year after losing in the immediately preceding elections.
Section 13(b) provides that the Secretary of Health is the ex officio nonvoting Chairperson of the Board.
Section 13(c) requires all appointive Board members to undergo specified health-financing and HTA training prior to term start; noncompliance is a ground for dismissal.
Section 13(c) directs that within thirty (30) days from effectivity, the GCG shall promulgate the nomination and selection process for appointive members in line with Republic Act No. 10149.

Appointment and classification of PhilHealth officers

Section 14 requires the President of the Philippines to appoint the PhilHealth President and CEO upon Board recommendation from Board non-ex officio members.
Section 14 prohibits the Board from recommending a President/CEO unless the candidate is a Filipino citizen with at least seven (7) years experience in public health, management, finance, and health economics or a combination of these.

PhilHealth as public health workers

Section 15 classifies all PhilHealth personnel as public health workers under Republic Act No. 7305, “Magna Carta of Public Health Workers.”

Additional PhilHealth functions

Section 16(a) authorizes PhilHealth to fix reasonable compensation/allowances/benefits for all positions (including President and CEO) based on job analysis and audit of duties, subject to President of the Philippines approval.
Section 16(a) requires the compensation plan to be comparable with government social security institutions and subject to periodic Board review no more than once every four (4) years (without prejudice to merit-based reviews or productivity/efficiency increases).
Section 16(b) authorizes PhilHealth to establish its organizational structure and staffing pattern for central and regional offices, including foreign coverage if expedient, and to periodically inspect such offices, subject to Board approval.
Section 16(c) authorizes PhilHealth to maintain a Provident Fund with contributions from PhilHealth and its officials/employees and earnings, for benefits to officials/employees or dependents/heirs under terms set by the Board and approved by the President of the Philippines.
Section 16(d) authorizes PhilHealth to adopt/approve annual and supplemental budgets of receipts/expenditures (including salaries/allowances/early retirement) and authorize needed capital and operating expenditures/disbursements, subject to Section 12’s administrative expense ceiling; it requires submission of the corporate budget to DBM for information purposes only.

Health services delivery systems

Section 17 directs DOH to endeavor to contract province-wide and city-wide health systems for population-based health services.
Section 17 requires each province-wide and city-wide health system to have minimum components: (a) primary care provider network with patient records accessible throughout the system; (b) accurate, sensitive, and timely epidemiologic surveillance systems; and (c) proactive and effective health promotion programs/campaigns.
Section 18(a) directs PhilHealth to endeavor to contract public, private, or mixed provider networks for individual-based health services, while ensuring member access is not compromised.
Section 18(a) requires provider networks to agree to service quality, co-payment/co-insurance, and data submission standards.
Section 18(a) authorizes PhilHealth and DOH to incentivize health care providers forming networks during the transition.
Section 18(a) authorizes apex/end-referral hospitals determined by DOH to be contracted as stand-alone providers by PhilHealth.
Section 18(b) directs PhilHealth to shift to performance-driven, close-end, prospective payments based on disease or diagnosis related groupings using validated costing methodologies without differentiating facility and professional fees; it requires differential payment schemes considering service quality, efficiency, and equity; it also requires strong surveillance and audit mechanisms for network compliance.

Local health integration structure

Section 19 directs DOH, DILG, PhilHealth, and LGUs to integrate health systems into province-wide and city-wide health systems.
Section 19 assigns oversight and coordination to Provincial and City Health Boards to oversee integration of health services for province-wide and city-wide systems composed of municipal and component city health systems and city-wide systems in highly urbanized and independent component cities.
Section 19 gives Provincial and City Health Boards management of the Special Health Fund under Section 20 and administrative and technical supervision over health facilities and health human resources within territorial jurisdiction.
Section 19 entitles municipalities and cities included in province-wide/city-wide health systems to a representative in the Provincial/City Health Board.
Section 20 requires province-wide or city-wide systems to pool and manage health resources through a Special Health Fund for population-based and individual-based health services, health system operating costs, capital investments, and remuneration of additional health workers and incentives for health workers.
Section 20 directs DOH, in consultation with DBM and LGUs, to develop guidelines on use of the Special Health Fund.

Special Health Fund allocation rule

Section 21 requires that all income derived from PhilHealth payments accrue to the Special Health Fund, allocated by LGUs exclusively for improvement of the LGU health system.
Section 21 provides that PhilHealth payments shall be credited to the annual regular income (ARI) of the LGU.

Matching grants to improve delivery

Section 22 provides that the National Government shall make available commensurate financial and non-financial matching grants, including capital outlay, human resources for health, and health commodities, to improve province-wide and city-wide health system functionality.
Section 22 requires priority for underserved and unserved areas in grant allocation.
Section 22 requires grants to follow approved province-wide and city-wide health investment plans accounting for complementation of public and private care providers and public or private health sector investments.

Human resources master planning and retention

Section 23 requires DOH, with stakeholders, to ensure formulation and implementation of a National Health Human Resource Master Plan for generating, recruiting, retraining, regulating, retaining, and reassessing the health workforce based on population health needs.
Section 23 requires continuity in health program delivery by guaranteeing permanent employment and competitive salaries for health professionals and health care workers.
Section 24 requires creation of a National Health Workforce (NHW) support system to support local public health systems in addressing human resource needs, prioritizing deployment to GIDAs.
Section 25(a) requires CHED, TESDA, PRC, and DOH to plan expansion of allied and health-related degree and training programs, including for community-based health care workers, and to regulate enrollment numbers based on population health needs and underserved areas.
Section 25(b) requires CHED and DOH to expand scholarship grants for allied and health-related undergraduate and graduate programs, based on the needed cadre of national and local health managers and health professionals, with priority for bona fide residents of unserved or underserved areas or indigenous peoples.
Section 25(c) requires PRC and DOH, in coordination with duly-registered professional societies, to set up a registry of medical and allied health professionals including current number and location of practice.
Section 25(d) requires CHED, PRC, and DOH, in coordination with professional societies, to reorient education and certification/regulation toward producing health workers with competencies in primary care services.

Scholarships: return service requirement

Section 26 requires all recipients of government-funded scholarship programs in allied and health-related courses to serve in priority areas in the public sector for at least three (3) full years, with compensation, under DOH supervision.
Section 26 provides incentives for those who serve an additional two (2) years, as determined by DOH.
Section 26 encourages graduates from state universities and colleges and private schools to serve in these priority areas.
Section 26 directs DOH to coordinate with CHED and PRC for effective implementation and establishment of guidelines for noncompliance.

Regulation: safety, quality, and clinical standards

Section 27(a) requires PhilHealth to establish a rating system under an incentive scheme to acknowledge and reward facilities providing better service quality, efficiency, and equity, recognizing third-party accreditation mechanisms as basis for incentives.
Section 27(b) requires DOH to institute licensing and regulatory systems for stand-alone health facilities, including those providing ambulatory and primary care services, and other modes of health service provision.
Section 27(c) requires DOH to set standards for clinical care through development, appraisal, and use of clinical practice guidelines with professional societies and the academe.

Regulation: affordability and price controls

Section 28(a) requires DOH-owned health care providers to procure drugs and devices guided by price reference indices, following centrally negotiated prices, sell them following prescribed maximum mark-ups, and submit a price list of procured and sold drugs/devices to DOH.
Section 28(b) requires constitution of an independent price negotiation board with representatives from DOH, PhilHealth, and DTI among others, to negotiate prices for DOH and PhilHealth guided by parameters including new technology, innovator drugs, and single-supplier sourcing.
Section 28(b) requires that negotiated prices in the framework contract apply to all health care providers under DOH, and that the price negotiation board adheres to Government Procurement Policy Board guidelines.
Section 28(c) requires health care providers and facilities to make readily accessible to the public and submit to DOH and PhilHealth all up-to-date information regarding prices of health services and all goods and services offered.
Section 28(d) requires drug outlets to carry the generic equivalent of all drugs in the Primary Care Formulary and to provide customers a list of therapeutic equivalents and their corresponding prices when fulfilling prescriptions or transactions.
Section 28(e) requires DOH, PhilHealth, HMOs, and life and non-life private health insurance (PHIs) to develop standard policies/plans complementing the Program’s benefit schedule, and it mandates a coordination mechanism between PhilHealth, PHIs, and HMOs to ensure no benefits are unnecessarily dropped.

Equity requirements and bed-capacity rules

Section 29(a) requires DOH to annually update its list of underserved areas as the basis for preferential licensing of health facilities and contracting of health services.
Section 29(a) requires DOH to develop framework and guidelines to determine bed capacity and number of health care professionals of public health facilities.
Section 29(b) requires guaranteeing equitable distribution of health services and benefits by prioritizing GIDAs.
Section 29(c) requires bed capacity operating thresholds as basic or ward accommodation:
- Government hospitals: not less than 90%
- Specialty hospitals: not less than 70%
- Private hospitals: not less than 10%
Section 29(c) requires all government hospitals, specialty hospitals, and private hospitals to regularly submit reports to DOH on the allotment/percentage of beds used for basic or ward accommodation, and DOH shall issue guidelines for immediate implementation.

DOH health promotion framework and reporting

Section 30 directs DOH, as overall steward, to strengthen coordinated national efforts emphasizing scaling up health promotion and preventive care.
Section 30 requires DOH to transform the existing Health Promotion and Communication Service into a full-fledged Health Promotion Bureau.
Section 30 requires the Health Promotion Bureau to formulate a framework strategy for health promotion, serving as basis for DOH programs increasing health literacy; scaling population-wide promotion programs; coordinating policy across government instrumentalities; and providing technical support to local R&D programs/projects.
Section 30 requires that within two (2) years from effectivity, the cost of implementing health promotion programs be at least one percent (1%) of DOH’s total budget