1 PhilHealth Programs and their impact on women’s utilization of health services during...

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PhilHealth Programs and their impact on women’s utilization of health services during child-delivery –

the evidence using National Demographic Health Survey data*

Raymunda Silfverberg, PhL., Rouselle Lavado, PhD., Anna Lindgren, PhD., and Björn Lindgren, PhD.

•Paper extracted from Licentiate Degree Thesis of the first author from the Department of Health Sciences, Faculty of Medicine, Lund University, Sweden, 2009

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RESEARCH ISSUES

General objective: To analyze the contribution of a national health-insurance program towards improving utilization of health services for households in a low- to middle- income country;

the Philippines and its reforms in the second half of the 1990s served as a case for the empirical analysis.

R R. Silfverberg et al, June 2009

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Specific objectives

1.) To analyze the impact of the Philippine national health insurance on women’s utilization of maternity care services during child delivery: place of delivery and skilled birth attendance


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PRESENTATION OF THE PAPER:

• Brief background on maternal health care issues

• Applied methodology

• Main Findings

• Lessons to be learnt

R R. Silfverberg, et al., June 2009

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Table 1. Selected health status indicators, Philippines, Sweden and selected regions


South East-Asia Region

Western Pacific Region

Lower-middle-income countrie Sweden

High income: OECD

1990 2006 2006 2006 2006 2006 2006

Life expectancy at births, total (years) 65 68 64 74 71 81 80 Life expectancy at births, male (years) 61 64 63 72 69 79 77 Life expectancy at births,female (years) 68 71 65 76 73 83 82Maternal mortality ratio per 100,000 WHO estimates (modeled) 2005 230 450 82 180 3 9

Source: WHO Statistics 2008

Philippines

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Philippines

Southeast Asia Region

Western-Pacific Region

Low-middle income countries Sweden

High Income: OECD

2006 2006 2006 2006 2006 2006

Antenatal care coverage* 70 no data no data no data no data no data

Birth attended by skilled health personnel* 60 48 92 86 no data 99

Neonates protected againstneonatal tetanus 64 86 75 81 no data 78

Source: WHO Health Statistics 2008

RRSilfverberg et al., June 2009

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a.) Place of delivery

0% 20% 40% 60% 80% 100%

National capital Region

Autonomous Regions of MuslimMindanao

Urban

Rural

Lowest education

Highest education

Poorest

Richest

Health facility Home


8

0% 20% 40% 60% 80% 100%

National capital Region

Autonomous Regions of MuslimMindanao

Lowest education

Highest education

Urban

Rural

Poorest

Richest

Professional Traditional


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Philippine health care spending

Figure 2. Trends in per capita health expenditure at current andConstant (1985) prices, Philippines 1995-2005

0

300

600

900

1200

1500

1800

2100

2400

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Per capita health expenditures, in pesos at current pricesPer capita health expenditures, in pesos at 1985 constant prices

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Figure 1.4 Trend in share of total health expenditure to GDP, Philippines, 1995-2005

0,0

0,5

1,0

1,5

2,0

2,5

3,0

3,5

4,0

Year

Per

cen

t

% Share of health expenditures to GDP

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1995 2000 2003 2005Total health expenditures by use of funds

Personal care 77.0 73.0 75.7 78.4Public health care 11.8 14.4 12.3 11.6Others 11.2 12.6 12.1 10.0

Total health expenditures by sources of funds Government 35.0 40.6 34.2 28.7 National 19.2 21.2 16.7 15.8 Local 15.8 19.3 17.5 12.9

Social health insurance 4.5 7.0 9.5 11.0Private source:Out-of-pocket 50.0 40.5 44.0 48.4Other private sources 10.4 10.7 11.3 11.9

Sources: NSCB 2002, 2003, 2005

Share (%)

Share (%)


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Philippine health care financing

National Health Insurance – PhilHealth

Legislated 1995

Fully implemented 1998

Programs:

• Employment Program

• Individually-Paying Program

• Sponsorship Indigent Program

• Non-Paying Program (Lifetime Program)

• Overseas Filipino Workers Program (established 2005)


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Philippine Health Insurance…

Benefits• In-patient care coverage• Out-patient care coverage

Ambulatory surgeries and procedures incl. dialysis, radiotherapy and chemotherapy

Professional fees max 1,200Operating room 385

• Special benefit packages Natural spontaneous delivery (2003) 4,500

Hospital charges 2,500Professional fees 2000

Newborn care package (2006) 1000

Applicable to PHI Corporation accredited facilities/ health professionals, public and private. Benefits portable nationwide.


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Why do Filipino women continue to give birth at home and seek the services of traditional birth attendants?

Why the slow uptake in skilled professional birth attendance and delivery in health facilities, despite expansion of PHI population and benefit coverage?

Impact of health insurance, PhilHealth programs on mother’s access to (or utilization of) prenatal care, child delivery and post-partum care?

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APPLIED METHODOLOGY

Theoretical framework:

Grossman model : Demand for health and health care (1972) in the context of developing country

Bolin, Jacobsson and Lindgren : Extended Grossman model to family unit (2002)

Liljas : Demand for health with insurance (1998)


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APPLIED METHODOLOGY …

Data used: National Demographic Health Survey Philippines 2003

• Women interviewed: 13, 633 individual women aged 15 – 49

• Only women with the most recent pregnancy and live birth during the past five years prior to survey -

4,920 women out of 6,954 livebirths

• Only NSD births, excluding caesarian cases: final sample - 4,519 women


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Descriptive analysis

Econometric analysis: Multinomial logit model

Dependent variables in MNL models:

Place of delivery: Public or private health care facility with home setting as base group

Birth attendant: Medical doctor or nurse/midwife with traditiona birth attendant as

base group


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Independent variables

PhilHealth insurance by type of program – maininterest of the study (excluded other types of

healthInsurance)

• PHI-None, PHI-Employed, PHI-IPP/SIP/NPP

• PHI status of woman, husband, father of daughter below 21 years


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Independent control variables:

Individual characteristics: woman’s age, child’s birth order, birth complications, antenatal care visits;

Household level characteristics: wealth status, woman’s education, partner’s education, woman’s employment status, woman’s empowerment status, number of children below 5 years old, household size;

Community variables: urban/rural residence with/without accessibility problems, regional location.

Important econometric considerations in analyses• Treatment of the endogeneity problem of health insurance


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MAIN FINDINGSDescriptive statistics: selected variablesN = 4519

Place of delivery:Home delivery 67.4 %Public health facility 21.4 %Private health facility 11.0%

Skilled birth attendantsTraditional birth attendant 43.9%Midwife/nurse 28.2%Doctor 27.5%

PHI membership status of womenPHI none 76.0%PHI-EP 15.5%PHI-IPP/SIP/NPP 8.2%

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I. Descriptives

Figure I.1 Distribution of women by PHI insurance and wealth status, and by educational background


0%

20%

40%

60%

80%

100%

Poorest Poorer Middle Richer Richest

PHI-None PHI-EP PHI-IPP/SIP/NPP

0%

20%

40%

60%

80%

100%

Low educ Secondaryeduc

Higher educ

PHI-None PHI-EP PHI-IPP/SIP/NPP

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I. Descriptives: Women’s utilization of health services: Place of delivery and skilled birth attendance

Figure I.3 Women’s health service utilization by PHI status

Place of delivery

0

20

40

60

80

100

PHInone PHI-Employment PHI-IPP/SIP/NPP

Home facility Public facility Private facility

Skilled birth attendant

0

20

40

60

80

100

PHInone PHI-Employ ment PHI-IPP/SIP/NPP

Perc

ent

TBAs Midwife/nurse Doctor


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I. Descriptives:

Figure I.3 Women’s health service utilization by wealth status

Place of delivery

0

20

40

60

80

100




0

20

40

60

80

100


Perc

ent

TBAs Midwife/nurse Doctror


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MAIN FINDINGS

Descriptives:

Figure I.4 Women’s health service utilization by educational background


Place of delivery

0

20

40

60

80

100

Low education Secondaryeducation

Highereducation

Perc

ent

Home facility Public facility Private facillity


0

20

40

60

80

100

Loweducation

Secondaryeducation

Highereducation

Per

cent

TBA Midwife/nurse Doctor

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MAIN FINDINGS

Descriptives:

Figure I.5 Women’s health service utilization by residence/accessibility problems

Place of delivery

0

20

40

60

80

100

Urbanwithoutdistran

problem

Urban withdistranproblem

Rural withoutdistran

problem

Rural withdistran

problem


Skilled birth attendance

0

20

40

60

80

100

Urban without

distran problem

Urban with

distran problem

Rural without

distran problem

Rural with

distran problem



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MAIN FINDINGS

Descriptives:

Figure I.6 Women’s health service utilization by antenatal care visits to health professionals


Place of delivery

0

20

40

60

80

100

With ANC visits to TBAs With up to 3 ANC visits tomedical professional


Skilled birth attendance

0

20

40

60

80

100

With ANC visits to TBAs With up to 3 ANC visits to medical

professional


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MAIN FINDINGS

Descriptives:

Figure I.6 Women’s health service utilization with pregnancy complications

Place of delivery

0

20

40

60

80

100

With pregnancy complication

Per

cent

Home facility Public facility Private facillity


0

20

40

60

80

100

With pregnancy complicationP

erce

nt



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MAIN FINDINGS

Descriptives:

Figure I.6 Women’s health service utilization with birth complications

Place of delivery

0

20

40

60

80

100

With birth time complication

Per

cent



0

20

40

60

80

100

With birth time complicationP

erce

nt



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MAIN FINDINGS

MNL regression results:

Direct and positive impact of the Philippine Health Insurance Employment Program (PHI-EP) on women’s utilization of private care facilities and the services of medical doctor during child-delivery.


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Public care Private care

Predicted EstimatedPredicted

Estimated

Insurance status: with PHI-EP + + + + *** PHI-SIP/NPP + + - -

Midwife/nurse Doctor

Predicted EstimatedPredicted

Estimated

Insurance status: with PHI-EP + + + + ** PHI-SIP/NPP + + - -

Table 5. Predicted versus estimated signs of coefficients of insurance variables on women's utilization of health services during child-delivery

Significance level: (**) 5%; (***) 1%

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MAIN FINDINGSMNL regression results…

Effects of control policy variables on use of public and private care, midwife/nurse and medical doctor delivery attendance

Positive effects: • Child’s lower birth order• Birth time complications• With antenatal care visits with health

professionals• Maternal and paternal higher educational level• Household higher wealth status• Household size (small to large)Negative effects:• Presence of distance and transport problems

(especially in rural areas)• Location in non-metropolitan regions

32RRSilfverberg et al., June 2009

LESSONS TO BE LEARNT FOR PHILIPPINE POLICY-MAKERS

• Potential effectiveness of programs in improving access to affordable health care for target population groups: general population (informal sector),and indigent

• IPP,SIP – no impact yet on maternal health care utilization

• Determination of actual population coverage.

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RSilfverberg et al., June 2009

Lessons to be learnt for Philippine policy-makers…

• Design and features of the PHI programs - influence on utilization

o Hospital vs primary care setting

o For the less-wealthy IPP/NPP members?

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Lessons to be learnt for Philippine policy- makers…

• Promotional efforts of program directed to:

o women/mothers

o lowly-educated

o poor

o rural segments of the society

Picture- philhealth premium payment


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Lesson to be learnt for Philippine policy-makers… • PHIC’s incentives to LGUs (as insurer) to widen enrollment of indigents

• PHIC and DOH’s incentives to LGUs (as provider) – improvement of quality of care and accreditation of public health care facilities, i.e. birthing facilities

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Lesson to be learnt for Philippine policy-makers…

• More attention for in-depth empirical studies on the demand for health care alongside supply- related determinants of health care utilization.

PHI Corporation in coordination with other stakeholders: government agencies and research institutions (RITM, PIDS, UPSE, UPHA)

• Separate assessment of different health insurance schemes vs target populations


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MORE IMPORTANT ISSUES FOR FUTURE ANALYSES

• Impact of specific insurance programs from demand-side - target household populations: poor, women, children, rural sectors • Demand (utilization) studies with insurance factor, focused on major policy agenda, i.e. maternal health care

• Impact of health insurance programs on equity issues in access across income groups

• Impact of health insurance programs on the quality of public care

• Impact of health insurance on women’s health per se.

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Thank you!


EFFECTS OF OTHER CONTROL POLICY VARIABLES

Public care Private care Midwife/Nurse DoctorWoman’s age: -/- - **/- (a) - / + (a) - ** / - (a)

Child's birth order: Lower order + ***/ +*** + ***/+*** + / +

+***, -***(b) /+**, -* (b)

Complications (Pregnancy and birth) Around birth time + ***/ +*** + ***/ +*** + / + + *** / +**With prenatal care visits with practitioner + ***/ +*** + ***/ +*** + *** / +*** + *** / +**Mother’s education: Higher education + ***/ +*** + ***/ +*** + *** / +*** + *** / +**Mother’s employment status +/- +/ + *** +/ + + / +Woman's empowerment status +/ - +/ + * - / - +/-Household’s wealth status:Wealthier group + ***/ +*** + ***/ +*** + *** /*** + *** / +**Number of children below 5 yrs +/- - /- + * / + + / -Household size +***/ +** + ***/ +*** +* / + +***/ +***Residence: UrbanDistance/Transportation problemUrban with distance/transport problem -/- ** +/- + / + -**/-***Rural with distance/transport problem +***/ -*** -***/ -*** - ***/ -*** - ***/ -***Regional location: Metropolitan regions Non-metropolitan - ***/-*** - *** / -*** -*** / -*** -*** / -***

Significance level: (*) 10%; (**) 5%; (***) 1%; signs to the left- under PHI-EP, signs to the right – under PHI-IPP/SIP/NPPa.) Age 20-29 years; b) Positive effect at lower birth order but negative effect at higher order.

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