Action 1.2 Initiate Rapid Expansion of the Sponsored Program with National Government financing using updated targeting mechanisms (proxy means testing) and strictly enforce service utilization and quality targets for which PHIC is held accountable
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In the absence of stricter measures to mandate LGUs to enroll poor families into the Sponsored Program, the best option is for the national government to cover the program costs. The NSSHRP is already supporting this activity with project financing of US$40 million. The move towards targeting based on the National Household Targeting System-Proxy Means Test (NHTS-PMT) is already happening. Rapid expansion of this program will mean that additional resources for the health sector are channeled towards poverty alleviation goals. However, this move must be complemented by a strictly enforced set of performance indicators for PHIC to ensure that enrolled persons have timely access to health services.
Policy Area 2: Expanded Coverage and Improved Fiscal and Institutional Sustainability of Health Insurance
Action 2.1 Expand PHIC coverage to all indigent families and informal sector workers and expand the PHIC benefits package for all members
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While in the short-term, the expansion of the SP will be initiated using revised targeting mechanism (NHTS-PMT), in the medium-term, it is expected that all eligible families will be enrolled under the Program. Cost per family under the existing benefits package is 1200 pesos (approximately US$26), and the Department of Social Welfare and Development (DSWD) estimates that there are 4.7 million households that are eligible under the NHTS-PMT. Therefore, the estimated costs of enrolling all families are 5.7 billion pesos (US$125 million) per year. Given that the DOH’s budget for national government counterpart financing for the SP, is 5 billion pesos (currently), the costs of scaling up the SP from national budget financing seems reasonable. Implement a cost-effective program for enrolling informal sector workers.
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In parallel, the Government needs to implement benefits package expansions for all members to cover inpatient and outpatient services and outpatient drugs with a co-payment system, and exemptions for sponsored program enrollees. For inpatient care, provider payment reforms can be implemented to shift away from the current fee-for-service payment scheme and balanced billing to a primarily case payment scheme with clear co-payment requirements (for example, for additional non-medical services, such as private rooms and special meals). Primary health care under the outpatient benefits package will be implemented through capitation agreements with preferred providers, and bypassing primary health care will result in full out-of-pocket payments. The expansion of primary care benefits to the entire enrolled population under PHIC should be considered. The fiscal sustainability of a comprehensive benefits package will be ensured by undertaking measures such as: (i) capturing out-of-pocket payments by enrolling persons outside PHIC coverage, especially the non-poor working in the informal sector, (ii) improving the efficiency of current expenditures, (iii) channeling additional intergovernmental transfers conditional on need.
Action 2.2 Implement Comprehensive Reform of the PHIC
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The PHIC plays an extremely critical role in helping the country achieve improved health outcomes and financial protection. As the single-purchaser in the health system, it must exert itself fully to ensure that members have adequate coverage and are able to access quality services in a timely manner. Moreover, to increase its coverage, PHIC, in coordination with the Government, has to implement a comprehensive program for enrolling informal sector workers. In addition to enhancing resource mobilization and risk pooling, PHIC will have to devote time and attention to converting itself into an active purchaser of health services, using contracting as a tool to achieve better quality services at reasonable costs for its members. This major reform of PHIC will require among other, overhaul of the outdated information systems and processes. Full implementation of modernized systems and processes is expected to take at least 3 years and cost approximately US$6 million (276 million pesos). Other related actions include: the integration of evidence-based medicine into reimbursement decisions by PhilHealth; and, the determination of how the relatively large PHIC reserves (over 90 billion pesos) can be used for co-financing premiums for the uninsured (for example, in the informal sector) as well as for improving operational efficiency of PhilHealth. Retraining staff to focus on the PHIC modernized functions also needs to be part of the program.
Policy Area 3: Health Services Delivery System Reform
Action 3.1 Develop and Implement a needs-based facilities and health personnel master plan
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The DOH will provide leadership in the development and implementation of the needs-based facilities master plan and human resources for health (HRH) master plan to determine how the distribution of health sector inputs can be rationalized to ensure equity and efficiency. This master plan will also, in the future, be used to determine “certificate of needs” for expansion of private health facilities and identify, jointly with PHIC, mechanisms to encourage expansion of public or private sector inputs to improve access to health services.
Action 3.2 Implement health facility autonomy
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Most of the provider payment reforms planned under PHIC are likely to have little impact until health care institutions have fiscal and institutional autonomy over budgets, hiring and firing of staff, and in determining investments. Performance-based approaches at the facility level, as well as quality improvements, will also have limited impact without greater health facility autonomy. To take this reform agenda forward, the DOH needs to provide the leadership in the development of a “road map” for facility reform that can then be taken forward jointly with other stakeholders in the health sector, including LGUs and PHIC.
Policy Area 4: Strengthened Stewardship of the Health Sector and Focus on Emerging Public Health Challenges
Action 4.1 Support implementation of health information systems for improved monitoring and evaluation and regulation of the health sector
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To effectively carry-out functions such as monitoring and evaluation, evidence-based policy-making and regulation, the DOH requires modernization of its information systems and staff capacity-building. In order to do this, DOH will need to (i) build a cadre of trained staff (ii) implement a higher level group within the DOH that is able to oversee efforts in this area, (iii) develop standards to facilitate the integration of existing systems and provide the foundation for building further applications, and (iv) develop new, orchestrated support mechanisms for hardware/software support and training.
Action 4.2 Integrate the prevention of non-communicable diseases and road accidents into public health and primary health care services
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DOH needs to identify how non-communicable diseases are affecting poor households and the factors for NCD burden among the poor. This needs to be followed by a strategy to address NCDs within the broader context of public health and primary health care services. Addressing trauma needs to be a part of this strategy.
References
World Bank. 2010. The Philippines: Health Sector Assessment: power point presentation on preliminary findings and policy Options. The World Bank, Washington DC
_________. 2009. Inclusion Growth in the Philippines. Chapter on Health, Nutrition and Population, In Draft, The World Bank, Washington DC
National Statistics Office (NSO) [Philippines] and ICF Macro. 2009. National Demographic and Health Survey. 2008. Claverton, Maryland, National Statistics Office and ICF Macro.
World Bank. 2007. On Streamlining the Core Business Processes of PHIC. Report by Dennis Streveler. The World Bank, Washington DC.
_________. 2006. National Sector Support for Health Reform Project, Project Appraisal Document (PAD), Report # 35405-PH, International Bank for Reconstruction and Development, The World Bank.
_________. 2005. Second Women’s Health and Safe Motherhood Project. Project Appraisal Document, Report # 31456-PH, International Bank for Reconstruction and Development, The World Bank.
Note prepared by:
Sarbani Chakraborty and Eduardo Banzon
with inputs from: Roberto Rosadia, George Schieber, Ajay Tandon, Loraine Hawkins, Dennis Streveler and Oscar Picazo
The World Bank
PHILIPPINES Discussion Note No. 12
Basic Education
Accelerating Progress in Basic Education Attainment
Several decades ago, the Philippines was considered to have one of the most successful systems of education among developing countries. This is no longer the case, as the Philippines now trails behind a number other countries with substantially lower income levels in this area. Furthermore, net enrolment indicators have stagnated or deteriorated over the last decade, jeopardizing the Philippines’ chances of attaining the Millennium Development Goals in education by 2015. The Philippines’ comparatively poor performance on the education front reflects important obstacles to access to education, a poor quality of education and an insufficient allocation of public resources toward education. To successfully address these challenges, the Philippines needs to (i) increase the access to education by poor and marginalized groups through targeted programs and a greater reliance on complementary partnerships with the private sector, (ii) improve the quality of education through concerted implementation of critical basic education sector reforms, an improved curriculum and expanded basic education system, and better performance incentives for teachers and principals, and (iii) significantly increase the basic education budget.
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The Philippines Today: Progress and Challenges
Key Challenges
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To most Filipinos, good education is the pathway to a richer, healthier and more secure life. For the poor especially, it is the single most important means of escaping poverty. Good education enables children to develop lifelong learning skills and take advantage of opportunities for gainful employment and self-employment in a rapidly changing and increasingly globalized economic environment. For these reasons, access to good education must rank among the top priorities of any government administration.
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Improving access to education, particularly for the poor, is a major challenge in the Philippines. Since the late 1990s, the Philippines has lost ground to its neighboring countries – as enrolment rates significantly increased for these countries, the Philippines experienced a reverse in trends. Both elementary and secondary enrollment rates have declined from the peaks of over 90 percent and 70 percent in the 1990s to 84 percent and 60 percent respectively in 2008.2 Of the children 16 years or younger who are in school, the proportion increases by expenditure quintile: from 85 percent in the poorest quintile to 98.1 percent in the richest (Figure 1). Gaps in access are also evident between poor and non-poor areas: for example, in the ARMM, only 82.9 percent of children 16 years or younger attended school compared to the national average of 91 percent, and 94.7 percent in the National Capital Region (NCR); see Figure 2. The secondary education Net Enrolment Rate (NER) is a low 59.4 percent. Furthermore, elementary and secondary NERs have stalled or even declined during this decade (Table 1). As a result, the Philippines compares unfavorably with other countries in education attainments3 and may miss the MDG for universal primary education by 2015; Table 2.4
Figure 1:
Percentage of Children in School, by Quintile
Figure 2:
Percentage of Children in School, by Region
Source: Basic data from 2004 Annual Poverty Indicators Survey (APIS)
Source: Basic data from 2004 Annual Poverty Indicators Survey (APIS)
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The low quality of basic education is also a challenge. While the latest available data on the National Achievement Test (administered to Grade 6 and Second Year High School students) show that results have begun to improve at the national level, overall achievement levels continue to be mediocre. Average test scores of Grade 6 students improved from 55 percent in 2005-2006 to 65 percent in 2007-2008, but the average achievement level remains mediocre for Mathematics, Science and English (about 60 percent). Overall, the achievement levels are poor at the secondary level, with mean scores in Mathematics and Science remaining below 50 percent. The average test score of Filipino eighth grade children was only 378 in Mathematics against the international average of 466 of participating countries in the Trends in International Math and Science Study (TIMMS) of 2003 (See Table 1). Results were similar for Science.
Table 1: Selected Philippine Education and Demographic Indicators: 2002-2008
|
Indicator
|
2002
|
2003
|
2004
|
2005
|
2006
|
2007
|
2008
|
Net Enrolment Rate (Elementary, %)
|
90.69
|
89.30
|
87.36
|
84.83
|
83.87
|
83.60
|
83.75
|
Net Enrolment Rate (Secondary, %)
|
59.48
|
60.85
|
59.85
|
58.55
|
58.39
|
58.48
|
59.38
|
Total Education Spending as % of GDP
|
3.39
|
3.24
|
2.86
|
2.68
|
2.65
|
2.70
|
2.63
|
Total Education Spending Per Student; PhP
|
7,112
|
7,067
|
6,688
|
6,619
|
6,818
|
7,403
|
7,403
|
School age population (Ages 7-17); thousands
|
20,280
|
20,543
|
20,796
|
21,041
|
21,275
|
21,501
|
21,723
|
Basic Education Spending, as a % of GDP
|
2.91
|
2.76
|
2.42
|
2.29
|
2.26
|
2.32
|
2.27
|
Basic share of Total Education Spending (%)
|
85.84
|
85.19
|
84.62
|
85.45
|
85.28
|
85.93
|
86.31
|
Education share of Total Gov’t Spending (%)
|
22.65
|
21.75
|
21.45
|
20.31
|
19.63
|
19.07
|
19.75
|
Sources: World Bank-World Development Indicators and World Bank (forthcoming), 2010 Philippines Basic Education Public Expenditure Review.
Note: All spending figures are in 2002 prices and include both local and national levels.
|
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Table 2: Education Outcomes in the Philippines and Selected Countries
|
|
Net Enrollment Rate (2007)
|
|
2003 TIMSS: Average Test Scores of 8th Graders
|
|
Elementary
|
Secondary
|
|
Science
|
Math
|
Philippines (2007)
|
83.6
|
58.5
|
Philippines
|
377
|
378
|
Philippines (2002)
|
90.7
|
59.5
|
Singapore
|
578
|
605
|
Colombia
|
88
|
65
|
Hong Kong, China
|
556
|
586
|
India
|
89
|
n.a.
|
International ave.
|
473
|
466
|
Indonesia
|
95
|
60
|
|
|
|
Korea
|
98
|
96
|
|
|
|
Malaysia
|
97
|
69
|
|
|
|
Mexico
|
98
|
70
|
|
|
|
Peru
|
96
|
72
|
|
|
|
Thailand
|
94
|
71
|
|
|
|
Source: For enrolment rate: World Bank (forthcoming), 2010 Philippines Basic Education Public Expenditure Review for the Philippines; and World Bank-World Development Indicators for other countries. For student achievement scores: Trends in International Mathematics and Science Study (TIMSS), 2003.
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Demand and supply side issues contributing to poor education outcomes. Lack of demand for good education due to income poverty is a fundamental factor for low education outcomes (King and Orazem 1998). Until recently, the main instruments for raising demand have been to reduce school fees and making it easier for children to physically access public schools. Now that almost all communities have a complete elementary school, the impact of further reductions of distance to schools on enrolment and completion rates has become more limited. Conditional Cash Transfer (CCT) programs such as the government’s Pantawid Pamilyang Pilipino Program (4Ps) have been found empirically to be highly effective in raising demand for schooling, in addition to reducing poverty, in many countries, including Brazil, Colombia, and Mexico (Fiszbein and Schady 2009). On the supply side, the Philippine public school system is chronically short of classrooms, teachers and educational materials in many areas, and pedagogical practices are often ineffective.
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