Cancer and Universal Health Coverage in the Philippines

Context

The journey to Universal Health Coverage (UHC) in the Philippines began in 1969 with the adoption of the ‘Philippine Medical Care Act’ which drove the development of a ‘Medicare’ health insurance program which came into force in 1971. Some twenty-five years later, the National Health Insurance Act of 1995 paved the way for the creation of the Philippine Health Insurance Corporation (PhilHealth), which is mandated to provide social health insurance coverage to all Filipinos. Initially, coverage was estimated at about 50% of the population, and increased to 89%[1]. Nevertheless, inequalities in access to health care were observed in the country, with high levels of out of pocket spending (OOP) particularly for high-cost procedures, including those related to cancer. 

A major political stimulus for UHC came in March 2019 when President Duterte signed a Universal Health Care (UHC) Bill into law (Republic Act No. 11223). This automatically enrols all Filipino citizens in the National Health Insurance Program and instigated complementary reforms in the health system to enable the provision of UHC.

The journey from the ‘Z Benefit Package’ to the UHC Bill

Cancer is the third leading cause of morbidity and mortality in the Philippines, and the leading causes of cancer related deaths in the country are lung, liver, breast, colon cancers and leukaemia.

In 2011 the government launched the Z Benefit Package to address health conditions that trigger prolonged hospitalisation and very expensive treatments. The Z Benefit Package is offered to all PhilHealth members, which includes those in formal employment, individual paying members, sponsored members, indigent members and other categories. PhilHealth classifies disease conditions from type A (the simplest and cheapest) to type D (the more severe and costly), and so the Z benefits package was deliberately named as such because it covers diseases which are perceived to be medically challenging and potentially economically catastrophic. The services covered include hospital room and board fees, medicines and laboratory exams, operating room costs, professional fees, services required per illness and is being implemented in PhilHealth accredited government tertiary hospitals across the country.

At its inception, the Z Benefit Package included breast cancer, prostate cancer, cervical cancer and childhood cancer (Acute Lymphocytic Leukaemia), and in 2015, colon and rectum cancer were added. The process by which Z Benefit Package was developed included the following steps:

• An analysis of the country’s epidemiological burden
• A Cost effectiveness analysis of potential interventions to address high-burden cancers nationally  
• An actuarial study that included risk management and a comparative analysis of the funds available and the utilisation of funds
• The creation of the Z benefits package with the bundled package of chemotherapy, radiotherapy and surgery for cancer
• The selection of government hospitals that would be eligible to participate in the Z Benefit programme
• Dissemination of information to the public about the Z Benefit Package

Public data on the impact of the Z Benefit Package on access to treatment and care and cancer outcomes is not yet available. Some challenges have been observed with uptake of the package where doctors in participating hospitals are not aware of the institution’s PhilHealth accredited, and therefore are not referring eligible patients. Other challenges include treatment abandonment and administrative barriers in accessing the programme where cases have not been diagnosed in a PhilHealth accredited hospital.

At least one study1 has found that OOP spending for catastrophic conditions, like cancers, is increasing and financial protection remains low in the Philippines. Despite the Z benefit package development, at least one study has found that OOP spending for catastrophic conditions, like cancers, is increasing and financial protection remains low in the Philippines1. In response, the parliament of the Philippines proposed a UHC bill to ensure/enforce automatic enrolment of Filipinos into the Z Benefits Programme, entitling them to the benefits of PhilHealth. Advocates also anticipate an expansion of the PhilHealth benefits packages with the passing of the Universal Health Care Bill.

The UHC Bill focuses on improving the comprehensiveness of national networks of care, with a particular attention to how the health care system is organised, strengthening referral pathways both in public and private institutions, as well as financial mechanisms needed to support these. Procedures relating to health conditions will be included in the implementing rules and regulations that will be periodically updated reflecting current knowledge and best practice.

Alongside the UHC Bill and Z Benefits Package, the Philippines adopted a Sin Tax Reform Law in 2012 which placed higher excise taxes on alcohol and tobacco to help address premature deaths associated with non-communicable diseases. Revenues from the Sin tax law have been allocated for health. In 2016, the Department of Health (DOH) budget had doubled compared to 2013 (122.63 billion PHP, 2.44 billion USD[2]).  Similarly, money earmarked for PhilHealth in the DOH budget went up to 43.89 billion PHP (0.88 billion USD) and was largely used to pay the contributions for the indigent members of PhilHealth1. In January 2018, the government began imposing a tax of 6 Philippine pesos per litre (around 13%) on sweetened beverages to lower the burden of obesity[3], The funds for implementing the UHC Bill will be managed through PhilHealth and will be financed through general taxation, payments from PhilHealth members, and revenues from the Sin Tax law and sugar-sweetened beverage tax.

The National Integrated Cancer Control Act

In February 2019, President Duterte signed the National Integrated Cancer Control Act (NICCA) (Philippines Republic Act 11215) to strengthen cancer control in the country, increase cancer survivorship and reduce burden on families and cancer patients.

As part of NICCA, the National Integrated Cancer Control Program was created to serve as the framework for all cancer control activities of the government. The passing of NICCA was welcomed by civil society organisations working on cancer in the Philippines,  and who advocated strongly for an overarching law on cancer to ensure continuity of the national cancer control programme in the Philippines regardless of changes in government leadership, and with dedicated human and financial resources for its implementation.

Key provisions under NICCA include the creation of the Philippine Cancer Center to promote and encourage cancer research, provide training to medical professionals, and house the population-based cancer registry. It also mandated the creation of a Cancer Assistance Fund and the National Integrated Cancer Control Council, a multi-sectoral and multi-stakeholder body that will act as the policy making, planning and coordinating body on cancer control, headed by the Secretary of Health. By law, three representatives from civil society and patient support organisations will have a voting seats in this council.

NICCA also states that PhilHealth will expand its benefit packages to include primary care screening, detection, diagnosis, treatment assistance, supportive care, survivorship follow-up care, rehabilitation, and end-of-life care for all types and stages of cancer in both adults and children. Cancer will become a notifiable disease and hospitals (both public and private) will be required to have a hospital-based cancer registry as a prerequisite for licencing.

Efforts are currently underway in the government, together with civil society and international agencies such as WHO, to align and harmonise the implementation of the National Cancer Control Act with the UHC Law.

The active involvement of civil society and other stakeholders

Both of these landmark legislative acts were the result of strong and sustained advocacy, planning and consultation, involving the government, civil society organisations, legislative champions, the private sector and international organisations. For the UHC Bill, a series of public hearings was held in Cebu, Davao, Legazpi and Lingayen involving a wide range of stakeholders, including Local Government Units, civil society organisations and the citizenry. The Philippines Senate also convened technical working groups to discuss the content of the bill and participants were invited to read through the bill and offered feedback drawing on expertise from Senators, private sector, civil society and WHO.[4] The development of the NICCA also included well-attended public hearings, consultations in both legislative houses and further consultations in Manila, Cebu, Davao.

The passage of NICCA was a direct result of civil society, patient support organisations and medical societies working on cancer control joining forces. These organisations formed a coalition and committed to go beyond specific ‘cancer disease’ siloes in order to promote the needs and interests of both adults and children with cancer. A core group of organisations (The Cancer Coalition Philippines) worked closely with supportive ‘champions’ in the Ministry of Health and the Senate and the House of Representatives. The 2017 World Health Assembly Resolution “Cancer Prevention and Control in the Context of an Integrated Approach” was a useful resource that was shared directly with legislators during initial ‘buy-in’ meetings and formed the basis for framing and structuring the proposed law. This was also aided by the involvement of the then Minister of Health of the Philippines in the crafting of the WHA resolution.

Cancer Coalition Philippines consulted with other cancer organisations, cancer patients, survivors and their families, patient support groups and medical societies, bringing them together several times to shape a common agenda, framework and provisions for the proposed NICCA. The advocates adopted a ‘connect, collect’ strategy which continuously gathered information, perspectives and partners to intensify support, sustain momentum and solidify agreement on priorities for cancer control in the country. This was considered essential to ensure a unified voice within the cancer community in the Philippines, ensure a strong sense of ownership of NICCA and commitment to its implementation nationally.

Success factors

Reflecting on the work to date, it is possible to identify several success factors which have contributed to the progress so far in the Philippines:

• Utilised political ‘champions’ to drive cancer control up the political agenda and built on a strong advocacy movement with public and political support for cancer control nationally
• Actively engaged cancer organisations from across the cancer control spectrum to maximise the effective use of resources, to share information and build broad support
• Championed the voices of cancer patients, their carers’ and families 
• Made use of existing global agreements to help sensitise decision-makers and structure national discussions