Yellow Pad This time, I try to write differently, patterned after the Financial Times weekly column called “Lunch with the FT,” an institution of what probably is the world’s best business newspaper. “Lunch with the FT” is an interview over lunch that features the world’s leading figures in politics and diplomacy, economics and business, science and technology, philosophy and religion, culture and the arts, and all their subfields. What makes it engaging is that the interview digests both the ideas being tackled by the interviewee, and the food ordered by the interviewer and the interviewee. The rule is the interviewer picks up the tab. But in this case, “Lunch with the Yellow Pad” is quite different. I wish I could describe the food, but I forgot what the food was all about, except that it was the standard buffet at the Marriott Hotel. Good enough, considering it was a free lunch. Thus, unlike “Lunch with the FT,” “Yellow Pad” did not pay for the bill. The interviewer and the interviewee were both participants in a conference on non-communicable diseases hosted by the Department of Health at the Marriott Hotel. And unlike “Lunch with the FT,” “Lunch with the Yellow Pad” does not involve a famous personality like Carter, Kissinger, Gaddafi, Soros, Merkel, or Krugman. The name of my interviewee is Beverly Ho. Her name has a nice ring to it, but it doesn’t ring a bell to many. So, who’s Ho? The famous Ho in my book is Uncle Ho — Ho Chi Minh. Note that Uncle Ho’s full name consists of monosyllables. My friend Boom Buencamino remarks, over fine dinner at his favorite Marco Polo hotel, that Tsinoys love to have polysyllabic first names to accompany a surname with one syllable. He cites our friend Wilfreda Lim. And I can cite Beverly Ho. Beverly, or Bev, is a young doctor of medicine. When I met her the first time, I observed how respectful she is; she calls me Tito. And she has a girlish giggle. Bev has decided to work at the Department of Health (DoH) to serve the people. (She graduated from the University of the Philippines, the university of the people, although her serving the people is not just the influence of her alma mater but also a product of many things in her life and environment.) Before joining the DoH, Bev cofounded the Alliance for Improving Health Outcomes (AIHO). AIHO’s mission is “to steer the Philippine public health system towards social and economic growth, such that it is able to provide quality health care for all Filipinos.” Bev and her colleagues’s motto, to attract young like-mined health professionals to their mission, is: “Public health is an exciting career path.” Now, Bev is the chief of the Research Division of the DoH’s Health Policy Development and Planning Bureau. The DoH leadership has given her the task of shepherding the bill on Universal Health Care (UHC), which the House of Representatives has passed and which the Senate will tackle soon. I came to know Bev through Tessa Tan Torres, a long-time friend who is now coordinator of the World Health Organization’s Health Systems Financing. Bev describes Tessa as her mentor, and Tessa, according to Bev, considers me her mentor. Tessa and her husband Ruben once hosted a late lunch for me, and we discussed UHC. My organization, Action for Economic Reforms, is known for its advocacy on tax reforms, including the sin tax legislation, which earmarked the bulk of the incremental revenue to UHC. Tessa told me to talk to Bev who is most knowledgeable about the many issues pertaining to UHC, including its financing. And so, I interviewed Bev. Here is the interview: Filomeno Sta. Ana III (FSAIII): Bev, please describe what universal health care or universal health coverage is. Beverly Ho (BH): Universal Health Coverage is defined by the World Health Organization as all people getting the health services they need without financial hardship. In the Philippines, we have been using “Universal Health Care” or Kalusugan Pangkalahatan. However UHC as an aspiration and as a program are two very different things, the latter being more focused and limited in scope, as would be required for programs to be implementable. UHC as an aspiration can be explained using the three axes of a cube, each describing the three dimensions of coverage — who (population coverage), what services (service coverage) and how much of the health care costs are covered (cost coverage). How big the cube is largely determined by the funds the country sets aside for health. With this, it must be clarified that: UHC is not only about the poor — it pertains to all, 100% of Filipinos. UHC is not only about inpatient services — it encompasses all health services, delivered at the community, outpatient and inpatient health facilities. UHC is not about making all health care free; it differentiates between services that must be made free and those that require cost-sharing. Different countries, depending on their context and values, have different approaches to UHC. When a country considers health as a right and a public good, we see a very dominant public sector. When a country considers health as a commodity that can be sold, the private for-profit sector is allowed to grow, as in the case of the Philippines. Regardless of values and dominance of the public or private sector however, countries have never been clearer about delineating roles — on who does the financing versus delivery of services, or a purchaser-provider split. Instead of public facilities receiving a fixed line item budget regardless of how well they perform, many health systems globally have anointed a national agency (health insurance or health security) to pool and manage fragmented funding and develop payments mechanisms to maximize provider performance. FSAIII: Is UHC the same as health insurance coverage? BH: No. First of all, what does health insurance coverage mean? It can pertain to people, services, or cost covered by the health insurance scheme. Second, UHC is an aspiration, while health insurance is just one means to achieve the aspiration. FSAIII: Is population coverage same as health insurance coverage? BH: Yes, but only if we have decided as a country that health insurance is the primary means to access health services should we equate health insurance coverage with population coverage. FSAIII: Is population coverage the same as PhilHealth coverage? BH: If we assume that all health funds are pooled to PhilHealth and it becomes the primary means to access health services, then, yes, they are the same. However, the reality is, funds for health in the country are fragmented. For example, funds in the DoH that are used to buy TB or cancer drugs benefit the poorest. So this means that for the “UHC Cube of DoH,” the population coverage is limited to the poor, the service coverage to TB and cancer. On the other hand, funds in PhilHealth that are used for various inpatient conditions means that for the “UHC Cube of PhilHealth”, the population coverage is 92% (PhilHealth’s reported membership coverage), the service coverage also expansive (almost all inpatient conditions except a few). FSAIII: Does UHC discount the need to invest in health facilities and health care workers (e.g. supply-side interventions)? BH: Absolutely not. Service coverage can only be realized when there are enough health facilities for the population to go to, enough health workers to market these health facilities functions. The DoH operationalizes the Ambisyon 2040 Vision for health as all Filipinos being able to access health services at the community, outpatient and inpatient facilities with cost-sharing arrangements depending on ownership of the health facility as in the case of outpatient services, and type of accommodation for inpatient services: • Community: no cost-sharing or zero out-of-pocket expense. • Outpatient: zero out-of-pocket expense when accessed in public provider and fixed co-payment when accessed in private providers. • Inpatient: zero out-of-pocket expense when admitted in basic accommodation and fixed co-payment when admitted in non-basic accommodation. For inpatient, basic accommodation refers to often shared-type of accommodation generally without frills (e.g. TV, air-conditioning). Currently, these can be ably represented by the refurbished charity wards or PhilHealth wards of various government hospitals. Ensuring acceptability of UHC reforms means that it should not just be the citizens/patients’ interests that need to be ensured, but other key stakeholders as well. For example, institutional health care providers must have healthy profit margins; professional health care workers must have work arrangements that make them feel well compensated and valued; and suppliers of goods and technologies must be incentivized to innovate and develop cost-effective interventions. Meeting these goals requires key structural changes in the health sector that can only be enabled by a coherent legislative proposal, which is currently being provided by House Bill No. 5784, already submitted to the Senate, and Senate Bill No. 1458. FSAIII: Can I have the last say? I wish you and the DoH success in having the UHC bill passed. The challenge, too, is the financing of the UHC, which I heard will entail an additional budget of more than P65 billion for the medium term. The way we can support UHC is to ensure its funding; that’s why we have to support a good version of the comprehensive tax reform. And the sin tax, which allots the incremental revenue to UHC must be part of the immediate tax reform package. Which Bev and the DOH agree to. So that’s “Lunch with Yellow Pad.” It was a good lunch because our talk about UHC was substantive. Next time, I will treat Bev to lunch and talk about the food and her mentor Tessa. Filomeno S. Sta. Ana III coordinates the Action for Economic Reforms.