Over the past two decades, infant mortality in the Philippines has dropped by more than half. The number of women dying in childbirth has declined, and mortality rates from diseases such as tuberculosis have fallen. The country, however, still isn’t close to meeting the 2015 health targets in the United Nations Millennium Development Goals.
One problem is limited access to quality health care among low-income families. The Philippines Health Insurance Corporation, PhilHealth, has generally focused on inpatient care, and only included an outpatient benefit for poor families two years ago, including covering premium costs. As part of the changes, poor families are entitled to treatment without charge for certain designated diseases diagnosed during health screenings, such as hypertension, diarrhea, diabetes, and cervical cancer.
A national health insurance plan, even with expanded access and broader benefits, can’t be good if the care isn’t good and no one’s signed up to receive it. Already, certain changes have taken place to boost usage and quality. Under changes implemented in a 2012 new benefits package, health clinics are no longer paid a capitated rate based on the number of low-income people in the area who qualify for the health insurance program. Instead, the payments are made based on the number of qualified people actually enrolled in the insurance program. A portion of this payment is allocated to the municipality as bonus payments for health providers based on enrollment. In the future, the payments also will be linked to the number of patients the clinic sees.
To see what can be done to encourage clinics and patients to be more proactive, PhilHealth is piloting a new payment method and an information campaign. Some clinics will receive the bonus payments directly, rather than have the money transferred first the local municipality, which normally distributes the payments. The information campaign, which in some areas will be piloted separately and in others in concert with the new payment method, will make public the data on clinics’ performance in giving the recommended treatments for the designated diseases. The idea is to empower and motivate the community, doctors themselves, and officials.
Will it work? The World Bank’s SIEF Trust Fund  is supporting research to find out. With a grant received in SIEF’s first call for proposals, a research team will evaluate the program’s impact on enrollment, quality of care, and use of services.
Junko Onishi, the World Bank Task Team Leader and one of three Principal Investigators on the project, talked with me about her involvement.
Q: How did you first become interested in the health care system in the Philippines and what makes this important to you?
A: My first job in the Philippines was to work on an impact evaluation  of a World Bank-financed conditional cash transfer program. That started in 2009. Later on, as PhilHealth began its new plans, I got involved with researchers who were working on a proposal to apply to SIEF for money to study the impact of steps to make primary care more available and more effective.
This work, like other projects I’ve been involved with, really is meaningful for me. I want to make a difference to people's lives in whatever issue that I am working on. I feel truly blessed by the fact that I work on issues so close to people's lives, whether it is on social assistance programs or on health.
Q: What’s the biggest health care issue faced by the Philippines -- would you say it’s more one of access or quality? Or are the two inter-related?
A: Access and quality are inter-related problems here. The Philippines has a very decentralized health system, with municipalities being responsible for basic health services. This means that unless the municipalities, which are headed by an elected mayor, are committed to providing appropriate health services, the policies and quality measures set by the national Department of Health might not be followed.
This impact evaluation aims to evaluate the effect of interventions designed to shift the relationship between the municipalities and the health care providers. Direct payments may be a bigger incentive to health providers, instead of having the payments go through layers of bureaucracy before reaching the very group we want to motivate. The provider payments, in essence, will empower the service providers by giving them more control over the bonus payments and giving them more information about how well they and the clinics are meeting quality benchmarks.
Q: Pay-for-performance programs have grown in popularity. What has the evidence around the world shown researchers and how has that informed the design of the evaluation in the Philippines?
A: The evidence is mixed, particularly when it comes to quality of services. The impact evaluation in the Philippines is not strictly an evaluation of a pay-for-performance intervention. It aims to answer so-called second generation questions. In other words, questions related to implementation of the government’s own pay-for-performance mechanism and what might improve its effectiveness.
Q: Part of the evaluation is looking at the effects of increasing the disclosure of health information to communities and officials so that there is more transparency in the health care process. How does more information influence the health choices that people make?
A: The way the social health insurance is set up, patients are assigned to health facilities and do not have a choice in the service they receive. This is, of course, if they decide in the first place to use the services covered by the social health insurance. There are lots of problems with the implementation of this insurance, starting with making sure that qualified households are enrolled and making sure they know what benefits they are entitled to.
The idea behind providing more information about health care services is to empower the three main parties. Communities, once they know what benefits are available and how well the clinic is providing them, are in a better position to demand more and better services. Health care providers, who will know how much they should be getting for meeting quality and enrollment targets, will be able to demand from the local government authorities their fair share of the health budget transferred to the local government unit by PhilHealth. And finally, officials in the national government will be able to get information on the quality and quantity of services provided by health care workers in the municipality.
Q: Has the government been supportive of the evaluation?
A: The Department of Health and PhilHealth are both very supportive of the evaluation. PhilHealth researchers are involved with the impact evaluation and are strong partners in this evaluation. The evaluation results will help PhilHealth determine whether any supplementary intervention is necessary in the first place, and if yes, which would be the most effective and cost-effective approach, and whether the interventions could be scaled up for implementation across the whole country.
Q: The World Bank is focused on promoting the use of evidence in policymaking. What’s the view of PhilHealth when it comes to taking into account the results of the evaluation, whatever they may show?
A: The commitment from PhilHealth is to make this work. As part of the proposal writing, we revisited the objectives of the study and made sure that the evaluation was among the key issues for PhilHealth. The Korean Development Institute is also a strong partner in this study, and the level of ownership among the three agencies of this study – PhilHealth, the Korean Development Bank and the World Bank -- is something I have rarely seen in other studies. It's been a great collaborating effort between the three agencies.
Interview conducted with assistance from Daphna Berman.
Follow the World Bank Health Team on Twitter: @worldbankhealth 
Strategic Impact Evaluation Fund 
World Bank Universal Health Coverage Country Study Series