Underutilization of Social Insurance among the Poor: Evidence from the Philippines

Many developing countries promote social health insurance as a means to eliminate unmet health needs. However, this strategy may be ineffective if there are barriers to fully utilizing insurance.We analyzed the utilization of social health insurance in 30 hospital districts in the central regions of the Philippines between 2003 and 2007. Data for the study came from the Quality Improvement Demonstration Study (QIDS) and included detailed patient information from exit interviews of children under 5 years of age conducted in seven waves among public hospital districts located in the four central regions of the Philippines. These data were used to estimate and identify predictors of underutilization of insurance benefits--defined as the likelihood of not filing claims despite having legitimate insurance coverage--using logistic regression.Multivariate analyses using QIDS data from 2004 to 2007 reveal that underutilization averaged about 15% throughout the study period. Underutilization, however, declined over time. Among insured hospitalized children, increasing length of stay in the hospital and mother's education, were associated with less underutilization. Being in a QIDS intervention site was also associated with less underutilization and partially accounts for the downward trend in underutilization over time.The surprisingly high level of insurance underutilization by insured patients in the QIDS sites undermines the potentially positive impact of social health insurance on the health of the marginalized. In the Philippines, where the largest burden of health care spending falls on households, underutilization suggests ineffective distribution of public funds, failing to reach a significant proportion of households which are by and large poor. Interventions that improve benefit awareness may combat the problem of underutilization and should be the focus of further research in this area

Factors associated with the delay in seeking inpatient and outpatient care services in the Philippines

Despite the country's policies and programs towards universal health care, health is not improving as well as expected, which suggests that households still face significant barriers to their choice of and access to health care, and their timing of use of health services. Using a nationally representative sample of households, we investigate the factors that affect the timing of outpatient care and inpatient care utilization. We define two indicators of delay in seeking care, namely: one for outpatient care, as the number of days from onset of symptom until visit of a clinic or provider, and another for inpatient care, as the number of days from doctor's advice until hospital confinement. Given our dependent variables are measured in terms days until visit, we estimate proportional hazard models (Cox, Weibull and Gompertz) to identify the significant factors associated with delay in seeking health care services. The factors associated with delay are classified in terms of health needs, financial access, physical access, opportunity costs, other household factors and location. Our findings suggest health needs and opportunity costs are the main factors associated with the delay in seeking outpatient and inpatient care services among Filipinos in need of medical attention. Perhaps more importantly from a policy perspective, we also find that physical and financial access variables do not significantly affect timing of care. We draw some implications from the results on increasing access to health care, through improvements in awareness of social health insurance and in the actual quality of health facilities. We also identify directions for future research