How are government hospitals funded? What are the sources of their funds and how are these allocated to them? This Note takes a deeper look at this and offers some insights and suggestions in addressing certain issues attendant to it.health sector, health care reform, health management, Philippines, health, health funds, government hospitals

Lavado, Rouselle F.

English

Research Papers in Economics

How are DOH hospitals funded?
Rouselle F. Lavado
Philippine Institute
for Development Studies
Surian sa mga Pag-aaral
Pangkaunlaran ng Pilipinas
Policy Notes
No. 2010-15 (December 2010) ISSN 1656-5266
PIDS Policy Notes are observations/analyses written by PIDS researchers on cer-
tain policy issues. The treatise is holistic in approach and aims to provide useful
inputs for decisionmaking.
This Notes is largely culled from PIDS Discussion Paper No. 2010-02 titled “How
are government hospitals performing? A study of resource management in DOH-
retained hospitals” by the same author, and refers to the data that are more com-
plete in said Discussion Paper. The author is Senior Research Fellow at the Insti-
tute. The views expressed are those of the author and do not necessarily reflect
those of PIDS or any of the study’s sponsors.
Background
When health services were devolved in 1992
under the Local Government Code (LGC), it
had the unintentional consequence of
breaking down the referral network among
health care service providers. As a result,
hospitals became the locus of health care
delivery in the Philippines. Various health
surveys show that patients routinely bypass
basic health care service providers1 and health
centers, and instead go straight to hospitals
even for the simplest of health concerns.2
Tertiary hospitals,3 for instance, which are
designed to cater to more serious diseases,
are also accommodating cases such as
immunization and malnutrition that can be
handled by lower level facilities. Because of
this, hospitals now require more financial
resources to be able to attend to all their
patients.
As of 2009, there was a total of 1,822
licensed public and private hospitals with the
Department of Health (DOH). Of this number,
public hospitals accounted for only 40
percent. Despite this marginal share, public
hospitals serve the most number of patients.
On average, government hospitals are bigger
in size with 68 beds per hospital as opposed
to private hospitals with only 44 beds. The
final referral center among public health
facilities are the DOH hospitals. Thus, DOH
______________
1 This pertains to barangay health stations (BHS) manned
by barangay health workers (BHW). A barangay is
considered as the smallest political unit in the Philippines.
2 Among these surveys are the Filipino Report Card,
National Demographic and Health Survey, and the PIDS-
UNDP Local Services Delivery Survey. Basic health care
service providers pertain to barangay health stations (BHS)
and rural health units (RHU).
3 Hospitals can either be private or publicly owned and
classified as either Level 1 (primary and infirmary), Level 2
(secondary), or Levels 3 and 4 (tertiary). Levels 3 and 4
hospitals are facilities offering the highest level of health
care service delivery.PN 2010-15
2
Policy Notes
hospitals carry the brunt of public health care
service delivery in the Philippines.
To date, there are 67 DOH hospitals.4
Historically, the DOH spends more than half of
its budget for the upkeep of these hospitals.
From 2003 to 2007, the budget for DOH
hospitals accounted for 60 percent or more of
the total budget. However, in 2008, a shift in
priority of the DOH from personal health care
to public health programs saw a drastic
decline of allocation for DOH hospitals to just
35 percent of total budget (Table 1). The DOH
budget accounts for as much as 70 percent of
hospitals’ total fund. Given the DOH hospitals’
status of referral-of-last-resort for public
health facilities and patients’ preference for
hospital treatment over other health
facilities, the tightening of budget
support from DOH is a serious concern.
A hospital under DOH management
would now have to contend with less
financial support for an ever-
expanding demand on its services.
It now becomes vital for the
government to determine whether or
not DOH hospitals are using their
limited resources in an efficient
manner. Unfortunately, despite the crucial
importance of DOH hospitals in the health
care sector, there is little systematic
understanding on how public hospitals utilize
these public resources. How do DOH hospitals
allocate their budgets? What can be done to
improve the efficiency of spending in DOH
hospitals? If the DOH budget for hospitals
declines further, can DOH hospitals survive?
This Policy Notes, an extract from a previously
released Discussion Paper titled, “How are
government hospitals performing? A study of
resource management in government-retained
hospitals,” will center on the budget sourcing
and allocation process of DOH hospitals. The
purpose of this analysis is to raise
understanding of issues surrounding the
sector and outline recommendations for more
informed policy decisions on health sector
design and implementation.
Inefficiencies in allocation from GAA
Of the total available funds for DOH hospitals,
about 80 percent are from the General
______________
4 This number pertains to the number of retained hospitals
in 2010. During the study period (2003–2008), there were
72 hospitals which included the original 45 hospitals
retained under DOH after devolution, the 21 renationalized
hospitals such as the Veterans Regional Hospital and
Region 1 Medical Center, and six newly established
hospitals such as the Talisay District Hospital and Conner
District Hospital.
Table 1. DOH budget for hospitals, nominal and real values
(in million pesos)
2003 2004 2005 2006 2007 2008
In nominal terms
Total budget for hospitals 6,119 6,084 5,099 5,997 6,777 6,594
Total DOH budget 9,281 9,281 9,725 10,038 11,399 18,912
In real termsa
Total budget for hospitals 5,377 5,045 4,699 4,349 4,779 4,304
Total DOH budget 8,156 7,696 7,492 7,279 8,039 12,345
% allocation for hospitals 66 66 63 60 59 35
a adjusted for inflation, at constant 2000 prices
Source: General Appropriations Act, various years.PN 2010-15
3
Policy Notes
Appropriations Act (GAA) while 20 percent are
from hospital income (Figure 1). The 80
percent GAA funds are sourced from the
following: 70 percent from the DOH budget
and 10 percent from various special purpose
funds (SPFs). More specifically, out of the
funds sourced from the DOH budget, 67
percent are directly allocated to the hospitals
while 3 percent are suballotments (SAA)5 from
the DOH Central Office. As for the 10 percent
coming from special funds, 9 percent are from
personnel-related SPFs and 1 percent is from
the Priority Development Assistance Fund
(PDAF).
Unfortunately, as per the analysis done by
this study for each source, inefficiencies in
resource management can already be detected
from the allocation of GAA funds, to wit:
Budget from DOH-Central Office. Payments to
hospital personnel comprise the largest share
of total budget appropriated to DOH
hospitals. In 2008, personal services (PS)
accounted for three-fifths of the budget.
There has been a steady decline in the share
of Maintenance and Other Operating Expenses
(MOOE) in the total hospital budget, from a
level of 44 percent in 2000 to just 32 percent
in 2008. From 2000 to 2008, MOOE declined
by as much as 52 percent in real terms.
Capital outlay (CO) had been zero from 2001
to 2006, partly due to the fiscal crisis and the
austerity measures imposed during this time.
Allocation for CO was resumed in 2007, but
______________
5 SAA are transfers usually requested by the DOH hospital
from the DOH Central Office to fund staff trainings and are
counted as Maintenance and ther Operating Expenditure
(MOOE).
Figure 1. Sources of funds
Acronyms: GAA – General Appropriations Act; PDAF – Priority Development Assistance Fund (pork barrel); MPB –
Miscellaneous Personnel Benefits Fund; PGF – Pension and Gratuity Fund; PCSO – Philippine Charity Sweepstakes
OfficePN 2010-15
4
Policy Notes
this was scaled back in 2008, with only 13
hospitals receiving CO appropriations.
It is unclear what criteria are used for the
allocation of hospital budget. It used to be
that the budgets are based on the number of
hospital beds, but as hospitals evolved with
more complex composition of cases, this
practice no longer applies. Analysis of the
budget from 2000 to 2008 based on three
possible criteria—hospital bed capacity,
geographic character (population and regional
poverty incidence), and the number of poor
patients served—shows inconsistencies. This
raises the question on whether or not
prioritization is done across types of hospitals
or by regions. It is also not clear whether or
not efficiency in the use of resources is an
allocation criterion.
The reality is that prior to the implementation
of Formula One for Health (F1), the framework
for health sector reforms, the DOH had no
clear plan for the hospitals left under its care
after devolution.
Budget from PDAF. Allocation of PDAF to
hospitals is ad hoc. Congressmen are allowed
to contribute their PDAF to any hospital of
their choosing, regardless of whether a
particular health facility is located in the
district where they serve. Since allocation of
PDAF is subject to the “whim” of
congressmen, this usually means that PDAF
goes to the biggest hospitals which attract a
lot of patients. From 2000 to 2008, for
instance, PDAF went to relatively richer,
highly urbanized hospitals and medical
centers in the National Capital Region (NCR),
Central Visayas, and Davao. On the other
hand, PDAF is low or nonexistent in health
facilities located in the poorer regions of
Caraga, Cagayan Valley, Northern Mindanao,
Ilocos, Zamboanga Peninsula, Northern
Mindanao, and SOCCSKSARGEN. If allocated in
a more systematic manner, without political
subjectivity, PDAF could have supplemented
the MOOE of hospitals located in poorer
regions in dire need of additional resources.
High budget execution,
poor planning
In the aggregate, DOH hospitals showed high
budget execution ratios in the years covered
in this analysis. Allotments for all expense
categories were fully released by the end of
the year. The PS appropriations were fully
obligated while the MOOE was 99 percent
obligated. The total capital outlay program of
all DOH-retained hospitals, on the other hand,
was only 34 percent obligated due to long
procurement cycles.  A probable reason for
the high budget utilization rate was the use
of savings as payment for magna carta6
benefits.
Compared to the utilization of DOH funds,
meanwhile, PDAF execution rate is quite low,
______________
6 Under Republic Act 7305, or the Magna Carta of Public
Workers, public workers are entitled to several benefits
(subsistence and laundry allowances, hazard pay,
retirement, etc.). Since the law’s passage in 1992, however,
the government has failed to fully provide in the budget
the payment of such benefits, forcing hospitals to fund the
gap through savings elsewhere (usually salary and wages).PN 2010-15
5
Policy Notes
with only 71 percent by year-end. The
percentage of appropriations obligated is
especially low for the following types of
government hospitals: a) extension hospitals,
b) district hospitals, and c) special hospital-
regular.
But it is not budget execution that is the
main concern in the utilization of funds in
DOH hospitals. With scarcity in resources, it is
hardly surprising that DOH hospitals have
high utilization rate. What the study actually
shows as the two areas of concern in the use
of funds in DOH hospitals are planning and
monitoring.
Lack of planning. In principle, the budget
planning process within DOH hospitals can be
characterized as following the bottom-up
needs approach. In practice, however, it is
less clear how hospitals plan their budget.
Planning and budgeting at the hospital level
seems to be ad hoc and lacking in overall
strategy. There are no oversight arrangements,
with no clear guidelines existing in budget
preparations specifically designed for
hospitals.
Poor monitoring. Planning and budget
preparation is poor because there are gaps in
monitoring and reporting in hospitals.
Reports such as Budget Execution Documents
(BEDs), Budget Accountability Reports
(BARs), and Statement of Allotments,
Obligations, and Balances (SAOBs) are
sometimes incomplete, inconsistent, and
often flawed. Accurate decisions in budget
allocation are difficult to make when the data
are flawed and their integrity compromised.
The way forward
As shown earlier, the GAA is not the only
source of funds for DOH hospitals. Hospital
income, which accounts for 20 percent of DOH
hospitals’ budget, is derived from out-of-
pocket payments of patients, PhilHealth7
reimbursements, and other sources such as
training fees, certification fees, Philippine
Charity Sweepstakes Office (PCSO) donations,
and rental income. However, this money is not
enough to finance MOOE and CO, the two
expenditure items that barely receive budget
support from the DOH. An analysis of the
MOOE coverage ratio in the study shows that
in the four years since income retention was
allowed, only 33 percent of hospitals can
cover MOOE subsidy through income. Thus,
DOH hospitals must learn to better manage
the resources they receive to maintain the
depth (variety) and quality of their services.
Improvement in resource management in DOH
hospitals, however, is not a burden to be
carried by DOH hospitals’ management alone.
The government, the DOH hospitals’ biggest
donor and supervisor, and whose mandate is
to provide affordable and quality health care
to all its citizens, must bear equal, if not
greater responsibility.
To this end, what should be done?
______________
7 The Philippines’ national health insurance program.PN 2010-15
6
Policy Notes
Revise the basis for DOH budget allocation.
Before a budget is allocated using the
Organizational Performance Indicator
Framework (OPIF), there is a need to first
reset the amount allocated to each hospital.
This new allocation criterion should reflect
the current status of each hospital with
consideration to its various activities such as
the complexity of cases it handles and the
number of service patients it serves.
Provide clear guidelines for PDAF allocations.
To prevent arbitrary allocations of the PDAF,
clear guidelines must be made. One restriction
worth considering is the allotment of PDAF
within the districts being served by the
congressmen making the PDAF contributions,
to ensure that poorer regions with smaller
hospitals will also receive additional funding
support.
Require that Magna Carta benefits no longer be
funded by hospital savings. The current
financial status of most hospitals suggests
that they are already overstretched in
meeting hospital operational expenses. Giving
them the additional burden of shouldering the
expenses to pay for Magna Carta benefits is
likely to result in unequal compensation of
hospital workers among DOH hospitals. An
alternative source of fund is the professional
fee reimbursement from PhilHealth as
opposed to the current practice of funding
the benefits from PS and MOOE savings. It will
also provide incentive for hospital workers to
encourage patients to enrol in PhilHealth.
Provide training in planning and budget
preparation for hospital personnel. Hospital
personnel must be trained in planning and
budget preparation so that resources are not
only used efficiently but also effectively. The
DOH should provide a manual outlining in
detail budget preparation specifically
designed for hospitals. This type of trainings
also increases awareness and appreciation for
proper monitoring for performance appraisal.
Underscore the need for an overall plan for all
DOH hospitals. Various plans have been
drafted in different health sector reform
strategies in the past. A “disconnect”
between the Central Office plan and the
hospitals, however, remains because agencies
in charge of the implementation do not have
a strong authority to implement reforms. A
possible solution would be to have a hospital
administrator within the DOH who will
oversee the implementation of the hospital
plan in all DOH hospitals. This administrator
should be given the appropriate authority to
give sanctions for noncompliance and provide
rewards for good performance. 
For further information, please contact
The Research Information Staff
Philippine Institute for Development Studies
NEDA sa Makati Building, 106 Amorsolo Street, Legaspi Village, 1229 Makati City
Telephone Nos: (63-2) 894-2584 and 893-5705
Fax Nos: (63-2) 893-9589 and 816-1091
E-mail: rlavado@mail.pids.gov.ph; jliguton@mail.pids.gov.ph
The Policy Notes series is available online at http://www.pids.gov.ph. Reentered
as second class mail at the Business Mail Service Office under Permit No. PS-
570-04 NCR. Valid until December 31, 2010.

How Are DOH Hospitals Funded?

http://dirp4.pids.gov.ph/ris/pn/pidspn1015.pdf

How Are DOH Hospitals Funded?

Abstract

Similar works

Full text

Available Versions

Research Papers in Economics