# **5. Discussion**

In this section, we compare the Philippines’ performance to other countries in the region, discuss data and measurement limitations, and explore policy implications.

# **5.1 The Philippines in a regional context**

While the considerable variation in survey instruments across countries limits comparability across countries<sup>7</sup> , it seems fair to say that the Philippines does not fare too badly compared to other middleincome countries in the region at a similar level of economic development when it comes to protecting households against the financial effects of health expenditure. Figures are in a similar ballpark to recent estimates from Indonesia, Thailand and Vietnam (see Table 2).

Table 2 Incidence of catastrophic and impoverishing expenditure in Indonesia, Thailand and Vietnam

|**Country**|**Year**|**Catastrophic**<br>**headcount**|**payment**|**Percentage poi**<br>**impoverishme**|**nt change in**<br>**nt**|**Data**|
|---|---|---|---|---|---|---|
|||10%<br>of<br>consumption|40% of non-<br>food<br>consumption|US$1.25 per<br>day threshold|US$2.00<br>per<br>day<br>threshold||
|Indonesia|2011|4%|1.8%|0.9pp|1.3pp|SUSENAS|
|Thailand|2009|1.8%|0.2%|0pp|0pp|HSES|
|Vietnam|2008|7.8%|2.5%|2.pp|3pp|VHLSS|
|**Philippines**|**2012**|**7.7%**|**2.3%**|**1pp**|**1.5pp**|**FIES**|

Source: Limwattananon et al. (2013) for HSES 2009; World Bank staff calculations for SUSENAS (2011), VHLSS (2009) and FIES (2012).

But, findings on financial protection from the FIES should be interpreted together with information on health care utilization because one reason for apparently good financial protection could be that people are not accessing care, due to financial or physical barriers, and therefore not incurring health expenditure. In the Philippines, in 2008, 74 percent of households reported that “getting money for treatment” was a struggle and 56 percent of households reported that the distance to health facilities was a problem (National Statistical Office 2008). There is, therefore, likely to be a share of households who forgo care (or perhaps self-medicate) because of high treatment costs and, therefore, are not considered in the financial protection calculations. Indeed, data from the 2014 World Health Report show that the Philippines performs worse than most of these comparators when it comes to access to care: skilled birth attendance is only 72 percent (compared to 99 percent in Thailand, 83 percent in Indonesia and 92 percent in Vietnam) and access to antenatal care is 78 percent (compared to 80 percent in Thailand, 88 percent in Indonesia and 60 percent in Vietnam) (WHO 2014).

An additional lesson from the region is that the Philippines is not alone in finding that an expansion of health insurance does not necessarily translate into an improvement on financial protection indicators or the (expected) drop in out-of-pocket health spending. In Indonesia, the roll-out of the Askeskin/Jamkesmas program of tax-financed care for the poor did not reduce households’ medical expenditure; in fact, out-of-pocket payments even increased among the targeted urban population (Sparrow et al. 2014). In China, it has been found that the expansion and deepening of coverage of the

> 7 Differences include the number and type of health spending examined and whether spending is measured gross or net of health any insurance reimbursements, among others.

12