Extending Social Protection through Health Micro-Insurance Schemes for Women in the Informal Economy PHILIPPINES RAS/02/MNOR/01

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1 Extending Social Protection through Health Micro-Insurance Schemes for Women in the Informal Economy PHILIPPINES RAS/02/MNOR/01 Final Report for January 2003 to March 2005 The project, Extending Social Protection through Health Micro-Insurance Schemes for Women in the Informal Economy, is funded by the Norwegian Government and implemented by the ILO in the Philippines and Nepal. In the Philippines, it has been integrated into the National Action Programme on Decent Work, which the ILO Sub Regional Office Manila jointly launched with its tripartite constituents in May The Action Programme on Decent Work reflects priorities expressed in the Medium-Term Philippine Development Plan ( ) that sets out the government s poverty reduction strategy. Its overall objective is to work towards the elaboration and implementation of a coordinated set of national policies and programmes for Decent Work in the country. The project contributes in achieving the objectives of social protection and gender equality. The first phase of the project, from 2001 to 2002, produced two (2) case studies and a compendium of health micro-insurance schemes in the Philippines. The project s second phase started its activities on January 2003 managed by a National Project Coordinator (NPC) and backstopped by the Social Protection and Gender Specialists based in Manila and by the STEP Focal Point Person who is also a Local Development Specialist based in Bangkok, Thailand. The Norwegian Government approved the request of STEP and ILO SRO Manila for a no-cost extension in The extension was requested to sustain the gains of the project particularly linkage of the health micro-insurance schemes with the National Health Insurance Program (NHIP) and collaboration of the Local Government Units and the schemes for better access to health care. A proposal to extend the project for another three years was prepared to develop sustainable linkages between the national and community-based risk pooling schemes for health. The proposed project will work through organized groups, building their capacity to link with the national health insurance program, facilitate policy dialogue relating to health insurance for the poor and the informal economy and provide technical support to organized groups through a network of advocates and practitioners. 1

2 This progress report covers the activities and achievements of the project from January 2003 until December Where possible experiences of the project are annotated and enclosed in a box to highlight lessons and recommendations. The report is arranged as follows: A. Objectives of the Project B. Beneficiaries C. Project s Achievements D. Difficulties and Challenges Encountered E. Lessons Learned and Recommendations F. List of Documents and Publications This progress report is prepared by Anna Lucila A. Asanza, MD, NPC with valuable inputs from Ms. Ginette Forgues, Senior Local Development Specialist and STEP Focal Person based in Thailand; Ms. Naomi Cassirer, Senior Gender Specialist, Mr. Kenichi Hirose, Social Protection Specialist and Ms. Sylvia Fulgencio, Program Officer of SRO Manila. A. OBJECTIVES OF THE PROJECT It is the long-term goal of the project to improve the quality of life through better access to health care for organised women and their families, working in the informal economy. The project worked towards the achievement of the following immediate objectives to reach our long-term goal: A. Improved management and services of health micro-insurance schemes B. Health micro-insurance schemes, managers and members respond better to gender issues C. Increased awareness/capacity of local and national government officials on benefits of HMIS D. Knowledge development and sharing on contribution of HMIS to poverty reduction and local economic and social development 2

3 B. BENEFICIARIES Members of nine (9) farmers cooperatives and three (3) workers organizations nationwide directly benefited from the project. These were the farmers cooperatives from (1) Esperanza, Aurora, Isabela; (2) San Francisco, Bulacan, Bulacan; (3) Bicao, Carmen, Bohol; (4) Balcon Melliza, Jordan, Guimaras; (5) Ciabu, Baybay, Leyte; (6) Mangloy, Laac, Compostela Valley: (7) Sta. Josefa, Agusan del Sur; (8) Garsica, North Cotabato and (9) Tagpako, Gingoog, Misamis Oriental. Groups of informal economy workers particularly home-based workers, vendors and tricycle drivers from Angono, Rizal also benefited from the project. Using a tool 1 based from the criteria in setting-up a health micro-insurance scheme, the above communities were chosen as beneficiaries. (Please see annex.) The project worked very closely with the Department of Agrarian Reform (DAR) 2 in providing capability building activities and monitoring progress of the different farmers cooperatives which are recipients of the Comprehensive Agrarian Reform Program (CARP). The project initially intended to work with seventeen (17) CARP communities implementing a health micro-insurance scheme. However, in an assessment of their HMIS showed that major assistance is required to upgrade efficiency in the management of the schemes prompting STEP to concentrate on a few sites to facilitate better transfer of knowledge and skills. The Local Government Unit (LGU) 3 of Angono, Rizal has placed social protection coverage of informal economy workers through health micro-insurance schemes as an objective of the municipality from 2001 until It was therefore very much involved in developing this scheme for their constituents. The LGU was the coordinator and monitor of all activities at the community level. To take advantage of existing structures in the community, the LGU 1 The tool was developed by the NPC. A report of visited sites and assessment of each site can be found in the annex. 2 The Department of Agrarian Reform (DAR) is pilot-testing a community-based health insurance project in 17 communities nationwide. The project called DAR-Agraryong Pangkalusugan aims to provide access to health care through innovative health financing schemes. The project began in Year 2000 and is now being evaluated for possible mainstreaming in DAR s program. 3 The Philippines recognizes the importance of local governments. The President exercises supervision over the whole country but for purposes of administrative control, the Philippines is divided into units of political subdivision namely provinces, municipalities, cities and barangays. Each of these units is called a Local Government Unit. There are 77 provinces, 1,540 municipalities, and 67 cities. The Province is the largest political unit headed by an elected governor of the provincial government. Each province is composed of municipalities commonly called towns. A city is also a unit of local administration. It is created by a special law. Municipalities and cities are headed by mayors. Each municipality or city is composed of a number of villages or barangays. The barangays are the smallest units of local government in the Philippines. 3

4 worked with an established and well-respected cooperative in the area Angono Credit and Development Cooperative (ACDECO) to facilitate the management of finances and study how their services could be extended to the different workers groups. Though there were no formal agreement as to how STEP should be implementing the project in the presence of a very strong National Health Insurance Program (NHIP), the Philippine Health Insurance Corporation (PhilHealth), both at the local and national levels, has always been involved in the planning, implementation and monitoring of the different schemes. The experiences from STEP are being considered inputs to the goal of PhilHealth for universal coverage particularly those in the informal economy. C. PROJECT S ACHIEVEMENTS 1. Improved management and services of health micro-insurance schemes Outcome 1.1: Several HMIS managed by selected community-based organizations function better Outcome 1.2: HMIS and local government health providers collaborate in providing preventive care and advocacy activities among the local population There were in total nine (9) farmers cooperatives that benefited from the project s expertise on health insurance. However, two (2) communities Jordan, Guimaras and Bulacan, Bulacan - experienced difficulties in continuing with their schemes during the course of implementation. One had problems with managers of the cooperative leaving a one-man team to take care of all its activities and projects and the other could not attract members to its HMIS because members wanted the cooperative to develop a mechanism with PhilHealth for them to be recognized as collecting agents. The former paid their collected premiums to a local government-run health insurance facility for members and their dependents insurance and the latter is negotiating with PhilHealth for them to be accredited in the PhilHealth Organized Group Initiative (POGI) 4 or any mechanism for them to be able to enrol their members to PhilHealth. Three (3) other communities expressed their intentions to participate in some training with DAR partly subsidizing their participation. Hence the project had nine (9) farmers cooperative instead of the planned six (6). 4 POGI is an initiative of PhilHealth to reach out to the informal economy through organized groups like cooperatives. It is being pilot-tested from May 2003 until the first quarter of

5 The Angono Health Micro-Insurance was launched on 03 December 2005 witnessed by the members of the different informal economy workers including volunteers from the, representatives from the Local Government Unit of Angono, Rizal and leaders of PATAMABA. 5 It had an initial membership of 150 mostly coming from the home-based workers and from the municipal volunteers. The following interventions were done to improve the capacity of the groups to manage their health micro-insurance schemes: a. Training needs assessment for 17 farmers cooperatives and DAR personnel An assessment of the training needs of managers and implementers of existing HMIS were done to determine how the project can provide a more responsive intervention for the different schemes. DAR personnel were also included in the assessment because they are STEP s partners in the field who gave technical support and monitored progress of each scheme. Results showed that all respondents managers of schemes and DAR personnel needed to understand the concepts of health insurance indicating that inputs given in the past were not effective. They also needed information on how to promote the schemes to the communities aside from a true lack of knowledge on social marketing; this could also be a result of a lack of understanding of health insurance in particular and social protection in general. These results became the basis for STEP in concurrence with DAR to concentrate on fewer sites for activities to be focused and more directed towards the community. b. Community survey to assess social protection needs of target communities A survey tool 6 was developed (1) to assess social protection needs of target communities; and (2) develop and redesign benefit packages for them to be more responsive to the needs and wants of the communities. Aside from these two intended objectives, the results of the surveys were used as examples of the social protection needs of workers from the informal economy. There were 1,655 respondents (945 males, 714 females) from 7 communities (1,038 rural workers and 617 informal economy workers). 5 PATAMABA is a national organization of home-based workers in the Philippines. It has a chapter or unit in Angono, Rizal composed of mostly women home-based workers. 6 The survey tool developed by STEP-Philippines was also used as a sample tool in the Local Economic and Social Development (LESD) of INTEGRATION and it was used as reference for other similar surveys. 5

6 Results showed that most of the schemes were not attracting enough members because of a lack of available information. It became apparent that cooperative board of directors and managers of the scheme need to have a guide to promote their schemes. Leadership of each cooperative also played a very big factor in the success of the scheme. Members would not join if they are not sure of the integrity of the leaders. In general other findings are: (1) most potential members would want to have health insurance, (2) they are willing to participate in the program and can pay Php per month or Php annually, (3) most respondents want out-patient care benefits plus coverage of drugs/medicines, (4) majority of respondents go to public facilities for health care, (5) they would want some funds available for educational expenses of their children. c. Training activities at the national level Training on social marketing and on management of HMIS were conducted in Manila for all beneficiaries and partners. Gender concerns are mainstreamed in the training program. The management tools developed by STEP for Africa were adapted for the Philippine setting. The training program of the Philippine Information Agency (PIA) on social marketing was used. d. Training activities at the local level Leaders of the workers organizations and staff of Angono, Rizal s LGU had several workshops and training on site on social protection and health insurance. Workshops in DAR communities were focused on the same topics plus a review of their management systems, developing linkages with local government units and the HMIS role in the Health Sector Reform Agenda (HSRA). 7 There are several advantages in conducting training at the local level: 1) more people could participate in the training because of lesser cost; 2) participants can continue with their livelihood activities, (activities usually stop by 3 o clock in the afternoon or starts at 9 o clock in the morning to allow the workers to attend to their jobs like vending and farming) 3) parents, particularly the mothers, are more at ease because they could bring their children along, and 4) the LGU became more involved in the process. 7 The Health Sector Reform Agenda (HSRA) is a program of the Department of Health (DOH) to reduce the gaps in health care delivery eventually contributing to poverty reduction. The five major reforms of the program are: a) Fiscal autonomy to government hospitals, b) Funding for priority public health programs, c) 6

7 Below is a table showing the status of the different schemes at the end of the project: Name of Community Status at the Start of the Project Status at the End of the Project Remarks 1. Angono, Rizal 3 workers groups and LGU wanted to extend social protection coverage through HMIS Angono Health Micro-insurance launched 03 December 2004 with 150 members; LGU main provider of basic health care services; currently studying how to link with PhilHealth 2. Esperanza, Aurora, Isabela 3. San Francisco, Bulacan, Bulacan 4. Balcon Melliza, Jordan, Guimaras 5. Bicao, Carmen, Bohol To be filled up 60 members; HMIS could not attract more members because they are interested in joining PhilHealth 38 members; HMIS linked to LGU-ran health insurance program; cooperative has no enterprise or income generating activities 30 members with Php 20,000 in HMIS fund; very good collaboration with LGU for provision of services to members; most members of cooperative are To be filled up HMIS put on hold and cooperative in negotiating with PhilHealth so they could be financial intermediary for their members. Encountered problems in management of cooperative, HMIS had to be stopped; collection was paid for premiums to the LGU-ran health insurance for continued members coverage. Expanded coverage of scheme to five other communities currently determining administrative and financial arrangements; Negotiating with Development of local health systems, d) Strengthening the capacities of health regulatory agencies and e) Expand coverage of the National Health Insurance Program. 7

8 recipients of PhilHealth s Sponsored/Indigent Program. LGU so they could replicate the example of the community in Compostela Valley 6. *Ciabu, Baybay, Leyte To be filled up To be filled up Only joined the last training: Management of a Gender-Sensitive HMIS. No site visit done by NPC. 7. Mangloy, Laak, Compostela Valley 250 members with Php 200,000 in their health fund. HMIS now has 1,300 members. Collaborated with the LGU to enrol indigent members to PhilHealth with members paying LGU premium counterpart. Very good example of community developing linkage with the national system. PhilHealth officials visited the community and 1)they wanted the initiative documented for it to be considered in the program for informal sector of PhilHealth, 2) they have been promoting the initiative to other communities and LGUs. 8. Santa Josefa, Agusan del Sur 20 members with benefit package for inpatient care; target members are mostly recipients of PhilHealth s Sponsored/Indigent Program; very poor and slow response from the community; works with LGU for promotive and preventive health care Modified benefit package based on needs of community; now has 60 members and attracting more members to join; they claimed that because of HMIS, other activities/enterprise of the cooperative were developed. 9. *Tagpako, Gingoog, Misamis Oriental To be filled up To be filled up Participated in the two national training. No site visit by NPC. 8

9 10. *Garsica, North Cotabato To be filled up To be filled up Only joined the last training: Management of a Gender-Sensitive HMIS. No site visit done by NPC. *Communities that were not part of the original sites agreed with DAR. intervention done at the community level. No direct 2. Health micro-insurance schemes, managers and members respond better to gender issues Outcome 2.1: Women members from selected organizations have completed training on the concept of HMIS management as well as specific empowerment activities Though the project s objective was initially to provide HMIS to women in the informal economy, it was felt that enlarging the focus to gender sensitive HMIS was more suitable notwithstanding the necessity to give special attention to women s health and their needs arising from their reproductive capacity. There are many advantages to having a broader gender perspective, some of which being: 1) it allows for the total family to access adequate health care via HMIS, thus diminishing risks of women having to provide livelihood for their whole family because of their husband s poor health; 2) it also extends HMIS to the children again diminishing the mothers stress, their time and their weak resources consumed for treating diseases; 3) it still allows for HMIS to carry special benefits geared to women s needs and for the men to recognize the importance of these benefits for their wives and for the families as a whole. Capability building activities were done to improve and/or develop the capacities of leaders to manage health micro-insurance schemes. Needs of men and women were always considered in the conduct of training such as avoiding training/workshops that are more than 3 days long, conducting training at a certain time of the year (not during harvest time) or of the day (not too early, not too late, or in the evenings and weekends), allowing parents to bring their children to the training. This created an environment that was more suited to their needs and schedule allowing more involved participation. 9

10 Breaking Barriers: STEP has allowed women to bring their children to trainings and workshops to develop an environment where women can perform their reproductive and productive roles as well as break barriers of socially-defined roles taking care of children at home preventing them to participate in other activities. The participants during workshops and training are always workers from the informal economy (workers groups, cooperative management and staff) and from the formal economy (DAR personnel, LGU staff). This arrangement served two purposes: 1) the workers from the formal economy will eventually provide technical support and guidance to the informal economy workers during project implementation so they had to be part of all capability building activity and 2) this will help sensitize formal economy workers in conditions that informal economy workers live. During a training conducted in Manila where the different groups come together, there was one mother who requested that she be allowed to bring her 9-month old son along she was breast feeding and no one could take care of the baby during the three-day training. We received several complaints from participants saying that they could not concentrate on the task at hand because the baby cried every so often. When the incident was discussed with the group, it was surprising that most of those who complained were workers from the formal economy. Lessons learned: Concepts of gender sensitivity and equality should have been discussed for participants to have a more open perspective. Project management has to be prepared to process these kinds of experiences with the group immediately. A lived experience has more impact than something given to a purely conceptual note. Advocating for gender equality is a life-long work that takes a lot of effort, commitment and dedication. Mainstreaming gender concerns is a start and breaking through social barriers is a challenge. Outcome 2.2: Maternity benefits and preventive health care activities (also on HIV/AIDS) are included in at least 5 HMIS The public health systems in the Philippines provide free pre-natal and post-natal care to expectant mothers. Birth deliveries are also given free at government facilities from a rural health unit as well as from hospitals. In one LGU, Angono Rizal, mothers are even given a delivery kit containing alcohol, cotton, diapers, etc if they avail of at least seven (7) prenatal check-ups. All of the HMIS are promoting and at the same time advocating the use of these services at the local health centres to all members. All of the schemes have included preventive health care as part of their programs and they are tapping the expertise of public health care providers. 10

11 Outcome 2.3: Gender-sensitive training/awareness raising materials produced Several printed media (comics, posters, brochures, flip charts) were developed to increase awareness on health insurance. These were translated into English, Tagalog and three (3) dialects Ilocano, Hiligaynon and Visayan. Several members of the schemes and the gender consultant pre-tested these materials. Management and marketing tools were gender mainstreamed as well. 3. Increased awareness/capacity of local and national government officials on benefits of HMIS Outcome 3.1: As a result of capacity-building and study tours, members of selected HMIS and local government offices responsible for local economic development have gained and shared experiences on ways to effectively operate HMIS Outcome 3.2: Joint activities between national and local structures Outcome 3.3: Increased reference to the importance of including HMIS managed by local communities into poverty reduction strategies and programmes that deals with the extension of social protection in health to workers in the informal economy 4. Knowledge development and sharing on contribution of HMIS to poverty reduction and local economic and social development Outcome 4.1: At least two (2) case studies produced A case study on the HMIS of Bicao Small Farmers Multipurpose Cooperative in Carmen, Bohol is being done. It highlighted how the cooperative set-up and managed its HMIS and how it integrated its systems to existing services in the community like observing the referral system being promoted by the Department of Health, and coordinating with a pharmaceutical foundation assisted by the Belgian Government. The project also developed a process manual for DAR personnel for setting-up, supporting CARP beneficiaries and monitoring and evaluating a health micro-insurance. This also documents experiences and best practices from eight (8) HMIS. 11

12 An update of the two (2) case studies in the Philippines NOVADECI and ORT Health Plus is also being done to look at their progress, experiences and lessons learned and the HMIS impact to the community. Outcome 4.2: Qualitative and quantitative data collected on the role of health microinsurance are packaged in articles, reports and information materials An inventory of micro-insurance schemes in the Philippines is finished. There were 41 schemes identified and the possibility of others existing is not eliminated. Most of the schemes surveyed provide life insurance and for those providing health micro-insurance, most of them cover hospitalization. There were a total of 1.3 million beneficiaries covered by these schemes. Outcome 4.3: Reports and recommendations for future action drafted and disseminated In preparation D. CHALLENGES ENCOUNTERED BY THE PROJECT Health micro-insurance was introduced by the International Labour Organization to the Philippines in year HMIS has been in used by communities who are excluded from the formal schemes almost a decade before that and as such there were existing practices that run contrary to the ILO advocates like providing maternity protection, providing primary health care and preventive health care as part of the benefit package. Most of DAR s HMIS were given the idea that schemes will not be viable if maternity and outpatient package were included in the program. The project had to conduct several reorientations for managers of schemes to understand and appreciate the merit of introducing preventive, primary and maternity care in their benefit packages. The participation of men in the project is encouraged for them to be more involved in the health needs of their families, a role which is generally seen for women. We targeted the small transport drivers tricycle drivers as a group. We were able to hurdle an initially difficulty in getting their participation by selecting a few respected men in the group instead of targeting the whole population. During the discussions, it was apparent that they are willing to participate especially on something that concerns the family however their participation again became a problem due to local elections. Since the LGU of 12

13 Angono was very active in the project, they saw it as a political manoeuvre of the incumbent to gain votes. The other groups which are predominantly women decided to continue the process of setting up the scheme without the tricycle drivers groups because it was delaying the process so much. They will invite the tricycle drivers group after the scheme has been set up. President Gloria Macapagal-Arroyo launched the Plan 5 Million last February 2004 that aims to provide free health insurance to the poorest 5 million families in the country. Unlike the Sponsored Program of the Philippine Health Insurance Corporation (PhilHealth) which stipulates a partnership between the Local Government Unit (LGU) and the national government by sharing premiums, this project is entirely shouldered by the national government from contributions of the Philippine Charity Sweepstakes. The normal screening process was also waived for the recipients of Plan 5 Million. Almost all of the cooperatives that the project worked with could not promote their health micro-insurance schemes to the community members. There was very little progress in membership which hampered growth of the schemes. The Plan 5 Million was seen as a disincentive to a community member to participate more actively in a social protection program. However after one year of implementation, most of the focused-group discussions done by the cooperatives with members who are recipients of the project are willing to pay for their premiums or at least a portion of their premiums. This validates the surveys findings that the poor will participate in social protection programs which they see as responding to their needs. Introducing pension schemes for informal economy workers can also be explored. The elections in the Philippines were held in May 2004 and candidates could start campaigning three months before actual date. Most of negotiations with Local Government Units (LGU) such as partnerships with LGUs and HMIS to access PhilHealth s services, LGU providing assistance through more health personnel in the area, had to slow down because either the LGUs were avoiding electioneering charges or the HMIS do not want their cause to be used as a political tool. In both situations, the project concentrated its efforts to strengthening the management team of the schemes through training and assisting them in continuously promoting their HMIS. As much as possible negotiations with mayors, vice-mayors and any local official 13

14 was avoided during the period but the services of the public physicians, midwives and health volunteers were always sought for health education sessions or health promotion activities. E. LESSONS LEARNED Participation in decision-making processes is a factor that can sustain community-based initiatives. The communities can develop mechanisms for linkages with the local and national schemes. National schemes have to make necessary adjustments to accommodate informal economy workers. Gender concerns have to be considered in the planning and implementation of a program. There is a value in having equal representation of men and women in a project s management team especially when there s a mixed target group. F. LIST OF DOCUMENTS AND PUBLICATIONS PRODUCED BY THE PROJECT Studies TITLE No. of Date Produced Pages 1. Extending maternity protection to women in the informal 45 December 2004 economy: An overview of community-based health financing schemes - In collaboration with ILO/CONDIT 2. An inventory of micro-insurance schemes in the Philippines 200 December Social Protection Needs Assessment Survey of Informal Economy Workers 40 June 2004 Case Studies 4. Case Studies of Health Micro-Insurance Schemes in the Philippines 180 December 2004 Technical Reports 5. Gender Strategy Paper 44 February Workshop report: A Gendered Approach to Social Protection 100 October 2003 for the Informal Economy in the Philippinew 7. Training Needs Assessment Report and Tool for the Department of Agrarian Reform s DAR-AP Program 100 September

15 8. Workshop Report: Promoting Health Micro-Insurance 140 November 2004 Schemes to Local Communities 9. Workshop Report: Management of a Gender Sensitive Health 130 December 2004 Micro-Insurance Scheme 10. Progress Report: 1 st Quarter of April Progress Report: 2 nd Quarter of July Progress Report: 3 rd Quarter of September Progress Report: January to December January Progress Repport: January to June July Progress Report: July to December January End of Project Report: Extending Social Protection through Health Micro-insurance Schemes to Women in the Informal Economy 30 March 2005 Training Material 17. Reference Guide and Tools for Health Micro-Insurance 350 December 2004 Schemes in the Philippines 18. Management of a Gender-Sensitive Health Micro-Insurance 150 December 2004 Scheme Fecilitator s Guide 19. Guide for Social Marketing Health Micro-Insurance Schemes 100 December Process Manual: A Guide for DAR-AP s Facilitators (Done 2000 February 2005 with the Department of Agrarian Reform for DAR-AP s Field Coordinators) Tools 21. Site Selection Tool plus Report of Project s selection Process 15 June Survey Tool: Assessment of Social Protection Needs 6 August Awareness-raising material: Flip chart on Social Protection 40 April 2003 and Health Micro-Insurance Schemes for Local Executives (English) 24. Awareness-raising material: Comics information tool on HMIS 2 May 2004 (English) 25. Awareness-raising material: Comics information tool on HMIS 2 May 2004 (Tagalog) 26. Awareness-raising material: Comics information tool on HMIS 2 May 2004 (Visayas) 27. Awareness-raising material: Flip Chart on Social Protection 32 May 2004 and HMIS for community members (English) 28. Awareness-raising material: Flip Chart on Social Protection 32 May 2004 and HMIS for community members (Tagalog) 29. Awareness-raising material: Flip Chart on Social Protection and HMIS for community members (Visayas) 32 May

16 30. Information material: Brochure on Health Micro-Insurance Schemes (Generic Format, information filled-up by each Scheme) 2 June