The White Papers

Here's a column I wrote for the last issue of SHInet, a technical newsletter on social insurance collaborated on by PhilHealth and GTZ-SHI.

Thought I'd post it in case someone (not likely) finds it interesting. :-)

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The White Papers
An insider’s view of Social Health Insurance…from the outside

According to Whatis.com, a white paper is defined as: “an article that states an organization's position or philosophy about a social, political, or other subject, or a not-too-detailed technical explanation of an architecture, framework, or product technology.” In government service, at least in the Philippine setting, a white paper has a more, let us say, unpleasant connotation. Here, a white paper is synonymous with a poison-pen letter – an anonymous letter or note containing malicious statements about a third party.

So you may be wondering, why did I choose such a negative concept to serve as the title of this discourse? Actually, I didn’t. The name was chosen for me by my colleagues, with the notion that “it best suits my personality.” I don’t know about that, but if nothing else than for this column, I fully intend to change the context of the term “white paper” into something positive. Especially since this publication is about the intricacies, as well as the latest developments on the social health insurance front. So, if you would bear with the title and with me for the moment, let us get started...

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When first faced with the prospect of writing a column about social health insurance, the first thing that struck my mind was whether or not I am actually qualified to write about the concept. It’s not as if I am a full-pledged expert on the issue. However, as an employee for the past nine years of a government corporation with the specific purpose of administering a national health insurance program, the only one of its kind in Asia, I guess I can claim to have some experience on the matter.

During the past nine years, I have moved around different organizational units within the corporation, and have performed a myriad of functions. I have dabbled in policy-making and research, in planning and monitoring, in procurement and administration, in systems development and project management, and just about everything in between. Does that make me an expert in social health insurance? No. It doesn’t. Not by a long shot. But at the very least it gives me a very distinct perspective on the concept, a perspective created by observing the concept in action from the points of view of different disciplines. Add to that my interest in history and politics, and I should be able to come up with some unique insights and ideas on the subject. I can’t promise that my ideas would be conventional, but I guess that’s precisely the reason why I was given this task. Now, going to the subject at hand...

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It may not at all surprise you if I told you that social health insurance is not a new concept. In fact, the concept is more than a hundred years old, and its practical origins stemmed from the inadequacies of private health insurance in ensuring the health and well being of a country’s citizenry. The main point of contention is the fact that there is indeed a conflict between the fundamental reasons of existence of any private health insurance firm – that is, to earn profit, versus the need, no, makes that the right of people to be healthy. Both goals are obviously mutually exclusive. Combine this with the general precepts that being healthy is not a privilege but a basic human right, that all physicians have a moral obligation to do everything in their power to ensure the health and well being of their patients, and that a state with a significant portion of its population continually burdened with illness will have adverse effects on its economy and growth potential, you can definitely see for yourself why health insurance has become ripe for government intervention.

As such, while private insurance has continued to exist and even flourish as an industry, its public counterpart, social health insurance, sometimes known as publicly funded medicine, socialized medicine, nationalized medicine, universal healthcare or single payer healthcare, has sprung forth as an attempt to resolve this conflict. This has entailed the fine-tuning and subsequent application of an idea which was first conceived of in 18th century Germany during the time of Kaiser Wilhelm II and Chancellor Otto von Bismarck. Even then, and until now, the concept of socialized health insurance has been the subject of much heavy debate, with plenty of historical and political side issues. In this light, social health insurance is not just about patients and doctors; it represents a divergent means of how the state interacts with its citizens. Unsurprisingly, it has its supporters and its naysayers as well.

It is also about statistics. The nature of illness is such that it is very difficult to project what illnesses an individual may contract during the course of his life. We do however, have in our possession tons of statistical material built up over the course of several generations which makes it relatively easy in comparison to predict the occurrence, frequency and distribution of various illnesses within the general population. This means that while we cannot reasonably project that health costs to be incurred by a single person in his lifetime, we can, with a certain degree of accuracy, project the health costs that can be incurred by a large group of people. This is just one of those subjects which is easier to deal with on a collective rather than individual basis. Knowing the aggregate cost of health care for a given population makes it possible to divide up the costs on a per capita basis – one of the key assets of social health insurance. Thus, a sizeable insurance fund can easily be built-up using the nominal contributions of the members of a population, collected either through taxation or through premium contributions. By distributing the cost equitably among the populace, the majority in effect subsidize the cost of health care of the minority who are struck down by illness. The concept may sound simple enough, but in reality, it is much, much more complex, with multiple factors and variables which can affect the viability of such a program.

I’ve only touched the proverbial tip of the iceberg when it comes to the topic of social health insurance, but this early on I feel as if I have already opened a can of worms. One cannot discuss this concept without taking the time to consider its various aspects, of which we have only touched on a few in this installment. I do have to remind myself that this is a column, and not a thesis, so I shouldn’t force the issue in just one go. In the next issue we will continue this discussion, and with any luck, we may both learn a thing or two as we go along.

Until then.