Seeing beyond spreadsheets: PIDS, World Bank push smarter use of PhilHealth data for universal health care

Philippine health authorities are poised to tap into a wealth of invaluable data that could potentially leapfrog universal health care (UHC) across the country: in 2024 alone, PhilHealth processed some 15 million claims, a rich source of potential health care insights.
“Claims data tell a much bigger story than just the cost of care,” explained Dr. Valerie Gilbert Ulep, Program Director of the Philippine Institute of Development Studies’ Health Economics and Finance Program (PIDS-HEFP). “They show us not just who gets sick, but how the country’s health care system responds, and whether that response is fair and effective.”
Smarter, better health claims
At a recent workshop co-organized by PIDS-HEFP and the World Bank Group, with support from the Australian Government through the Advance UHC partnership, health sector policymakers and data experts explored how health insurance claims data can drive smarter, evidence-based decisions for universal health care as the Philippines transitions to a new provider payment mechanism mandated by Republic Act No. 11223, or the UHC Law.
Held at the Marco Polo Ortigas Manila, “Data-Driven Decision-Making for UHC: Leveraging Health Insurance Claims Data” highlighted how PhilHealth’s vast trove of claims records could become a powerful tool for improving efficiency, accountability, and equity in healthcare delivery. The workshop provided insights into how healthcare claims data can be used when conducting health systems analysis.
Connecting statistics with patients’ stories
The goal of the workshop is to equip health-sector policymakers and data analysts with the capacity to “see beyond spreadsheets,” to connect statistics with patient stories and policy outcomes.
According to World Bank Lead Economist Dr. Ajay Tandon, analyzing PhilHealth claims can reveal where hospitals are efficient or overburdened, and whether patients are receiving timely, appropriate treatment.
Preliminary analysis showed that one in three inpatient PhilHealth claims are for ambulatory-care-sensitive conditions—that is, conditions for which timely and effective primary care can help reduce the risks of hospitalization. This pattern possibly points to both supply- and demand-side issues in primary healthcare access, according to PIDS analysts.
For example, by examining trends in key areas and procedures such as cesarean deliveries, readmissions, and tobacco-related illnesses, policymakers can spot inefficiencies and redirect resources to where they matter most.
Moving forward with DRGs
The workshop built on the HEFP’s broader initiative to institutionalize Diagnosis-Related Groupings (DRGs), a new payment mechanism mandated under the UHC Law that rewards hospitals for quality and efficiency rather than volume of services. The same data analytics underpinning the training will be essential for calculating fair DRG rates and monitoring their impact once implemented.
Over the past year, PIDS-HEFP has led a series of high-level engagements with PhilHealth, the Department of Health, and professional medical societies to prepare hospitals for the upcoming DRG pilot tests. The new claims analytics effort forms part of that continuum, transforming raw administrative data into insights that can potentially shape long-term policies.
The workshop is the latest in a line of capacity-building and stakeholder events spearheaded by PIDS-HEFP this year, from the nationwide rollout of the DRG awareness campaign to technical briefings for hospital administrators and policy forums with medical societies. Each initiative reflects a shared vision: a transparent, data-driven health financing system that delivers “Dapat, Sapat, Tapat” care for every Filipino. PIDS-HEFP