IMPLEMENTATION AND OUTCOMES OF ZERO-BILLING POLICIES IN PUBLIC HOSPITALS: MEDICAL PERSONNEL'S PERSPECTIVE

Volume-09 Issue 12, December -2025 ISSN: 2456-9348 Impact Factor: 8.232 International Journal of Engineering Technology Research & Management (IJETRM) https://ijetrm.com/ IJETRM (http://ijetrm.com/) [634] IMPLEMENTATION AND OUTCOMES OF ZERO-BILLING POLICIES IN PUBLIC HOSPITALS: MEDICAL PERSONNEL’S PERSPECTIVE April Joy A. Dela Torre MPA-LGA Student, College of Development and Management, University of Southeastern Philippines Aristeo C. Salapa, DPA Dean, College of Development and Management, University of Southeastern Philippines ABSTRACT This study examines the implementation and outcomes of the Zero-Billing Policy in public hospitals from the perspective of medical staff to assess its impact on Universal Health Care (UHC). A systematic review of institutional reports, government documents, and peer-reviewed literature was conducted in accordance with the PRISMA 2020 guidelines, guided by the CIPP evaluation model, with a focus on financial protection reforms and no-balance-billing schemes, and 50 of the 74 relevant publications that were examined using the PRISMA approach were kept, while 24 were eliminated. The policy is presented as a redistributive mechanism with the goal of eliminating out-of-pocket expenditures, and it is based on UHC literature and Republic Act No. 11223. Medical staff report increasing workloads, staffing and supply restrictions, payment delays, and administrative difficulties that compromise service quality and sustainability, despite viewing zero-billing as ethically just and equity-enhancing. The results reveal ongoing gaps between policy objectives and accessible inputs and procedures when viewed through the CIPP lens. According to the study's findings, the sustainability and efficacy of the Zero-Billing Policy depend on stable funding, enhanced health system capacity, significant frontline involvement in policy creation, and formalized feedback mechanisms to safeguard the welfare of both patients and employees. Keywords: Zero-Billing Policy, Universal Health Care (UHC), Medical Personnel Perspectives, and Financial Protection INTRODUCTION Health security has become the most significant challenge faced by the world, as it demands intensive support from governments to address. Health security in the Philippines has been continuously eroded by inadequate national government oversight, corruption, and issues with resource allocation. Achieving the intended outcome necessitates a collaborative process. Poverty persists not merely as a consequence of individual choices, but as an outcome of deeper structural conditions shaped by both internal governance failures and international systems under globalization, which collectively determine the unequal distribution of resources and opportunities which can be traced back to colonialism, where colonizers abusively extracted and exploited everything the colonies have, leaving them in despair (Claudio, 2014). Having that being said, I categorically affirm John Rawls’ theory of justice as fairness, which maintains that social and economic disparities must be structured to benefit the most vulnerable and disadvantaged members of society, which should be given the highest priority when it comes to access to health care (John Rawls, n.d.). The Philippines adopted healthcare principle enshrined in Sustainable Development Goals (SDG no. 3) of ensuring the health and well-being of every citizen of the country, thereby institutionalizing in strengthening its realization through Republic Act No. 11223, enacted in 2009, in providing quality, accessible, and affordable healthcare for all Filipinos by providing financial support in the healthcare system (LawPhil.net, 2019). Consequently, the principle of universal healthcare was mandated and was made compulsory for all local governments. The province of South Cotabato has innovated its policies with initiatives such as the Zero Billing Policy, thereby granting opportunities not limited to the most vulnerable sectors of society (women, indigenous people, and the poor), but covering all patients of the Provincial Hospital of South Cotabato. However, implementing the policy has faced systemic hurdles, including issues with service quality, health facilities, and funding (Teodoro, 2025). Volume-09 Issue 12, December -2025 ISSN: 2456-9348 Impact Factor: 8.232 International Journal of Engineering Technology Research & Management (IJETRM) https://ijetrm.com/ IJETRM (http://ijetrm.com/) [635] This study will examine the policy’s efficacy and determine gaps from the perspective of medical personnel, as their position at the intersection of policy and practice provides a strategic standpoint for a critical assessment of policy implementation OBJECTIVES The primary objective of this study is to examine the implementation and efficacy of the Zero-Billing Policy from the perspective of medical personnel, who play a significant role at the nexus of policy and practice. Specifically, this study aims to: (1) Assess the perspective of Medical Personnel on the perceived benefits and challenges associated with the implementation of the Zero-Billing policy at South Cotabato Provincial Hospital; (2) Identify and analyze the factors that affect the sustainability and operational efficacy of the Zero-Billing Policy from the perception of medical personnel; and (3) Formulate evidence-based recommendations from medical personnel on enhancing the implementation and effectiveness of the Zero-Billing policy to better achieve the objectives of Universal Health Care. METHODOLOGY This research utilized a descriptive-evaluative framework, guided by Stufflebeam's CIPP Evaluation Model. Descriptive-Evaluative research design is a systematic methodological framework that delineates current conditions, practices, or services while concurrently assessing their adequacy, quality, or effectiveness, all without the manipulation of variables (Dajac, 2025). The design is suitable for the study, which aims to delineate and evaluate the viewpoints of medical personnel regarding the advantages, obstacles, sustainability, and overall effectiveness of the Zero-Billing policy at South Cotabato Provincial Hospital. It records both the current circumstances and the evaluative assessments that could guide enhancements in policy execution. To systematically identify relevant studies addressing the perspectives of medical personnel on the implementation and outcomes of zero-billing or no-balance-billing (NBB) policies in public hospitals, a comprehensive literature search was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The search strategy included peer-reviewed journal articles, national and local government reports, and gray literature indexed through Google Scholar. The following electronic databases were systematically searched: PubMed, Scopus, Web of Science, and JSTOR. Google Scholar was utilized to capture additional peer-reviewed articles, theses, and institutional studies not indexed in traditional databases. As a result, 50 of the 74 collected literature were used, and 24 were eliminated. With a focus on policy alignment with UHC principles and Republic Act No. 11223, each article was examined to ascertain its applicability to the adoption of zero-billing in public hospital settings. The input component concentrated on vital resources that affect policy execution, including infrastructure, administrative processes, human resources, budget allocation, and sustainability mechanisms. The process dimension examined operational procedures, including the provision of services, adherence to policies, administrative compliance, and the implementation difficulties encountered by medical staff. Last but not least, the product component evaluated reported results, including perceived advantages, unexpected effects, sustainability, efficiency, and suggestions for improving policy. The results were thematically synthesized to identify common implementation facilitators and obstacles, providing empirical support for assessing the Zero-Billing Policy and informing evidence-based suggestions aligned with the goals of Universal Health Care. Studies were included if they discussed financial protection policies, such as zero-billing or no-balance-billing, examined the results, sustainability, advantages, difficulties, and implementation of these policies, and included viewpoints from experts, patients, administrators, healthcare professionals, or organizations. Moreover, studies that were commentary, opinion pieces, or editorials without empirical support, that only addressed insurance reforms and had no bearing on hospital-based billing practices, that did not go through peer review, that were duplicates or lacked full text, or that were government-issued and supported by evidence are all excluded. Volume-09 Issue 12, December -2025 ISSN: 2456-9348 Impact Factor: 8.232 International Journal of Engineering Technology Research & Management (IJETRM) https://ijetrm.com/ IJETRM (http://ijetrm.com/) [636] (The systematic review process, based on the PRISMA flow diagram.) RESULTS AND DISCUSSION Based on the data gathered through a systematic review guided by PRISMA method and analyzed, following the PRISMA 2020 guidelines found in the sources, the screening of relevant literature to include in this study began with screening the global and local related studies on Universal Health Care (UHC) and No Balance Billing (NBB) and or the Zero-Billing policy in the Philippines enshrined in RA No. 11223. From the initial screening, studies were prioritized that focused on the implementation, efficiency, and impact of the Zero-Billing policy, as well as the perspectives of medical personnel and their recommendations for improving the policy's implementation. A total of 74 related studies were gathered, and 50 of those were identified as serving highquality studies, typically included in such reviews to further synthesize evidence based on this study. The results have identified financial risk protection (Employees understand that ZBP, and its development into the No Co-payment policy, serves as a vital safety net, lowering the possibility that families would fall into poverty as a result of unmanageable medical costs), equitable access (Medical professionals believe that the approach, which allocates health services according to need rather than financial capacity, fosters social unity), and increased utilization (Formal healthcare seeking has significantly increased as a result of similar reforms, especially for primary care and institutional deliveries) as the benefits perceived by medical personnel from the Zero-billing policy. Eventually, delayed reimbursement (The sluggish turnaround for PhilHealth reimbursements, which causes facilities to have cash flow problems, is a major worry among staff and administrators), resource scarcity (Employees often claim that "free" care is compromised by shortages of necessary medications and supplies, which forces patients to pay for them elsewhere), and an overburdened workforce (Understaffing and an increased burden for current employees impede implementation and frequently result in burnout and demotivation) are identified as the perceived challenges of the policy for medical personnel. Meanwhile, financial integration, operational efficacy, and information systems are the factors influencing the sustainability and efficiency of the policy. The implementation of the Zero-Billing Policy in public Hospital is at the "nexus of policy and practice". While the UHC Act mandates automatic enrollment and immediate eligibility, the actual experience of medical personnel reveals a gap between policy intent and facility-level reality. Health System Integration faces the challenge of managerial integration, which requires shifting from a fragmented, decentralized setup to a unified Health System. Personnel perceive that without structural integration, Zero-Billing Policy (ZBP) remains a "political token" rather than a functioning clinical reality. Volume-09 Issue 12, December -2025 ISSN: 2456-9348 Impact Factor: 8.232 International Journal of Engineering Technology Research & Management (IJETRM) https://ijetrm.com/ IJETRM (http://ijetrm.com/) [637] The Role of Incentives Efficacy is heavily tied to provider payment reforms. Medical personnel suggest that current reimbursement rates do not reflect the actual cost of care, leading to a "distrust" of the national purchaser, PhilHealth. Sustainability is only possible if the Special Health Fund is managed transparently by local health boards to ensure "fair remuneration" for frontline workers Drawing from the suggestions offered by medical personnel in the sources, the following recommendations are proposed: Expedite Reimbursements: Streamline the claims process through digitalization and the adoption of the Integrated Financial Management Information System to ensure facilities have the cash flow to sustain ZBP, Strengthen Primary Care: Use primary care as a gatekeeper to navigate patients effectively through the network, reducing unnecessary tertiary hospital congestion and costs, Invest in Health Human Resources: Revisit the Local Government Code to provide better job security, competitive salaries, and mandatory "onboarding" training for UHC to ensure staff are "primary-care ready" and Enhance Supply Chain Management: Implement pooled procurement at the provincial level to ensure a consistent supply of medicines, thereby truly achieving a "zero-bill" for patients ACKNOWLEDGEMENT The researcher extends sincere gratitude and appreciation to the individuals and institutions that provided support, guidance, and cooperation, making the completion of this study possible. First and foremost, I would like to extend my heartfelt appreciation to Professor Aristeo Salapa, for the invaluable guidance, patience, and understanding he invested in this class. Professor Salapa’s expertise and wisdom greatly contributed to the refinement and completion of this study. Secondly, the researcher extends her utmost gratitude to her family and friends, whose encouragement and advice greatly influenced her to have the courage to complete this study. Additionally, the researcher would like to thank the University of Southeastern Philippines, particularly the College of Development and Management, Mintal Campus, for providing a conducive academic environment and necessary institutional support that facilitated this research endeavor. Above all, the researcher gives thanks to the Almighty God for the wisdom, protection, strength, and all his provisions granted throughout the journey of completing this academic work. This study is humbly dedicated to all who contributed, either directly or indirectly, to its successful completion. CONCLUSION Based on the sources, the conclusion to the study on the implementation and efficacy of the Zero-Billing Policy (ZBP) from the perspective of medical personnel can be summarized as follows: The implementation of the Zero-Billing Policy serves as a critical financial safety net, promoting equitable access to health services and significantly increasing healthcare utilization among vulnerable populations. However, medical personnel perceive that the policy’s operational efficacy and sustainability are severely hindered by chronic administrative bottlenecks, specifically delayed PhilHealth reimbursements that create liquidity crises for facilities and frequent stock-outs of essential medicines. Furthermore, while personnel support the humanitarian intent of the policy, they face significant challenges, including increased workloads, uncompetitive remuneration, and a lack of job security for deployed staff. To achieve the objectives of Universal Health Care, the sources suggest that the policy must transition from a "top-down" mandate to a functionally integrated, province-wide health system supported by digitized information systems, transparent management of the Special Health Fund, and strategic provider payment reforms, such as Diagnosis-Related Groups (DRGs). Ultimately, for ZBP to be effective, the government must move beyond the "decision to abolish fees" and prioritize the recruitment and empowerment of the health workforce who serve at the frontline of policy execution. REFERENCES [1] Allen, L. (2022). The Philosophical Foundations of health for all and the Universal Health Coverage. Int J Equity Health [2] Cabaylo, K.J. (2025). 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