Lynchpin of targeting: Understanding the role of street-level bureaucrats in nationwide targeting for social health insurance

The Philippines’ social health insurance, administered by Philippine Health Insurance Corporation (PhilHealth), was able to achieve almost universal coverage of the entire population. However, despite its commendable population coverage, it is still being underutilized, especially by the poor. This research investigates the effectivity of using targeting systems on social policies with universal nature by taking the case of social health insurance. Among other factors, eligibility criteria of the program are crucial in effectively translating coverage to utilization of benefits. The research uses the lens of street-level bureaucrats who are put in a critical position to identify eligible patients, and act as pseudo-targeters for PhilHealth. This is done by conducting literature review on academic debates and desk review of studies conducted on targeting in social health insurance, triangulated with interviews of street-level bureaucrats as key informants. A framework is proposed to analyse the role of street-level bureaucrats in targeting, while also looking into the factors affecting how they operate and its impact to benefits received by the poor. Using the framework, this research suggests that the street-level bureaucrats can be considered as a “lynchpin of targeting” in implementing social protection programs targeted to the poor. Due to the inefficiencies of Listahanan as the official targeting system, street-level bureaucrats make discretionary actions in order to cater the needs of their clients. By taking advantage of their discretionary measures together with relative autonomy they can exert, street-level bureaucrats are able to significantly influence targeting to the extent that they, in principle, make policies they are tasked to merely implement.