Pen Point 46

Clearly, we now see the need to invest more in our health system to improve its capacity to address the growing needs of the Filipino people. After this pandemic, let us urge our lawmakers to push for more funding, innovation, and research.

Recommendations to Address the Potential Local Nursing Shortage Amid the COVID-19 Pandemic

The role of nurses has been considered crucial in managing this pandemic, most especially in implementing strategies to #flattenthecurve. While this is the case, shortage in the nursing workforce will not make the management of the pandemic any easier. We recommend an integrated approach comprised of some or all the recommendations mentioned in this policy brief. However, these recommendations are interim solutions to a possibly chronic nursing workforce shortage in the Philippines. A national investment in the nursing profession is needed to address this shortage. Such investment will require significant political will, support, and financial investment.

Thank you Neil Roy Rosales for writing this with me. Please feel free to share with your colleagues.

Link to full policy brief: Recommendations

Foster collaborative relationships

Immediately after the news broke that three doctors died due to COVID-19, people took their frustration to Twitter and were quick to blame patients for their failure to divulge accurate health and travel history. For many, this alleged ’lie’ caused the life of an unsung hero who was at the frontline battling the pandemic.

A patient withholding facts and misleading health workers is no laughing matter. Physicians cannot appropriately diagnose and treat patients unless the latter share information freely. Thus, the feelings of anger, hatred, and frustration felt by many doctors last week were all valid. These feelings make them human after all. But, this is more than a simple case of dishonesty. To directly equate a person’s death to a lie, whether intentional or not, is a bit overstretched. Alternatively, our frustration directs us to question what could have possibly gone wrong between the patient-physician relationship.

Patients also fear for their lives, much like the rest of us in the field of health care. Some patients are intimidated, only to share their whole health history after their first conversation with a health worker.  Truth be told, it is sometimes difficult to share private information to our friends and families. What more to people you barely know? Unfortunately, this is not an excuse for patients to deliberately lie about their health status.

Although motivations for withholding the truth vary from patient to patient, options to address this problem are rooted in one concept: a collaborative patient-health worker relationship. It is important, I suppose, for our patients to feel that we trust them and that they, too, can trust us. Let us allow our patients to freely verbalize their thoughts and feelings. Let us take time to listen to them so that they can put their trust in us.

Conversations with patients are almost always difficult. But given the gravity of what’s at stake, we are encouraged to find ways to expand and make better the existing lines of communication. We are encouraged to find ways to make patients more comfortable to admit embarrassing behaviors, and facts about themselves. Finally, we are encouraged to create a trusting environment embedded in the system to allow and support collaborative relationships between patients and health workers.

Pen Point 45

Why do we keep treating people for illness, only to send them back to the conditions that created the illness in the first place?

It is a bit frustrating to give your all just so they can be wasted in the end. Clearly, the current system is inefficient and cure-centric. How do we cure a sick health system?

Nudging in health care

We saw a dramatic change in people’s behavior brought about by information (and misinformation) regarding the worldwide spread of COVID-19. People began clamoring for more health information and others started wearing surgical face masks to protect themselves. Following advice from the Department of Health, several organizations cancelled their scheduled conferences and conventions this year.

What surprised me, however, is the fact that many food, retail, and service companies started providing hand sanitizers not only to their employees but also to their customers. Schools, hospitals, and shopping malls did the same, and even placed posters at entry and exit points to inform the public on infection control measures that should be observed within their premises. The placement of posters, the availability of and accessibility to alcohol or hand sanitizers created a positive reinforcement that influenced individual and group decision-making leading to a change in behavior. In behavioral science, this is best explained by the “Nudge Theory”.

The reaction of the Filipino community to this actual health threat is a manifestation of how the theory works. Based on observation, some people who saw hand sanitizers and alcohols on counter tops actually rubbed some on their hands. To an extent, the mere presence of these alcohol-containing preparations ‘nudged’ people to make the right decision which is to practice hand hygiene. Studies in other countries such as the UK have been successful in providing empirical evidence to support the use of nudging to influence behavior in health care settings. Such practice, however, has not been extensively explored in the Philippines.

While we focus on containing the local transmission of COVID-19 in Metro Manila for now, health care professionals and policy makers can take this opportunity to review existing policies on hand hygiene, infection control, and even outbreaks. We have been accustomed to using the rational choice model to create policies influencing people’s behavior. Using this model, we assume that humans are rational beings and given adequate information, they will rationally act on their own self-interest. Sadly, this approach does not work well in real life. Fortunately, the nudge theory, introduced by Nobel-prize winner Richard Thaler and law professor Cass Sunstein, provides policy-makers with another approach to influencing behavior. This theory suggests that we cannot stop people from being irrational because much of instant decision-making is influenced by context and environment. We can, however, seek to influence decision-making impulses to produce outcomes that are beneficial both at the individual and societal levels.

At the moment, we are pleased and thankful for the initiatives of private companies to educate their employees and customers on proper hand hygiene, and providing the necessary facilities to practice hand hygiene procedures. In the future, we should hope to see how the government will use nudging techniques to influence people’s behavior. As the theory can be applied even in realms outside health, nudging presents a low-cost and effective policy option that can perhaps complement or replace traditional regulation with nudges to influence people’s everyday choices without restricting their freedom of choice, and imposing penal charges or taxation.

Foreign ownership in the health care market

The proposed measure to allow foreign ownership of transportation and telecommunication services clearly sets a precedent for other public services in the Philippines, such as health care.

Opening the Philippine health care market to foreign ownership, obviously, has potential benefits including employment opportunities, better provision of health services, and health technology exchange. Foreign ownership of health facilities/service providers, however, has the potential to negatively affect the already struggling health care system of the country.

First, foreign investors may be enticed by the government to own hospitals and other health facilities (laboratories, ambulatory clinics, etc) in places where the government has failed or is yet to invest in. In this way, the government is lifting itself from the burden of expanding its public health services by allowing foreign investors to build and own these facilities. While this could be a win-win situation, poor regulation might undermine the primary intention of such set-up which is to improve access to health care services. In places where there is only one (monopoly) or few firms (oligopoly) providing health services, there is a potential for these firms to collude in order to maximize profits.

Second, foreign ownership has the potential to further promote a two-tiered health care system, separating the upper class from the low and middle classes. Having a two-tiered system means enabling price discrimination as an effective price-setting strategy. With price discrimination, some consumers will end up paying higher prices.

Unpaved road to UHC

Almost every day I see patients (or their relatives) looking for stretcher beds as there are no longer available beds in the emergency room. This scenario, I suppose, will persist even when hospital renovations are finished this year. While increasing the hospital’s bed capacity potentially decreases waiting time for patients, no amount of beds will ever suffice. The neverending influx of patients in the Philippine General Hospital is a result of the increasing demand for health care among poor Filipinos amidst rising health care costs. The same is true, or even worse, for other government hospitals.

PGH is a microcosm of the Philippine health care system. Our experiences in this hospital mirror big challenges that the country will continue to face while implementing the universal health care law. First, poor gatekeeping at the primary care levels will allow patients to seek care at higher level facilities even when lower level facilities are capable of handling their medical conditions. This, coupled with patients’ poor confidence of primary care health workers, encourage them to flock in tertiary level facilities which results in overcrowding.

Second, chronic lack of manpower and other resources delay necessary care. Patient waiting time is high for common radiologic procedures (e.g. x-ray, ultrasound) because there are only few machines available for hundreds of patients. Nurses, faced with high patient workload, leave out essential care elements to meet only the urgent physiologic needs of their patients. Our study on nursing care rationing in PGH showed that 45% of nurses kept a patient who rung for a nurse waiting longer than five minutes. More than half of respondents disagree that there are enough nurses to get the job done or to provide quality care. More than half of nurses also reported a physician did not come or took a long time to arrive after a call.

These are few of the challenges that patients and health care workers in PGH continue to face. While we strive to be a model of health care delivery, our current set up is far from what we all have dreamed of – a hospital that transforms lives through excellent care, education and research. I cannot imagine how other hospitals and health workers deal with poorer work conditions.

The road to UHC is quite long. PGH is a reflection of the government’s failure to adequately lay concrete interventions that will make our journey smooth. Gatekeeping at the primary care level and provision of adequate human resources for health are two key elements that will drive the realization of universal health care.