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.

The frontline

As a nurse, waking up each day is a struggle knowing that there is a high risk for us to acquire the disease. However, we are constantly reminded of our duty to the people. That it is our duty and responsibility to help those in need, especially the poor, weak, and vulnerable.

Times like this make us realize that effective communication is key. Sadly, the field of health has failed to do it well in many instances. Today, more than ever, I fervently ask our leaders to first show TRANSPARENCY. Make things clear for us. Make us understand how things will be managed, coordinated, and disseminated. Make us feel that you are on top of this and that processes are as clear as they can be.

Second, I ask for CONSISTENCY. We are tired of hearing conflicting statements, especially those from the higher ranks. Such conflicting statements create confusion which in turn causes panic. Let there be a single message from a single source.

Finally, I ask for INTEGRITY. Let us not fool each other. Again, kabaro mo na. Sana hindi ka na isahan pa. Tayo-tayo dapat ang nagtutulungan. Hindi dapat nag-gugulangan. Let us be honest to each other so we can all work well together. After all, we all aim for one goal – the end of this crisis.

The coming weeks will show how resilient and responsive our health care system is. The circumstances will test how our current systems will adapt and change according to the pressing needs of the people. Our experiences during this pandemic will surely change how we will implement the UHC law in a bigger scale in the following years.

Please pray for everyone, especially those in the frontline. It is a scary, scary world and we have nobody to save us but ourselves. Ingat!

DISCLAIMER: There is no way this post pertains to a particular individual, hospital, or organization. Before you try to twist whatever I said in this post and send complaints, please clarify them first with me. Send me a message. It’s free.

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.

Call for fair and adequate hazard pay

How much is the price of upholding the rights of nurses in the country? For some, it costs nothing.

Nurses are at the frontline of the health care delivery system. They become the first and last health workers in contact with patients and their families. As such, nurses are exposed to low- and high-risk hazards during their working hours. Exposure to these hazards could result in discomfort, illness, and even death. It is imperative, therefore, to provide additional compensation to nurses performing their jobs in hazardous work areas.

Through Republic Act No. 7305 or the Magna Carta of Public Health Workers, the State recognizes the need to provide extra compensation to nurses for performing duties that expose them to potential health hazards. However, recent reports slap us with the reality that some nurses in the country receive little to no hazard pay.

We aspire for fair and adequate hazard pay for nurses in the Philippines. Fair in the sense that all nurses are well-compensated considering the health risks associated with the nature of their work. Adequate in the sense that it follows the rates set forth by the law. Fair and adequate hazard pay ensures the protection of nurses who relentlessly offer their lives to the service of the people. Fair and adequate hazard pay puts premium on the lives of both the health care workers and the patients they serve.
While we recognize the financial limitations being experienced by many local and provincial government units, this should not restrain the government from exercising its lawful duty to protect health workers from the dangers associated with the delivery of health care.

I call on the Department of Health (DOH) to look at the undocumented issues surrounding the non-payment of hazard pay experienced by nurses in various parts of the country. Moreover, I call on the local and provincial government units to (1) review its annual budgetary allocation and bring back health at the top of its priorities and, (2) ensure that nurses are compensated hazard allowances equivalent to the appropriate percentages as specified by the law. Finally, I call on Congress, DOH and the Department of Budget and Management to revisit the Magna Carta for Public Health Workers, specifically the provisions on salaries, hazard pay, and other forms of allowances.

The right to health is not limited to a privileged few. The government carries the burden of ensuring that this right is upheld as a human right equally enjoyed by all Filipinos. The promises of universal health care cannot be realized when the primary drivers of the health care system, our health care workers, are left at the brim.

Alagaan ang mga tapag-alaga

PNA National Day of Protest | 8 November 2019 | Kartilya ng Katipunan

Minsan. Minsan kahit katatapos lang natin sa trabaho ay iniisip na natin ang susunod na araw. Kumusta na kaya ang pasyente kong si Juan? Nainom na kaya niya ang mga gamot niya? Kumusta na ba si Maria? May kirot pa kaya siyang nararamdaman?

Madalas. Madalas iniiwan natin ang trabaho natin na mistulang post-apocalytic scene sa isang pelikula. May mga pasyente na nagsisiksikan sa iilang kama. May mga pasyente na walang mainom na gamot dahil walang pera. At may mga nurse na kayod kalabaw pero kahit pagod, gutom at ihing-ihi na, nakangiti pa ring nakaharap sa mga pasyenteng sinumpuan niyang paglingkuran. Kahit gaano man kahirap gampanan ang mga responsibilidad ng isang nars, paulit-ulit pa rin nating pinipili na maglingkod sa bayan.

Bakit nga ba tayo gumagawa ng ingay? Bakit ba paulit-ulit ang ating panawagan? Iisa lang ang sagot – dahil hindi sila nakikinig. Gusto natin alagaan ang ating mga pasyente nang husto at may dignidad. Gusto natin magtrabaho bilang mga nars na nirerespeto at binibigyang halaga. Gusto natin muling ipakita ang ligaya sa likod ng natatanging pag-aalaga. At, gusto natin na umuwing panatag na maaalagaan din natin ang ating mga sarili at pamilya.

Tunay nga ba ang kabataan ang pag-asa ng bayan? Ngunit, paano tayo aasa sa isang bulok na sistema? Para sa mga kabataang nars na gaya ko, napakahalaga ng pagtitipon na ito. Ito ang araw na minarkahan natin ang simula ng mas marami pang aksyon mula sa nagkakaisang mga nars na naglilingkod para sa bayan. Ito ang simula ng pagpapanday ng isang mas magandang bukas para sa aming henerasyon at sa mga susunod pa. Ito ang nagsisilbing katibayan na may pag-asa pa. May pag-asa pa para sa isang mas maayos, tuwid at makatao na sistemang pangkalusugan.

Hiling ng mga kabataan na tulad ko ang isang bukas na hindi perpekto ngunit malapit sa uliran: sapat na sahod, regularisasyon at hindi kontraktwalisasyon, makatwirang nurse-to-patient ratio, at ligtas at maayos na lugar ng trabaho.

Alam natin na hindi rito nagtatapos ang laban. Alam din natin na mahaba-haba pa ang lalakbayin. para sa mga inaasam. Pero kaming mga kabataan, lubos na umaasang ngayon kami ay tuluyang pakikinggan. Sa huli, iisa lang naman ang ating panawagan: alagaan din ang mga tagapag-alaga.

SG15, ipatupad!

Sahod ng nurses, dagdagan! Dagdagan!

Advocate for equal pay for both government and private sector nurses

This is in response to Maristela Abenojar’s letter titled “Pass law on nurses’ minimum base pay” (Philippine Daily Inquirer Opinion, 14 October 2019).

I am one with the Filipino Nurses United (FNU) in their call for higher wages for nurses in both the public and private sectors. However, pushing for a P30,000 minimum base pay for nurses in both sectors will not result in the equality that the proposed policy is aiming for. Currently, Salary Grade (SG) 15 is equivalent to P30,531. Thus, nurses in the public sector are already receiving a base pay higher than what is being proposed.

When Congress decides to change the law, it usually does so prospectively. Therefore, rather than setting the minimum or base pay at P30,000, it might be more beneficial (for private nurses) if we lobby for equal pay for both private and government nurses. Equal pay would mean pegging the salary of all nurses, whether in private or public sector, at the base pay set by the law for government nurses which is SG 15. Hopefully, in the long run, any increase in the base pay of government nurses based on the Salary Standardization Law and General Appropriations Act would mean the same increase for those in the private sector, creating an equal footing for all nurses regardless of the sector they are working in.

While this is a far-fetched policy alternative, with possible resistance from private health care institutions, it will guarantee private nurses with salaries at par with salaries of government nurses. I call on FNU, the Philippine Nurses Association (PNA) and Bayan Muna partylist to review House Bill No. 3478 and look at other policy alternatives that will ensure Filipino nurses’ right to just compensation.

Filipino nurse: a global good?

Do we cast Filipino nurses as “global goods” rather than “domestic providers” of health care? Do we implicate them as sources of remittance income rather than for their potential contributions to the local health system?

Trade in health services is continuously growing. There are four ways based on the General Agreement on Trade in Services (GATS) by which the Philippines can take advantage of. In particular, Mode 4 (Movement of Health Professionals) offers possibilities for the entry and temporary stay of health professions in a foreign country in order to supply a service. Two forms for the international trade in health services exist: (a) temporary movement of health professional to provide services abroad, and (b) short-term health consulting assignments. As such, developing countries including the Philippines, export health care professionals to other countries most especially to the developed ones.

The ASEAN Economic Community promotes different forms of trade in health services. It ranges from exportation of cross-border health care to migration of health professionals, and direct foreign investment in the health sector. The liberalization of trade in health services, espoused by the ASEAN Integration, has further promoted the migration of health professionals.

The Philippines is known to be among the countries with the highest labor exports. Since the “world price” of nurses is higher than the “local price”, the Philippines has a comparative advantage in producing nurses, and substantially gains by producing and exporting more. According to the Commission on Filipinos Overseas, 4.3 million Filipinos were living outside the Philippines under temporary, work-related residence programs. Many health professionals are among those living outside the country for work-related reasons.

The majority of deployed health professionals are nurses, which is estimated to be around 87,000. These nurses are deployed mostly in the Middle East. Destination countries for temporary residents include Saudi Arabia, United Arab Emirates, Kuwait, Hong Kong, and Qatar. For permanent residents, the destination countries include USA, Canada, Australia, United Kingdom, and Japan.

Several reasons push nurses to leave the Philippines. The main push factor identified by nurses is low salary. Other push factors include poor work environments and lack of employment opportunities. On the other hand, nurses are primarily attracted to better working conditions and higher remuneration offered by other countries, which is about five times more than they would receive in the Philippines.

The movement of health professionals from low-income to high-income countries somehow improve economic efficiency. For receiving countries, migration helps alleviate shortages of domestic health professionals observed in middle- and high-income countries.

In a way, migration tends to ease the sending country’s problem with unemployment by allowing unemployed and underemployed health professionals to take on jobs that are available for them abroad. More importantly, one of the favorable effects of nurse migration for the sending country such as the Philippines is the considerable remittances sent home by these nurses each year. In the case of Filipino nurses, a significant share of their earnings is usually remitted home. The remittances of these health workers help finance the health care needs of the local population.

Unfortunately, these remittances will not be able to offset the loss of skilled nurses due to migration, leaving behind an already disadvantaged health care system. How do we balance competing interests in overseas health professionals’ remittances and the need for qualified health workforce in our weak health system extremely affected by the uneven distribution of health workers?

The migration of HCPs has the potential to create an imbalance in supply and demand of health workforce in both the home and destination countries. So far, the migration of nurses from the Philippines has not led to any domestic shortages unlike in Indonesia and Malaysia where migration exacerbated shortages of nurses. The mushrooming of nursing schools in the Philippines has relieved concerns on the potential domestic shortage of nurses due to exportation. However, concerns with the quality of education provided by new nursing schools have been raised in recent years.

Another negative effect that the Philippines experience is the loss of educational expenditure. When a government-subsidized nurse migrates to another country, the Philippines do not only lose a health care professional but also the money invested in his/her education. However, if nurses return home after a number of years, they will be bringing back with them new knowledge and skills. In contrast, permanent migration risks substantial human resource or capital losses with expected long-term effects on social and economic development.

Clearly, trade in health services creates both opportunities and risks. At the end of the day, it is important that we ask who truly gains and loses in this kind of trade. Do the losses, if any, exceed the gains? Is this kind of trade motivated by the government’s desire for revenue? Or is it motivated by the desire to cope with overproduction and lack of job opportunities for nurses in the Philippines?

References:

Arunanondchai, J., & Fink, C. (2007). Trade in health services in the ASEAN region. The World Bank.

Dayrit, M., Lagrada, L., Picazo, O., Pons, M., Villaverde, M. (2018) The Philippines health

system review. World Health Organization Regional Office for South-East Asia. Retrieved from http://apps.searo.who.int/PDS_DOCS/B5438.pdf

Lorenzo, F. M., Galvez-Tan, J., Icamina, K., & Javier, L. (2007). Nurse migration from a source country perspective: Philippine country case study. Health services research, 42(3 Pt 2), 1406–1418. doi:10.1111/j.1475-6773.2007.00716.x

Rodolfo, M. C. L. S., & Dacanay, J. (2005). Challenges in Health Services Trade: Philippine Case (No. 2005-30). PIDS Discussion Paper Series.

Sriratanaban J. (2015). ASEAN integration and health services. Global health action, 8, 27199. doi:10.3402/gha.v8.27199