Share the road

Due to the COVID-19 pandemic, the public transportation system was paralyzed to limit our mobility. Some government agencies, hospitals, and private organizations were quick to assist medical and non-medical frontliners in their day-to-day travel to and from work by providing other means of transportation such as free shuttle services. Notably, more bike riders are now seen on the streets due to various bike programs. Many of whom are health care workers, myself included.

However, even with the enhanced community quarantine, private vehicles continue to swarm the roads. Some of these vehicles deliberately disobey traffic rules (e.g. beating the red light) which increases the probability of road accidents. This makes it more difficult for bike riders or cyclists to navigate their way to their homes or workplaces.

More health care workers are now opting to walk or ride a bike to work. Thus, it is imperative for the government to reemphasize the importance of respecting traffic rules to avoid unnecessary accidents and deaths. With the growing interest in bike riding and road sharing, we hope to see more bike lanes and road sharing policies in the future to ensure the safety of people choosing alternative modes of transportation in the post-pandemic world.

Health Economics Series: Provider Payment in the UHC era

The country is considering several options for provider payment reform that will help achieve universal health care. Population-based interventions will be primarily offered by the government. As such, provider payment mechanism for these interventions will include salary and capitation. Philhealth considers primary health care capitation to promote integrated care through the service delivery network; thus, ensuring efficiency resulting to better health outcomes and financial protection. Moreover, funds in provincial and city-wide service networks for both population- and individual-based interventions will be pooled into a special health fund intended for health services. Sources for this fund include grants and subsidies from the national government, income from Philhealth payments, and other financial grants or donations.

For individual-based interventions, several payers are likely to use various payment mechanisms. The country’s social health insurance (SHI) will continue to use case rate payment system and capitation while transitioning to diagnosis related groups (DRG) for contracted networks and apex hospitals. Private companies, such as HMOs and PHIs, will likely continue to offer case rate payment and/or fee for service payment for their customers.

HPS 252 Provider Payment

The diagram sends us a message that various provider payment mechanisms will continue to exist in the country’s health care system. Emphasis is placed, however, on the current movement towards using performance-driven, prospective payments based on DRGs. At the end of it all, “mixing” of provider payment mechanisms can be complementary or compensatory. It is promising how incentives will come into play when these mechanisms align themselves during the implementation of the UHC law.

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

Reproductive Health in the Philippines: An Ecological Analysis

Faced by the challenges of a growing population and rapid urbanization, the Philippines has inconsistently acted on issues of population control and reproductive health. Some previous policies on reproductive health and population control where “conservative” and reflective of the Catholic Church’s position on family planning. Under the Arroyo administration, government policy on family planning focused solely in mainstreaming natural family planning (NFP) as the only acceptable method of birth control and even leaving local government units (LGUs) with the responsibility of allocating budget for these family planning methods.

More recently, however, the Aquino administration strongly advocated for reproductive health both as a demographic and health intervention. As such, in December 2012, Republic Act No. 10354 commonly known as the Reproductive Health (RH) Law was approved by then President Benigno Aquino III – a battle partly won. The long-standing debate on reproductive health in the Philippines centered on the morality of instituting reproductive rights for all Filipinos, most especially women, putting aside the essence of the RH law which is the “right to reproductive health”.

The RH law seeks to increase the availability of and improve accessibility to reproductive health services such as family planning, prevention of abortion and management of post-abortion complications, prevention and management of reproductive tract infections and sexually transmittable infections, prevention and management of infertility and sexual dysfunction, among others.

A defining element of the law – RH education – sits at its core. Recognizing the need to change perceptions and behavior towards reproductive health, the law mandates that RH education be taught to adolescents by adequately trained teachers in an age-appropriate manner. Moreover, education and counselling on sexuality and reproductive health will also be offered to adults.

Shifting age old mentality and changing acquired behavior is a curse for some public policies. While this is true, the government still recognizes that education and counseling as vital tools in changing perceptions and behavior therefore adequately incorporating them into the core elements of the RH law. Human perception and behavior towards reproductive health, however, are highly influenced by social, political, and cultural contexts. Creating an environment that supports positive behavioral change requires critical analysis of these contexts.

In this paper, I discuss the ecology of reproductive health in the Philippines utilizing the relevant types of human ecology in relation to human life.

 

Behavioral and Cognitive Ecology

Behavioral ecology analyzes the ecological basis of human behavior and uses behavior to make predictions about ecological patterns. Cognitive ecology, on one hand, brings together cognitive science and behavioral ecology. Thus, in this section of the paper, we discuss the behavior of Filipino women towards reproductive health. We will examine behavior of women as a result of interactions within their environment. Behavior varies with age, and is seemingly associated with level of education and socioeconomic status. As such, behavior of women towards reproductive health is seen as an outcome of the dynamic interplay of several elements in their environment.

Women and their reproductive health

The number of children a woman bears depends on many factors. Postponing first births and increasing the interval between births reduce fertility levels and produce positive health outcomes. In the contrary, short intervals between births can lead to negative health outcomes both for the mothers and their newborns.

Age

According to the 2017 National Demographic and Health Survey, eighteen percent of women age 25-49 years engaged in sexual intercourse before they were 18 years old. By the age of 25, 73% of women have had sexual intercourse. The total fertility rate (TFR) is 2.7 children per woman, a huge decline from the TFR in 1993 which was 4.1 children per woman.

Teenage pregnancy is associated with an increased risk of acquiring complications during pregnancy and childbirth, including neonatal mortality. The median age at first birth among women age 25-49 was reported to be 23.5 years. The percentage of women age 15-19 who have begun childbearing increased from 7% in 1993 to 9% in 2017.

Contraceptive prevalence

Date from the Family Health Surveys (FHS) showed that the contraceptive prevalence rate among currently married women of reproductive age (15-49 years old) exhibited an increasing trend but has not significantly (statistically) changed in the last decade. According to the 2011 FHS, the prevalence rate for modern methods was 2.9% or 13 times the estimate for the year 1968.

For all age groups of currently married women, the prevalence rate of modern methods was higher than traditional methods. Birth control pill was the leading contraceptive method used by 19.8% of currently married women as reported in the 2011 FHS, higher than in 2006 where only 16.6% of women reported using the pill for contraception. Female sterilization and withdrawal were the next two most commonly used methods used by 8.6% and 8.2% of women, respectively. Only 1.2% of women reported using male condom as method of contraception.

Education, socioeconomic status and contraception

Level of education

The use of modern family planning methods was correlated with the level of education and socioeconomic status. The 2011 FHS found that women with higher educational attainment are more likely to be using any form of contraception than less educated women. Regardless of educational attainment, however, women preferred modern over traditional methods of contraception. Ligation was the most popular method among women with postgraduate education. For other women without postgraduate degrees, oral contraceptives were the most common method followed by ligation

Data from the 2017 NDHS also showed that the TFR declines women’s educational level increases. Among women with college education, TFR was 2.0 children per woman while women with no education have a TFR of 4.6 children per woman.

Socioeconomic standing

The same survey found that the overall contraceptive prevalence rate was higher among currently married women belonging to non-poor households than those belonging to poor households at 51.3% and 43.1%, respectively. Regardless of socioeconomic status, modern methods were more widely used than traditional methods by currently married women in 2011. Overall, oral contraceptives were the most popular method of contraception for both the poor (18.7%) and non-poor (20.3%).

The TFR and desire to have more children also declines with increasing household wealth. Women in the poorest households generally want more children than those in wealthier households. In the poorest 20% of household, TFR was 4.3 children per woman. Among those living in wealthiest households, the TFR was calculated to be 1.7 children per woman.

Birth interval (or spacing) and teenage pregnancy have also been also been associated with household wealth. Women in the lowest quintile have the shortest median birth interval (31.2 months) while those in the highest quintile have longer median birth interval of 52.6 months. The percentage of women age 15-19 years and 15-24 years who have begun childbearing decline with increasing wealth.

Women’s fertility preferences

Information on women’s fertility preferences help direct family planning program planners by assessing women’s desire for children, the extent of mistimed and unwanted pregnancies, and the demand for contraception to space or limit childbirths.

In 2017, 15% of women wanted to have another child within the next two years and another 15% wanted to wait at least two years before having another child. However, 60% reported that they do not want another child. The NDHS also reported that 74% of births were planned at the time of conception while 11% were unwanted pregnancies. About seven in ten women reported that they are in consensus with their husbands on the number of children they would like to have.

Social and Molecular Ecology

Social ecology studies the relationship between people and their environment, particularly the interdependence of people and societal institutions. It bridges ecological and social issues. In this section, we discuss the interaction of women and the greater society in relation to reproductive health.

Nominally Catholic

With the exception of the Catholic Church, all other major religions supported the RH law. Although majority of Filipinos (~80%) are (at least nominally) Roman Catholics, surveys showed that nearly eight out of ten Filipinos favored the passage of the RH Bill, supported the provision of RH education and of free RH goods/services to all, especially to the poor.

While majority of Filipinos identify themselves as Catholic, their attitudes and perception indicate rejection of Catholic Church teaching on contraception. In June 2011, SWS reported that 73% of Filipinos wanted information on legal methods of family planning while 82% said the FP was a personal choice. Thus, it can be inferred that the RH fiasco and narrative was controlled mainly by Catholic bishops and some of their loyal followers whilst neglecting the call of majority of the members of the Church to enact a law for reproductive health rights.

RH in PH health system

With the Reproductive Health Law, couples are guaranteed universal access to methods of contraception, fertility control, reproductive health education, and maternal care. Thus, couples can freely utilize these contraceptive goods and services to limit the number of children or space childbirth.

As these goods and services are more readily available to the public through the public health system, one could expect higher rates of family planning utilization among Filipinos. Data from the NDHS showed that 83% of women who are not using contraceptives did not discuss family planning either with a fieldworker or at a health facility. More than half or 56% of women using modern contraceptive methods obtain their method from the public sector.  Among women currently using modern methods of contraception, 73% were informed about the potential side effects of the method they were using, while 65% were informed about what to do if they experienced these side effects.

Despite efforts of the government and private sector to make access to and availability of reproductive health goods and services better for most women, some married women (17%) and sexually active unmarried women (49%) reported unmet need for family planning. The demand for family planning among currently married women, however, remains high at 71%.

Politics

We cannot deny how politics influenced reproductive health care in the Philippines. In this section, we examine how politics played a crucial role in shaping perception and cultivating behavior of Filipino women towards reproductive health.

It was during the Marcos regime when the country first recognized the role of family planning in population control. In 1970, the government advocated small family size and provided information and services to reduce the country’s fertility rate through the National Population Program. At the time, the average Filipino family had 6.8 children and the country’s population was 37.8 million.

Post-martial law, the change in government also signaled a change in government stance on population control. Rather than advocating for small family size, the Aquino administration advocated for the right of couples to determine the number of their children. This campaign was supplemented by integrating family planning into the country’s health programs highlighting its role in improving maternal and child health.

It was during the Ramos administration when then DOH Secretary Juan Flavier strongly advocated for family planning and reproductive health to limit family size through the provision of artificial birth control methods. The Ramos administration encouraged the use of male condoms to prevent unplanned pregnancies and the spread of HIV. However, the effort of the Ramos administration was short-lived as it was surpassed by the Catholic Church’s war against modern contraception.

Estrada, on one hand, continued the efforts of his predecessors and introduced other contraceptive methods to reduce fertility rate. Much like the Aquino administration, the Arroyo administration inexplicitly sided with the Catholic Church’s stance on reproductive health and family planning. Thus, the government shifted its focus on mainstreaming natural family planning methods.

Benigno Aquino III’s administration turned the tide when it was finally able to enact a much-awaited law on reproductive health. However, several legal road blocks prevented the full implementation of the RH law. With the FDA certification of contraceptive goods as non-abortifacients, the DOH now freely distributes contraceptives through its regional offices and partner NGOs.

Conclusion

Crucial to the overall perception and subsequent behavior towards reproductive health is the politics surrounding it. Many Filipinos, especially those in the lowest economic quintiles, heavily rely on goods and services provided by the government through its devolved health care system. Thus, improving maternal and child health as well as reducing fertility rate require that the government ensure that reproductive health goods and services are available and accessible at an affordable cost.

Reproductive health, particularly in the Philippines, is a complex health and legislative issue. And in this paper, we have explored the various ecological elements that can influence and potentially predict the behavior of Filipino women towards reproductive health. Reproductive health is a personal choice and the law respects this ‘freedom of choice’ by leaving the discretion to women (and their partners) on how they deal with their own reproductive health while providing options to support their RH needs.

Finally, education and socioeconomic status were seen to have direct influence on how women decide and utilize RH goods and services. Not until we close the gap among the poor and non-poor, educated and not educated, can we truly realize the goal of the RH law which is to improve the reproductive health of women (and men), and maternal and child outcomes.

Pen Point 35

Issues with equity have influenced health care for many years. Equity, in the context of social health insurance such as the Philippines’ Philhealth, means access of the whole population to a package of health services by paying an affordable contribution, and sometimes no contribution at all (for senior citizens and indigents). Philhealth can improve access to health care for some groups and could potentially increase resources for health care.

The increase in demand for health care of those covered by Philhealth may require an efficient allocation of scarce resources, such as medical staff, medicines, as well as hospital beds. Philhealth’s commitment to ensure access to health care services must be coupled with the government’s commitment to an acceptable level of supply.

Does the current national social health insurance program increase or decrease the efficiency of the use of scarce resources? Is ‘access’ rather than ‘utilization’ of health services a better measure of equity in health care?

POLICY ANALYSIS REPORT: Graphic Health Warnings Law (Part 4)

POLICY EVALUATION

Evidence is one factor that influence policy-making and this can be generated through research. Research is a scientific process designed to produce new knowledge to improve the understanding of the world or to explain a phenomenon. It has substantially contributed to this policy in many ways at various stages of the policy cycle. The succeeding sections present the role of research in these stages.

Issue Recognition and Policy Identification

Research, in the early stages of the policy cycle, helped define the nature and severity of the problem. It helped issues get into the government’s policy agenda. Research evidence were effectively utilized by several policy actors such as the WHO, DOH, and anti-tobacco groups.

Health statistics from the DOH provided policy actors and the public with the information about the health effects of tobacco use, specifically tobacco-related diseases. This information supported the argument for the enactment of better, stricter tobacco control policies that will lessen the burden of these diseases.

National and global surveys such as the Global Adult Tobacco Survey (GATS) and the Global Youth Tobacco Survey (GYTS) helped monitor tobacco use among Filipino adults and the youth. These surveys provided essential information regarding the tobacco epidemic. These surveys covered essential indicators such as (1) knowledge and attitudes towards cigarette smoking, (2) prevalence of cigarette smoking, (3) role of media and advertising in the use of cigarettes, (4) access to cigarettes, (5) environmental tobacco smoke, and (6) cessation of cigarette smoking. Information from these surveys stimulated the development of tobacco control policies and programs in the country.

Global and local surveys proving the ineffectiveness of text-only health warnings on cigarettes products to change smoking behavior prompted policy actors to review existing policy options. As such, studies proving the effectiveness of large graphic health warnings in changing smoking behavior and deterring non-smokers from taking up the habit were used as justifications for the enactment of a policy similar to the recommendations of the WHO.

Policy Formulation

Research has also played a significant role in the formulation of the policy. The WHO FCTC, a set of tobacco control guidelines established from systematic review of research evidence, contributed to the introduction of strong health warnings and the adoption of graphic health warnings in the country.

In the Philippines, a concept test on cigarette packaging designs was conducted by FCAP in 2007 through a quantitative Concept Acceptance Test. The nationwide study provided a background on the public’s perception about smoking and its health effects. Likewise, the study provided feedback on various graphic health warning mock-ups that helped anti-tobacco advocates choose which were the most effective for the Philippine market.

Policy Implementation

Currently, no study has explored the impact and effect of the graphic health warnings on smoking behaviors of Filipino smokers nationwide. A small study, however, that explored how graphic health warnings had affected smoking behavior of Quezon City residents was conducted by UP Diliman Communication Research students in 2016.

The researchers surveyed 402 Quezon City smokers and conducted two focus group discussions from October to November 2016. The results of the study suggest that thinking about the dangers of smoking and correct knowledge of smoking-related diseases are the strongest factors correlated with the intention to quit or change smoking behavior which is in congruence with the overall goal of the GHW law (Aseo et al., 2016).

The study also presented aspects of the implementation where the policy is problematic. First, the fact that buying cigarette on a per-stick basis is prevalent in the Philippines greatly reduces the probability of smokers being informed of the dangers of tobacco use. And second, most smokers do not rely on tobacco packages for health information. Majority of smokers actually rely on other media (i.e. television) for information on smoking.

What’s Next?

While current evidence suggests that graphic health warnings are effective in informing smokers of the health effects of tobacco consumption, future research will be helpful in evaluating the effectiveness of graphic health warnings in changing consumer behavior (i.e. decreasing tobacco consumption, deterring non-smokers from initiating smoking). Findings from future studies will eventually determine the fate of the policy – whether to improve or repeal the policy.

 

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Crisostomo, S. (11 February 2016). Tobacco panel issues rules for graphic health warning law. The Philippine Star. Retrieved from https://www.philstar.com/headlines/2016/02/11/1552156/tobacco-panel-issues-rules-graphic-health-warning-law

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POLICY ANALYSIS REPORT: Graphic Health Warnings Law (Part 3)

POLICY IMPLEMENTATION

Principal-Agent Approach

The policy uses the principal-agent approach of implementation where the government has mandated its various agencies to implement the law in various capacities. Other than the DOH, several government agencies are also given mandates for purposes of the implementation of this law.

The Bureau of Internal Revenue (BIR) is mandated to ensure that cigarette stamps are not affixed on noncompliant packages and to certify under oath that the products withdrawn are compliant with R.A. No. 10643. The Inter-Agency Committee on Tobacco (IAC-T), created under R.A. No 9211, monitors overall compliance with the law, and institutes the appropriate action for any violation of the law. The Department of Trade and Industry (DTI) shall hear complaints of violation of this law filed by the IAC-T or any private citizen, corporation, or organization. Finally, the Department of Education (DepEd) is mandated to use the Graphic Health Warnings templates to educate children on the ill-effects of tobacco and ensure that these are included in relevant subjects under the K-12 curriculum.

 

Factors Affecting Implementation

While many advocates laud the passage of the GHW as a tobacco control measure, much has to be done in its effective implementation. The policy addresses the issue on information asymmetry; however, it lacks the ability to fully change several mental models (i.e. smoking is cool & masculine) and other unique factors imbedded in the Filipino culture that could drive or deter the implementation of the policy.

Tobacco Industry Interference

While there seems to be a strong political will from the DOH leadership to sustain the measure, there is certainly room for some resistance to change. Many stakeholders have identified the PTI as a stakeholder that actively opposes GHW as a tobacco control policy. While this opposition was made apparent by PTI in the past, it eventually expressed moderate opposition to this policy during the policy formulation phase when it realized that the enactment of the policy was inevitable.

As the sole group of opponents with the intention to protect their commercial interests, tobacco companies effectively used their power to challenge, discredit, and obstruct the implementation of effective tobacco control measures such as the GHW Law. Due to their overwhelming resources and ability to effectively mobilize these, PTI has the capacity to hire the best law firms for their legal defense pitted against underpaid government lawyers with a ton of caseloads.

Research conducted by anti-tobacco groups showed that these actions included (1) demanding a seat at government negotiating table, (2) drafting and distributing sample legislation that is favorable to the tobacco industry, (3) attempting to bribe legislators, (4) financing government initiatives to gain favor, (5) using tobacco farmers as ‘front groups’, (6) and defending commercial profit (HealthJustice Philippines, 2014).

The PTI has a long history of opposing tobacco control measures. In 2014, PTI successfully reduced the size of originally proposed graphic health warning labels on cigarette packs and convinced legislators to place them on the lower portion of the front and back panels which is opposite the recommendation of the WHO (SEATCA, 2018).

The tobacco industry’s powerful influence on the policy process also became apparent during the policy’s implementation. Despite proven capacity to produce cigarette products with graphic health warnings, Philippine tobacco companies delayed the implementation of the law citing administrative feasibility, logistical nightmare, and costly exercise among their reasons. For transnational companies, this was a case of double standards.

The law took effect on March 2016, two years after it was signed into law, where local and imported cigarettes started to be sold in packages with graphic health warnings. However, based on the law, the absolute prohibition on the retail sale of tobacco products without GHW started only on November 2016. Manufacturers and importers were given a year to print the graphic health warnings on tobacco packages and retailers have been given an additional eight months to exhaust stock with text warnings.

Many anti-tobacco groups blame the powerful tobacco lobby for the delay. This further demonstrated the power of tobacco companies to influence not only policy formulation but also the implementation of the law. Coincidentally in 2014, the WHO released the Tobacco Industry Interference Index showing that the Philippines ranked third among countries with strong industry interference with a performance rating of 71 following Indonesia and Malaysia.

Most stakeholders also do not agree with PTI being included in the Inter-Agency Committee-Tobacco (IAC-T). Most stakeholders believe that PTI could meddle with decision about cigarette policies of the government by sitting in a government tobacco regulatory body that seeks to regulate their industry. Many of these stakeholders have called on the government to remove the PTI from the IACT.

There is no doubt that the passage of the GHW law greatly benefited from strong political support, leadership from DOH, and advocacy-driven action by anti-tobacco groups. The country’s experience may not be comparable with the experiences of other countries that have implemented similar reforms. The tobacco industry’s power remains a significant influence in the tobacco control policy process of the Philippines. However, the experiences with the GHW policy process in the country has established a strong foundation for future reforms, especially in tobacco control.

 

Health information source

With the end goal of effectively instilling health consciousness and deterring potential smokers, the GHWs on tobacco product packages were introduced to deliberately present the harmful effects of tobacco use and to change the wrongful notions associated with smoking. Graphic health warnings are intended to prompt the smokers to think that they could contact diseases depicted in the pictures. Worldwide, GHWs were proven effective in prompting smokers to think about the dangers of smoking which is associated with increased intention to quit.

It is assumed that (1) the more smokers think about the dangers of tobacco use, the more likely they are to consider quitting; (2) and exposure to the dangers of smoking will prevent non-smokers and the youth from initiating tobacco use. This is where the graphic health warnings should supposedly show their impact.

In the case of the Philippines, this is not entirely true. Graphic health warnings lag behind other media as a primary source of information about smoking. It was found that smokers prefer television as primary source for smoking information. Not much has changed since 2008 when the study by FCAP found that 77% of smokers saw warnings on television while only 19% saw them on cigarette packaging.

A more recent study showed that 73% of smokers relied on television to learn about tobacco-related diseases (Aseo et al., 2016). Graphic health warnings only ranked as the second most cited source of information about the health effects of tobacco use. The same study found that majority of smokers had seen the graphic health warnings on cigarette packages. Some of the respondents said they were disgusted and scared by the graphic health warnings and actually prefer throwing the packs away. However, some of them did not pay attention to the graphics and simply threw the cigarette packs.

The use of GHW may only serve its purpose to a few smokers knowing the fact that most of these smokers actually rely for information through media other than the graphic health warnings printed on tobacco packages.

 

Mode of purchase

The Philippines was once called as a country having a “sachet economy” as it allows a consumer in making smaller cash outlays for smaller packages. Most Filipino smokers resort to buying one or two sticks at a time with an accompanying free light-up service from the vendor instead of buying a pack of cigarettes. The culture of per-stick buying in the country has greatly affected the implementation of graphic health warnings on tobacco packages.

Only about 20% buy cigarettes per pack (versus about 80% buying per stick) making it difficult to ascertain the effectiveness of GHW on tobacco packages in changing the tobacco landscape of the country (Aseo et al., 2016). Buying cigarettes per stick as opposed to buying per pack significantly removes the probability of a smoker or potential smoker of seeing these GHWs and thus, defeating the purpose of the policy.

The DOH was concerned about this aspect of the policy’s implementation –  cigarettes sold per stick by vendors or retail stores. Hence, in 2016, the Department tapped local government units (LGUs) to help monitor the full implementation of the law at the street or community level. To date, no policy has been issued to regulate the sale of cigarette products per pack at the community level.

In general, the graphic health warnings have been proven to be effective in informing smokers about the dangers of tobacco use. It plays a huge role in changing the behavior of smokers regardless of literacy and economic class. It has been shown that around 42 percent of those who changed their behavior said the graphic health warnings had a big impact on their decision (Aseo et al., 2016). But despite these evidence, graphic health warnings fall short in attaining the maximum benefit it promised due to lapses in the policy’s implementation.