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.

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.

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.

Pen Point 39

The procurement policies and procedures of the government are not flexible which makes them economically inefficient. Sometimes, this inflexibility becomes a barrier given the varied choices now made available to the market, difficulty in standardizing the specifications of materials to be procured, and the fragmented nature of the market. These guidelines are set to standardize procurement rules to eradicate bias and/or fault of human discretion, as well as corruption. The rigidity of these rules renders procurement officers vulnerable to administrative sanctions when one or two of these rules are violated. The rules do not allow negotiations for economically efficient alternatives. Thus, we end up having a scarcity of materials needed to run the government.
In health care, an inefficient procurement process leads to scarcity of essential medicines and equipment. This has direct effect on quality of patient care, and more importantly, on patient outcomes. Sometimes, there is limited attention to the quality of the procured materials which leads to further inefficiency in the provision of patient care. The current procurement process is reduced to a set of guidelines to be strictly followed, with little regard to economic efficiency. While the policy is aimed at reducing corruption, the current mechanism actually increases government wastage in terms of time, money, and procured materials of poor quality, all at the expense of quality patient care.

Sugar taxation: revenue or health?

We have a heavy problem with obesity and taxation isn’t the answer. Obesity is one of the major risk factors for a number of chronic, non-communicable diseases including the top leading causes or morbidity and mortality in the Philippines (i.e. diabetes, cancer, and cardiovascular diseases)1,2. In 2016, 22.3% of Filipino adults above the age of 18 were overweight and 4.7% were obese3. These numbers translate to about 18 million overweight and obese Filipinos. The cost of treating obesity and obesity-linked diseases has a sizeable impact to the public health system. The cost of obesity in the Philippines was estimated between US$500 million and US$1 billion, or between 3.5% to almost 8% of total healthcare spending in 2016. Obesity also reduces life span by an average of four to nine years across ASEAN member states. Among Filipino males, obesity-linked diseases reduce productive years by between eight to twelve years4.

The over-consumption of sugar is associated with weight gain. As such, the consumption of sugar-sweetened beverages (SSBs) has been linked to obesity, as they are unnecessary sources of empty calories (little to no nutritional value). Hence, the recent introduction of SSB excise tax as a health measure, sits on the premise that such tax will curb consumption of SSBs by encouraging individuals to make healthier choices.

Policy Analysis

Given the economic and social costs of obesity, the case for responding quickly is undisputable. Taxation is an undeniably efficient source of public funding. In the Philippines, it has been introduced to address the obesity epidemic and chronic non-communicable diseases associated with it. In October 2018, the government reported that is has collected P30 billion in excise taxes from SSBs. However, this is short from the projected or target revenue of P40 billion5.

  • Sugar taxation adds weight to the heavy problem of obesity. The SSB excise tax does not live up to its promise of curbing sugar consumption. Studies have shown that the evidence that sugar taxes improve health is weak6.
  • The SSB excise tax is not encompassing; rather it is a ‘discriminatory’ tax. Research does not prove that purchasing fewer SSBs leads to significant weight loss6. Weight loss requires reducing total caloric intake. Therefore, measures to reduce the risks of diet-related, non-communicable diseases should not only focus on altering the consumption of individual food items (i.e. SSBs) but should encompass overall diet.
  • Taxation is neither necessary nor sufficient approach to the complex issues of obesity. Evidence shows that such taxes aimed at reducing purchases of SSBs may actually have a short-term impact on sales. In Mexico, it was found that the purchasing behavior of consumers returned to almost pre-tax levels just two years after it imposed tax on sugary drinks7,8.

Combating obesity and the obesity-associated NCDs requires a holistic, multi-sectoral approach. Challenges related to limited knowledge and understanding of nutrition, unbalanced and unhealthy diet, and lack of physical activity should be addressed. Below are more cost-effective strategies on how we can meaningfully and significantly shape a healthier environment to reduce calories and sugar in the diet.

 

Recommendations

  • Reformulate sugar-rich drinks and food, and control portion size

These measures are more cost-effective than taxation in reducing calories and sugar intake9,10. However, government policy is required to set appropriate food and drink standards allowing companies to operate on the same footing. The policy should be developed on the basis of a national quantitative study on major sources of sugar in a typical Filipino diet. The initiation of this process will require considerable time and effort as it warrants a comprehensive analysis of sugar sources and involving various stakeholders in the policy process. Moreover, the government can control portion size by restricting the ability of food establishments to offer large single serving beverages.

  • Behavioral: Enforce restrictions on marketing, advertising, and sponsorship of sugar-rich food and drinks; and accelerate health information drive

Increased consumption of SSBs and sugar-rich food is often attributed to successful marketing, low cost, and high availability11. As promotion and marketing of these products remain unregulated, policy on responsible marketing and packaging of products can be legislated. The government can restrict marketing of sugar-rich food and drinks especially targeted to the youth at point-of-sale and by using mass media. Warning labels on food and drinks with high sugar content similar to tobacco products can also be considered. The DOH and DepEd can complement responsible marketing with a more intensive health information campaign against obesity in public institutions, schools, and through the use of public information systems. This approach is a necessary background measure to inducing behavioral change; but health education alone is insufficient to achieve the desired outcome.

  • Structural: Improve people’s access to and availability of healthier food options, and alter unfavorable retail environment

The government can institute a ban on the sale of SSBs, sugar-rich food and/or products not meeting the desired nutritional requirement on school grounds and inside government facilities. Zoning requirements can be enforced to prevent fast food restaurants from sprouting near schools. Another feasible measure would be requiring vendors (in schools, malls, parks, etc) to place healthier food options in special displays and along check-out aisles while placing SSBs and sugar-rich food in the back of the store. These policies may be initiated by local government units. However, a national policy on the establishment and/or improvement of food environments can better support local change.

 

Implementation

The recommended measures can be implemented in three phases:

Phase 1: Comprehensive assessment and health education

  1. Establish a national committee on sugar reduction involving key stakeholders.
  2. Conduct a national study on Filipino sugar intake and sources of sugar in the Filipino diet.
  3. Initiate an education caravan at the grassroots level.

Phase 2: Reduction of sugar content and restrictions on marketing

  1. Enact policy to reduce the content of sugar in SSBs and sugar-rich food.
  2. Legislate policy to reduce opportunities to market SSBs and sugar-rich food across all media.
  3. Revisit and revise food labeling criteria and standards.

Phase 3: Establishment/improvement of healthy food environment

  1. Coordinate with LGUs in the formulation of policies on creating healthier food environments.

 

Conclusion

What is the real motivation of sugar taxation? Is it about revenue, not health? If we are truly determined to reduce sugar consumption and improve the health of the people, then, we shouldn’t end the campaign against obesity by simply taxing sugar. In fact, there are more cost-effective ways of battling obesity and its associated diseases. Time is up. The longer we wait, the heavier the problem becomes.

 

End note: This was taken from an academic exercise where we were required to write a policy memo against sugar taxation.

The Global Burden of Disease and Some Implications to Health Policy in the Philippines

The Global Burden of Diseases Study (GBD) is a collaborative project of about 500 researchers in 50 countries led by the University of Washington Institute for Health Metrics and Evaluation (IHME). It is the world’s largest systematic, scientific inquiry that quantifies the levels and trends of health loss by determining the prevalence, morbidity and mortality for hundreds of diseases, injuries, and risk factors that are of global significance. The results of the GBD show how socioeconomic development has generated many health achievements but also emerging challenges in both national and global contexts. Over the years, it has been extensively used to inform evidence-based policy and health systems design.

 

In the Philippines, the observed Filipino life expectancies increased by almost 2 years: females 73.1 (versus 71.4 in 1990), males 66.6 (versus 64.6 in 1990). We also saw a significant decline in the trend of child mortality between 1990 and 2017 (Under-5: 56.0, 26.6; Under-1: 36.0, 19.9). These numbers provide us a snapshot of how our current policies positively impact the health of the Filipino people.

 

As with many other low- and middle-income countries, the Philippines is still facing a double burden of disease. While the country continues to battle with the problem of infectious diseases, it is also experiencing a rapid increase in chronic NCDs at the same time. This double burden of disease places a great toll on the health system and the economy. Non-communicable diseases (NCDs) and lifestyle-related diseases like ischemic heart disease and stroke have remained in the top primary causes of death. In fact, six of the ten leading causes of death are non-communicable diseases (ischemic heart disease, stroke, chronic kidney diseases, diabetes, hypertensive heart disease and COPD). Lower respiratory tract infection and tuberculosis remain as the third and fifth leading causes of death, respectively.

 

Disability burden on Filipinos such as low back pain, headache disorders, diabetes, mental health problems, vision and hearing loss, and other chronic diseases, has significantly risen. The Philippines’ greatest risk factors driving the most death and disability come from a combination of metabolic (high fasting plasma glucose, high blood pressure, high BMI, high LDL, impaired kidney function), environmental (air pollution), and behavioral risks (dietary risks, malnutrition, tobacco, alcohol use).

 

According to the Financing Global Health Database (2017), the Philippine government spent $98 on health per person in 2015. Majority of health care spending came from out-of-pocket payments which was estimated to be $178 per person in 2015. The same database projected that in 2040, even when the government increases its health expenditure, the bulk of health care spending in the Philippines will still come from out-of-pocket payments. The expected OOP spending will rise to a staggering $590 per person or more than P30,000 in today’s exchange rate (US$1 = PhP52.15).

In summary, the study found that although people are living longer, we are spending more time and money in illness. These findings inform decision-making by providing policy makers with accurate, up-to-date information to identify vulnerable populations, conduct disease surveillance, and evaluate the efficacy and cost-effectiveness of current health interventions.

 

These findings also indicate that health issues can vary from country to country. Perhaps, we can expect that the same is true at the local level. Health issues will vary within the country especially when examined through our geopolitical divisions. People in the urban areas have greater access to health care services compared to those living in rural areas. However, urban areas also concentrate new risks and hazards for health. As such, the Philippines should address not only inequities in health care but also emerging threats brought about by rapid urbanization and globalization.

 

Data and information from GBD can assist the government in understanding the drivers/promoters of the observed trends. The government can effectively use data from the GBD to examine emerging challenges and explore opportunities for action. Future policies should extend across multiple sectors to include environment, urban planning, social insurance, education, and even transportation. There is a growing trend that emphasizes the need to strengthen (and maybe improve) current health interventions on infectious diseases. However, the country’s health system should now shift its focus from a highly curative system to one that is preventive and health promotive. Or maybe, at least be prepared in reducing health risks and hazards that are highly modifiable or preventable.

 

Ultimately, the GBD proved that development drives, but does not necessarily determine, the health status of the people. We must keep in mind, therefore, that health conditions exist in the same continuum which reflect underlying social conditions such as poverty and inequity. Given the nature of health conditions, the growing burden of disease reinforces the need for an integrated, multi-sectoral approach at the national and subnational levels that address health system functions (health promotion & prevention, cure, and rehabilitation) rather than disease categories by instituting cost-effective interventions that improve health beyond the health system.