Pandemic Financing: How the World is Funding the COVID-19 Response (Part 1)

Introduction

Many countries are scrambling to respond to the COVID-19 pandemic. The primary focus has been on strengthening health systems to improve surge capacity1,2. At the same time, countries are faced with the difficulty of balancing the demands of responding to the pandemic with the need to maintain the delivery of essential health services2. This increasing demand for health care can further strain health systems around the world. Thus, resulting in a dramatic increase in direct mortality from the outbreak and indirect mortality from preventable and treatable health conditions2.

A key challenge to the pandemic response is the struggle to reconcile scarce resources with many competing priorities. Many health systems, however, were already overwhelmed and underfunded even before the pandemic3. Unsurprisingly, the COVID-19 pandemic has caused a significant blow on the global economy, further constraining the fiscal capacities of economically-vulnerable countries3,4.

Timely policy actions are crucial to mitigate both the health and economic shocks brought about by the pandemic5. Therefore, governments must create a public finance environment that can provide sufficient funding to ensure a comprehensive pandemic response while also taking into account economic and fiscal constraints6.

How is the expression of health valuation and prioritization highlighted in the COVID-19 response?

Health financing policies are required to strengthen the pandemic response. Such policies should focus on (1) raising adequate revenues, (2) organizing these revenues to maximize risk-sharing across the entire population, and (3) mobilizing public funds so that they can be effectively translated into the provision of health services7.

Population-based services, such as comprehensive surveillance, data and information systems, and communication and information campaigns, take priority in the pandemic response. Funding these health services will help ensure that public health functions needed to respond to the crisis are all in place8. Unfortunately, in many countries, investment in the national capacity to prevent, detect, and respond to pandemics was not prioritized in recent years8. In some countries, a systematic financing response has not been established to help address these capacity gaps9.

Additional domestic spending can come from a mix of sources and is used to address different health system issues arising from the pandemic5. In Lithuania, the additional expenditure amounting to $386 purchasing power parity (PPP) per person was intended to cover equipment, salaries, and social security coverage10. In contrast, some countries, such as Bosnia and Latvia, have allocated less than $20 PPP per person from domestic resources for their pandemic response10. It is also interesting to note the variation of health spending across countries. Some countries have large additional budgets but have spent only a fraction so far. France and Croatia spend less than 2% of their regular health spending while Cyprus and Lithuania spend 12.4% and 27.2% of their regular health spending, respectively10.

The situation, then, begs us to ask the question, “How much additional funding should countries spend on their COVID-19 response?” Truth be told, it is difficult to determine the right amount of health spending for a pandemic response. The answer is probably context-specific and highly depends on the needs of the country. What is certain, however, is the fact that more additional funding will be required to meet the growing demand for non-essential health services together with the public health measures employed in the pandemic response. Undoubtedly, there will be higher health expenditure and more budget injections throughout the COVID-19 pandemic.

What are the challenges in financing the COVID-19 response?

In response to this, many countries have already reconfigured health service delivery to meet the immediate health care needs of their populations. However, a supportive health financing response is necessary to scale up both population-based and individual services, especially in countries that heavily rely on out-of-pocket payments1,8. Many of these countries were already experiencing significant gaps in health system coverage which can pose additional challenges to mitigating both health and economic shocks caused by the COVID-19 pandemic5.

1.  Inadequate sources of funding

Like previous public health emergencies (e.g. Ebola), the COVID-19 pandemic will again test public financial management systems in their capacity to support fiscal objectives. Challenges that these systems will face may come from (a) reassessing fiscal policy needs and identifying additional financial resources; (b) ensuring timely availability of funds to service delivery units; (c) tracking accounting for transparent reporting; and (d) ensuring business continuity11. Some countries will have an array of emergency response mechanisms at their disposal and most countries will utilize one or more of the available health financing tools to cope with emergency spending. Through public financial management systems, some governments have the capacity to activate contingency funds in emergency situations including pandemics5,6.

Arguably, major gaps in the health financing system are more challenging to address at the subnational level. In the Philippines, for example, funding level and spending capability vary substantially by local government unit. Some local government units have insufficient funds or sub-optimal budget allocation to implement an effective response to public health emergencies12. Thus, funding for a pandemic response may not always be allocated or readily available to support priority public health measures, especially at the subnational level.

Reprioritization through virements between government programs has been considered the primary action in securing budget funding for immediate pandemic response6. Private donations from individuals and local businesses have also been relied on as secondary sources of additional funding. Reallocating existing health budgets and private donations, however, may not be enough to fund health financing needs in the long run10. Conversely, many of the countries with low levels of an additional spending budget will eventually rely on funding from external donors such as the World Bank10.

2.  The need for timely and appropriate fund disbursement

More than the availability of funds, a financing mechanism is essential for the timely response to public health emergencies. Timely and appropriate financial decision-making requires a coordinated and harmonized governance structure across government agencies. The speed by which a country can respond to a public health emergency may depend on its public financial management system which establishes the rules and regulations for budget allocation and spending. In Australia and France, these rules are flexible which allowed for the rapid reallocation of program-based budgets and the immediate release of such funds to health care providers13.

An accelerated disbursement process will allow advance appropriation and fast-track payments to meet the spending needs of health systems. Several countries have explored different approaches to accelerate the release of public funds to government agencies and/or health service providers both in national and subnational levels14. In India, for example, procedures for fiscal transfers to subnational levels have been accelerated by authorizing emergency spending transactions without the approval of the Minister of Finance15.

In the Philippines, a quick response fund of the Department of Health is available and can be accessed when needed during times of emergencies and disasters. However, there is limited coordination and flexibility to reallocate or transfer the quick response fund to other key government agencies to support the response to public health emergencies12. The total turn-around time for the release of this fund takes about one to three weeks. When the disbursement of the fund is anticipated to last more than one week, the requesting office is asked to initially utilize their regular funds12. Hence, there is a need to enhance the capacity to optimize resource allocation by instituting innovative financing mechanisms that can hasten the disbursement of funds where they are needed most.

References:

  1. World Health Organization. How to purchase health services during a pandemic ? Purchasing priorities to support the. 2020;(April). https://www.uhc2030.org/blog-news-events/uhc2030-blog/how-to-purchase-health-services-during-a-pandemic-purchasing-priorities-to-support-the-covid-19-response-555353/.
  2. World Health Organization. Maintaining essential health services : operational guidance for the COVID-19 context. 2020;(June). https://www.who.int/publications/i/item/covid-19-operational-guidance-for-maintaining-essential-health-services-during-an-outbreak.
  3. Kurowski C, Evans D, Irwin A, Postolovska I. COVID-19 (coronavirus) and the future of health financing: from resilience to sustainability. Investing in Health. https://blogs.worldbank.org/health/covid-19-coronavirus-and-future-health-financing-resilience-sustainability. Published 2020. Accessed June 13, 2020.
  4. Development Aid. Financing of pandemic response: where does the money come from? https://www.developmentaid.org/#!/news-stream/post/62753/financing-of-pandemic-response-where-does-the-money-come-from. Published 2020. Accessed June 13, 2020.
  5. Thomson S, Habicht T, Evetovits T. Strengthening the health financing response to COVID-19 in Europe. 2020.
  6. Barroy H, Wang D, Pescetto C, Kutzin J. How to budget for COVID-19 response? 2020;(March):1-5. https://www.who.int/who-documents-detail/how-to-budget-for-covid-19-response.
  7. World Health Organization. Health systems governance and financing & COVID-19. https://www.who.int/teams/health-financing/covid-19. Published 2020. Accessed June 14, 2020.
  8. World Health Organization. Priorities for the Health Financing Response to COVID-19. DOI:10.1596/33738
  9. Glassman A, Datema B, McClelland A. Financing Outbreak Preparedness: Where Are We and What Next? Cent Glob Dev. 2018. https://www.cgdev.org/blog/financing-outbreak-preparedness-where-are-we-and-what-next.
  10. Cylus J. HOW MUCH ADDITIONAL MONEY ARE COUNTRIES ALLOCATING TO HEALTH FROM THEIR DOMESTIC RESOURCES? https://analysis.covid19healthsystem.org/index.php/2020/05/07/how-much-additional-money-are-countries-putting-towards-health/. Published 2020. Accessed June 18, 2020.
  11. Stone M, Saxena S. Special Series on Fiscal Policies to Respond to COVID-19 Preparing Public Financial Management Systems for Emergency Response Challenges 1. https://blog-pfm.imf.org/pfmblog/2020/03/preparing-public-financial-management-systems-to-meet-covid-19-challenges.html.
  12. World Health Organization. Joint External Evaluation of IHR Core Capacities of the Republic of the Philippines. Geneva, Switzerland; 2019. DOI:10.1142/9789812817945_0010
  13. Gupta S, Barroy H. The COVID-19 Crisis and Budgetary Space for Health in Developing Countries. https://blog-pfm.imf.org/pfmblog/2020/03/preparing-public-financial-management-systems-to-meet-covid-19-challenges.html. Published 2020. Accessed June 21, 2020.
  14. Barroy H. No calm after the storm: time to retool country PFM systems in the health sector. https://p4h.world/en/who-wb-no-calm-after-the-storm-time-to-retool-country-pfm-systems-in-health-sector. Published 2020. Accessed June 21, 2020.
  15. Verma A, Raj A. PFM Solutions in India to Combat the COVID-19 Pandemic.

 

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 42

Given adequate information, the market theory assumes that consumers know what is best for themselves; hence, they make choices that maximize their total satisfaction. If this assumption is wrong, markets may not efficiently produce. We call this satisfaction consumers gain from consuming a good or service as “utility”. The satisfaction (or utility) depends on the quantity and mix of goods and services chosen by a consumer. The theory holds that consumers get more satisfaction from more goods and services but the increase in satisfaction from consuming additional units gradually diminishes. In health care, how do consumers go about choosing the mix of goods and services which give them the maximum total utility? In places where there are few sources of health care goods and services, do people take into account their tastes/preferences and income when choosing a combination of goods and services which gives the people the highest utility? Do people’s preferences and tastes change in situations where there are very few choices? Or do they develop an acquired taste/preference because of limitations posed by societal inequities?

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?

A Day in the Life of a Neuroscience Nurse

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There is no typical day for a nurse. No, really, there isn’t. Every day or shift has the potential to be exhausting, challenging, inspiring, or everything combined. On any given day, nurses often see patients (and their families) at their weakest and most vulnerable, but sometimes at their strongest.

Nurses usually spend more than 8 hours in the hospital tending to the needs of their patients. For neuroscience nurses, 8 hours might not even be enough to do everything that you want and need to do for your patients. Almost all the time, neuroscience nurses handle patients diagnosed with cerebrovascular disease or stroke. However, there are times when patients with autoimmune diseases (i.e. Guillain-Barre syndrome, multiple sclerosis, chronic inflammatory demyelinating polyneuropathy) are admitted in the hospital. These patients warrant almost the same level of care as stroke patients.

It is almost impossible to write about a typical day for a neuroscience nurse given the fact that healthcare workplaces vary and the actual work differs from shift-to-shift depending on the type and number of patients a nurse needs to care for. The following is a broad outline of what a workday might be for a neuroscience nurse in the Philippine General Hospital during an 8-hour morning shift.

Early Bird

A nurse’s day often begins even before the sun is up. Most nurses have taken a bath and / or eaten breakfast before other healthcare professionals even hit their alarm’s snooze button. Those who do not live within the vicinity of the hospital often ride a bus, jeepney, or train to get to the hospital. You are lucky if the commute only lasts an hour or less. On a usual weekday, travel time doubles and sometimes even triples.

Some nurses arrive as early as an hour before the actual shift starts. The time is spent preparing for patients’ medications. Some oral medications (tablets) need to be crushed as they will be given to patients with dysphagia (inability to swallow as a consequence of stroke) via nasogastric tube. A tray will often be filled with vials of antibiotics that are diluted at least 30 minutes before they are administered to patients. Ampules of paracetamol, dexamethasone, and furosemide are immediately broken and aspirated into a syringe one after the other.

Sometimes, a nurse will do a quick round in the ward to see how many are intubated and connected to a mechanical ventilator. He/she then proceeds to prepare materials for tracheostomy or endotracheal tube care which will commence after the handover.

Handover

A hospital isn’t like any other workplace where one shift ends before another begins. Morning, afternoon, and night nurses usually work as a team ensuring that patients receive seamless care. This is made possible through nurse-to-nurse endorsements (handoff of information) at the start of every shift. The morning shift nurses get information from night nurses about what happened overnight, as well as other pertinent patient information or needs that are essential for the next shift. Depending on the number of patients, handovers usually take 30 minutes.

It is also during the handover when nurses check for supplies and inventory to make sure they have enough for their shift. The code cart (emergency cart or e-cart) is typically used for emergency cases such as when a patient goes on cardiac arrest. The e-cart contains essential emergency drugs, including epinephrine, used during cardio-pulmonary resuscitation (CPR). Hence, in the neurology ward (where a high-stress situation could easily arise), it is a-must for nurses to check the supplies contained in the e-cart every shift as one wouldn’t want to run low on supplies during emergency situations.

Morning Rounds

Average days or routine work doesn’t happen when you’re dealing with many patients, especially those in the neurology ward. Mornings are often busy for nurses. A lot can happen during and in-between shifts. Much of the hours in the morning are spent on hourly assessing the condition of patients, taking their neurologic vital signs (blood pressure, heart rate, respiratory rate, temperature, GCS, & pupil size and reaction to light), and monitoring blood sugar of patients with diabetes.

Neurologic diseases often affect cognitive as well as motor/muscle function. As such, more than half of the patients are highly dependent on the nurses. During the morning rounds, nurses often position these patients on high back rest. This is in preparation for various morning care routine and the subsequent tube feeding.

The actual work starts by administering Salbutamol through a nebulizer followed by suctioning of secretions (i.e. sputum, saliva). The ward has only one nebulizer and three cheap portable suction machines that are used for 18 patients. Suction machines use ‘suction’ to pull out pooled secretions in the patient’s tube or mouth to remove obstruction in the airway. Unfortunately, some of these machines have worn out, unable to effectively suck thick, frothy secretions. As a result, some of the patients’ relatives often take the initiative to buy their own machine/s.

After routine morning care and bathing, both oral and intravenous medications are administered to patients. Some patients have multiple antibiotics which are run for 1-2 hours each. Others are given hypertonic saline solution ranging from 150 mL to 400 mL depending on the latest serum sodium of a patient.

Oral medications are mostly given via a nasogastric tube before or after (depends on the medication) tube feeding with osterized (blended) feeding or milk. Patients are left on moderate to high back rest positions after feeding, and observed for drug-related adverse reactions.

Noon

Patients’ vital signs are continuously monitored throughout the shift. Other explicit and implicit needs of patients (e.g. suctioning, bed turning) are also addressed throughout the shift.

Some doctors ask for blood, urine, and sputum samples from their patients to be tested at the hospital laboratory. Neurology nurses often take these samples at or before noon and are eventually collected some time after by a laboratory aide.

Other procedures such as x-ray, ultrasound, and CT scan have varying schedules and these procedures should be taken into account when planning the care of patients. Routine care can be disrupted by these procedures especially when they are ordered stat (medical abbreviation for ‘immediately’ or ‘urgent’).

Some patients who are ordered to be discharged from the hospital are assisted by nurses in accomplishing hospital billing clearance. Most patients in the charity wards go home without paying a single centavo as they are required to enroll in Philhealth (the Philippines’ national health insurance provider). When a patient’s hospital bill is beyond the case rate determined by Philhealth, he/she is automatically referred to other government institutions (e.g. DSWD, DOH, PCSO) for financial assistance.

Patients who are to be discharged are also referred to the hospital’s Dietary Department for nutrition-related lecture conducted by a nutritionist/dietician. Patients with diabetes who are already insulin-dependent are taught by nurses about diabetes and insulin administration prior discharge.

As most days are busy, nurses will often try to take some time for lunch in the middle of the day. This doesn’t always happen though. Sometimes, a ‘lunch’ would be whatever you could grab in-between nursing tasks. Nothing’s guaranteed for nurses, especially a decent mealtime (and even toilet time). Having the time to eat can be a luxury when you’re dealing with an endless list of patients who have immediate needs all day.

Afternoon Rounds

Much like the morning rounds, afternoon rounds kick off by checking if any patient’s status has changed since the last rounds. Some patients require strict hourly monitoring especially when their blood pressure readings are erratic. A patient may be given nicardipine (to decrease BP) or norepinephrine (to increase BP) which is titrated hourly to maintain a specified blood pressure.

By the afternoon, some patients could have been discharged or released but several more will have been admitted in the interim. Nurses can often find themselves managing new patients and administering any medications that need to be given at that time. And of course, during this time, most nurses catch up on charting/documenting nursing care and carrying out doctors’ orders.

The afternoon also include visiting hours. Nurses often use their ‘people skills’ during this period. Nurses are often tasked with updating family members on a patient’s condition. They also educate new patients (and their families) about their diagnosis, treatment and nursing care plans, as well as unit/hospital rules and regulations. Nurses will have to answer patient questions and ensure that both the patient and his/her family have adequately internalized what they need to know.

Handover

Despite the toxicity, one may consider it a good day if no patient went on cardiac arrest or had to be intubated.

Before going home, a neurology nurse will have to make sure that everything has been properly documented. Nurses will have to double-check patient charts and update handover notes for the next shift. Nurses need to make sure that the transition to the next shift goes as seamlessly as it was in the morning so that patients are getting consistent care.

When the afternoon shift nurses arrive, morning shift nurses (usually the charge nurse) will brief them and leave the care of their patients to these nurses with equally capable hands. After the final ward rounds, morning shift nurses go home, enjoy their hard-earned rest, and start again the cycle after 16 hours.

End Notes

There is no typical day for a nurse, especially a neurology nurse. No matter what a nurse does, or where he/she does it, there is always the unpredictability of how a day will start and end. It is an incredibly demanding field, but it can be a rewarding and fulfilling one.

 

UP Manila says ‘No’ to Medical Cannabis Legalization in the Philippines

I agree that:

1) further research on Cannabis’ efficacy and safety should be done under strict protocols (provided by national institutions) to ensure patient safety and safeguard public health.

2) any policy, especially public health policies, should be evidence-based.

“UP Manila says ‘NO’ to Medical Cannabis Legalization”
Download whole document: https://www.upm.edu.ph/node/2264

Electronic info to raise quality of PH healthcare

Philippine Daily Inquirer | 12:29 AM July 13th, 2015

RECORD-KEEPING or documentation is an essential part of nursing practice that has clinical and legal significance at the same time. It is said that quality documentation improves patient care which results in better outcomes, while poor documentation often contributes to poor-quality nursing care (Prideaux, 2011). Nursing documentation, a precursor to good patient care, is a vessel for efficient interdisciplinary communication and cooperation (Ammenwerth, Mansmann, Iller, & Eichstadter, 2003).

Nurses in majority of healthcare facilities in the Philippines still practice paper nursing documentation. A report of the Maryland Nursing Workforce Commission (2007) revealed that such method of documentation reduces the time spent at the bedside for patient care, thus directly affecting outcomes. This is where Nursing Informatics comes in.

Nursing Informatics “aims to improve the health of populations, communities, families and individuals by optimizing information management and communication” (ANA, 2001). It is fundamental in providing cost-effective high-quality healthcare, of which an important component is accurate clinical information.

Thede (2003) explained that electronic information systems provide an avenue for more effective communication and collection of patient health information resulting in more effective patient care. One example of such information system is the electronic health record or EHR, where multiple systems that cross to share data are networked to support efficient information management and communication within a healthcare system. EHR is largely advantageous because it tends to store large amounts of data that are made accessible at the same time in different places. What makes this system more interesting is its ability to provide healthcare teams with clinical alerts and reminders when abnormal parameters are identified in both laboratory and assessment data.

Electronic-based documentation systems would be of great value to Philippine hospitals with a nurse-patient ratio higher than the ideal. When the staffing ratio is high, nurses tend to allot more of their time documenting rather than actually caring for their patients at the bedside. In an electronic-based documentation system, trends in patient outcomes will be highlighted alongside medical and nursing management.

Such systems, while integrating the concepts and theories of nursing science, computer science and information science, propel the entire healthcare delivery system into a practice that is evidence-based and culturally-relevant. These systems should not be regarded as a substitute for clinical judgment or as a predictor of critical illness but as a tool that could help identify life-threatening cases.

Though most of Philippine hospitals are quite far from achieving this, such information systems should be viewed as a crucial facet in promoting a culture of patient safety where the documentation standards help and/or equally meet the standards of medical and nursing care.

—REINER LORENZO JARABE TAMAYO, reinerlorenzo@yahoo.com

 

link: http://opinion.inquirer.net/86638/electronic-info-to-raise-quality-of-ph-healthcare