[Webinar] Insights for public health policy - Philippine Public Policy Network

On April 9, 2021, I presented a talk analyzing the Philippines' pandemic response as part of a webinar organized by the Philippine Public Policy Network, entitled "Moving to the Next Normal: Behavioral Insights for Public Health Policy". Joining me in the session moderated by Dr. Jalton Taguibao were Prof. Marie Fe Mendoza who gave opening remarks, Joanne Yoong who offered behavioral insights, as well as Senator Risa Hontiveros who related the pandemic with universal health care. 

My presentation focused on the following 'pathologies' of the country's COVID response, namely (1) the 'responsibilization of the individual'; (2) "covidization” of health care; (3) “one size fits all” solutions; and (4) (mis)use of science and expertise. Taken together, these elements characterize what I call 'medical authoritarianism' in the country. 

Managing the epidemic of fear: Reflections on last year's National School Deworming Day

by Gideon Lasco, MD

Last year, the Department of Health launched the National School Deworming Day (NSDD) - a timely initiative that combined the need to actually treat children for intestinal parasitism and the need to educate public the importance of deworming in children’s health and nutrition.

Unfortunately, it was marred by reports of children being brought to hospitals after taking the deworming tablets, and rumors of more serious problems.

The most virulent rumor was that children actually died as a result of the deworming, amplified by the radio station in Pagadian City which actually reported it. DOH officials now suggest that this rumor was a major reason many parents actually brought their children to the hospitals. “They just wanted to be sure,” an Inquirer report cited a nurse as saying.

Then there were intrigues suggesting that the chewable Albendazole tablets given to the children were expired. DOH Secretary Janette Garin had to show the actual tablets used in the deworming to show that expiration is not until 2017.

What can explain the alarm? First, some of the children could be experiencing the body’s natural reaction to the drug. Upset stomach is one of the common side effects of Albendazole, and the process of deworming could be felt as a sign that the drug . Studies show that the more worms children have, the more they might experience drug-related reactions.

Second, some of the cases can be attributed to “mass hysteria” or “mass psychogenic illness”. My colleague Dr. Harvy Liwanag, who has worked in parasitology research, recounts a deworming activity in Negros Oriental where, there was suddenly a large number of schoolchildren complaining of the same symptoms. The exact mechanism of mass hysteria remains poorly understood by scientists.

The fear of having been poisoned by the drug could itself be a cause for the symptoms children experience, as when some parents in Zamboanga were reported to have given remedies like coconut milk and coconut oil that could very well cause upset stomach.

But the damage has been done. Some towns actually suspended the deworming activtiy as soon as the reports came in, and there were also reports of parents refusing to send their children to school. My medical colleagues say that some of their patients are already telling them that they will never allow their children to take deworming tablets again. Thus, while emphasizing that medical problems were dealt with, the DOH must now seek to manage the epidemic of fear that could greatly undermine deworming efforts in our country.

***

Misconceptions about diseases and their treatments can be as devastating the diseases themselves. The widely-discredited claim that measles, mumps, and rubella (MMR) vaccines can cause autism continues to be believed by many parents, and is directly responsible for the increased incidence of mumps and measles - as well as deaths from these otherwise-preventable viral infections.

In the Philippines, we have a similar example in the tetanus-infertility scare in the 1990s. Following a report that showed traces of a hCG, human hormone in tetanus vaccines, various groups quickly jumped to the conclusion that the anti-tetanus vaccine can cause infertility (the hCG levels were far too low to be significant). This too, has led to many people refusing tetanus shots, rendering themselves - including their babies - at risk of contracting an deadly infection.

These cases remind us that people do develop misconceptions about health interventions, even in the face of unequivocal scientific data. Enough people believe in the measles-autism link in the US that some politicians are even cowered into not taking a clear stand about it. The malignancy towards which these rumors can escalate should make the DOH redouble its efforts in conducting a thorough investigation and providing an explanation of this deworming incident in way that the public can easily understand.

***

Intestinal parasitism is one of the reasons why Filipino children are malnourished; why many children are stunted, and consequently, why many Filipinos are short. These truths must also be emphasized. One very recent study in the US showed that parents are more likely to vaccinate their children when informed of the risks of a certain disase, than assurances that the vaccine against it is safe and effective.

Rather than sensationalize the reports and intrigues, the media for their part should be mindful that they can be an accessory to the propagation of this epidemic of fear.  Even if we accept it as natural that the media will highlight the hundreds who were hospitalized over the millions who weren’t, there is no room for reporting based on rumors - as that radio broadcaster in Pagadian did.

Of course, anticipating adverse reactions and orienting everyone about what to expect are crucial parts of any health intervention. If, as Undersecrtary Dr. Vicente Belizario reminds us, the “chemical reactions are signs that the drug is working or showing its effectiveness,” then this should be relayed in advance to children, teachers, and parents. And if, as Dr. Eduardo Janairo of DOH MIMAROPA said, children should have eaten something before taking the medicine, then this too, should be (even more) emphasized.

As the National School Deworming Day - and deworming incident in Zamboanga demonstrates -  public health is not just about documenting health problems and coming up with programs to deal with them. It is also about successfully communicating these problems - and programs - to the people.

Making sense of "Bawal umihi dito" signs in the Philippines

by Gideon Lasco, MD

Bawal umihi dito: It is an ubiquitous injunction in urban spaces, often boldly painted onto walls, and it translates to "it is forbidden to urinate here". The audience? Filipino men, many of whom continue to take the liberty of emptying their bladders in front of walls, electric posts, and yes, jeepney tires. Go to any densely-populated nooks of the metropolis and there's no denying the pungent odor of piss, which ironically juxtaposes with the aforementioned sign, as if to affirm its relevance by its violation.

Occasionally, the sign is accompanied by the threat of fines, i.e. 500 pesos. In some cases, a municipal ordinance is even invoked, complete with penalties such as imprisonment, as if to make sure that the would-be audience will be convinced about the veracity and seriousness of the sign.

But the very existence of these signs call for some thoughts on this matter. What does it mean for our society? How does it bode for our future?

It is a masculine privilege to take a piss in a very convenient way; it is one of the most obvious gender differences a child observes as he or she grows up. The female toddler is laughed at when she pisses, which requires her to assume an inferior, I.e. squatting position. On the other hand, male children find it fun to manipulate their penises, "shooting it in the toilet bowl" when called for, among themselves; there is some experimentation, like as a contest of having the tallest, farthest stream of piss, an early exploration of sexuality. Today, "pataasan ng ihi"  it continues to be a metaphor for male rivalry. Developmentally, it precedes other forms of male contests, such as "palakihan" (having the largest penis). These things suggest that urinating is not seen as an embarrassing activity at all for many Filipino males; it may be labelled as mischievous, but it is not shameful.

It is very likely that for the longest time, nobody bothered to have male urinals, particularly in rural areas where the bare earth is still visible everywhere. After all, it only takes a few hours before the urine, and its smell, is drained by the soil.

But urbanization took place: villagers flocked to cities, and villages became cities. What was once soil was covered with cement; the open spaces became farther and farther away from people's homes. Backyards became smaller, and more people lived in lesser space.

Sanitation became a problem. Where nearby streams freely flowed through villages, carrying, in the cities, pipes and sewer systems were required, and with it, a financial cost, a need to subscribe to water. Comfort rooms, a taken-for-granted feature of modern living, became unreachable to many, especially the homeless, and those living in the slums. Those of us who have always lived with water faucets may likewise take for granted the availability of water, which in many areas have to be collected and transported to their houses. This is the origin of the term 'pila balde' - a queue of pails as they wait their turn for a fill of water. Some of those pails have come several hundred meters away, and having brought it thus far, you will not waste it just to rinse away urine.

I once had the opportunity to ask a slum dweller how she disposes of human waste considering that her houses consisted of a tiny room in a patch of iron sheets and wooden planks. "I just throw it away," she said laughingly, adding, "like a flying saucer".

There are no more open spaces in the city - save for the rivers, the lakes, and the ocean which have become the unfortunate receptacles of human waste and pollution. Of all the structures of the metropolis: the buildings, the subdivisions, the malls, the only one that is truly accessible to the general public is the street, and thus it is in the street where petty crimes happen, where money is earned in ways that skirt the boundaries between legal and illegal, and yes, it is the locus where offences such as urinating occur.

In 2003, the MMDA embarked on a program to populate the metropolis with pink urinals for men. More than a decade later, it is unclear whether this initiative have had an impact, which, given the number of men in the cities, would at best be minimal. In fact, in 2012, an INQUIRER article reports how a government audit found that, aside from millions of pesos wasted on the program, “...the purpose of procuring such urinals was not satisfactorily achieved as manifested by the foul smell coming from most of the urinals installed.” You could almost see the article's title coming: MMDA urinals leave stink in COA report. 

***

"Bawal umihi dito", as the MMDA experience shows, is not simply a numerical deficiency of toilets in our streets. It a sign that we have not fully come to terms with the urbanization of our society.  Not too ago, people lived with the bare earth and rolling streams which cleansed their environments. Alas, the habits of this bygone era persist in the city, which is a concrete jungle, where evaporation takes time and drainage takes forever.

Moreover, it is a symptom of the overcrowding of our cities, a shared adaptation to limited resources, a lack of access to water and sanitation, and the poverty of the environment.

Finally, it is an example of how people flaunt the law, how people know that not all laws are implemented, and how people who are 'madiskarte' can get away with many things in the country. It's not just Bawal umihi dito, but "Bawal tumawid dito" (you cannot cross the road here) and "Bawal magtapon ng basura" (you cannot throw away garbage) and many others that are oftentimes ignored. In this specific form of ordinance, we saw how it is permitted by cultural norms as a privilege of masculinity. I would argue that it is also enabled by a general attitude towards the law that is not helped by government officials being seen as lawbreakers, instead of lawmakers and law-abiding exemplars.

It will take more than municipal or city ordinances to cleanse the streets of putrid smell. It will take a nationwide effort to be disciplined in things large and small, a respect for the law which goes hand in hand with the respectability of the lawmakers and law enforcers, and inclusive growth that will reach the slums, the poorest of the poor. Finally, a civic consciousness should emerge that goes beyond "tapat mo linis mo" towards "tapat natin, linis natin".

Quezon City
January 7, 2015

Three challenges for governance in health care in the Philippines

by Gideon Lasco, MD
Universal Health Care Study Group,
National Institutes of Health, UP Manila

Public discourse operates in opposites, particularly in the health sector. We see this in the ongoing debate on the reproductive health bill, where opponents and proponents are known as "anti-RH" and "pro-RH". In the US, the 'Obamacare' is attacked as a 'leftist'  policy, even as certain Republican counter-proposals are labeled as 'right-wing social  engineering'. In the Philippines, critics of PhilHealth object to 'privatization' as if public and private sectors were in opposition to each other. Public vs. private, pro vs. anti, left vs. right: does it always have to be "versus"?

In a recent talk as part of DOH-supported "Secretary's Cup" - a series of talks, debates, and town hall meetings on Universal Health Care - former DOH Secretary Alberto Romualdez defines governance as "not just about government, but deals with how the government and other institutions arrive at decisions and implement them towards meaningful changes that are beneficial to the people." The government's role, thus, is to aim at building consensus and forming partnerships, replacing the operative word "versus" with "and", paving the way for synergism and constructive, not oppositional relationships.

In this article, we discuss three relationships, which have to be reconciled to achieve good governance in health. These relationships also delve into the heart of health problems in the Philippines.

Local and national: Transcending bureaucracy in health
In 1991, the Local Government Code drastically altered the bureaucratic landscape by transferring the management of public health program and government hospitals at the municipal and provincial levels, from the DOH to local government units (LGUs). Not long after, the advantages and disadvantages of this new, decentralized system began to emerge. While it enabled LGUs to deal with their own particular health needs, it also opened the possibility for LGUs to neglect health care delivery. Moreover, health became enmeshed in local politics; good programs ascribed to a political opponents are spurned, even if the program was actually helping the people. Health officials are deployed for medical missions intended to gain political capital for the incumbent.

In a Universal Health Care scheme, the Department of Health would have to build strategic partnerships with local governments. While it is clear that there has to be a centralized body to coordinate macro-level functions, such as health information gathering, policy formation, and the operation and management of tertiary hospitals, there are also strengths in empowered local governments. It must also encourage the strengthening and expansion of Interlocal Health Zones - adjacent towns and cities that cooperate on health at the district level. These Zones have already demonstrated  better health outcomes where they were successfully implemented. Dr. Alberto Romualdez, who spearheaded the Health Sector Reform Agenda in 1998 as DOH secretary, has advanced the notion that the district health system ought to be the level of devolution, and that a referral system must be in place to weave things together: from the smallest rural health unit to the district hospital.

PhilHealth can act as leverage to optimize local-national partnerships, by providing incentives to local governments that perform well, and as well as setting standards in the accreditation of LGU hospitals, ensuring quality and safety, and providing additional capital with which enough human resources and quality health services can be guaranteed.

Finally, by building a constituency on health sector reform, which is what the Secretary's Cup aims to achieve, a political capital on health is built, creating incentives for local and national politicians to work together towards better health outcomes.

Private and public: Building public-private partnerships  
One of the flagship projects of the Aquino administration is the pursuit of public-private
partnerships (PPPs). In the health sector, health facilities enhancement was seen as the major focus of PPPs, with the P54-million NKTI Hemodialysis Center, a collaboration with Freseneus Medical Care Philippines, as a flagship project. Additionally, there are also examples of private sector engagements with LGUs that are remarkable for its successful outcomes. For instance, the Zuellig Family Foundation has helped initiate and sustain heath reforms in 485 municipalities located in Geographicaly Isolated and Disadvantaged Areas (GIDA), leading to significant decreases in maternal and infant mortality.

On the other hand, several groups have voiced their concern that these so-called 'partnerships'  may actually lead to the privatization of health care, which in turn would cause the spiraling of heath costs and the disenfranchisement of the indigent poor. These fears were exacerbated when it was announced that charity beds in public hospitals might be eliminated in favor of 'PhilHealth beds'.

Safeguards need to be instituted to ally fears. Just as importantly, the Department of Health needs to communicate to the general public what the PPPs mean for ordinary citizens. It is imperative for the stakeholders to project the whole picture of health reform, because focusing on just one part can slant the news. For instance, the claim that charity beds would be 'eliminated' was true, but it was just one part of the story: in fact, this 'abolition' is contingent upon the universal coverage of the indigent poor, who would then be able to avail the rechristened 'PhilHealth beds'.

In instituting safeguards, PhilHealth can once again play a pivotal role. By adopting 'case payment' schemes in which rates for particular procedures are fixed, patients are protected from overpricing, but these policies should also allow for some flexibility so as not to stifle the freedoms of medical practice. By setting standards for hospitals, PhilHealth is also able to ensure parity in terms of health service delivery, for private and public facilities alike.

Moreover, the Department of Health's strategic thrust towards 'health facilities enhancement' needs to be pursued aggressively. By enhancing government hospitals to be at par with private facilities, patients' perception of public health care will improve. By being competitive in terms of quality health services, a good performing public health care delivery system is perhaps the best deterrent to contain costs of private hospitals.

With PhilHealth emerging as a major player in health care, it must be managed carefully. Universal Coverage (PhilHealth coverage for every Filipino) does not necessarily translate to Universal health Care (good health for every Filipino), but it is an important prerequisite. Hence, the government needs to place more effort in making sure that everyone gets covered. As we mentioned earlier, the “correct-ness” of policies such as the change from 'charity beds' to 'Philhealth beds' depends on this. The National Household Targeting System, while effective, is still imperfect. Indigenous and marginalized peoples need to be integrated into this system without feeling threatened by the paperwork involved.

Professionals and laypersons: The team approach in health care delivery
Finally, health care must be seen not as an authoritarian imposition of doctors and industry upon patients and consumers; but as a team effort among doctors, nurses, midwives, patients, as well as among producers, regulators, and consumers of pharmaceutical products and health services. In a larger context, this 'teamwork'  approach mirrors the 'social solidarity' concept that rationalizes the social health insurance scheme of PhilHealth.

The 'community health teams' program of the Department of Health is a good move towards this direction. In recognition of the dearth of doctors in rural areas, the CHTs serve to augment the health needs of communities, particularly those that have indigent families. It also mobilizes nurses and midwives, by providing them with experience, training, and also an exposure to community health. In his paper on Health Human Resources published in the Acta Medica Philippina, Dr. Ernesto Domingo departs from the conventional notion of doctors as automatic leaders, saying, “Requiring the presence of a physician even for clusters of barangays is not only unrealistic, but also uneconomical and unsustainable in the long run.” Indeed, it is about time to mobilize and empower the health professionals we have rather than stick to outdated notions of hierarchy.

Involvement in health care must likewise extend to the patients themselves, and the community as a whole; the only thing that can beat a 'community health team' is a community that works as a health team. The bayanihan spirit, if applied to health, can mean community members engaging in healthy activities, cooperating with local health centers in the immunization and regular check-ups of children and pregnant women, as well as  public health endeavors such as the elimination of dengue-bearing mosquitoes in their areas, and planting of leafy vegetables and medicinal herbs. These acts may seem small, but by staying healthy and by not being dependent on hospital-based care for minor illnesses that the community can handle anyway, the health care system is unclogged, allowing it to focus on patients who need it the most.  

Conversely, patient empowerment can be maladaptive if coupled with mistrust in the health system overlaid with perceptions and experiences of unaffordable drugs and unfriendly health care providers. This leads to self-medication and its corollary ills of antibiotic resistance and numerous side effects, as well as the pursuit of alternative and traditional medicine which, by diverting patients from legitimate and life-saving procedures, can be even more harmful.

Patient education, thus, needs to be emphasized, with a focus on how to navigate the health care system. In line with the Department of Health's strategy of collaborating with other government agencies, the Department of Education can contribute to patient education by strengthening the health curriculum of students. Patient “miseducation”, by way of misleading advertisements, should likewise be dealt with. Regulatory agencies such as the Food and Drug Administration (FDA) need to be strengthened, and they must seen and perceived to be acting in the interest of patients.

In addition, patient groups and consumers groups need to be organized. Patient groups can clamor for more benefits from PhilHealth; consumer groups can become allies of regulators in ensuring quality and safety of products that are available in the market. What Secretary Esperanza Cabral proposed when she was in office – to translate “No Therapeutic Claims” into “Hindi Ito Gamot” is significant not only in who was involved: government vs. industry, but also in who was not involved: the consumers who are the users of these products in the first place. Perhaps what legislation or regulation cannot achieve, consumers can.

Moreover, the 'Daang Matuwid' battlecry must be applied to government hospitals; the system of patronage, where those with friends among the hospital staff can easily get admitted in charity wards, should be eliminated so as not to alienate patients who have no 'connections'. Financial protection should be extended to vulnerable populations, so they will not seek potentially unsafe alternatives.

Finally, a 'team' paradigm requires reforms in the curriculum of health professionals, which should emphasize not just patient education, but also the reciprocal concept of patient feedback (i.e. physician education). Performance in health must be measured not only in terms of health outcomes or economic gains, but also in terms of patient satisfaction.

Conclusion: Universal Health Care is the way
Universal Health Care, in the context of governance, can thus be defined, to paraphrase JFK, as 'health for the people, by the people'. Through consensus-building and rapprochement, the oppositional relationships can be transformed into partnerships.

Today, with the Aquino administration and the DOH under Secretary Enrique Ona supportive of Universal Health Care, and with the increased confidence in the government both by the people and by the private sector, we are presented with the perfect opportunity to push through with these reforms, the legislation needed to enable them, and the constituency needed to build political and social capital to make sure that our leaders place health as a top priority. By articulating Kalusugan Pangkalahatan, the Department of Health is opening the way for a meaningful discussion on how to achieve UHC. Questions such as, “Should private hospitals be exempt from the no balance billing policy of Philheath?” and “Should DOH should exercise oversight functions?” are some of the debate questions in the “Secterary's Cup” but they should also be debated  upon in pubic discourse until consensus is reached.

The urgency of moving towards Universal Health Care is underscored by the persistent and emergent health threats that continue to put our people at risk: ominous health indicators such as the rising cases of HIV/AIDS and the persistently high maternal mortality rates, and just as importantly, the everyday risk of bankruptcy that many Filipinos continue to face. They remain vulnerable to 'catastrophic illnesses': a single car accident or a cancer diagnosis could spell doom not only to the patient, but also his family. How many houses, farmlots, and carabaos have to be sold as the price and health and hope? With people's lives and well-being at stake, the chance to move towards a health care for every Filipino is an opportunity that must be lost.

Manila
August 12, 2012