Can%20We%20Learn%20From%20History?%20Policy%20Responses%20

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Can We Learn From History? Policy Responses
Strategies to Meet Health Care Needs in Times of
Severe Economic Crisis

• Assoc. Prof. Kai-Lit Phua, PhD
• School of Medicine Health Sciences
• Monash University
• Sunway (Malaysia) Campus
• (May 2009)

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Biographical Details

• Kai-Lit Phua received his BA (cum laude) in
  Public Health and Population Studies from the U
  of Rochester and his PhD in Sociology (Medical
  Sociology) from Johns Hopkins University. He also
  holds professional qualifications in health
  insurance. Prior to joining academia, he worked
  as a research statistician for the Maryland
  Department of Health Mental Hygiene and for the
  Managed Healthcare department of a leading
  insurance company in Singapore. He was awarded an
  Asian Public Intellectual Senior Fellowship by
  the Nippon Foundation in 2003.

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Ongoing Economic Crisis

• Appears to be the worst since the Great
  Depression of the late 1920s and 1930s
• Severe problems in the financial sector that
  spread to the real economy dramatically
  falling exports, rising unemployment, budget
  deficits, economic contraction
• The IMF expects the impact on low income
  developing countries to be severe1
• Research shows a significant negative impact of
  unemployment on health at both the level of the
  population and the individual
• This negative impact may occur after a time lag
• At the population level, KL Phua detected a
  negative impact of a decline in the variable
  real export earnings (i.e. inflation-adjusted)
  on the infant mortality rate in his analysis of
  Philippine data (1959-1986)2.

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Can We Learn From History in Terms of the
Following?

• Changes in patterns of health risk, thus
  affecting morbidity and mortality, during times
  of severe economic crisis, e.g. substance abuse,
  domestic violence, suicides and parasuicides,
  malnutrition, immunization levels, homelessness,
  utilisation of health services
• Differential impact of economic crisis on the
  health of more vulnerable groups such as ethnic
  minorities, single women with children, the poor,
  the elderly and the disabled
• Changes in demand for public sector health
  services
• Impact on the private health sector, e.g. as
  experienced during the Asian economic crisis of
  the late 1990s
• Possible policy responses and strategies to
  alleviate the negative impact of economic crisis
  on health

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Changes in Patterns of Health Risk, Morbidity,
Mortality

• Homelessness exposure to elements, higher risk
  of being assaulted, risk of infectious disease in
  homeless shelters
• Substance abuse (including alcoholism)
• Domestic violence
• Suicides/parasuicides and other mental health
  problems e.g. pioneering research by Brenner at
  the population level3,4,5,6 and Catalano, Dooley
  and associates at the individual level7,8,9 Chang
  et al. studied the Asian economic crisis and
  suicide rates in East Asian countries10
• Poverty and malnutrition, e.g. micronutrient
  deficiency
• Immunization levels, e.g. dropped in the former
  Soviet Union in the late 1990s (diphtheria cases
  shot up)11
• School enrolment/completion rates (especially for
  girls)
• Loss of job-linked health insurance serious
  problem in USA (delays in care-seeking, medical
  debt and medical bill-related bankruptcy)12,13

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Differential Impact on Social Groups

• Higher risk groups14 i.e.
• Ethnic minorities (especially those who
  suffer from
• strong discrimination such as Roma)
• Poor
• Single mothers with children
• Elderly
• Disabled
• These groups will bear the brunt of cutbacks in
  government spending on health and other social
  services

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Changes in Demand for Health Services and its
Impact on the Public Sector and the Private
Sector

• Asian economic crisis of late 1990s shows15,16
• Reduction in access to health services
• Shift in demand from private sector to the
  public sector and NGOs (cheaper care)
• Some people will delay care-seeking, self-treat
  or even forgo care-seeking from health providers
  altogether17

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Possible Policy Responses and Strategies
Substance Abuse

1. Increase taxes steeply on alcohol and tobacco so
   as to increase the street price and thus lower
   demand
2. Stricter enforcement of existing alcohol control
   and tobacco control laws
3. Raise the legal age for drinking alcohol and
   buying tobacco
4. Modify the environment to make access harder,
   e.g. ban sales of alcohol and tobacco through
   vending machines

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Possible Policy Responses and Strategies
Domestic Violence

1. Counselling programmes for unemployed workers
2. Anger management programmes for unemployed
   workers
3. Shelters for victims of domestic violence

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Possible Policy Responses and Strategies
Suicides

1. Suicide prevention programmes aimed at
   economically-distressed people (these should
   include a substance abuse component)
2. Anti-suicide telephone hotlines

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Possible Policy Responses and Strategies
Malnutrition

1. Encourage people to grow food in food gardens and
   community gardens and to raise poultry or fish in
   backyards (public health laws may need to be
   amended temporarily to encourage these)
2. Food-for-work programmes (including public works)
   
3. Targeted feeding programmes, e.g. school lunch
   programmes for poor children at risk of hunger
   and malnutrition
4. Food fortification to prevent micronutrient
   deficiency18
5. Food subsidies (for foods commonly consumed by
   the poor)
6. Publicly-run controlled price food shops (with
   rationed sales)
7. Income support programmes to preserve or increase
   purchasing power for food, e.g. reductions in
   government fees and taxes, extended unemployment
   compensation, wage subsidies to save jobs in
   private sector, microcredit schemes, cash
   transfer programmes.19

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Possible Policy Responses and Strategies
Immunizations

1. Stepped-up vaccination campaigns
2. Compulsory immunizations in return for being
   enrolled in public sector and NGO-run social
   welfare programmes (such as feeding programmes)

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Possible Policy Responses and Strategies
Homelessness

1. Government anti-foreclosure programmes (to make
   it harder for banks to foreclose)
2. Help NGOs to provide shelter to the homeless
3. Programmes to reduce homelessness and disguised
   homelessness e.g. temporary shelter in mobile
   homes or tents
4. Programmes to provide accommodation in return for
   work done rehabilitating abandoned houses or
   building new public housing (this will also
   increase the housing stock)

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Possible Policy Responses and Strategies
Vulnerable Groups

1. Public health and medical care programmes
   specially designed to meet the needs of groups
   such as ethnic minorities, the poor, single women
   with children, the elderly, the disabled

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Possible Policy Responses and Strategies
Funding of Medical Services (to Preserve Access)

1. Prepayment schemes for employed people that
   promote risk-pooling
2. Encourage barter trade or in-kind payments for
   medical services provided by private sector
   health providers and NGOs
3. Government engages in negotiations with drug
   companies to lower the prices of proprietary
   drugs. If this fails, resort to parallel imports
   or compulsory licensing.
4. Eliminate user fees for poor people seeking
   primary care at public facilities
5. Introduce other innovative schemes, e.g. IOU
   schemes when people seek more expensive treatment
   at public sector health facilities

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References

• 1. International Monetary Fund. The implications
  of the global financial crisis for low-income
  countries. 2009 Washington, DC IMF.
• 2. Phua KL. An analysis of the effects of
  national economic difficulties and social
  expenditure patterns on the infant mortality
  rate the case of the Philippines. Unpublished
  PhD dissertation, Johns Hopkins University, 1994.
• 3. Brenner MH. Economic changes and heart disease
  mortality. Am J Pub Health 1971 61(3) 606-11.
• 4. Brenner MH. Fetal, infant and maternal
  mortality during periods of economic instability.
  Int J Health Serv 1973 3(2) 145-59.
• 5. Brenner MH. Trends in alcohol consumption and
  associated illnesses. Some effects of economic
  changes. Am J Pub Health 1975 65(12) 1279-92.
• 6. Brenner MH. Mortality and the national
  economy. A review, and the experience of England
  and Wales 1936-1976. Lancet 1979 2(8142)
  568-73.
• 7. Catalano R, Dooley CD. Economic predictors of
  depressed mood and stressful life events in a
  metropolitan community. J Health Soc Behav 1977
  18(3) 292-307.
• 8. Catalano R, Dooley D, Wilson G, Hough R. Job
  loss and alcohol abuse a test using data from
  the Epidemiologic Catchment Area study. J Health
  Social Behav 1993 34(3) 215-25.
• 9. Dooley D, Catalano R, Wilson G. Depression and
  unemployment panel findings from the
  Epidemiologic Catchment Area study. Am J
  Community Psychol 1994 22(6) 745-65.
• 10. Chang SS, Gunnell D, Sterne JA, Lu TH, Cheng
  AT. Was the economic crisis 1997- 1998
  responsible for rising suicide rates in
  East/Southeast Asia? A time-trend analysis for
  Japan, Hong Kong, S. Korea, Taiwan, Singapore and
  Thailand. Soc Sci Med 2009 68(7) 1322-31.

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• 11. Vitek CR, Wharton M. Diphtheria in the former
  Soviet Union reemergence of a pandemic disease.
  Emerging Infect Diseases 1998 4(4).
• 12. Fry-Johnson YW, Daniels EC, Levine R, Rust G.
  Being uninsured impact on childrens healthcare
  and health. Curr Opin Pediatr 2005 17(6) 751-2.
  
• 13. Seifert RW, Rukavina M. Bankruptcy is the tip
  of a medical-debt iceberg. Health Aff 2006
  25(2) w82-92.
• 14. Levy BS, Sidel VW. eds. Social injustice and
  public health. 2006 New York OUP.
• 15. Waters H, Saadah F, Pradhan M. The impact of
  the 1997-98 East Asian economic crisis on health
  and health care in Indonesia. Health Policy Plan
  2003 18(2) 172-81.
• 16. Yang BM, Prescott N, Bae EY. The impact of
  economic crisis on health-care consumption in
  Korea. Health Policy Plan 2001 16(4) 372-85.
• 17. Australian Agency for International
  Development. Impact of the Asian financial crisis
  on health. 2000. Macfarlane Burnet Centre for
  Medical Research.
• 18. Hertrampf E, Cortes F. National
  food-fortification program with folic aid in
  Chile. Food Nutri Bull. 2008 29(2 Supp) S231-7.
• 19. Ramesh M. Economic crisis and its social
  impact lessons from the 1997 Asian economic
  crisis. Draft working paper prepared for the
  UNICEF Conference East Asia and the Pacific
  Islands. 6-7 January 2009, Singapore. Bangkok
  UNICEF East Asia and Pacific Regional Office.
• Thank you