Can We Learn From History? Can We Learn From History? Policy Responses & Policy Responses &

Strategies to Meet Health Strategies to Meet Health Care Needs in Times of Care Needs in Times of Severe Economic Crisis Severe Economic Crisis

Assoc. Prof. Kai-Lit Phua, PhD Assoc. Prof. Kai-Lit Phua, PhD

School of Medicine & Health School of Medicine & Health Sciences Sciences

Monash University Monash University

Sunway (Malaysia) CampusSunway (Malaysia) Campus(May 2009) (May 2009)

Biographical Details Biographical Details Kai-Lit Phua received his BA (cum laude) in Public Kai-Lit Phua received his BA (cum laude) in Public

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

Ongoing Economic Crisis Ongoing Economic Crisis Appears to be the worst since the Great Depression of Appears to be the worst since the Great Depression of

the late 1920s and 1930sthe late 1920s and 1930s Severe problems in the financial sector that spread to Severe problems in the financial sector that spread to

the “real economy”: dramatically falling exports, rising the “real economy”: dramatically falling exports, rising unemployment, budget deficits, economic contractionunemployment, budget deficits, economic contraction

The IMF expects the impact on low income developing The IMF expects the impact on low income developing countries to be severecountries to be severe11

Research shows a significant negative impact of Research shows a significant negative impact of unemployment on health at both the level of the unemployment on health at both the level of the populationpopulation and the and the individualindividual

This negative impact may occur after a time lagThis negative impact may occur after a time lag At the population level, KL Phua detected a negative At the population level, KL Phua detected a negative

impact of a decline in the variable “real export impact of a decline in the variable “real export earnings” (i.e. inflation-adjusted) on the infant earnings” (i.e. inflation-adjusted) on the infant mortality rate in his analysis of Philippine data (1959-mortality rate in his analysis of Philippine data (1959-1986)1986)22. .

Can We Learn From History Can We Learn From History in Terms of the Following? in Terms of the Following?

Changes in patterns of health risk, thus affecting morbidity and Changes in patterns of health risk, thus affecting morbidity and mortality, during times of severe economic crisis, e.g. substance mortality, during times of severe economic crisis, e.g. substance abuse, domestic violence, suicides and parasuicides, abuse, domestic violence, suicides and parasuicides, malnutrition, immunization levels, homelessness, utilisation of malnutrition, immunization levels, homelessness, utilisation of health serviceshealth services

Differential impact of economic crisis on the health of more Differential impact of economic crisis on the health of more vulnerable groups such as ethnic minorities, single women with vulnerable groups such as ethnic minorities, single women with children, the poor, the elderly and the disabledchildren, the poor, the elderly and the disabled

Changes in demand for public sector health servicesChanges in demand for public sector health services

Impact on the private health sector, e.g. as experienced during Impact on the private health sector, e.g. as experienced during the Asian economic crisis of the late 1990s the Asian economic crisis of the late 1990s

Possible policy responses and strategies to alleviate the Possible policy responses and strategies to alleviate the negative impact of economic crisis on health negative impact of economic crisis on health

Changes in Patterns of Health Risk, Morbidity, Changes in Patterns of Health Risk, Morbidity, Mortality Mortality

Homelessness: exposure to elements, higher risk of being Homelessness: exposure to elements, higher risk of being assaulted, risk of infectious disease in homeless sheltersassaulted, risk of infectious disease in homeless shelters

Substance abuse (including alcoholism)Substance abuse (including alcoholism) Domestic violenceDomestic violence Suicides/parasuicides and other mental health problems e.g. Suicides/parasuicides and other mental health problems e.g.

pioneering research by Brenner at the population levelpioneering research by Brenner at the population level3,4,5,6 3,4,5,6

and Catalano, Dooley and associates at the individual and Catalano, Dooley and associates at the individual levellevel7,8,97,8,9 Chang et al. studied the Asian economic crisis and Chang et al. studied the Asian economic crisis and suicide rates in East Asian countriessuicide rates in East Asian countries1010

Poverty and malnutrition, e.g. micronutrient deficiency Poverty and malnutrition, e.g. micronutrient deficiency Immunization levels, e.g. dropped in the former Soviet Union Immunization levels, e.g. dropped in the former Soviet Union

in the late 1990s (diphtheria cases shot up)in the late 1990s (diphtheria cases shot up)1111

School enrolment/completion rates (especially for girls)School enrolment/completion rates (especially for girls) Loss of job-linked health insurance – serious problem in USA Loss of job-linked health insurance – serious problem in USA

(delays in care-seeking, medical debt and medical bill-related (delays in care-seeking, medical debt and medical bill-related bankruptcy)bankruptcy)12,1312,13

Differential Impact on Social Differential Impact on Social GroupsGroups

Higher risk groupsHigher risk groups1414 i.e. i.e. Ethnic minorities (especially those who suffer Ethnic minorities (especially those who suffer

fromfrom strong discrimination such as Roma)strong discrimination such as Roma) PoorPoor Single mothers with childrenSingle mothers with children ElderlyElderly DisabledDisabled These groups will bear the brunt of cutbacks in These groups will bear the brunt of cutbacks in

government spending on health and other social government spending on health and other social services services

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

SectorSectorAsian economic crisis of late 1990s Asian economic crisis of late 1990s

shows:shows:15,1615,16 Reduction in access to health servicesReduction in access to health services Shift in demand from private sector to Shift in demand from private sector to

the public sector and NGOs (cheaper the public sector and NGOs (cheaper care)care)

Some people will delay care-seeking, Some people will delay care-seeking, self-treat or even forgo care-seeking self-treat or even forgo care-seeking from health providers altogetherfrom health providers altogether1717

Possible Policy Responses and Possible Policy Responses and Strategies – Substance Abuse Strategies – Substance Abuse

1.1. Increase taxes steeply on alcohol and Increase taxes steeply on alcohol and tobacco so as to increase the street price tobacco so as to increase the street price and thus lower demand and thus lower demand

2.2. Stricter enforcement of existing alcohol Stricter enforcement of existing alcohol control and tobacco control lawscontrol and tobacco control laws

3.3. Raise the legal age for drinking alcohol Raise the legal age for drinking alcohol and buying tobaccoand buying tobacco

4.4. Modify the environment to make access Modify the environment to make access harder, e.g. ban sales of alcohol and harder, e.g. ban sales of alcohol and tobacco through vending machines tobacco through vending machines

Possible Policy Responses and Possible Policy Responses and Strategies – Domestic ViolenceStrategies – Domestic Violence

1.1. Counselling programmes for unemployed Counselling programmes for unemployed workers workers

2.2. Anger management programmes for Anger management programmes for unemployed workersunemployed workers

3.3. Shelters for victims of domestic violence Shelters for victims of domestic violence

Possible Policy Responses and Possible Policy Responses and Strategies – Suicides Strategies – Suicides

1.1. Suicide prevention programmes aimed at Suicide prevention programmes aimed at economically-distressed people (these economically-distressed people (these should include a substance abuse should include a substance abuse component) component)

2.2. Anti-suicide telephone hotlines Anti-suicide telephone hotlines

Possible Policy Responses and Possible Policy Responses and Strategies – Malnutrition Strategies – Malnutrition

1.1. Encourage people to grow food in food gardens and Encourage people to grow food in food gardens and community gardens and to raise poultry or fish in backyards community gardens and to raise poultry or fish in backyards (public health laws may need to be amended temporarily to (public health laws may need to be amended temporarily to encourage these)encourage these)

2.2. Food-for-work programmes (including public works) Food-for-work programmes (including public works) 3.3. Targeted feeding programmes, e.g. school lunch programmes Targeted feeding programmes, e.g. school lunch programmes

for poor children at risk of hunger and malnutritionfor poor children at risk of hunger and malnutrition4.4. Food fortification to prevent micronutrient deficiencyFood fortification to prevent micronutrient deficiency1818 5.5. Food subsidies (for foods commonly consumed by the poor)Food subsidies (for foods commonly consumed by the poor)6.6. Publicly-run controlled price food shops (with rationed sales)Publicly-run controlled price food shops (with rationed sales)7.7. Income support programmes to preserve or increase Income support programmes to preserve or increase

purchasing power for food, e.g. reductions in government purchasing power for food, e.g. reductions in government fees and taxes, extended unemployment compensation, wage fees and taxes, extended unemployment compensation, wage subsidies to save jobs in private sector, microcredit schemes, subsidies to save jobs in private sector, microcredit schemes, cash transfer programmes.cash transfer programmes.19

Possible Policy Responses and Possible Policy Responses and Strategies – Immunizations Strategies – Immunizations

1.1. Stepped-up vaccination campaignsStepped-up vaccination campaigns2.2. Compulsory immunizations in return for Compulsory immunizations in return for

being enrolled in public sector and NGO-being enrolled in public sector and NGO-run social welfare programmes (such as run social welfare programmes (such as feeding programmes)feeding programmes)

Possible Policy Responses and Possible Policy Responses and Strategies – Homelessness Strategies – Homelessness

1.1. Government anti-foreclosure programmes Government anti-foreclosure programmes (to make it harder for banks to foreclose)(to make it harder for banks to foreclose)

2.2. Help NGOs to provide shelter to the Help NGOs to provide shelter to the homeless homeless

3.3. Programmes to reduce homelessness and Programmes to reduce homelessness and disguised homelessness e.g. temporary disguised homelessness e.g. temporary shelter in mobile homes or tents shelter in mobile homes or tents

4.4. Programmes to provide accommodation in Programmes to provide accommodation in return for work done rehabilitating return for work done rehabilitating abandoned houses or building new public abandoned houses or building new public housing (this will also increase the housing (this will also increase the housing stock) housing stock)

Possible Policy Responses and Possible Policy Responses and Strategies – Vulnerable Groups Strategies – Vulnerable Groups

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

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

1.1. Prepayment schemes for employed people that Prepayment schemes for employed people that promote risk-pooling promote risk-pooling

2.2. Encourage barter trade or in-kind payments for Encourage barter trade or in-kind payments for medical services provided by private sector medical services provided by private sector health providers and NGOshealth providers and NGOs

3.3. Government engages in negotiations with drug Government engages in negotiations with drug companies to lower the prices of proprietary companies to lower the prices of proprietary drugs. If this fails, resort to parallel imports or drugs. If this fails, resort to parallel imports or compulsory licensing.compulsory licensing.

4.4. Eliminate user fees for poor people seeking Eliminate user fees for poor people seeking primary care at public facilitiesprimary care at public facilities

5.5. Introduce other innovative schemes, e.g. IOU Introduce other innovative schemes, e.g. IOU schemes when people seek more expensive schemes when people seek more expensive treatment at public sector health facilitiestreatment at public sector health facilities

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Thank youThank you