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


1
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)

2
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.

3
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.

4
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

5
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

6
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

7
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

8
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

9
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

10
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

11
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

12
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)

13
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)

14
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

15
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

16
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.

17
  • 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
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