Assoc. Prof. Kai-Lit Phua, PhD School of Medicine & Health Sciences Monash University

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 shows:15,16 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 • Increase taxes steeply on alcohol and tobacco so as to increase the street price and thus lower demand • Stricter enforcement of existing alcohol control and tobacco control laws • Raise the legal age for drinking alcohol and buying tobacco • 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 • Counselling programmes for unemployed workers • Anger management programmes for unemployed workers • Shelters for victims of domestic violence

10. Possible Policy Responses and Strategies – Suicides • Suicide prevention programmes aimed at economically-distressed people (these should include a substance abuse component) • Anti-suicide telephone hotlines

11. Possible Policy Responses and Strategies – Malnutrition • 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) • Food-for-work programmes (including public works) • Targeted feeding programmes, e.g. school lunch programmes for poor children at risk of hunger and malnutrition • Food fortification to prevent micronutrient deficiency18 • Food subsidies (for foods commonly consumed by the poor) • Publicly-run controlled price food shops (with rationed sales) • 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 • Stepped-up vaccination campaigns • 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 • Government anti-foreclosure programmes (to make it harder for banks to foreclose) • Help NGOs to provide shelter to the homeless • Programmes to reduce homelessness and disguised homelessness e.g. temporary shelter in mobile homes or tents • 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 • 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) • Prepayment schemes for employed people that promote risk-pooling • Encourage barter trade or in-kind payments for medical services provided by private sector health providers and NGOs • Government engages in negotiations with drug companies to lower the prices of proprietary drugs. If this fails, resort to parallel imports or compulsory licensing. • Eliminate user fees for poor people seeking primary care at public facilities • 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 children’s healthcare and health. CurrOpinPediatr 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