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)
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.
Ongoing Economic Crisis
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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.
Can We Learn From History in
Terms of the Following?
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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
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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
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Changes in demand for public sector health services
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Impact on the private health sector, e.g. as experienced
during the Asian economic crisis of the late 1990s
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Possible policy responses and strategies to alleviate the
negative impact of economic crisis on health
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
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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
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, selftreat or even forgo care-seeking from
health providers altogether17
Possible Policy Responses and
Strategies – Substance Abuse
1.
2.
3.
4.
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
Possible Policy Responses and
Strategies – Domestic Violence
1.
2.
3.
Counselling programmes for unemployed
workers
Anger management programmes for
unemployed workers
Shelters for victims of domestic violence
Possible Policy Responses and
Strategies – Suicides
1.
2.
Suicide prevention programmes aimed at
economically-distressed people (these should
include a substance abuse component)
Anti-suicide telephone hotlines
Possible Policy Responses and
Strategies – Malnutrition
1.
2.
3.
4.
5.
6.
7.
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
Possible Policy Responses and
Strategies – Immunizations
1.
2.
Stepped-up vaccination campaigns
Compulsory immunizations in return for being
enrolled in public sector and NGO-run social
welfare programmes (such as feeding
programmes)
Possible Policy Responses and
Strategies – Homelessness
1.
2.
3.
4.
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)
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
Possible Policy Responses and
Strategies – Funding of Medical
Services (to Preserve Access)
1.
2.
3.
4.
5.
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
References
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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): 292307.
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 timetrend 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 children’s 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 healthcare 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