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Bridging Health Inequalities
2014 Commencement Speaker of the Ateneo de Zamboanga University School of Medicine (ADZUSOM) formerly Zamboanga Medical School Foundation (ZMSF)
April 27, 2014 (Sunday), 4 pm
Before anything else, I like to thank the organizing committee of this commencement exercise led by Dr. Sam Cristobal and Dean Fortunato Cristobal for inviting me to be the 17th Commencement Speaker of the Ateneo de Zamboanga University School of Medicine. I consider this invitation an honor and privilege.
I am actually a balikbayan to the Ateneo de Zamboanga University School of Medicine. Twenty years (20) ago, in 1994, when the School was called Zamboanga Medical School Foundation, I was part of the preparatory team for the establishment of the School and designer team of its innovative medical curriculum, a problem-based, competency-based, and community-based medical curriculum. Ten years ago in 2004, I came back to the School to receive a plaque of appreciation for being part of the pioneer faculty. Today, 2014, 20 years after the establishment of the School, I am back here, this time to be its Commencement Speaker. I will not belabor you with details on my connection with the School as I have limited time to accomplish my objectives as your speaker. Suffice it to say, that I am grateful to Dean Fortunato Cristobal and Father William Kreutz for inviting me in 1994 to be part of the history of the School. For me, at least, the Ateneo de Zamboanga University School of Medicine is known to be one medical school in the Philippines that is producing graduates who go to the underserved communities. The second reputation that Ateneo de Zamboanga University School of Medicine has and should be recognized for, is that it is the first medical school in the Philippines that has produced graduates with dual degrees, specifically MD-MPH. Even with just these two milestones and reputation, I know there are more, I am proud and I am happy to be a part of the history of Ateneo de Zamboanga University School of Medicine, formerly Zamboanga Medical School Foundation. My beloved graduates, you too should feel proud and happy to be part of this school, now your alma mater. Are you willing to clap your hands now to express your gratitude and happiness to be a graduate of Ateneo de Zamboanga University School of Medicine? (Pause for response – graduates clapped.)
Dean Fortunato Cristobal in his invitation to me to be your Commencement Exercise Speaker indicated that the theme of this ceremony is “Bridging Health Inequality.” That is a cue for me to give a talk on this topic. Thus, the theme of my thoughts, perceptions, opinions and recommendations will be on this topic.
With your graduation today, with your conferment of MD and MPH degrees, I can now consider you as my partners and collaborators in a task that we, physicians have to do, that is, bridging health inequality in our Philippine community, you in your chosen community in the South of the Philippines and I in Metro Manila where I live.
With this background situationer, I decided to entitle my talk as “Bridging Health Inequality: What You and I Can Do as Partners and Collaborators.”
Let me start by contextualizing the three key words in the title of my talk which is also the theme of this graduation ceremony: “Bridging Health Inequality.”
Simply put, bridging health inequality means fixing the gaps in health equality in the community, in the Philippines in particular.
What does health inequality mean?
Health inequality cannot and should not mean that all human beings should have or be the same in the following parameters: lifespan; disease potential; curability of diseases obtained or incurred; prognosis of the diseases; physical wellness; mental wellness; productivity; and other parameters of health. The simplest reason for this statement is that it is realistically impossible to have absolute health equality in the parameters that I just mentioned as no two persons are the same in genetic make-up. No two persons are the same in mental capacity. No two persons are the same in personality. Not all human beings live in the same physical and natural environment on earth. It is a given that in a certain human population like the Filipino population, there will be different lifespan, some will live longer and some will live shorter. There will be differences in disease potential; curability and prognosis. There will be differences in physical wellness, mental wellness, and productivity.
It is a given that there is and will always be health inequality if one uses the parameters that I just mentioned. Since we do not have control on these parameters, let’s not include them in the concept of health inequality. Let’s just include parameters that we have control on.
The mother of all the parameters that we somehow have control on or that we somehow can control and, that is the key issue in health inequality, is accessibility to health care. There is health inequality because of differences in accessibility to health care in the human population. Again, simply put, health inequality is inequality in accessibility to health care.
Now, what does accessibility to health care mean? Or what does inaccessibility to health care mean? We have to define these to be able to determine the gaps that we have to fix as partners and collaborators.
There are lots of concepts on accessibility to health care that have been presented and published in the literature and in the Internet.
Allow me to give you my thoughts, perceptions, opinions and recommendations on the concept of accessibility or inaccessibility to health care in the context of the task that I am enjoining you to work with me as partners and collaborators.
A patient, who is a human being or person with a health concern, wants to consult a health professional. There is no health professional available in the community that he lives in. This is inaccessibility to health care.
A patient is able to consult a health professional. However, the health professional says he cannot do the medical management because of his limited expertise. The patient is advised to seek the help of another health professional who is an expert in a certain field of medicine. However, the second health professional is not available in the community that he lives in. This is inaccessibility to health care.
A patient is able to consult a health professional. He is asked to undergo certain diagnostic tests to help in the diagnosis of his health concern. The diagnostic tests are not available in the community that he lives in. This is inaccessibility to health care.
A patient is able to consult a health professional. He is asked to undergo a certain treatment procedure. The treatment procedure is not available in the community that he lives in. This is inaccessibility to health care.
A patient has no or not enough money to travel and /or to pay for the needed services of a health professional and a health facility. This is inaccessibility to health care.
What I have so far presented are five scenarios that I think represent the concept, or my concept, of inaccessibility to health care or health inequality. If we convert the negative aspects of the scenarios to a positive one, then they automatically represent the concept of accessibility to health care or health equality.
If we collate and analyse the five scenarios, we can easily identify 3 aspects of accessibility or inaccessibility to health care. These are, namely: accessibility or inaccessibility to health professionals; accessibility or inaccessibility to medical procedures and health facility; and accessibility related to financial capacity or resources for health care needs.
In all communities in the Philippines, meaning in the entire Philippines, in all regions, provinces, cities, municipalities, and barangays, you and I see the presence of all the three kinds of accessibility concerns or issues that I mentioned. The degree of inaccessibility to health care just varies from one community to another, both in the individual aspect and in the 3 aspects combined. Examples, one community, such as Basilan or Sulu, will have more inaccessibility to health professionals than another, such as Zamboanga City, as there are more health professionals in the latter and less in the former. One community will have more facilities for medical diagnostic and treatment procedures than another. Lastly, one community will have greater percentage of the population who can afford to pay for their unavoidable medical expenses than another community. If we put several communities together with differing accessibility issues, then we have what we call health inequality among different communities. If we consider only one community, in the presence of accessibility issues within it, then we have what we call health inequality within that particular community.
Dear graduates, after you pass the Board of Medicine examination this year or next year, you will be working as a physician in your chosen community. I can assure you that you will see health inequality in whatever your chosen community is, health inequality based on health inaccessibility to health care, inequality in accessibility to health professionals; inequality in accessibility to facilities for medical procedures; and inequality in accessibility related to financial capacity or resources for health care needs.
What will you do? With the training that you just completed in Ateneo de Zamboanga University School of Medicine whose curriculum tries to make you a 5-star physician, physician-clinician-family-community problem-solver; physician-manager; physician-teacher; physician-researcher; and physician-learner, what will you do to fix the health inequality in your chosen community?
I am confident that with the training that you just completed, you will be able to formulate a solution to the health inequality in your chosen community. I am confident that you will be able to contribute to mitigating the health inequality if you cannot totally eradicate it. In your exposure to your assigned community and in the learnings that you got in the community health modules of the school, by this time, I am sure you have some idea on how to reduce health inequality in your chosen community.
As your partner and collaborator in this task, allow me to give you more inputs on how to reduce the health inequality or inequality in accessibility to health care in your chosen community. I will share with you some of the activities that I have been doing along this line and in the task of helping bridge the health inequality in the place of my practice and at times, expanded outside Metro Manila.
Health Inaccessibility – Health Inequality Scenario No. 1:
A patient, who is a human being or person with a health concern, wants to consult a health professional. There is no health professional available in the community that he lives in. This is inaccessibility to health care.
Recommended Strategies:
You, as the new graduates, can go the communities that have no physicians yet. This is the most direct and most commendable solution.
If for one reason or another, you cannot go to a community that has no physicians yet, try to entice other physicians, especially your physician-friends, to go there. Inform them of the need for that community to have a physician. In my personal capacity, I support the DOH Doctors to the Barrios program. I have supported the community-based medical curriculum of your school in 1994 up to present and the community-based medical curriculum that I had introduced to Bicol Christian College of Medicine in Legaspi and Southwestern University College of Medicine in Cebu circa 1995.
If there are no physicians in a particular community and you cannot go there on a permanent basis, formulate a structured comprehensive outreach medical program, either going to the doctorless community on a planned intervals to see and treat patients or conducting distance public health education through radio and other media so as to equip the community with at least on some know-how on personal, family, and community health care. In other words, try to promote a healthy population through distance education. In my personal capacity, I have this Education for Health Development in the Philippines program since 1989, initially personally going to various underserved communities in the Philippines to conduct educational programs and later, using online tools, such as blogs and social media, to reach out to communities outside Metro Manila and the entire Philippines and even to Filipino oversea workers.
Utilize the knowledge and skills that you developed from the module on community management, physician-manager, and physician-educator.
Health Inaccessibility – Health Inequality Scenario No. 2:
A patient is able to consult a health professional. However, the health professional says he cannot do the medical management because of his limited expertise. The patient is advised to seek the help of another health professional who is an expert in a certain field of medicine. However, the second health professional is not available in the community that he lives in. This is inaccessibility to health care.
Recommended strategies:
Try to entice health professionals with specialty to go to the community where there is a need for their services.
Have a list of health professionals with specialty residing in other communities to whom you can readily refer when needed. Establish a network with them. Entice them to go to your community on the basis of an outreach program.
Go for further training and learning on the specialty that you lack and is direly needed in your community because of the absence of specialists. You can either go for a formal training or do a problem-based and self-directed learning (the skills you have acquired in ADZU School of Medicine).
Utilize the knowledge and skills you have developed as a physician-researcher to complement your problem-based and self-directed learning skills.
In my personal capacity, in my role as hospital and department administrator or as well as a practicing physician, I entice and invite specialists to join my hospital and department; I have a list of specialists whom I can easily refer to when needed; I went for further training in general surgery and later surgical oncology; and I also do problem-based and self-directed learning and research to expand my knowledge and skills beyond my core competency.
Health Inaccessibility – Health Inequality Scenarios Nos. 3 and 4:
A patient is able to consult a health professional. He is asked to undergo certain diagnostic tests to help in the diagnosis of his health concern. The diagnostic tests are not available in the community that he lives in. This is inaccessibility to health care.
A patient is able to consult a health professional. He is asked to undergo a certain treatment procedure. The treatment procedure is not available in the community that he lives in. This is inaccessibility to health care.
I will put scenarios No. 3 and No.4 together as they involve health facilities, in diagnostic and treatment procedures.
Recommended strategies:
Try to convince health facilities owners, whether government or private, to have the needed diagnostic and treatment procedures be available in the community.
If you can afford it, or if not, get a group of partners or collaborators, to have the needed diagnostic and treatment procedures be made available in the community.
Have a list of health facilities in other communities to whom you can readily refer to for your diagnostic and treatment procedures need. Establish a network with them to facilitate your referral.
Consider the availability factor of diagnostic and treatment procedures in your community in your decision-making on what procedures to do. There is no such as one and only option in medicine in doing diagnostic and treatment procedure. There are always other available options which can accomplish the objectives of doing a diagnostic or treatment procedure with a good and acceptable batting average. An example for diagnostic procedures, a chest x-ray can be an alternative option to CT scan which is not readily available. Chest x-ray may be as good as a CT scan in certain patients. Chest x-ray is more readily available than CT scan. An example for treatment procedures, an open cholecystectomy is an alternative option to laparoscopic cholecystectomy which may not be readily available. Open cholecystectomy is as good as laparoscopy cholecystectomy in terms of success in gallbladder removal.
Utilize the knowledge and skills you have developed as a physician-clinician, physician-manager, physician-researcher and physician-learner to look for solutions in the inaccessibility to diagnostic and treatment procedures and health facilities.
In my personal capacity, in my role as hospital and department administrator or as well as a practicing physician, I recommend or find ways to make acquisition of needed diagnostic and treatment procedures be made available in my hospital and department; I have a list of facilities which I can easily refer to when needed; I consider the availability factor of facilities in my problem-solving and decision-making for my patients; and I research and study on the pros and cons of the different options for diagnostic and treatment procedures.
Health Inaccessibility – Health Inequality Scenario No. 5:
A patient has no or not enough money to travel and /or to pay for the needed services of a health professional and a health facility. This is inaccessibility to health care.
Recommended strategies:
Give pro bono services to those patients who have no money.
Give discounts on your professional fees for services rendered to those patients who have not enough money.
Consider the cost and availability factors of diagnostic and treatment procedures in your community in your decision-making on what procedures to do. There is no such as one and only option in medicine in doing diagnostic and treatment procedure. There are always other less expensive and available options which can accomplish the objectives of doing a diagnostic or treatment procedure with a good and acceptable batting average. An example for diagnostic procedures, a chest x-ray can be an alternative option to CT scan which is costlier and not readily available. Chest x-ray may be as good as a CT scan in certain patients. Chest x-ray is less costly and more readily available than CT scan. An example for treatment procedures, an open cholecystectomy is an alternative option to laparoscopic cholecystectomy which may costlier and not be readily available. Open cholecystectomy is as good as laparoscopy cholecystectomy in terms of success in gallbladder removal.
For patients whom you have to refer, refer them to health professionals who readily give pro bono and discounts to patients with financial constraints and who consider the cost and availability factors in their decision-making on what procedures to do. Have a list of these health professionals whom you can readily refer to. Network with them.
Have a list of health facilities, both private and government, that contains information on the prices of services, diagnostic and treatment procedures and contact persons. This list will facilitate your assisting patients who are hard-up in finances for their required medical management. Establish network with the contact persons in the health facilities so as to facilitate assisting the poverty-stricken patients.
Support the PhilHealth program particularly in keeping the cost of your medical management within the benefits allotted by PhilHealth.
Practice value-based health care services which is providing services in such a way that the cost of the health care management is kept to the lowest minimum possible or most reasonable expense possible while continuing to maintain and improve quality and safe outcomes. Value-based health care services emphasizes the importance of accurate clinical diagnosis to avoid unnecessary expenses; no unnecessary paraclinical diagnostic procedures; no unnecessary treatment procedures; no unnecessary drugs and miscellaneous expenses; but still maintaining quality and safe outcomes. It also emphasizes the use of management options with minimum possible or most reasonable expenses yet maintaining and safe outcomes.
Assist your poverty-stricken patients and their relatives in getting out of the poverty line through coaching and referrals to government and non-government organizations.
In my personal capacity, as a practicing physician, I practice the 8 recommended strategies that I just mentioned to patients who see me in my clinic and who have no or not enough money for their health care management.
I am done with my inputs to you on how to reduce the health inequality or inequality in accessibility to health care in your chosen community. I have shared with you some of the activities that I have been doing along this line and in the task of helping bridge the health inequality in the place of my practice and at times, expanded outside Metro Manila.
As I have said earlier, I prefer using the differential accessibility to health care as the motherhood parameter for health inequality as it is more realistic and somehow controllable. If we reduce the inequality in accessibility to health care, then we can already say that we have bridged health inequality in our community. What come after are value-added in the sense that reducing inequality in accessibility to health care definitely has the tendency to improve lifespan, curability and prognosis of disease, physical and mental wellness, and productivity. However, they will never be same for all the human beings residing a community.
In the beginning of my talk, I said that with your graduation today, with your conferment of MD and MPH degrees, I can now consider you as my partners and collaborators in a task that we, physicians have to do, that is, bridging health inequality in our Philippine community, you in your chosen community in the South of the Philippines and I in Metro Manila where I live.
Dear graduates, before I end my talk, I will be asking you two questions answerable with yes or no. I like to hear and see a clear and documented response to my questions. If your answer is NO, just remain seated. If your answer is YES, stand up. OK?
The first question is on the training that you got from ADZU School of Medicine. With the modules and the entire curriculum of ADZU School of Medicine that you went through to be a 5-star physician, namely, physician-clinician-family-community problem-solver; physician-manager; physician-educator; physician-problem-based and self-directed learner; and physician-research; do you think they will facilitate your helping bridge the health equality in your future chosen community? (Pause to see response – all graduates stood up.)
With your unanimous YES answer, let us give a big round of applause of appreciation to the faculty and administration of the ADZU School of Medicine. They have trained you well.
The second question is on my invitation. Will you accept my invitation to be partners and collaborators in bridging health inequalities, as I have earlier presented, in the Philippines, you in the South and I in and outside Metro Manila? (Pause to see response – all graduates stood up.)
With your unanimous YES answer, let us again give a big round of applause of appreciation to the faculty and administration of the ADZU School of Medicine. They have achieved their vision and mission of producing graduates who will help solve the problems of their chosen community.
On a personal note, I am very happy with your responses, dear graduates. Twenty years ago, I was part of the designer team of the medical curriculum of ADZU School of Medicine. Today, I saw affirmation of the positive results and impact of the medical curriculum.
The second reason, of course, is that all of you have accepted my invitation to be partners and collaborators in bridging health inequality in our respective communities.
By the way, I will convert strategies that I presented earlier into a formal action plan and memorandum of agreement. I will post them in my Facebook page. You have to ink the contract of partnership and collaborators within one week. After signing the contract, Dean Cristobal and I will monitor the implementation and results of our MOA.
On that note, I congratulate all of you, graduates, on your graduation day. I congratulate your parents, guardians, and loved ones who supported you. Lastly, I congratulate your faculty and the Ateneo University of Zamboanga School of Medicine for producing additional 77 graduates to help in the health development of the Philippines, particularly, in the South, 77 graduates who will bridge health inequality in their chosen community.
God speed to all.
ROJ@17apr17
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