Featured image: World Fellow Beverly Lorraine C. Ho.
By Sarah McKinnis
Beverly Lorraine C. Ho is one of sixteen Maurice Greenberg World Fellows on Yale’s campus this fall. She hails from the Philippines, where she serves as the Chief of the Health Research Division of the Health Policy Development and Planning Bureau in the Philippine Department of Health, as well as the Special Assistant to the Secretary of Health for Universal Health Care.
The Globalist: First, I wanted to ask what your experience has been like as a World Fellow. What’s the most exciting thing you’ve been a part of during your time in New Haven?
Beverly Lorraine C. Ho: I look at being a World Fellow here on two fronts. First is what I receive from Yale, and the other one is what I give to the Yale community.
So among all those things, currently I would say the most interesting I’ve been doing [are] drafting a case study, a teachable case study, on some of the reforms we’re doing in the Philippines healthcare system. And I’m happy to have a professor based at the School of Public Health who’s guiding me on that.
Then, second, we have a small project with two Jackson master’s students, and it relates to recognizing that there may be limited opportunity within the University to explore work in global health. That sentiment is also echoed within the School of Public Health because most of the faculty work on America and domestic public health, rather than global health systems, or if it’s global health, it’s more communicable disease, rather than systems work. We will be starting a few rounds of key informant interviews and focus group discussions among key stakeholders, to see what Jackson could do, since health could be a clear track for Global Affairs majors, but also hiring faculty… that may be extreme and very expensive, so should we have, say, regular mechanisms to invite someone from Harvard or Columbia, for example? Little things so that not only the people who have a direct interest in health already, but others who might be able to contribute to health in the future [get involved].
The Globalist: You mentioned your work in the Philippines, and I know you were significantly involved in the passage of the Universal Health Care Act. I was hoping you could talk about what it was like to work so closely with the legislative aspect of public health?
Ho: In public policy, we have a concept of a window, right, and that window seldom opens, but when it opens, it’s a confluence of a lot of factors, particularly some very good technical basis, political will, and also social pressures. I’d say that my involvement with this is partly serendipitous. UHC was not overnight; it was a long ongoing struggle since 30 years ago.
Prior to entering the Ministry of Health, I was able to work on a project commissioned by planning ministry wherein they ask technical experts to write the twenty-five year plan for [the] five sectors, and one of the sectors is the health sector. So, suffice to say, I had the opportunity through those instances to have extended dialogue with scholars in the country […] and in short was able to draft the road map [for] what we call Ambition 2040, which is the ambition for the Philippines in 2040. And then I went into the Ministry of Health after that. While in the Ministry of Health, it was serendipitous that lawmakers filed a bill in Congress on Universal Health Care. I was asked by my undersecretary to go to the hearing and give a statement on behalf of DOH, and it was my first time to speak like [that], be a witness in Congress. Also at that time, coincidentally, the planning ministry adopted our drafts of the vision strategy, sent it to the president, and the president signed it. Now it’s a question of how to translate it into specific policy action.
To be quite honest, before this instance, I wasn’t really working so much with legislators […] and oftentimes when you read it on the papers, you wouldn’t really trust politicians. But in this instance, I think I was very lucky. The head of the Committee on Health is a physician herself, and she knew the issues because she practiced as well. So she knew what the issues [are] with reimbursements, people paying high out of pocket, etc., so her passion to get this through [was] not just because she wants to be credited, but because she genuinely wants to reform the system. [It] was a very positive experience for me. It actually changed a lot of how I perceived politicians and certainly I walked away from that experience really believing that politics can be used for good.
The Globalist: Now that it’s been passed, what’s the biggest challenge you foresee with the implementation of the UHC in the Philippines?
Ho: First would always be availability of financing. The reform is ambitious and it’s always meant to be that. Shoot for the moon, land on the stars. We have a very good relationship with the Ministry of Finance […] in terms of raising new money for health. [We] passed another round of tobacco taxes last June, of which 80% of revenue will go to this reform. But that is also still not enough. An issue that has plagued us in the last five to seven years has been the ability of the health sector to absorb huge amounts of money. Even if you’re given all this money, it’s not overnight that you can build the hospital, that you can train health workers. There is an in-between for the flow of money: the actual structures, the people, and obviously the outcomes, so that chain is always going to be questioned when you ask for more money.
Next is implementation capacity. At this point in time the Philippines is only getting about one percent of our health expenditure from international partners, which means that ninety-nine percent is domestically funded. That said, we are also moving from lower-middle income status towards high-middle income status, so we’re less and less eligible for grants and technical assistance. It means that we have to do it our way, with local people, and we’re unlike Singapore and Australia, where civil servants are paid par with private sector, so now it’s a challenge to get bright, good intentioned professionals back into the government. And why is this important? We have followed the American model in a way in building our healthcare system, which means it’s largely market based. 70% of care is being provided by the private sector, and when you have that, you have to have good regulatory capacity, and you can’t have good regulatory capacity without good people.
The third thing I would say is not simply awareness, but citizen engagement. For the longest time I think we have managed the health sector assuming [citizens] are passive beneficiaries, and all the studies now are pointing to people having more agency. It’s not just about knowledge. Someone can know that smoking tobacco or vaping is bad, but they will still do it. So, we have a lot of work that needs to be done on that aspect, from prevention, to actually convincing Filipinos that it’s good to have a primary care provider, set up a primary care system… not just, “Oh I have a headache, I need to go to a neurologist,” or “I have a tummy ache, I need to go to a gastroenterologist,” which has become the norm because people pay out of pocket and wherever they go, they just pay. We don’t have what you have here, where it’s based on what network or primary care you have.
The Globalist: Your last point reminded my of a question I had about the report you worked on about the sugar-sweetened beverage tax. I was intrigued by one of the end lines that reads, “such a tax could be a tangible first step towards re-engineering an obesogenic environment by denormalizing the consumption of sugar-sweetened beverages.” I was wondering if you could talk about how public health deals with public perception and culture, and how policies can be written to address these perceptions?
Ho: In behavioral economics, they have this concept of libertarian paternalism. On one end of it is “let’s just mandate everything,” but the other thing is recognizing that people can still choose. In the past, we’ve always assumed from traditional economics that people are rational, so let’s tell them soft drinks, with ninety spoons of sugar is bad. So, assume you’re smart and rational: you will not take it. But they will take it, so then it’s a question of whether you go over-paternalistic and ban everything. But the health sector does not operate in isolation. The whole Philipine economy is still built on an economic platform, so it’s not as easy as saying, “take that out,” because you know jobs will be lost, etcetera, so it’s always a balance. That balance is libertarian paternalism. I would say that that’s the policy all over the country: increase the prices to try to reduce consumption. But in certain cases like schools, we have tried to ban soft drinks all together because we assume that children need more protection than adults, so I guess it’s a range of interventions that we do, and we find that we need to be more responsible for the more vulnerable population.
The Globalist: You had mentioned the U.S. healthcare system before, and as you must know, healthcare is a big topic leading up to the presidential election in 2020. Do you think it would be feasible to implement universal health care in the U.S., especially with such a big private sector?
Ho: I feel like with the resources you have, it’s actually not an issue to implement it. What I am concerned with is the fact that the concept and the principles behind universal health care [are] something that people in this country find it difficult to imbibe or to understand. In other settings, when you say health is a right, you don’t need to pay for it, you have to get it. Everyone is equal, it’s accepted. But this country’s engine was built on the fact that, I guess, everyone is not equal, and the more you do the more you get. So if you don’t have anything—even if that’s a result of structural social injustice—then it’s your problem. So I guess once that is settled in the national identity of the country, then the technical reform is not an issue. In leadership, there’s what we call a technical challenge and an adaptive challenge. I think the U.S. will never have a problem in the technical challenge. You have the best minds, best data crunchers, best universities[…] so to come up with proposals on how to reform your system, it’s easy. That other part is the harder part. The adaptive challenge of getting citizens to see that whatever I have, my neighbor should have, too. And then another part of it will really just be how can you de-corrupt a system.
I asked [one of our speakers], “Why is it so hard for U.S. to go through healthcare reform?” It’s really just how much of your economy is made up of healthcare. If you talk about less spending in healthcare, you’re talking about maybe some people losing their jobs. In both our countries, the power of the healthcare sector is so glaring, but so invisible. Why? Because the doctors, the professionals who can lobby the most, don’t lobby in the regular lobby place. It’s when a powerful person is on his deathbed, is sick, is in his most vulnerable state, that this healthcare group, person, practice has helped him. The person cannot say no. It’s that very unique power that healthcare lobbyists have that no other sector has.
World Fellow Beverly Lorraine C. Ho at a press conference in 2018 about the Universal Health Care Act.
The Globalist: I’d like to switch directions a bit now and talk about the non-profit you co-founded, Alliance for Improving Health Outcomes. What was that experience like?
The motivation for founding Alliance for Improving Health Outcomes was to ensure that we have a steady flow of young people who will go and do public health professionally. When we say young professionals, we don’t mean only doctors, and in the Philippines if you want to work in this space, either you work full time in government, do consultancy work, or you do part time research. In our experience—ten of us medical graduates who went into public health—we noticed that we were finding it hard to retain non-doctor people into this space, because they can have a three month gig, do the research, then the project is done, then maybe not have a job for two months, then maybe have a job again. And if this is the case, they might as well just go to a low-paying private sector job, where it’s stable. What we thought about was the real mechanism to retain them. Fortunately, [due to] the inequality of things, we doctors find it easier to get all these projects, even if we’re newbies, so we thought, let’s found this organization and for our earnings, we keep them in the organization, and that’s the money we use to hire our staff. So that if we hire someone, we’re committed to hire them for two years. Even if we lose projects in the middle, we will use that buffer savings to pay them, and they will be able to do whatever research project they want when we don’t have one. What we’re guaranteeing them is two years of guaranteed payment to stay in the sector, and after two years they have enough experience they’ll be valuable enough to anyone’s team.
So what were our lessons from that experience? First, it’s difficult to find people, people who are genuinely interested, who are committed. You know, you have a lot of promising people, but finding the right people is difficult. Second, you just have to be ready for plus and minuses: train a group of five to make sure you have two. It’s not always a one hundred percent success rate. Third, most of us are around the same age and […] we actually were surprised with the reception we received from the sector. It seems like the sector was ready for the new generation of young public health professionals. The challenge for us in the beginning was making sure that even if we’re young, we’re treated professionally, and not just “let’s just get them so we can order them around.” But as we grew, and grew the organization, the challenge now is quality assurance, because most of us were able to use this platform [to go elsewhere]. For me, to go into government, and someone went into an international development organization. With this flow of people now, how do you keep the ethos, how do you keep the standards, the work ethics?
Finally, I would say that a very good thing happened because the organization now is able to earn good money, so we are able to invest in strategic projects. Slowly, our agenda becomes less donor-driven, so we’re able to pursue certain advocacies and medical schools, public health schools, because we can subsidize the cost of those advocacies.
The Globalist: I’m a prospective psychology major, and I’m very interested in the mental health aspect of public health. I know there was a recent law passed in the Philippines regarding mental health care in addition to the UHC Act, and I’m wondering what you see as the most critical pieces of mental health care in your country from a public health perspective.
Ho: Like many things in public health, when [mental health] is being discussed I think what people often look at is the care delivery side of it, meaning when someone is already diagnosed, the care that they get through the process. I think now the more I talk to school administrators, people who work in the corporate world, it’s more ubiquitous than it seemed before. I look at it as not just a responsibility of the health sector persay, but of everyone as humans and as members of communities. I have a couple of friends and teachers, relatives, who now have experienced some level of loss or disability from mental health. One of them has actually proposed this “kindness revolution” that we need to have.
I’m actually not quite sure what the mix of interventions is except just to say that screening has to happen more, and if screening has to happen and we’re not training enough psychologists and psychiatrists as soon as possible, then more information and training of lay people—friends to detect each other—has to happen. From a preventive standpoint, I think we have to do something about reimagining our culture and the way we live. I live in a country where family plays a very big role. We seldom move out of our homes when we’re not married, for example, so people live on each other’s spaces. And I would like to think that to some extent, that’s protective, right. But that’s not the case for many developed countries, including here. You live alone very early. And so you’re alone, your gadget forces you to be alone, and your way of interpreting liberty to do things forces you to further be alone, so I think there has to be some kind of rethinking about what we want our future communities to be like. Because now we’re just being overtaken by circumstances, rather than an actual design. Yale is a creative community, and I feel like the effort of this university to cultivate small, intimate groups—which is seldom in big universities—is laudable, the fact that you know people intimately, not just big organizations. People bond in organizations here, to the detriment that you have every little organization for every little issue, but I think the underlying relationships are stronger, and the fact that I see people coming back here to New Haven because of this attachment to people and relationships […] I think it’s a good start. It means going back to a level of community intimacy that has been lost.
The Globalist: Lastly, what is one piece of advice that someone gave you, or something you wish you knew when you were starting out, that you would give to students who may be interested in going into public health?
Ho: Something that I always remember that holds true until this day is that if you want to go into public health or public policy, you have to have a balance of sufficient confidence and humility. No one will ever say thank you to you for the work that you’ve done […] “You’ve saved 1,000 lives!” Whatever, no one cares, because you’re in the background, you’re not the doctor who they shake hands with after. So you have to be confident, you don’t need constant reassurance that you’re good. But at the same time, humility is important because ideas come around in public policy and public health such that you can never pinpoint a moment where you say “I was a driver of this and I alone,” because it’s a confluence of a lot of factors, and you just happen to be at the right place at the right time. Likely someone planted it years before, and it just didn’t get to that trajectory. So that balance is often difficult, but I think it’s important.
Sarah McKinnis is a sophomore in Trumbull College. You can contact her at firstname.lastname@example.org.