My Bayanihan Story

Multiple Fronts - The many roles of a Melbourne alumnus in the Philippine response to COVID-19

By Jose Rafael A. Marfori, MD, MPH
Master of Public Health, The University of Melbourne, Class of 2015




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My humble desk adjoins the office of the Director of the Philippine General Hospital (PGH), Dr Gerardo “Gap” Legaspi.  He asked what I thought about the call of the Department of Health (DOH) and of private hospitals to turn our hospital into a COVID-19 Referral Center.  Knowing he would make the right decision regardless, and aware that he was facing near-unanimous opposition for it, I merely boiled it down for him to a question of, “Is it the right thing to do?”  His conviction must be absolute, I replied, to outlast the prevailing sentiments of fear, which were to be expected. The next day his letter to the PGH community made the news, proclaiming in its last line, “Let us do this because deep in our hearts – devoid of fear and anger – it is the right thing to do.”




Recent professional background

As Special Assistant to the Director for Flagship Projects, PGH, I handle priority non-routine initiatives.  These used to include, among others, the PGH Cancer Center project as a public-private partnership guided by the International Finance Corporation, World Bank Group, and the computerization of PGH in partnership with Data Center, Inc., the information technology (IT) subsidiary of the Development Bank of the Philippines.

Simultaneously, I am the Assistant Program Leader for Philippine Primary Care Studies (PPCS).  PPCS demonstrates how to revive or strengthen primary care in urban, rural, and remote settings.  Primary care is the foundation for universal health care (UHC).  We do this through whole-system research & development, by implementing and evaluating health policy and systems enhancements in real-world settings for sustained periods.  Our work was among the inputs into the 2019 UHC Act.



Overview of my COVID-19 work

The outbreak of COVID-19, however, radically changed my role particularly at first.  It forced a set of immediate-phase responses, later overlapped by more strategic and proactive public health maneuvers.  Most recently, it opened up an opportunity to reconfigure health systems in preparation for the so-called new normal, which turns out to be strikingly similar to the vision of the UHC Act.

Initial acute-phase responses

Within days of the lockdown on March 16, 2020, PGH transformed.  COVID areas were walled off, ventilation systems installed, rotation schedules drastically altered, and elective admissions and surgeries cancelled.  We had masts without flags, a fleet of transports in our driveway contrasting against Manila’s empty streets, and a staging area for logistics and supplies where an orchestra once played for Christmas.  The hospital was on a war footing.

Transportation Programs

I was placed in charge of transportation amid a transportation crisis that stranded hundreds of our health workers on campus and thousands in their homes.  Racing against contagion in the hospital, and to ensure our ‘army’ of health workers could reach the front lines well-rested and protected, I organized a dedicated shuttle service of eight routes based on a rapid survey of employee addresses.  Our farthest routes reach beyond Metro Manila.  Other initiatives include an electric kick scooter lending program fit for our 10-hectare land area, a small fleet of flexible volunteer-driven vehicles with online requests, and additional or modified bus lines co-organized with the Department of Transportation and numerous donors of buses, drivers and petrol.

The PGH Bike Program

The Spanish flu of 1918 spotlighted the value of cycling.  On March 26 we set up a comprehensive PGH Bike Program.  It assigns bicycles to employees in need, some of whom were walking for hours to and from work.  For a subset of bikes, our lowest-income workers are assigned bikes through an ‘express lane’ prioritizing them, co-developed with the PGH Chaplaincy.  The Bike Program supports COVID-19 control in three ways.  It decongests shared modes of transport, eases round-the-clock access to the nearby free lodging for health workers around PGH, and provides night-shift personnel a safe alternative to walking deserted streets.  Learning directly from exemplary programs in Melbourne, Australia, it ensures fair distribution, orients bikers on safety and maintenance, connects them to enthusiasts and to one another, tunes bikes before release, and tracks units and accessories.    The Bike Program has raised and lent close to 200 donated bikes in a month, and it will keep growing.

Contributions to PPE strategy

Anticipating a personal protective equipment (PPE) shortage, I synthesized findings and made recommendations in late March to contacts in the Department of Health, who promptly elevated the matter.  My conclusions strongly supported local PPE production, based on intelligence shared by colleagues from the World Health Organization (WHO) regarding the global PPE situation, combined with cost and volume projections of local fashion industry players who were about to manufacture and donate PPEs to PGH.  In early April, the Department of Trade and Industry launched local high-volume production of medical-grade PPEs.

Strategic and systemic initiatives

While important, the above efforts focus on what is essentially the last line of defense: the hospital.  As PGH was steadily secured on numerous fronts by a competent Crisis Management team, I began to contribute to first-line initiatives beyond our walls.  Within striking distance were the national mass testing strategy and health financing policy.

Mass testing strategy

Having kept abreast of global good practices, I generated a blueprint for mass testing for COVID-19 in the Philippines.  This was well received by colleagues at the DOH.  The document provided the overall framework that the DOH fleshed out more comprehensively.  Designed around the patient journey, it works in conjunction with other COVID-19 activities of the government such as mass quarantine and public-facing IT applications.  It was structured to allow stakeholders to work together yet semi-independently.  That way, the various moving parts along the testing chain could scale up quickly while the DOH orchestrated the whole.  The framework espoused a conversation with the patient from start to finish: from how to shape public information before testing, to what configurations and enablers could maximize capacity, to how the consequences of various test results should be managed.

The need for this strategy was amplified by the actions of a non-medical interest group whose rhetoric around antibody-based testing threatened to not only undercut health sector directives but also potentially worsen the pandemic.  Understandably, theirs was a reaction to the low albeit rising national capacity for RT-PCR, the recommended test.

I countered this behind the scenes, by bridging scientific know-how straight to senior management contacts at private companies.  One is among the largest conglomerates in the Philippines, which was on the fence regarding testing; another is the country’s largest health maintenance organization, which was feeling the pressure from other companies to use antibody-based tests.  Through constant explanatory and exploratory dialogue, I translated the scientific community’s thoughts into operational and financial terms for them, to help guide their companies toward the proper testing approach.  I mediated their feedback to the DOH including their eventual willingness to get aligned, in hopes of emboldening the DOH to secure RT-PCR investments.  These efforts bore fruit when the titans of Philippine business agreed to bolster RT-PCR test capacity in the country.

COVID-19 health financing policy

The Philippine Health Insurance Corporation (PhilHealth) aims to leverage COVID-19 financing policy to meet the needs of health systems at this crucial time.

With colleagues from PhilHealth, WHO, and the University of the Philippines (UP), I functioned as Secretariat for consultative meetings designed to structure the next generation of benefits for COVID-19.  I have worked out a framework for an innovative modular type of benefit package to accommodate the nuances of COVID-19 care.  There are several nuances to consider.  The illness is multi-systemic beyond the lungs, varies widely in severity, may cost anywhere from virtually nothing to PHP 4 million (over AUD 125,000) in hospital bills, and has a complex eligibility aspect, being simultaneously a distinct condition and an add-on that can significantly alter the course of other health conditions.  On top of that is the ethical question of how to spend public money with so much uncertainty surrounding numerous unproven therapies for COVID-19.  The world is still learning what the best practices are in treating this illness – which normally form the basis for financing.  Pending higher level approvals, the framework we developed may be revisited alongside other recommendations arising from our consultative meetings.

The new normal

Finally, I am now scouting ahead to the new normal in health systems, with support from the same PhilHealth-UP-WHO team, and PGH.  I am writing the group’s proposal for PGH to serve as the demonstrator and innovator for what health care could look like when we transition from a COVID-19 crisis to a COVID-19-aware society.  Health systems must adapt to having the virus persist as a potential threat at all times to every patient and every health worker.  There is strong interest from PhilHealth and WHO to fund this top-to-bottom demo.  The timeline is short.  We aim to begin showing a replicable model before or in parallel with the gradual lifting of lockdown restrictions.

When that happens, health systems will seek an as-yet undefined equilibrium between caring for all patients as much as possible, and doing so with extreme caution.  On one hand, patient care outside of COVID-19 needs to be resumed.  Much of it has been deferred due to the lockdown, especially in COVID-19 Referral Centers like PGH.  On the other hand, providers still need to protect both patients and the health workforce itself, by minimizing exposure.  This tug of war leads us to favor networked, decongested health care in consonance with global thought leaders and the published literature on this topic.

The plan includes a strong telemedicine component and a single-record system.  I am coordinating with the Departments of Medicine and Family and Community Medicine as spearheading units.  With the joint efforts of the PGH IT Office and our computerization partner, DCI, we have prepared some of the necessary hardware, software, and IT infrastructure including the UP-designed PPCS electronic health records system.  The next steps will bring aboard external partners to operate satellite PGH clinics.  Arrangements will be made to synchronize and finance auxiliary health providers along the patient journey.  The resulting scheme must then be communicated to the public or a subset of it, in measured tones.  

In reality, this proposal builds on my previous work of setting up networked health systems for UHC.  Under PPCS, we connected communities Municipality-wide to village health outposts, then to primary care hubs and auxiliary providers, including parts of hospitals.  Necessarily, we formed virtual teams among health workers, encouraging team practice that would be responsible for the catchment population across its geographic entirety.  Synergy was a must among implementers and across disciplines such as IT, transportation, and health financing.  These are the themes that must underpin the new normal in health services, whether for reasons of pursuing UHC or adjusting to COVID-19.

From the PGH perspective, gaining a foothold on the new normal can reopen our Outpatient Department for health services and training alike.  From the DOH, PhilHealth, and WHO perspectives, this demonstration can restore momentum toward health system strengthening for UHC – momentum that was interrupted by the pandemic.  All parties agree that we cannot simply return to pre-pandemic systems.

Sustained COVID-19 control requires that the last lines of defense (i.e. hospitals and COVID Referral Centers) are not overwhelmed.  This in turn requires strong first lines of defense (i.e. RT-PCR test collaborators, primary care network partners, and so on).  Against a highly contagious virus, all levels must work together efficiently to respond quickly for pandemic control.  With good coordination, the system can remain responsive to all other patient types.  Pregnant women, children with congenital illnesses, and people with cancer, to name a few, need appropriate health care as much as patients with various stages of COVID-19.  The implication is that health providers must be networked, and services allocated distinctly among the levels of health care.  UHC was building such health systems before COVID-19.



Conclusion

Extraordinary circumstances have forced extraordinary measures to be deployed, but much of the work on COVID-19, including my own, is not unique to this disease.  Rather, it is anchored on fundamental goals and relies on tried and tested methods that health systems and countries have long grappled with.  This crisis, like many others, merely brings to light these sometimes hidden issues.

Both the pursuit of UHC and the response for pandemic control require responsive, coordinated care that is widely distributed and easily accessible to all.  Both agendas also require a whole-of-society, whole-health-system approach encompassing a range of disciplines affecting health care.  This means high-functioning first lines of defense, synchronized with well-prepared complex care centers.  This pattern applies to health care in general including mass testing specifically.

There is a silver lining.  The pandemic has intensified the need for solutions that experts have long advocated for bigger reasons than COVID-19.  This means the crisis is solvable, and that addressing it will bring other benefits too.  With like-minded and equally passionate colleagues, I am capitalizing on the urgency and synergy that these trying times have summoned, in order to advance some of the best parts of public health wisdom.  We can start with the parts needed now, but we cannot stop.

Months before the pandemic, Director Legaspi asked me after a hard day’s work, why I did what I did in my field of health systems.  The truth is I nearly followed him into Neurosurgery years ago.  Without a second’s hesitation, and referring to the huge gaps in Philippine health systems, my candid answer was, “Because it is the right thing to do.”