POLICY DISCUSSION PAPER
August 5, 2020
RECOMMENDATIONS FOR FiXING UP HEALTH CARE AND
THE ECONOMY UNDER MECQ
By J. Xavier B. Gonzales
Chairman, The Medical City
Here is what we know now that makes us able to act
more efficiently in dealing with this virus and
pandemic:
Covid is typically a 14-day disease. Days 1-3 you are
asymptoma c or presymptoma c and most infec ous.
You start showing symptoms day 3, and infec ousness
peaks day 5. Star ng day 8, as your body is beginning
to produce an bodies, you con nue to shed the virus,
but cannot infect others, unless you are older or
immunocompromised, in which case you need to wait
for day 10 before you are infec ous-free.
So here’s what you need to keep in mind:
● If you are mildly symptoma c, without fever
for 24 hours and under no medica on, you can
end your quaran ning within 10 days of
symptom onset.
● If you are moderately symptoma c (ie
exhibi ng difficulty of breathing), and/or if
your oxygen satura on is below 92 (you can
check this out with an oximeter), check into a
hospital for be er care.
● If you have been exposed to a covid-infected
person, quaran ne for 10 days a er PCR test
shows posi ve results, or for 14 days from
exposure.
Given that we are into a two-week reprieve at NCR,
here are whole-of-na on sugges ons that can simplify
a response to all this Covid clu er:
Stay Home
If you feel mild symptoms that are covid-similar, do not
immediately rush outside to take a PCR test. Call the
hospital or an MD for advice to start the monitoring
process. Quaran ne yourself and start the monitoring
process through telemedicine. if you turn moderately
symptoma c, check into a hospital.
For hospitals and LGUs, register and maintain daily
telemed contact with individuals as they go through
their disease journey. Keep a daily database of
infectees status. Ensure logis cal readiness of hospitals
for tes ng and treatment if symptoms turn moderate
to severe.
Create more ICU Beds
Severe and cri cal covid cases con nue to rise. They
now represent 1.5% of total ac ve cases. These cases
need ICU beds.
There are 525 ICU beds (@ 77% occupancy August 3) in
NCR out of 1400 na onally. We need to build the beds
now. As an example, it cost P40 million at our hospital
to ou it a 32-room wing for nega ve pressure ICU
capacity. Time to construct was one month. Total cost
for 525 more beds - P656 million.
A more efficient alterna ve might be to designate
certain public hospitals as stand-alone Covid. Pasig
tried to do this early on by conver ng its Child of Hope
Hospital. However, they were unable to handle
moderate to severe pa ents. East Avenue Hospital in
QC is currently under considera on.
At the end of the day, these ICU beds need to be
staffed properly, with intensivists and specialized
nurses which con nue to be in short supply.
Empty Non-urgent Covid Beds
Pa ents can be sent home faster.
The average stay for a covid pa ent at our hospital had
been 20 days. This can be cut in half for the recovering
covid pa ents by day 10, when they are not infec ous
anymore. We had an asymptoma c 96-year old lady by
exposure who went through two swabs by day 14, with
a request that she be kept longer un l PCR-nega ve. At
that point, she was clearly s ll shedding virus but
noninfec ous. Fortunately, the pa ent’s family
cooperated in bringing her home.
Doctors have to cooperate in this nudge. LGU s and
communi es need to change their return acceptance
policy to not include a swab test but just a doctor’s
cer ficate.
Timeout on Tes ng
Tests take too long - pa ents can be cured by the me
results come out. The rapid an body tests also miss
posi ve Covids that haven’t started developing
an bodies yet.
PCR Tes ng
● Given rapid disease cadence, it is useless to not
have results within 48 hours of PCR tes ng.
The ideal period is 24 hours. Otherwise, don’t
test.
● 24-hour results will enable be er triaging of
emergency pa ents at hospital gates and/or
less pressure on room alloca on (ie Covid or
Non-covid) as one enters the hospital through
the Emergency Department. There will be
minimal need for transi on rooms un l results
are available.
● 24-hour results availability will also make it
easier to minimize HCW cluster exposure risk
and the mass quaran ning we are again seeing
today in some hospitals.
Rapid An body Tes ng
● All serological tes ng Ini a ves should be
discon nued, except under special
circumstances endorsed by doctors. Rapid
an body test kits are prolifera ng because
demand is up, and demand is up because
businesses make this type of tes ng a
condi on for employees returning to work.
● These tests do not catch the virus, only the
an bodies, and an bodies emerge on day 8 of
the disease, when those who have the virus are
much less or not infec ous already. They also
miss at least 50% of those infected who do not
have an bodies yet but have the virus. This
approach has enabled more corrup on in the
healthcare system, especially given the
inconsistency with which LGUs and
corpora ons have applied return-to-work rules.
Our hospital con nues to examine the possibility of
coming up with a research protocol to determine the
probability of Covid infec on in a pa ent, to be
validated with PCR as the gold standard. If validated,
this could free the hospital from too much dependence
on PCR tes ng. By differen a ng covid from non-covid
pa ents, it will ease current triaging and
decision-making challenges in admission and bed
assignments.
Repurpose the HCW Resource
● Nurses should be able to handle daily telemed
calls, monitoring pa ents through the disease
journey, with mass clinical oversight for this
mass disease.
● Allied medical professionals, like medtechs and
physical therapists, extending even to the
non-boarded medical professionals, can handle
swabbing and contact tracing. In the US,
people self-swab and submit their results
directly to the labs.
● Specialized training, par cularly for ICU nurses
and intensivists, can be also systemically
incorporated in the hands-on One Hospital
group mandate, comprised of NCR public and
private hospitals and led by Undersecretary Dr.
Vega, which meets daily at 730 am.
Use Coopera ve Model for PPE Purchases
● At our hospital, cost is around P600-700/set.
This consists of N95 Mask, isola on gown,
green gown, earloop mask, boo es, head cap,
face shield or goggles; nitrile gloves. On April
1, the DOH announced the expected arrival of
PPE sets procured for P1.8 billion, or
P1800/set. That’s 3x.
● The One Hospital Group, in the demand war
zone, also has be er apprecia on for
purchasing economies for PPEs and equipment.
This can include even medicines with proven
efficacy like remdesivir (currently globally in
short supply) and dexamethasone. They
should be properly empowered to manage
supply requirements, pricing and logis cs, for
the NCR hospital ecosystem.
Improve Covid Diagnos cs with Research Support

From Day 5 onward, an bodies begin to a ack and
destroy lung ssue infected by the Covid virus. Chest
x-rays can document what may ul mately lead to a
cytokine storm, the last recourse of which is intuba on
taking over pa ent breathing. An interes ng perverse
indicator is oxygen satura on (as measured by an
oximeter) dropping below 92, with the person s ll
appearing normal even as lung destruc on is
accelera ng.
Our hospital has ini ated a randomised controlled
study of chest x-rays, as diagnosed by radiologists and
pulmonologists to verify covid infec on, for valida on
by an AI algorithm. Once the ini al results are out,
predic ve accuracy can be increased with more data
points from other hospitals, and we have be er early
warning signals to back pa ents off from the
precipitous covid cliff. Maybe at the end of the day,
this may be a good enough solu on (almost) in lieu of
tes ng - par cularly when affordability and access are
issues.
We have also used mesenchymal stem cell therapy
(MSC) from donated umbilical cords to reverse course
for pa ents about to be or already intubated. Case
studies are limited - but survival rates (6 out of 7) are
high. Metrics of recovery appear drama c. MSC can
be combined also with more established treatments
like remdisivir and dexamethasone, to stem the
dreaded cytokine storm. Compassionate use is the
model when pa ent survival is direly at stake.
For the range of data science methodologies, from
large volume clinical trials to individual case studies,
the DOST-DOH-Academic-Private Health communi es
can be er flag as one. Let us learn from the Filipino
test kit experience, and fully support transforma onal
scien fic research and innova on.
Funding research is not expensive. But it has significant
mul plier effects on health ecosystem sustainability.
Let us celebrate our wins here.
Properly Fund the Whole of Health Care
Here are some tradeoff challenges:
● Ra onalize tes ng. For 1.5 million PCR tests
alone, that’s a P7.5 billion (@P5000 per test)
bill. We suggest a more cost-effec ve
approach anchored on approaching the disease
like one does the common cold - monitoring
symptoms via telemed clinically, unless and
un l the situa on warrants hospital admission-
and not being necessarily dependent on a PCR
test for having to validate the disease for the
mildly symptoma c, or having to validate that
someone has recovered. This can be a more
cost-effec ve LGU-anchored strategy.
● Refocus reimbursements on in-pa ent
support. Let the private sector fund its own
tes ng, however wasteful the rapid an body
test kit exercise was. As stated earlier, the cost
of doubling NCR ICU capacity is (only) P656
million. But it is a strategic element of what
the lockdown was originally set to do - give the
health sector a reprieve to catch up,
par cularly for the severe and cri cal
immuno-compromised cases, which are
causing the hospital shutdowns. If we miss out
on health capacity planning (once again), we
shut down the economy (once more).
● Recapitalize Philhealth. By going overboard on
tes ng, whether it be on PCR or rapid an body,
at the expense of treatment, we not only
underinvest in physical capacity, but also
threaten private hospitals’ financial viability.
Our hospital is already out-of-pocket over P500
million, awai ng Philheath reimbursement, and
not just for Covid. There are other private
hospitals in the same boat. Because collec ons
have floundered with businesses shu ng
down, OFWs given pay-in waivers, Philhealth
finances need to be reset.
● Let Philhealth allow balance billing. Since
private hospitals, which comprise two-thirds of
the hospital sector, are not supported with
equipment and facility budgets by government
and have to pay their own way, Philhealth
should allow balance billing for Covid cases.
Part of the problem here is that Philhealth case
reimbursement rates are based simply on
pneumonia, thereby understa ng the impact of
Covid on other organ complica ons.
● Incen vize Covid disclosures. Since this is a
two-week disease, why not announce a P3k
shelter subsidy for targeted high-infec on
areas, based on symptom-based assessment by
a clinician, using other basic tools like a
temperature scan, oximeter, and chest xray,
 maybe with a confirmatory PCR swab if results
are available in 24 hours (otherwise forget it).
This can ferret out the mildly symptoma c,
with an accompanying op on (doctor s
discre on) to community quaran ne if space
isola on is an issue. Contact tracing for the
exposed will naturally follow suit (but without
the subsidy).
Since this whole disease began, there have
been over 100k covid cases. Flushing out
another 100k in high-infec ous areas to
reduce cluster transmission risk through
disclosure incen ves costs but P300 million.
This compares with the P1 trillion reduc on in
GDP and 5 million loss of jobs for 45 days’
lockdown.
Open Schools to Community Quaran ning
Back in April, when Covid spread was gaining
momentum, I sat down with Rep. Kit Belmonte of the
2nd district QC, to try to determine what the
bo lenecks were to more effec ve disease
management. He said he had been asking the DOE to
contribute its schools to the “heal as one” process, as
there was a lack of easily accessible community
quaran ning facili es.
Up ll today, schools have not opened, and are focused
on opening digitally. Let us selec vely give ourselves
the op on to use our school infrastructure wisely.
Reopen Public Transport on Two Shi s
A two-shi public transport system creates more space
for social distancing - and jobs.
Distance between persons and dura on of exposure
are two elements cri cal to controlling Covid spread.
Already among the longest and hardest lockdowns in
the world, NCR shut down its emergent public
transport system once again from August 4-18. Totally.
Headlines about the infec ve aspect of public transport
however suggest that with proper management, public
transport can remain open. “Is the Subway Risky? It
May Be Safer than You Think” (New York Times, August
2). “Fear of Public Transit Got Ahead of the Evidence”
(The Atlan c, June 14). The key is to reduce crowding.
Pre-covid, there were 15 million passenger trips daily
within NCR. Theore cally, there should be double the
number now, for social distancing purposes.
Work-from-home and elderly/kids not going out/to
school cuts trips by at least one-third. As part of a
hurry-up plan, the NCR bus fleet can also be increased
by 2.5x, to 12,000 units, and run on two shi s, also
saving jobs for displaced jeepney transport workers.
Buses are 2x jeeps in passengers moved daily, and 15x
cars. While we can raise transport fares and let the
market seek going-to-work equilibrium under the new
normal, there will be no crowding on public transport
and much less traffic.
In fact, if the na onal government changes its strategy
to stagger work hours from 5 am to 9 pm, the private
sector will follow, with more service and public-sector
jobs created.
Job crea on is a notch above direct transfers as a
preferred economic s mulus tool.
Nudge versus Punch
Because the disease is evolving, and policies are
constantly in flux because of new learnings, there is a
need for both simplifica on in policy, repe on in
communica on, and con nuing engagement of the
Filipino public in execu on.
For example, for all the messaging about the
advantages of wearing masks, the latest revela on is
that masks can act like a vaccine, crea ng a barrier to
Covid viral exposure, so that at lower levels of
infec on, infectees are more likely mild or
asymptoma c.
With muta on, the disease has become more
infec ous, but not necessarily more lethal. There are
second waves in Hong Kong, Japan and Vietnam, which
appeared to have the disease under control. Of course,
these breakouts are from very small bases, which have
not accelerated the way our case totals have over the
last two months.
Which way to go to be more effec ve in husbanding
both the economy and the disease - enforce or
persuade? Are we having too much of one or the
other?