Those Who Have Less In Life, Should Have More In Law:
The Necessity Of Enacting & Implementing A National Mental Health Policy and of Developing Community-Based Mental Health Care In The Philippines
Lito ang isip na… pauwi si Sisa….
Hindi madulumat ang nararamdaman niyang kasiphayuan.
… Ang banta ng pagkabaliw ay unti unting lumalamon sa kanyang buong pagkatao. Kinabukasan, nagpalaboy-laboy sa lansangan si Sisa.
Ang malakas na pag-iyak, hagulgol at pagsigaw ay nagsasalit at kung minsan ay magkasabay na ipinakita ang kanyang kaanyuan.
Lahat ng mga taong nakakasalubong niya ay nahihintakutan sa kanya.[1]
(With confused mind, Sisa frantically went home…
The sadness that enveloped her was just too deep to fathom.
And the dark bits of insanity are now engulfing her terrified mind.…
The next day, Sisa aimlessly wanders through the streets.
One moment she loudly cries, at another she uncontrollably hollers, at another she sobs as if without end. Her once languid, gentle features are now gone. Replaced by a horrific countenance that can come only from a cruel mix of sorrow, terror, regret, and brokenness.
Everyone who met her, was terrified by her appearance.)
So goes the tragic story of “Sisang Baliw,” (trans. “Crazy Sisa”). Who in the Philippines doesn’t usually know the sad tale of Sisa? One of the, if not the most tragic figure, of “Noli me Tangere,” one of the two very famous novels (the other is “El Filibusterismo”) of the Philippines’ national hero, Jose Protacio Mercado Rizal. The setting of the two novels were the close of the Spanish colonial period in the Philippines. And these two novels, are famously accepted as among the literary works which sparked the subsequent Philippine Revolution versus the colonial Spanish rule. The setting of Sisa’s story is way back 19th century. And Sisa’s tale shows that even way back then, Philippine society was already aware of mental illness. And not only that. But even the stigma which goes with mental illness, regardless of the cause, as the last line of the excerpt showed: “Lahat ng mga taong nakakasalubong niya ay nahihintakutan sa kanya. Everyone who met her, was terrified by her appearance.” And I venture to say, in terms of a nationwide, effective, coherent national mental health policy, our country, more than a hundred years after Rizal wrote “Noli Me Tangere,” is largely going the way of Sisa. Lost, floundering, listless. Thus, without much ado, I’d like to argue for the importance of effectively implementing a national mental health policy and of developing community-based mental health care in the country. Let’s count the ways.
Firstly, there is a big yawning hole of lacuna. Such has been categorically essayed by several incontrovertible resources. Even way back in 2007, the Executive Summary of the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS), on the mental health system in the Philippines said:
The Philippines have a National Mental Health Policy (Administrative Order # 8 s.2001) signed by then Secretary of Health Manuel M. Dayrit. There is no mental health legislation and the laws that govern the provision of mental health services are contained in various parts of promulgated laws such as Penal Code, Magna Carta for Disabled Person, Family Code, and the Dangerous Drug Act, etc. The country spends about 5% of the total health budget on mental health and substantial portions of it are spent on the operation and maintenance of mental hospitals. The new social insurance scheme covers mental disorders but is limited to acute inpatient care. Psychotropic medications are available in the mental health facilities. A Commission on Human Right of the Philippines exists, however, human rights were reviewed only in some facilities and only a small percentage of mental health workers received training related to human rights. These measures need to be extended to all facilities.
The National Program Management Committee of the Department of Health (DOH) acts as the mental health authority. Forty-six outpatient facilities treat 124.3 users per 100,000 populations. The rate of users per 100,000 general population for day treatment facilities and community based psychiatric inpatient units are 4.42 and 9.98, respectively. There are fifteen community residential (custodial home-care) facilities that treat 1.09 users per 100,000 general population. Mental hospitals treat 8.97 patients per 100,000 general population and the occupancy rate is 92%. The majority of patients admitted have a diagnosis of schizophrenia. There has been no increase in the number of mental hospital beds in the last five years. All forensic beds (400) are at the National Center for Mental Health. Involuntary admissions and the use of restraints or seclusion are common.[2]
Former Senate President Juan Ponce Enrile, of the Philippine Senate, the Upper House of the Philippine Congress, on November 2009 introduced Senate Bill 3509, entitled “The National Mental Health Act of 2009”. The bill’s introduction also echoes the necessity, ergo, the lack:
In the Philippines, mental health services are clearly lacking. Both human and financial resources are also wanting. Whatever mental health strategy our government currently follows is still hindered by a small budget and inadequate administrative framework. No mental health law has been founded. [3]
The Philippine Psychiatric Association in its website way back 2014 says:
According to the WHO, 1 in 5 people suffer from mental health problems worldwide, yet there are only 0.05 psychiatrists per 100,000 people in the Philippines; most health insurance companies still don’t cover mental health-related issues, and the stigma still weighs heavily on people suffering from mental illness. If you want this to change, act now. Sign the petition for the country’s first ever Mental Health Act.
An initiative by the Philippine Psychiatric Association, the Mental Health Act aims to protect the rights of people with mental disorders and/or disabilities by putting in place an official body that will oversee the policies and programs that need to be developed to prevent and treat mental illnesses, and to promote the mental health of Filipinos. [4]
Incumbent Philippine Senator Loren Legarda, last November 2014, then introduced Senate Bill 2450, also known as “Philippine Mental Health Act of 2014”. Of the lack for a specific legislation it says:
In a survey conducted by the Department of Health among 327 government employees in Metro Manila, 32% were found to have experienced mental health problems. Almost one per 100 households (0.7%) has a member with mental disability (DOH-SWS, 2004). As early as 2003, intentional self-harm was already found to be the 9th leading cause of death among 20-24 years old Filipino adults (DOH 2003). The incidence of suicide in males increased from 0.23 to 3.59 per 100,000 between 1984 and 2005 while rates rose from 0.12 to 1.09 per 100,000 in females (Redaniel, Dalida and Gunnell, 2011). Individuals with chronic mental illness, children, overseas Filipino workers and those in areas of armed conflict have higher risk of getting mental health problems.
Further adding to the woes of those afflicted with mental health illnesses is the shortage in qualified mental health professionals. At present there are only an estimated 490 psychiatrists and 1000 nurses working in psychiatric care, and even less general practitioners trained in early assessment and management of common mental health problem in the community. The number of addiction specialists, psychologists, occupational therapists, guidance counselors and social workers are extremely inadequate to meet the mental health needs of the 100 million Filipinos.
There are two mental hospitals, 46 outpatient facilities, four day treatment facilities, 19 community-based psychiatric inpatient facilities and 15 community residential (custodial home-care) facilities for the whole country. Almost all mental health facilities are in major cities, while the only mental hospital in the National Capital Region houses only 4,200 beds. [5]
From the above list can be derived other arguments. Second, is that, the lacuna of a unified mental health policy, fosters a very clear inequity in health. The above 2007 WHO-AIMS Philippine Country Report confirms such by saying that:
Five percent of health care expenditures by the government health department are directed towards mental health. Of all the expenditures on mental health, 95% are spent on the operation, maintenance and salary of personnel of mental hospitals. The percentage of the population that has free access (at least 80%) to essential psychotropic medicines is unknown. For those that pay out of pocket, the cost of antipsychotic medication is 0.46% and of antidepressant medication is 11.14% of the minimum daily wage (approximately US$ 0.035 per day for antipsychotic medication and US$ 0.75 per day for antidepressant medication). The Philippine HealthInsurance Corporation recently covered mental illness but limited only to patients with severe mental disorders confined for short duration. [6]
Such is also further buttressed by Sen. Legarda’s Senate Bill 2450:
Further adding to the woes of those afflicted with mental health illnesses is the shortage in qualified mental health professionals. At present there are only an estimated 490 psychiatrists and 1000 nurses working in psychiatric care, and even less general practitioners trained in early assessment and management of common mental health problem in the community. The number of addiction specialists, psychologists, occupational therapists, guidance counselors and social workers are extremely inadequate to meet the mental health needs of the 100 million Filipinos.
There are two mental hospitals, 46 outpatient facilities, four day treatment facilities, 19 community-based psychiatric inpatient facilities and 15 community residential (custodial home-care) facilities for the whole country. Almost all mental health facilities are in major cities, while the only mental hospital in the National Capital Region houses only 4,200 beds. [7]
And such inequity is clearly unwarranted by the fact that as early as 2013, even the World Bank has considered the Philippines as the new Tiger economy of Asia, thus having the economic wherewithal to fund a nationwide mental health policy:
“The Philippines is no longer the sick man of East Asia, but the rising tiger. There is macroeconomic stability, and the fiscal situation of the government is sound and improving. The fight against corruption is being waged with determination and it is paying off. Transparency is improving everywhere in the Philippines,” Motoo Konishi, WB country director for the Philippines, said at the closing of the 2013 Philippine Development Forum at the Marco Polo Hotel here (Davao City, Philippines). [8]
Another argument that can be inferred from the lack of a “national mental health policy and of developing community-based mental health care in the country” is its adverse implications on the rights of mental health patients. As the WHO-AIMS Country Report said:
A Commission on Human Right of the Philippines exists, however, human rights were reviewed only in some facilities and only a small percentage of mental health workers received training related to human rights. These measures need to be extended to all facilities. [9]
Another very salient argument that can be derived from the lacuna is its grave implications on the mental health of the Philippine society in general, more especially those belonging to the vulnerable population, as identified by the Legarda Bill:
In a survey conducted by the Department of Health among 327 government employees in Metro Manila, 32% were found to have experienced mental health problems. Almost one per 100 households (0.7%) has a member with mental disability (DOH-SWS, 2004). As early as 2003, intentional self-harm was already found to be the 9th leading cause of death among 20-24 years old Filipino adults (DOH 2003). The incidence of suicide in males increased from 0.23 to 3.59 per 100,000 between 1984 and 2005 while rates rose from 0.12 to 1.09 per 100,000 in females (Redaniel, Dalida and Gunnell, 2011). Individuals with chronic mental illness, children, overseas Filipino workers and those in areas of armed conflict have higher risk of getting mental health problems. [10]
The last argument I’d like to present is from the fact that the Department of Health, supposedly the lead agency for the implementation of a national mental health policy, itself as of the moment already has in fact a national mental health program in place as far back as 2103 which says that its over-all goal is “Quality Mental Health Care,”[11] and its over-all objective being that of :
Implementation of a mental health program strategy. The National Mental Health Policy shall be pursued through a mental health program strategy prioritizing the promotion of mental health, protection of the rights and freedom of persons with mental diseases and the reduction of the burden and consequences of mental ill-health, mental and brain disorders and disabilities. [12]
Out of the above the discussions, I’d therefore like to recommend the following:
1. Make the necessity of passing a National Mental Health Policy legislation a significant issue of the upcoming May 2016 nationwide elections. The May 2016 elections are supposed to choose to elect the Philippines’ new set of national political leaders like the new President, Vice-President, half of the total number of our Senators (i.e., 12 of the total 24), all the maximum 250 Members of the Lower House of Congress, all elected officials of local government units from the provincial down to the municipal or city levels (e.g., provincial governors, vice-governors, members of the provincial legislative boards; mayors, vice-mayors, and their councilors). Also, the result of May 2016 elections will determine the composition of the Cabinet members of the winning presidential candidate;
2. Pass into law Senate Bill 2450, sponsored by Sen. Loren Legarda;
3. After SB 2450 has been enacted onto a national law, an IRR (Implementing Rules and Guidelines) must immediately be formulated for the law to be expeditiously and judiciously implemented;
4. The youth voters, i.e., those 18 to 35 years old, comprising 50% of the qualified voters must also be aggressively wooed to support the passing of Senate Bill 2450. They must be conscienticized to push politicians running for office (especially those running for national positions) to make the passing of SB 2450 among their top priorities in their political platform.
The late Ramon del Fierro Magsaysay, seventh President of the Philippine Republic who served from 1954-1957, one of the most loved Philippine Presidents in our country’s history, famously said that “Those who have less in life, should have more in law.” May such magnanimity of the late President Magsaysay be a constant reminder and guide in the passage of a “national mental health policy and of developing community-based mental health care” in the country, thus, Sisa and her tragedy will eventually be put to rest.
Jose Ma. Ernesto Jacinto Ybanez Tomacruz, PhL, EMMB
PhD Fellow, Erasmus Mundus Joint Doctoral Program on the Dynamics of Health and Welfare 2014-2017
Linkoping University, Linkoping, Sweden
L’Ecole des Hautes Etudes en Sciences Sociales, Paris, France
Escola Nacional de Saude Publica, Lisboa, Portugal.
The Necessity Of Enacting & Implementing A National Mental Health Policy and of Developing Community-Based Mental Health Care In The Philippines
Lito ang isip na… pauwi si Sisa….
Hindi madulumat ang nararamdaman niyang kasiphayuan.
… Ang banta ng pagkabaliw ay unti unting lumalamon sa kanyang buong pagkatao. Kinabukasan, nagpalaboy-laboy sa lansangan si Sisa.
Ang malakas na pag-iyak, hagulgol at pagsigaw ay nagsasalit at kung minsan ay magkasabay na ipinakita ang kanyang kaanyuan.
Lahat ng mga taong nakakasalubong niya ay nahihintakutan sa kanya.[1]
(With confused mind, Sisa frantically went home…
The sadness that enveloped her was just too deep to fathom.
And the dark bits of insanity are now engulfing her terrified mind.…
The next day, Sisa aimlessly wanders through the streets.
One moment she loudly cries, at another she uncontrollably hollers, at another she sobs as if without end. Her once languid, gentle features are now gone. Replaced by a horrific countenance that can come only from a cruel mix of sorrow, terror, regret, and brokenness.
Everyone who met her, was terrified by her appearance.)
So goes the tragic story of “Sisang Baliw,” (trans. “Crazy Sisa”). Who in the Philippines doesn’t usually know the sad tale of Sisa? One of the, if not the most tragic figure, of “Noli me Tangere,” one of the two very famous novels (the other is “El Filibusterismo”) of the Philippines’ national hero, Jose Protacio Mercado Rizal. The setting of the two novels were the close of the Spanish colonial period in the Philippines. And these two novels, are famously accepted as among the literary works which sparked the subsequent Philippine Revolution versus the colonial Spanish rule. The setting of Sisa’s story is way back 19th century. And Sisa’s tale shows that even way back then, Philippine society was already aware of mental illness. And not only that. But even the stigma which goes with mental illness, regardless of the cause, as the last line of the excerpt showed: “Lahat ng mga taong nakakasalubong niya ay nahihintakutan sa kanya. Everyone who met her, was terrified by her appearance.” And I venture to say, in terms of a nationwide, effective, coherent national mental health policy, our country, more than a hundred years after Rizal wrote “Noli Me Tangere,” is largely going the way of Sisa. Lost, floundering, listless. Thus, without much ado, I’d like to argue for the importance of effectively implementing a national mental health policy and of developing community-based mental health care in the country. Let’s count the ways.
Firstly, there is a big yawning hole of lacuna. Such has been categorically essayed by several incontrovertible resources. Even way back in 2007, the Executive Summary of the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS), on the mental health system in the Philippines said:
The Philippines have a National Mental Health Policy (Administrative Order # 8 s.2001) signed by then Secretary of Health Manuel M. Dayrit. There is no mental health legislation and the laws that govern the provision of mental health services are contained in various parts of promulgated laws such as Penal Code, Magna Carta for Disabled Person, Family Code, and the Dangerous Drug Act, etc. The country spends about 5% of the total health budget on mental health and substantial portions of it are spent on the operation and maintenance of mental hospitals. The new social insurance scheme covers mental disorders but is limited to acute inpatient care. Psychotropic medications are available in the mental health facilities. A Commission on Human Right of the Philippines exists, however, human rights were reviewed only in some facilities and only a small percentage of mental health workers received training related to human rights. These measures need to be extended to all facilities.
The National Program Management Committee of the Department of Health (DOH) acts as the mental health authority. Forty-six outpatient facilities treat 124.3 users per 100,000 populations. The rate of users per 100,000 general population for day treatment facilities and community based psychiatric inpatient units are 4.42 and 9.98, respectively. There are fifteen community residential (custodial home-care) facilities that treat 1.09 users per 100,000 general population. Mental hospitals treat 8.97 patients per 100,000 general population and the occupancy rate is 92%. The majority of patients admitted have a diagnosis of schizophrenia. There has been no increase in the number of mental hospital beds in the last five years. All forensic beds (400) are at the National Center for Mental Health. Involuntary admissions and the use of restraints or seclusion are common.[2]
Former Senate President Juan Ponce Enrile, of the Philippine Senate, the Upper House of the Philippine Congress, on November 2009 introduced Senate Bill 3509, entitled “The National Mental Health Act of 2009”. The bill’s introduction also echoes the necessity, ergo, the lack:
In the Philippines, mental health services are clearly lacking. Both human and financial resources are also wanting. Whatever mental health strategy our government currently follows is still hindered by a small budget and inadequate administrative framework. No mental health law has been founded. [3]
The Philippine Psychiatric Association in its website way back 2014 says:
According to the WHO, 1 in 5 people suffer from mental health problems worldwide, yet there are only 0.05 psychiatrists per 100,000 people in the Philippines; most health insurance companies still don’t cover mental health-related issues, and the stigma still weighs heavily on people suffering from mental illness. If you want this to change, act now. Sign the petition for the country’s first ever Mental Health Act.
An initiative by the Philippine Psychiatric Association, the Mental Health Act aims to protect the rights of people with mental disorders and/or disabilities by putting in place an official body that will oversee the policies and programs that need to be developed to prevent and treat mental illnesses, and to promote the mental health of Filipinos. [4]
Incumbent Philippine Senator Loren Legarda, last November 2014, then introduced Senate Bill 2450, also known as “Philippine Mental Health Act of 2014”. Of the lack for a specific legislation it says:
In a survey conducted by the Department of Health among 327 government employees in Metro Manila, 32% were found to have experienced mental health problems. Almost one per 100 households (0.7%) has a member with mental disability (DOH-SWS, 2004). As early as 2003, intentional self-harm was already found to be the 9th leading cause of death among 20-24 years old Filipino adults (DOH 2003). The incidence of suicide in males increased from 0.23 to 3.59 per 100,000 between 1984 and 2005 while rates rose from 0.12 to 1.09 per 100,000 in females (Redaniel, Dalida and Gunnell, 2011). Individuals with chronic mental illness, children, overseas Filipino workers and those in areas of armed conflict have higher risk of getting mental health problems.
Further adding to the woes of those afflicted with mental health illnesses is the shortage in qualified mental health professionals. At present there are only an estimated 490 psychiatrists and 1000 nurses working in psychiatric care, and even less general practitioners trained in early assessment and management of common mental health problem in the community. The number of addiction specialists, psychologists, occupational therapists, guidance counselors and social workers are extremely inadequate to meet the mental health needs of the 100 million Filipinos.
There are two mental hospitals, 46 outpatient facilities, four day treatment facilities, 19 community-based psychiatric inpatient facilities and 15 community residential (custodial home-care) facilities for the whole country. Almost all mental health facilities are in major cities, while the only mental hospital in the National Capital Region houses only 4,200 beds. [5]
From the above list can be derived other arguments. Second, is that, the lacuna of a unified mental health policy, fosters a very clear inequity in health. The above 2007 WHO-AIMS Philippine Country Report confirms such by saying that:
Five percent of health care expenditures by the government health department are directed towards mental health. Of all the expenditures on mental health, 95% are spent on the operation, maintenance and salary of personnel of mental hospitals. The percentage of the population that has free access (at least 80%) to essential psychotropic medicines is unknown. For those that pay out of pocket, the cost of antipsychotic medication is 0.46% and of antidepressant medication is 11.14% of the minimum daily wage (approximately US$ 0.035 per day for antipsychotic medication and US$ 0.75 per day for antidepressant medication). The Philippine HealthInsurance Corporation recently covered mental illness but limited only to patients with severe mental disorders confined for short duration. [6]
Such is also further buttressed by Sen. Legarda’s Senate Bill 2450:
Further adding to the woes of those afflicted with mental health illnesses is the shortage in qualified mental health professionals. At present there are only an estimated 490 psychiatrists and 1000 nurses working in psychiatric care, and even less general practitioners trained in early assessment and management of common mental health problem in the community. The number of addiction specialists, psychologists, occupational therapists, guidance counselors and social workers are extremely inadequate to meet the mental health needs of the 100 million Filipinos.
There are two mental hospitals, 46 outpatient facilities, four day treatment facilities, 19 community-based psychiatric inpatient facilities and 15 community residential (custodial home-care) facilities for the whole country. Almost all mental health facilities are in major cities, while the only mental hospital in the National Capital Region houses only 4,200 beds. [7]
And such inequity is clearly unwarranted by the fact that as early as 2013, even the World Bank has considered the Philippines as the new Tiger economy of Asia, thus having the economic wherewithal to fund a nationwide mental health policy:
“The Philippines is no longer the sick man of East Asia, but the rising tiger. There is macroeconomic stability, and the fiscal situation of the government is sound and improving. The fight against corruption is being waged with determination and it is paying off. Transparency is improving everywhere in the Philippines,” Motoo Konishi, WB country director for the Philippines, said at the closing of the 2013 Philippine Development Forum at the Marco Polo Hotel here (Davao City, Philippines). [8]
Another argument that can be inferred from the lack of a “national mental health policy and of developing community-based mental health care in the country” is its adverse implications on the rights of mental health patients. As the WHO-AIMS Country Report said:
A Commission on Human Right of the Philippines exists, however, human rights were reviewed only in some facilities and only a small percentage of mental health workers received training related to human rights. These measures need to be extended to all facilities. [9]
Another very salient argument that can be derived from the lacuna is its grave implications on the mental health of the Philippine society in general, more especially those belonging to the vulnerable population, as identified by the Legarda Bill:
In a survey conducted by the Department of Health among 327 government employees in Metro Manila, 32% were found to have experienced mental health problems. Almost one per 100 households (0.7%) has a member with mental disability (DOH-SWS, 2004). As early as 2003, intentional self-harm was already found to be the 9th leading cause of death among 20-24 years old Filipino adults (DOH 2003). The incidence of suicide in males increased from 0.23 to 3.59 per 100,000 between 1984 and 2005 while rates rose from 0.12 to 1.09 per 100,000 in females (Redaniel, Dalida and Gunnell, 2011). Individuals with chronic mental illness, children, overseas Filipino workers and those in areas of armed conflict have higher risk of getting mental health problems. [10]
The last argument I’d like to present is from the fact that the Department of Health, supposedly the lead agency for the implementation of a national mental health policy, itself as of the moment already has in fact a national mental health program in place as far back as 2103 which says that its over-all goal is “Quality Mental Health Care,”[11] and its over-all objective being that of :
Implementation of a mental health program strategy. The National Mental Health Policy shall be pursued through a mental health program strategy prioritizing the promotion of mental health, protection of the rights and freedom of persons with mental diseases and the reduction of the burden and consequences of mental ill-health, mental and brain disorders and disabilities. [12]
Out of the above the discussions, I’d therefore like to recommend the following:
1. Make the necessity of passing a National Mental Health Policy legislation a significant issue of the upcoming May 2016 nationwide elections. The May 2016 elections are supposed to choose to elect the Philippines’ new set of national political leaders like the new President, Vice-President, half of the total number of our Senators (i.e., 12 of the total 24), all the maximum 250 Members of the Lower House of Congress, all elected officials of local government units from the provincial down to the municipal or city levels (e.g., provincial governors, vice-governors, members of the provincial legislative boards; mayors, vice-mayors, and their councilors). Also, the result of May 2016 elections will determine the composition of the Cabinet members of the winning presidential candidate;
2. Pass into law Senate Bill 2450, sponsored by Sen. Loren Legarda;
3. After SB 2450 has been enacted onto a national law, an IRR (Implementing Rules and Guidelines) must immediately be formulated for the law to be expeditiously and judiciously implemented;
4. The youth voters, i.e., those 18 to 35 years old, comprising 50% of the qualified voters must also be aggressively wooed to support the passing of Senate Bill 2450. They must be conscienticized to push politicians running for office (especially those running for national positions) to make the passing of SB 2450 among their top priorities in their political platform.
The late Ramon del Fierro Magsaysay, seventh President of the Philippine Republic who served from 1954-1957, one of the most loved Philippine Presidents in our country’s history, famously said that “Those who have less in life, should have more in law.” May such magnanimity of the late President Magsaysay be a constant reminder and guide in the passage of a “national mental health policy and of developing community-based mental health care” in the country, thus, Sisa and her tragedy will eventually be put to rest.
Jose Ma. Ernesto Jacinto Ybanez Tomacruz, PhL, EMMB
PhD Fellow, Erasmus Mundus Joint Doctoral Program on the Dynamics of Health and Welfare 2014-2017
Linkoping University, Linkoping, Sweden
L’Ecole des Hautes Etudes en Sciences Sociales, Paris, France
Escola Nacional de Saude Publica, Lisboa, Portugal.
[12] Ibid.
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