RUM 1: Reducing Medicine Abuse

I am starting a new thread in healthcare, the "rational use of medicines" or RUM. This will be the 7th thread or sub-topic under health topics in this blog. The other 6 and their latest issues are:

1. Drug Price Control 24: Forcing Drug Firms to Report Payment to Doctors, January 24, 2012
2. PhilHealth Watch 11: Hospital Bill Deductions (b), January 19, 2012
3. Lifestyle Diseases 14: Transformative Education on Health, January 18, 2012
4. IPR and Medicines 20: Scherer Paper on Pharmaceuticals R&D, January 12, 2012
5. Healthcare Competition 14: Centralization vs. Deregulation of Healthcare, December 31, 2011
6. Generic Drugs Asia 4: Vaccines from China, November 29, 2011

The reason why I open a new thread on RUM is because I attended the DOH Consultative Meeting on the National Framework on Rational Use of Medicines (NaFRUM), Consumer Group, yesterday at the DOH compound. The DOH is planning to issue a new Administrative Order (AO) on RUM, and they are doing a consultative meeting for various sectors (academe, government agencies, pharma industry, hospitals and drugstores, consumer groups).

I was actually curious what's this new initiative by the DOH, why another AO, can't this subject be not implemented under existing programs? That is why I attended the consultation. Almost all participants who came yesterday were also from member-NGOs of the Coalition for Health Advocacy and Transparency (CHAT). Like leaders from HealthWatch and MeTA-Philippines (former Gov. Obet Pagdanganan, Cecile Sison), COPA, Botika Binhi, AltHealth, Woman Health, Kilos Damit, HAIN, etc.

The event was organized by the National Center for Pharmaceutical Access and Management (NCPAM), the lead agency under the DOH in implementing the Philippine Medicines Policy (PMP), like generics promotion, Botika ng Barangay (BnB) or village pharmacy, P100 or Compact Treatment program, drug price control and related programs and policies.

New NCPAM Director, Dr. Ma. Virginia Ala, MD, Director IV, gave the opening and welcome message. She mentioned some pathetic sights like so many softdrinks in elementary kids' canteen and diet, junk and fatty/preserved foods on toddlers and children's diet, which are  unhealthy food and contribute to future diseases someday, which will require new medicines and other treatment. That was a good observation by Dr. Ala. She bolstered my repeated argument: healthcare is first and foremost, personal and parental/guardian responsibility, secondarily as government responsibility. I believe that government should come in only in controlling infectious and communicable diseases, in treating  pediatric diseases, and helping people with mental and physical disabilities because the treatment and theraphy for such conditions are usually very high and expensive.

Dr. Irene Farinas of NCPAM gave an overview about their office and its major activities, as well as some facts on Philippine health and pharmaceutical situation. Here are some interesting facts (at least for me) that she shared:

1. Drug price control via maximum retail price (MRP) -- but the illegal terms and concepts GMAP and MDRP are still used by the DOH -- is now a regular (and long-term?) policy under "Affordable medicines" program.

2. Lots of interventions to keep drug prices as low as possible, some to be given out free as regular entitlements for the poor. Such interventions aside from MRP are the BnB, mandatory 20 percent discounts for senior citizens (RA 9994), generics promotion, etc.

I have argued in the past in this blog that drug price control policy -- forcing the more popular, more saleable branded drugs by the innovator and MNC companies to become -- contradicts and defeats the generics promotion policy, as people shift from the lesser known generics to the more popular innovator branded drugs. The DOH never took notice of this. Or they may, but the politics behind such policy declaration in 2009 has overtaken it and the politics of the current administration still prevails to keep that wrong policy.

3. BnB is a popular program that contributed to cheaper and more accessible medicines in more barangays or villages nationwide. Here are the relevant slides she presented.

But the program is also problematic not only in terms of maintenance but also because it is easily hijacked by the local politicians during elections. Now there are 16,350 BnBs nationwide (as of June 30, 2011) that cost the DOH P567 million so far, and there are variants, like Botika ng Manggagawa (workers' pharmacy), Botika ng Taumbayan (people's pharmacy). Seed capital is P50,000 per outlet, targetting 100 outlets or P5M.

4. The P100 or Compact Treatment program is tied up to the DSWD's 4Ps or conditional cash transfer (CCT) program, provided the poor are registed with the DSWD and are PhilHealth member under the sponsored program.

Makes one think, it really pays to remain poor forever for some people: free cash, free PhilHealth membership, super-subsidized medicines, free education, subsidized housing, etc. And since these programs have no titmetable, they are forever programs, why aspire to get out of poverty? Or why not pretend to be poor even if actual income has actually increased? But I digress....

5. Entitlement (or free) medicines program, at least for fixed number of beneficiaries: leukemia (ALL-L2), breast cancer (stages 1 and 2), anti-rabies, Vitamin A for pregnant women, TB (AFB smear, insulin (for diabetics), Fluids (for DOH hospitals), Valsartan (for hypertensive), Rotavirus (for 0-6 months old babies), BEMONC (for women of reproductive age).

6. Outpatient benefits (OPB) will soon be shouldered by PhilHealth, by 2016. This will be both good news and bad news. The good news is that all members, not just the sponsored or indigent group, will be covered by OPB; the bad news is that this will most likely require more or higher monthly contribution, both employers and employees.

These are the additional entitlement medicines. They will not just be "cheaper medicines" but "free medicines", for certain diseases.

7. Electronic drug price monitoring system (EDPMS), forcing drugstores, chain or non-chain, to regularly upload their drug prices to the DOH's EDP, to enable the consumers to compare prices of drugs among competing drugstores and pharmacies. I think this is cool, if the cost of compliance is low. If compliance cost is high, say for the small chain (2-3 stores) or single drugstores with a non-computerized system, this requirement means additional cost which they will have to pass on to the consumers, resulting in higher drug prices. The website of the EDPMS is http://uhmis.doh.gov.ph/eedpms.

In a free market situation, sellers develop their own brand and corporate image. Say drugstore chain A is very clean, all outlets are air-con, in strategic places and corner stores, have licensed pharmacists all the time, etc., and their drug prices are generally high. Drugstore chain B is also clean, all outlets are air-con, in malls, and their prices are a bit lower or higher than A. Drugstore chain C have cheap drugs but their outlets are non-air con, in less convenient areas, the staff may not be licensed pharmacists, etc. And so on. So people and consumers can expect certain drug prices even without checking the DOH's EDP and the internet. There is a tradeoff between drug prices and convenience, of being in a good brand or lesser-known brand drugstore.

There was a discussion and exchange after Dr. Farinas' presentation. Gov. Obet asked what constitutes "generic medicines" and "branded medicines". I followed it up by asking if all products of Unilab for instance, a domestic generic manufacturer, can be considered as "branded medicines" since all their products have brands (Biogesic and Tempra for paracetamol, for instance). NCPAM guys said Yes.

I shared what I learned from Lyle Morrel of Watsons, and from Joey Ochave of Unilab, that there are 3 types of generic drugs in the Philippines:

a. product-branded generics
b. company-branded generics
c. generic-generics.

Examples of (a) are Biogesic, Tempra, etc. (for paracetamol)
Examples of (b) are RiteMed, "Unilab yan", "Pharex yan", "Alagang Pfizer", etc.
(c) would have no product brand, only the name of the molecule, and a small label for the name of the manufacturer, its address, etc.

The Generics Law of 1988 actually referred to (c) only and would consider (a) and (b) as belonging to "branded medicines" already. The (c) constitutes a very small portion of Philippine pharmaceutical products, perhaps just 5 percent, or even less.

The discussion later shifted to lifestyle diseases. I am happy to hear that more NGO leaders now realize the need to focus on preventive healthcare as the bulk of DOH and LGUs' health activities are focused on treatment and curative healthcare. People are sick of various diseases,  government instantly think of medicines and how to make them more affordable, more accessible.

(To be Continued...)