UHC 20: Health Equality Will Never Happen

In most discussions about universal health care (UHC) in the Philippines and abroad, focus is on having health equality among people, to be provided by the government. While it is a noble goal, I think it is an unrealistic one and will result only in more public disappointment, even public anger.

There is transportation inequality, some drive a sports car, others drive an ordinary sedan, others drive a motorcycle while others do not even have a bicycle. There is education inequality, housing inequality,  food inequality, labor inequality, businessmen inequality, and so on. Inequality is everywhere, here and abroad, and most people can live with an unequal world, so long as their right to life (against murderers, abductors, etc.), right to private property (against thieves, destroyers of property) and other basic freedom are protected.

Health equality or near equality will never happen. For one, people have different abilities, priorities and ambitions in life. Second, people have unequal health input into their own body and family. Some prioritize alcohol or tobacco or junk foods over vegetables and other healthy food. Some prefer to live in dirty surroundings (with rats, mosquitoes, other pests) just to be near something that is important to them, like near workplaces. 

If people look up to government as the implementer of health equality, they will be in for a big disappointment. As I posted in my previous blog posts, when I was working at the House of Representatives (1991-1999), we have three forms of health insurance: (a) Medical and dental clinic inside with a phalanx of full time doctors, nurses and dentists, with free medicines; (b) HMO coverage (Intellicare that time, I don’t know now) that conducts annual medical check up,  can cover both outpatient and hospitalization expenses, and (c) PhilHealth membership and contribution. I am sure this multiple health insurance is done also at the Senate, SC, BSP, Malacanang, DND, DepEd and many other departments and govt corporations. Also in big LGUs like provincial capitols and big city halls.

Many poor people especially in rural areas do not have even one of these. They may have access to a rural health unit but there are no full time doctors there, no free medicines.

To have UHC, what is important is that everyone should have a health insurance card, but it does not mean that it should be a government-monopolized service. Give people choices where they want to get their HC provider. Take the case of Switzerland:

There is no state monopoly. So you can choose an insurance group which is connected to your line of work. Or you could go with a trade union-run insurance co-operative. Or a private, commercial company. That means there is some competition among these companies to provide the best possible service for the lowest possible price. Then these companies, in turn, have some choice over which doctors and hospitals they commission to work for them. So again, the doctors and hospitals have to compete to offer the best facilities and treatment at the lowest possible cost. Poorer people get credits which enable them, too, to choose insurance.

(See Healthcare competition 1: Switzerland)

There should be competition among different healthcare providers, not monopolization by the national or central government. Where there is competition, people have choices, HC providers are under pressure to provide value for money.  In a nationalized, monopolized and politicized structure like PhilHealth, they exaggerate enrollment but cover as few as possible, or for those covered, to pay as little as possible. There should be surplus somewhere to cover political patronage elsewhere.

Thus, If we wish to have real UHC, there should be more competition, not more consolidation and monopolization. We are actually moving at the wrong track.

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PhilHealth held a national public consultation on the draft Implementing Rules and Regulations (IRR) of the new PhilHealth law last September 06, 2013 at Crowne Plaza Hotel, Ortigas. I attended it.

The IRR proposes to raise the mandatory monthly contribution from 2.5 to 5.0% of the monthly basic pay of those in the formal sector, 2.5% contribution each from employers and employees. This hike in mandatory salary deduction causes anxiety to many workers and employers. Then there are plans to hike also the mandatory SSS monthly premium or contribution, possibly in PagIBIG too. On top of regular hikes in the minimum wage.

Government is making hiring of people in the formal sector become more expensive. If it is expensive to hire workers, less hiring of workers will happen. Instead of hiring 10 workers, companies will hire only 2 or 3 multi-skills people, give them gadgets and pay them 2x or 3x the min wage. The other 7 or 8 people, they can try their luck elsewhere. Or be employed in the informal sector with no min wage, no SSS, PhilHealth, etc.

I respect Doc Quasi and the rest of the UHC Study Group (Docs Domingo, Paterno, etc.). But their advocacy of health equality and centralized, monopolized HC provision will never happen. 

Health Transparency 11: MeTA Philippines and Multistakeholder Process

The Medicines Transparency Alliance (MeTA) Philippines and its multi-stakeholder process and dialogues, along with the DOH Advisory Council on Healthcare (ACH), are the best venues that allowed me to get involved in many policy discussions and even debates on various health issues with various players and stakeholders in this country.

I began writing on health topics in late 2007 after the Symposium on Intellectual Property, Innovations and Health in early September 2007 at Manila Hotel, jointly sponsored by the International Policy Network (IPN) and Minimal Government. I produced lots of blog posts and oped articles in various newspapers, here and other papers in Asia, thanks to IPN media network, on health, especially on intellectual property rights (IPR), drug patents and compulsory licensing, in 2008.

In January 2009, I was invited by the DOH to a first meeting by the Advisory Council. I also invited by Ms. Klara Tisocki, previously with the EU and now with WHO, WPRO, to participate in the MeTA Civil Society Organizations (CSO) mapping two-days workshop. I missed the DOH Advisory Council meeting and the first day of the CSO mapping because I was in Singapore then, in a meeting with fellow free market leaders in Asia.

I was able to attend the 2nd day of the CSO mapping, I was glad to meet the various NGO leaders who were often in the news then because of their involvement in the discussions of the Cheaper Medicines Law or RA 9502, that was enacted in June 2008. I was in the US for the Atlas Liberty Forum when the law was signed that day.

Anyway, I was able to attend the 2nd MeTA National Forum, a 3-days event after the 2-days CSO mapping. I was amazed at the big audience and the wide range of topics that covered not only medicines policy but also other health issues. The officers of MeTA Philippines at that time were former DOH Secretary Alberto "Quasi" Romualdez as Chairman, former Bulacan Governor and former PITC President Roberto "Obet" Pagdangan as Chairman, and Dr. Kenneth Hartigan-Go as Secretary General.

Since then, I got involved in the formation of the Coalition for Health Advocacy and Transparency (CHAT), the civil society partner of MeTA Philippines, as well as other MeTA fora and discussions.

Below, during the MeTA National Forum in January 2010. This is the press conference made while there were on-going panel discussions. Second photo, from left: Nancy Tacandong, acting FDA Director at that time; Gov. Obet, Doc Quasi, Wilbert Bannenberg, the Technical Consultant of MeTA in London, and Reiner Gloor of PHAP.

Group photo also during the 3rd MeTA National Forum. It was a 2-days forum, also held at Diamond Hotel. I attended this forum but I don't think I joined that group photo. I got this from the MeTA website, http://metaphilippines.org.ph/.

Lower photo is another two-days MeTA forum on universal health care (UHC). I was able to attend this too, held at the Ramon Magsaysay Center.

More multi-stakeholder discussion workshops by MeTA sometime in March 2010. I was not there. Lower photo, I like that shot of a friend, respected academic and immediate past Director of FDA, Doc Suzette Lazo, speaking, nice.

We also have several discussions on our own in CHAT, photos below. MeTA Philippines alloted a separate budget for CHAT to conduct various health education and discussion activities.

I am thankful for the nth time, to MeTA Philippines and its multi-stakeholder process in policy discussions. Many members of the MeTA Council are also members of the DOH ACH. They have different agenda topics though as the latter is focused more on policy advice on certain issues to the DOH Secretary while those of MeTA are topics that each member and organization representatives should do in collaboration with each other.

The current officers of MeTA Philippines since about two years ago are Gov. Obet as Chairman, former DOH UnderSec and now PhilHealth VP Alex Padilla Unilab VP Joey Ochave as Vice Chairman, Cecille Sison of HealthWatch as Secretary General, and former PPhA President Normita Leyesa as Treasurer.

Recently, MeTa decided to expand membership of the Council. They will also be charging annual membership fees to members, both as organizational representatives and as individuals. For me this is a good move. A civil society organization like MeTA Philippines, should be able to raise funds internally through annual dues and other activities, and be less dependent on assistance from UK's Department for International Development (DFID) and WHO.

There is an expanded meeting this afternoon, I shall be attending it.
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See also:
Health Transparency 6: Physician Protectionism, May 19, 2012
Health Transparency 7: DOH Advisory Council, CHAT, June 04, 2012
Health Transparency 8: Advisory Council on RA 9502, June 11, 2012
Health Transparency 9: Physician Misdiagnosis, Dispensing Medicines, July 20, 2012
Health Transparency 10: Depoliticizing Health, Corporatizing Government Hospitals, September 18, 2012

Socialized Healthcare 6: Student Debates, Charity Beds and UHC

There is some positive twist in healthcare discussions in the country these days. And that is involving more non-healthcare students and professionals in various healthcare debates. Reiner Gloor of PHAP reports below that some 50 debate teams from different local universities will debate on various health issues, from no balance billing to corporatization of government hospitals and more, starting this month.

I am particularly interested how today's university student debaters would consider personal and parental/guardian responsibility in the overall healthcare discussions and public policy formulation. And how they would consider limiting government role in  dealing with infectious and communicable diseases like dengue. I just read today that for the first eight months of 2012 alone, some 74,784 people, mostly children, were hit by this mosquito-borne disease, with 448 deaths. This is 17.5 percent higher than last year's same months level.

A daughter of a friend who is a godfather to my second daughter, was admitted in a hospital the other day due to dengue. The son of another friend' also got that disease and was hospitalized for a week. These are middle class families who do not live in dirty places with many stagnant water. This disease which currently has no existing vaccine yet, is really nerve wracking for parents and other family members.

Anyway, former DOH Secretary Alberto Romualdez also discussed some of those health issues in his column. The three papers I am reposting below are:

1. Let's talk about health
2. The Secretary's Cup -- both by Reiner Gloor
3. Charity Beds and Universal Health Care -- by Alberto Romualdez

Enjoy.
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(1) Let’s talk about health

Posted on 05:53 PM, August 16, 2012
Medicine Cabinet -- Reiner Gloor

http://www.bworldonline.com/weekender/content.php?id=56923

Creating a forum where ideas are challenged and differences resolved through critical thinking and rational arguments, not force, is one of the goals of competitive debates.

Towards this goal, the International Debate Education Association (IDEA) was established and has recently named five Filipino universities in its top 100 debate societies in the world. They are the Ateneo de Manila University, the University of the Philippines (UP) Diliman, UP Manila, the Far Eastern University and De La Salle University.

Debates aim to raise discussions of opposing views to help the public in making informed decisions on critical issues. And one of the important issues involves health.

While significant milestones on health have been achieved, overall health outcomes and goals can be improved. In many cases, the fundamental problem lies with the broader health system and its ability to deliver interventions to those who need them, observed the World Health Organization (WHO). The same is true for the country and thus, health system strengthening is very much in order.

Beginning this month, 50 teams from various schools will be competing in a nationwide inter-collegiate debate on the so-called building blocks of a health system. Each month, the debate topic will be based on a specific building block namely governance, regulation, service delivery, human resources, information, and financing.

The debates are part of the Secretary’s Cup initiative being led by the Department of Health (DoH) and the Universal Health Care Study Group of the UP-National Institutes of Health, along with partners including the Pharmaceutical and Healthcare Association of the Philippines. The series of health debates will be examining the state of health of Filipinos while at the same time seeking to explain the role of universal healthcare as the more comprehensive path to attaining health for all.

For August, the participants are gearing to debate on governance issues. Former health secretary Alberto Romualdez will open governance month while Department of Local and Interior Government Secretary Jesus Robredo will join in public discussions.

Health Transparency 3: MeTA Forum January 2010 (Prevention vs. Medication)

The “3rd MeTA Forum” is on-going, January 26-27, at Diamond Hotel, Manila. It is sponsored by the MeTA Philippines.

I attended day 1 yesterday, and the topics were some updates on what MeTA International and MeTA Philippines have achieved so far in making medicines become more accessible to the poor. Other topics were procurement of essential medicines by the public sector (DOH-affiliated hospitals, local government units), and financing of such medicines.

There is a long and expanded discussion on medicines, their high prices compared to some Asian countries, the shenanigans in public procurement of medicines, other curative aspects of healthcare. Buried or not even mentioned in the discussions, is the preventive aspect of healthcare.

When people live in dirty places, say under a bridge or a creek with stagnant water, or shrubby areas that attract mosquitoes and various insects, people there, especially children, will be susceptible to various types of diseases. Or when people don’t observe proper hygiene like washing their hands well before eating. Or when people over-drink, over-smoke, over-eat fatty food, and so on.

So when people become sickly, the eyes of the public and political leaders are on medicines and the pharmaceutical companies that produce medicines.

Anyway, this is a forum by an organization with explicit and categorical mission to make access to quality medicines be easier to the poor. So we stick to the subject.

What I find rather strange, if not hypocritical, is the continued insistence that various government units, national and local, should be in the business of medicine procurement and distribution to the poor.

Last year in the 2nd MeTA Forum, there was a speaker from WB-Manila who documented instances of many drug warehouses by some big LGUs in the country – where rats, cockroaches, dust and garbage mix up in one room with useful drugs and expired drugs, and the room has no temperature control. In this case, even if we assume that there was no corruption and robbery in drug procurement, the big problem is the quality and efficacy of those medicines that LGUs will distribute to the public.

Yesterday, there was a session where speakers noted that drug procurement prices by government units are several times higher than those in a number of Asian countries. Which point to either, (a) certain government personnel are bloating their procurement amount so they can pocket and steal more money, or (b) pharma companies here, especially the multinationals, tend to price their products a lot higher in the Philippines than in other Asian countries. Or both happened.

If the main explanation is (a) above, then it’s one clear case of government failure, happening persistently. Then there should be some persecution of guilty parties in order to send a strong signal to other government personnel that stealing is heavily penalized, not forgotten. Then corruption in public procurement will be drastically reduced, if not controlled.

If the main explanation is (b) above, then it’s one clear case of the lack of competition among pharma companies, foreign and local. One policy implication is to encourage the entry of more players, both foreign and local, both manufacturers and traders (wholesalers, retailers).

Sadly, public policy actions in either (a) or (b) are not being done. Public procurement continues, foreign loans by the WB and other foreign aid institutions continue, poor health outcomes in the public continue, and endless taxation to pay for ever-rising expenditures and public debts on drug procurement and related healthcare items, continue.

So what is the result, the state of public health, especially the poor people, remains generally unchanged while public debts and taxes keep rising?

Cheap But Not Available

A presentation by Dr. Delen dela Paz of Health Action Information Network (HAIN) and also a faculty member at the UP College of Medicine, she mentioned one result of the HAIN medicines survey in 2009: essential generic drugs' prices in public drugstores are about 1/3 than prices in private drugstores. So many poor people go to government-run or sponsored "botika". Problem is that availability of such cheap drugs were only 31% in public outlets vs. 61% availability in private drugstores.

So, the hard lesson: cheap, yes, but less or not available.

Which is better: more expensive but available vs cheap but not available? If one is very sick, then price becomes a secondary issue compared to availability of a product that can make him/her well.

And this is one long-term effect of drug price control that advocates of the measure, including those in the government, seem not to realize: more effective drugs, more disease-killer medications, will theoretically be sold "cheaper" in the Philippines. But their availability is zero. Manufacturers and sellers of those drugs will sell such products in Singapore or Hong Kong or Japan or other Asian countries which have no drug price control policy, and not bring such products in countries where a price control is being implemented, or pulled out but can be re-implemented anytime, depending not on any health emergency, but on certain political emergencies of the big politicians and the administration in power. So desperate patients will be forced to purchase such drugs abroad, at a more expensive price because of the cost of shipping and storage.

Meanwhile, MeTA PHilippines leaders gave a press conference. Dr. Alberto Romualdez, former DOH Secretary and currently MeTA Philippines chairman, said that "More than half of the country’s annual expenditures for health products ranging from P100 billion to P150 billion are unnecessary because they hardly provide any therapeutic effect", see here, http://www.philstar.com/Article.aspx?articleId=544389

This is related to "irrational drug use" issue. People are buying medicines and vitamins even with little or no proven therapeutic effect simply because such drugs are cheap, or are heavily advertised (broadcast media, outdoor billboards, etc.).

One big local pharma company is the heaviest spender on drug advertising in the country.