UHC 16: Dialogue on UHC and Medicine Access, AIM July 25-26

The Department of Health (DOH), Philippine Health Insurance Corporation (PHIC or PhilHealth), FDA and the AIM Dr. Stephen Zuellig Center for Asian Business Transformation (AIM ZCABT) will hold a policy dialogue tomorrow and on Friday, on “Universal Health Care and Access to Medicine” at the Asian Institute of Management (AIM), Makati City.

I received the invite only today when the DOH National Center for Pharmaceutical Access and Management (NCPAM) extended the invite to all members of the DOH Advisory Council for the Implementation of RA 9502 (Cheaper Medicines Law of 2008). Thanks to Mhyanne Dioso, the chief “workhose” of NCPAM for the Advisory Council, aside from NCPAM Director, Doc Virgie Ala.

The main objective of the seminar is “to identify the gaps and solutions in ensuring universal access to medicines in the Philippines” and hence, contribute to attaining universal health care (UHC) or Kalusugan Pangkalahatan.

The DOH’s budget has been rising big time in recent years: from only P18.9 billion in 2008, marginally rising to P23.7 billion in 2009 and P24.6 billion in 2010. When the PNoy Aquino government came, the DOH budget jumped to P31.8 billion in 2011, P42.1 billion in 2012, to P52 billion this year. Next year, the DBM-approved budget that was sent to Congress is P87 billion, or a P35 billion jump over this year’s budget.

A big portion of such huge jump in the proposed spending next year will be used to cover more poor households in PhilHealth insurance system, as the President said in his State of the Nation Address (SONA) last Monday. And medicine procurement by DOH hospitals and other agencies will likely get a big boost too.

Please note that public health spending in this country does not only come from the DOH. There are also the LGUs through their provincial, city and district hospitals, provincial and city/municipal/barangay health centers. Then other government agencies like the AFP Hospital, Veterans (under the DND) hospital, PNP Hospital, UP-PGH, PCSO ambulances and health charities, and so on. And almost all departments and agencies have their own in-house clinics for the healthcare of their employees and their dependents. There is huge public spending in healthcare and many people do not realize it, so they ask for more subsidies through the DOH and PhilHealth.

Back to the forum tomorrow. Among the speakers will be DOH Secretary Enrique T. Ona, DOH UnderSec. Madeleine “Madz” Valera, PhilHealth President and CEO Alexander “Alex” Padilla, FDA Dir.- General Kenneth Hartigan-Go, and Mr. Deejay Sanqui of IMS Health.

I hope that Sec. Ona will give an overview of the big DOH budget next year seeking approval by Congress. It seems that the “creeping re-centralization” of healthcare is no longer creeping but already hopping. Healthcare is among those functions by the national government that were devolved and decentralized to the LGUs under the Local Government Code of 1991.

I also hope that PhilHealth President Alex will not announce another round of hike in annual premium, especially for those in the formal sector. PhilHealth hiked plans to hike the premium from 2.5 to 3.0 percent of the basic salary of those working in the formal sector just a few years ago. The premium of OFWs has been raised from P900 to P1,200 per year and the sponsored program, the poor, from P1,200 to P2,400 per year, but the poor do not pay this amount, the LGUs and/or the DOH do.

My advocacy for minimal government in healthcare does not include healthcare for pediatric diseases and infectious diseases for both children and adults. I support further DOH and LGUs spending for these two types of diseases. But I do not support more government subsidy for NCDs for adults. If people have money to buy lots of fatty/salty food and drinks, lots of alcohol and tobacco products, or nice flat tv and DVD players and become couched potatoes, and they become sickly later, they should also have the money to buy private health insurance to augment their PhilHealth insurance. To say that they have no money for their own healthcare while they can spend for those food, drinks and smoking, is simply “palusot” and must be checked.

PhilHealth I think, should prioritize issuing automatic membership card for all poor children, say 6 years old and below. If DOH and LGU resources cannot support automatic coverage for older children and parents from poor households, then other agencies like DSWD, PCSO, UP PGH, private charities and foundations can come in. But usually LGU hospitals provide universal coverage for their local residents, young and old alike.

Tomorrow afternoon panel discussion will be on “Innovating and Improving Access to Medicine via Good Governance” with Tarlac Gov. Victor Yap, Gov. Alfonso B. Umali, Jr. of ULAP, Ms. Esther Go of Medilink, and Dr. Peter Glen Chua of FDA as speakers.

The role of LGUs is important in this aspect as lots of waste if not corruption in medicine procurement and distribution happen at the LGUs level. Many LGUs do not have the proper training and expertise in the proper storage and dispensation of medicines given free to their local residents.  

On Day 2, July 26, there will be a panel discussion on “4Ps of Financing Pharmaceuticals”: Rational Pricing, Tailored Procurement, Strategic Purchasing, and Risk Pooling, with four speakers:

Dr. Melissa Guerrero of DOH-NCPAM, Mr. Bienvenido Bautista of PITC Pharma, Inc., Dr. Dennis Ross-Degnan of Harvard Medical School, and Dir. Carlos Da Silva of AHMOPI.

NCPAM has a big budget for medicine procurement for “drugs entitlement” on certain diseases like breast cancer. PITC Pharma is the state’s chief drug importer and wholesaler for the various DOH-sponsored Botika ng Bayan, Botika ng Barangay, and other DOH agencies.

I am curious about the lectures on various topics like the ASEAN Pharma Harmonization, Anti-Microbial Resistance (AMR), Drug Price Referencing, PPP to Improve Access to Medicine, and PHIC and PCB 2. The  speakers will be Ms. Joyce Cirunay of FDA, Dir. Virginia Ala of DOH-NCPAM, Mr. Alex Haasis of NCPAM, Dr. Anthony Faraon of Improving Access to Medicine Project, and Dr. Francisco Soria of PHIC.

We shall have an ASEAN Economic Community (AEC) in 2015 or less than two years from now. The ASEAN Free Trade Area (AFTA) will mature, meaning zero tariff for all imports from any ASEAN member-countries, except perhaps for poorer economies Myanmar, Cambodia and Laos who might slap import tariff on some imported products from other ASEAN countries.

Singapore is the regional headquarter of many innovator pharma companies, not only because it is a regional financial center at par with Hong Kong, but also it strictly respects IPR like patent and trademark. Thus, IPR-busting policies like compulsory licensing of new and patented medicines, and drug price control are not done there. An ASEAN harmonization plan will consider this disparity in IPR and drug pricing policy. Many ASEAN countries like the Philippines, Thailand, Indonesia, Malaysia and Vietnam have laws allowing CL or similar schemes, and drug price control policy. Singapore does not have such policies.

Another learning experience for me in the next two days in health economics and public policy.

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See also:

Socialized Healthcare 12: Nurses, Doctors and Other Resources, March 03, 2013

Socialized Healthcare 13: On Inequality and Inclusive Business in HC, March 19, 2012  

Socialized Healthcare 14: Over-extending Government Role in Health, May 22, 2013 

UHC 15: On DOH Plan to Recentralize Healthcare, June 27, 2013

Socialized Healthcare 13: On Inequality and Inclusive Business in HC

Two weeks ago, I attended this forum at the Asian Institute of Management in Makati, sponsored by the AIM-Zuellig Center for Asian Business Transformation, ACCESS Health, ASSIST and Globe Telecom.  Perhaps a coincidence, another forum that same day, same time, was held in Discovery Suites in Ortigas, about "inclusive democracy" starrring the UN and other groups. And this forum is about "inclusive business" starring the ADB and other groups.

Dr. Moser showed several slides how inequitable the Philippines' healthcare system is.  The Under 5 years old mortality rate (U5MR) is high in the lowest quintile of the population, and skilled birth attendance is highest in Metro Manila and other Luzon regions and provinces, and lowest in Mindanao regions. For the total healthcare expenditure (THE), more than half came from out of pocket or personal and household spending.

Health sector spending here refers to DOH budget only.

Financial protection by income. The two poorest quintiles are protected by the government, national and local, while the middle class and richer groups have private health insurance, on top of their PhilHealth membership contribution as this is mandatory especially for those in the formal sector. Ms. Moser's next slide is interesting. Many if not all ASEAN countries have strong private sector presence in healthcare even though their governments' health spending is substantial. Any discrepancy between actual spending and actual delivery can be attributed to bad governance and/or corruption.

Healthcare Monopoly 6: Cuba Socialism

Cuba's healthcare socialism is being touted by some health NGOs and academics here as a possible "model" for the Philippines. They like the service monopolization and big spending on healthcare by the socialist government there.

Among those who gave praises for the Cuban state monopoly "political will" in healthcare was Dr. Reynaldo Garcia, a life scientist academic and manager of technology and innovation at the same time. He is  the Director of the Technology Transfer and Business Development Office of the University of the Philippines (UP) System and a Full Professor at the National Institute of Molecular Biology and Biotechnology in UP Diliman. He got his PhD in Molecular Biology at the Australian National University (ANU) and his business degree (Master’s in Bioscience Enterprise) at Judge Business School and the Institute of Biotechnology of the University of Cambridge in England. 

During the 9th Science, Technology, Innovation, Knowledge and Entrepreneurship (STIKE) Kapihan Series on the subject, Technology Transfer and Healthcare last September 27, 2012, at the Asian Institute of Management (AIM) organized by the Dr. Stephen Zuellig Center for Asian Business Transformation, Dr. Garcia showed these slides below, among others.. My discussion of his talk on tech transfer and IPR is here, IPR and Medicines 25: Patents, Diagnostics and Technology Transfer (October 08, 2012).

The four charts show that (a) illiteracy rate in Cuba declined fast, (b) infant mortality as of 2000 was as low as that in the US, (c) physicians per capita is more than double that in Latin America and the US, and (d) life expectancy at birth similar to that in the US as of 2004. Lower photo shows free healthcare in Cuba.

Dr. Garcia also said that Cuba has the biggest biotech facilities in the developing world. There was no year indicated, but I think this was in late 2000s level. In terms of vaccine development, Cuba was also high tech.

And more vaccine R&D capacity, as of 2007. Cuba is known for good quality cigar exports, smoking is prevalent, so its government developed a vaccine against lung cancer.

I have high regard for the academic and professional credentials of Dr. Garcia but I cannot agree with him do not think that state monopolization of various health services -- from medicines and vaccine innovation and invention to hospitalization care -- is a good thing. Here now are my comments to Dr. Garcia's points above.

One, the good health indicators in Cuba at least as of 2004, do not match with its economic development or degree of industrialization. So data sources may be suspect, not indicated in his slides.

Two, assuming that the high physicians per 1,000 population data is correct, more than twice that of the US, I think Cuban government hospitals may simply be bloated with many doctors relative to number of patients. They could be mostly general practitioners with very few specialists.

Three, free healthcare is being done in many developed economies with nationalized or government monopolized healthcare system, and the result is almost always the same: demand is much much larger than supply, resulting in either (a) healthcare rationing like some patients waiting for days, weeks or even months to get free healthcare, (b) lousy services like seeing patients only for two or five minutes, write drug prescriptions then call the next patient, and/or (c) huge fiscal deficit and public debt as healthcare is a bottomless pit of spending. Cuba could be suffering from any or both of such malady.

Four, it is good news that the Cuban government has invested in medicines innovation and almost surely, generic production. But not being subjected to competition and international healthcare accountability system, I doubt if cases of adverse drug reactions (ADR) and similar problems are being appropriately addressed, like drugs recall and compensation of the adversely affected patients. Patients have no or little options anyway, there is only the government as sole drug distributor and/or manufacturer.

In contrast, in a competitive environment, if an innovator company produces a new drug, supposedly effective but has several ADRs and side effects, the company does not wait for huge public outcry or multiple lawsuits, it has to recall and pull out such immediately before more damages can happen and its entire corporate brand will be destroyed.  

In some reports though, hundreds of Cuban doctors have been migrating to other countries. From The Vincenton Post,

In 1998 there were already 400 Cuban doctors practicing medicine in South Africa’s rural areas. By 2004, there were about 1200 Cuban doctors working in African countries, including inAngola, Botswana, Cape Verde, Côte d’Ivoire, Equatorial Guinea, Gambia, Ghana,Guinea, Guinea Bissau, Mozambique, Namibia, Seychelles, Zambia, Zimbabwe, andareas in the Sahara.” (Source: Perez, L.A., Krull, C. and Marino, S.C., 2010, Cuban Studies 41. PA: University of Pittsburgh Press, pp. 92). 

Meanwhile, Venezuela's dictator Chavez is drying of cancer in a Cuban hospital. From the Investors.com, Hugo Chavez Hit by Cuba's Surgical Strike.

In July 2011, during (a)... summit in Caracas, Brazil's President, Dilma Rousseff, told a few of her colleagues — in private — that Chavez was likely to die as a result of 'his excessive paranoia rather than as a consequence of his serious — yet treatable — cancer,'" wrote Venezuelan consultant Pedro Burelli in a newsletter.

"What she meant to say," Burelli added, "was that by choosing secrecy in Cuba over medical competence at the Sirio-Libanese Hospital in Sao Paulo (where she had been treated successfully for lymphatic cancer) Chavez had condemned himself to a shorter life."

Burelli noted that it corresponded to his own sources, who told him that Chavez's chosen successor, Foreign Minister Nicolas Maduro, flew to Brasilia to meet with Rousseff and her oncologist.

He presented the diagnoses from Caracas and Havana and the Brazilian specialist "considered it treatable under world-class protocols available in his center."

Maduro signaled interest. But the Chavista regime then demanded to pretty much take over the 400-bed hospital, which the Brazilians rejected. "From that moment on the patient was doomed," Burelli wrote....

Too bad for Mr. Chavez, He's got lots of money from petroleum socialism and when he became seriously ill, health socialism in Cuba may not be able to save him. Another news from yahoo: 
Cuba to free doctors from onerous travel rules

By Andrea Rodriguez, Associated Press | Associated Press – Tue, Jan 8, 2013

HAVANA (AP) -- Cuba is eliminating longstanding restrictions on health care professionals' overseas travel as part of a broader migration reform that takes effect next week, an island doctor told The Associated Press on Monday.

Hospital directors learned of the new policy, which takes effect Jan. 14, in a Saturday meeting withHealth Minister Roberto Morales and word of the change was relayed in hospital staff meetings, according to the doctor, who attended one of the subsequent gatherings.

The minister's directive: "A doctor will be treated like any other citizen starting now and can exit freely, as long as the destination country allows it" by issuing an entry visa, said the physician, who spoke on condition of anonymity because he was not authorized to talk to foreign journalists.

"Apparently it has been completely repealed," he said. "No restrictions of any kind.

By indirectly imprisoning many Cuban doctors in their own country, their government has prevented them from acquiring more training and specialized education with more foreign practitioners, using more modern facilities, medications and other  treatment. 

I hope that more economic freedom for their people like free mobility across countries will be tolerated by the Cuban socialist leaders. Similar one-party system China and Vietnam already allow this.

Ultimately, I hope to see more political, economic and personal freedom be experienced by more people around the world. Especially from the clutches of dictatorial and totalitarian governments.
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See also:

Healthcare Monopoly 1: France and Canada September 05, 2010
Healhcare Monopoly 2: United Kingdom, February 17, 2011
Healthcare Monopoly 3: China, July 20, 2011
Healthcare Monopoly 4: Taiwan's NHI, December 05, 2011

Healthcare Monopoly 5: Canada, April 09, 2012

Climate Tricks 17: STIKE Forum on CC

I attended this lecture this week, October 23, at the AIM. The five lady speakers all have good if not outstanding academic credentials. When I received the email invite from the organizers two weeks before the event, I asked them if they also have a forum that will debate, not sing alleluiah, over this anthropogenic (or "man-caused" or "man-made") global warming (AGW) and climate change (CC). I added that it is a huge scam, a scheme towards global ecological central planning. And whether there is less rain or more rain, less snow or more snow, less storms or more typhoons, less dogs or more dogs, they are all proof of AGW/CC. The proponents and campaigners of this claim, led by the UN and Al Gore, are simply intellectually dishonest and rent-seeking. 

Dr. Alyssa Alampay got her PhD (Earth Sciences) from Scripps Institute of Oceanography, University of California, and is currently teaching at the UP National Institute of Geological Sciences (NIGS).

Dr. Laura David got her PhD (Physical Oceanography) also from the University of California, and currently teaching at the UP Marine Science Institute (MSI).

Dr. Raquel Fortun got her MD and now teaching at the UP College of Medicine, Department of Pathology. She is well known in Forensics science, consultant for criminal cases.

Dr. Corazon Claudio got her MS and PhD (Engineering-Econ Systems/Management Science and Engineering) from Stanford University. Currently President of the EARTH Institute.

Dr. Catherine Yu got her Ed. D. (Math Education) from the University of Georgia. TOWNS President, she is teaching at the Math Department, Ateneo de Manila University. 

IPR and Medicines 25: Patents, Diagnostics and Technology Transfer

We need patents and other intellectual property rights (IPR) to encourage innovation in medicines and  diagnostics. We need to link academic research with industry players and manufacturers to share the risks and rewards of innovation, to transfer technology from the academe to the consumers and patients. We need government political will to succeed in strengthening academic and industry research and development.

These are among the key messages shared by Dr. Reynaldo Garcia in his talk at the 9th Science, Technology, Innovation, Knowledge and Entrepreneurship (STIKE) Kapihan Series on the subject, Technology Transfer and Healthcare last September 27, 2012, at the Asian Institute of Management (AIM). The event was organized by the Dr. Stephen Zuellig Center for Asian Business Transformation. There were many participants who came, mostly from the Food and Drug Administration (FDA), DOH and AIM faculty members.

Dr, Garcia, above photo speaking, is a cool guy, a life scientist and a manager of technology and innovation at the same time. He is currently the Director of the Technology Transfer and Business Development Office of the University of the Philippines (UP) System and a Full Professor at the National Institute of Molecular Biology and Biotechnology in UP Diliman. He got his PhD in Molecular Biology at the Australian National University (ANU) and his business degree (Master’s in Bioscience Enterprise) at Judge Business School and the Institute of Biotechnology of the University of Cambridge in England, in collaboration with the Massachusetts Institute of Technology’s Sloan School of Management. Very bright guy, also very articulate and eloquent speaker.

Below are portions of his presentation that day. See the role of patents and other IPRs in protecting innovation.

From universities to markets and patients. This is a key message that Dr. Garcia said he keeps repeating even to UP natural scientists. There is a tendency among UP and other local scientists, even those who were trained abroad for their graduate and doctorate studies, to be suspicious and skeptical of the pharmaceuticals, IT and other sector (local and multinationals) players and manufacturers. So they do not share their academic research work and keep many of such to themselves and their academic departments. If ever they wish to share, they themselves want to develop and market their own invention, something that Dr. Garcia said is definitely not practical and viable. And rightly so.

Health Transparency 5: Forum on Good Governance in Health

Government (local and national) procurement of medicines, medical equipment and other supplies, hiring of health professionals and consultants, are among the problematic and not-so-inspiring stories in the country.

During the MeTA 2nd National Forum in late January 2009 that I attended, I observed and posted this:'

.... Second, medicine storage and warehousing by local governments for their constituents. A presenter from the WB showed some of his findings, complete with pictures: dirty warehouses, rodents, garbage and medicines mix up in one room. Warehouse personnel who do not make a regular inventory of medicines, how many have been disposed, how many are left, how many and what drugs are expired. Warehouses that do not have temperature control; one warehouse has a thermometer, fine, but the room temperature is several degrees hotter than the required minimum temperature for proper storage of some medicines. Some local health personnel release and give away expired drugs.

My proposal on this is that those warehouses by local government units (LGUs) should be closed down, LGUs can issue vouchers to their poor and needy constituents, the latter will go to government-accredited Botika ng Bayan or Botika ng Barangay to get the medicines, and the LGUs will pay those drug outlets later. There will be no need for LGUs and DOH then to train personnel for medicine procurement, warehousing, storage and inventory as internally proposed (using WB loans or additional budget appropriations) as these skills are already available in those government-accredited drug outlets. The comparative advantage of LGUs is politics and more politics, not efficient health care provision....

See, Health Transparency 1: MeTA Forum January 2009, January 26, 2009.

I actually expected the WB to demand major reforms in LGU procurement of medicines as the WB is a major lender to the government's health programs. But until now, I did not see or hear the WB, or ADB and other multilaterals, or the Department of Interior and Local Government (DILG), installing strict checking mechanisms to prevent the above wastes.

Ensuring good governance in health is an important and continuing challenge for the DOH and LGUs. Of course my personal policy bias is towards less governance in health, to assign more personal and parental/guardian responsibilities in healthcare to focus more on preventive than curative healthcare. But I digress.

This coming March 26, 2012, two big centers at the Asian Institute of Management (AIM), the Dr. Stephen Zuellig Center for Asian Business Transformation and the Hills Program on Governance will jointly sponsor the Good Governance in  Health forum. This is what the organizers wanted to achieve:

The key to providing concrete solutions against corruption is to maintain a consultative and cooperative relationship between stakeholder representatives and the government. This involves building stronger ties between health regulatory agencies and institutions concerned with fighting corruption and promoting good governance.

Following the mapping exercise on corruption cases and ethical dilemmas present in the delivery of health services in the Philippines, the second phase of the GGH program will involve the formulation of solutions and gathering of best practices in response to the identified cases. These solutions will be translated to the health sector through an extensive advocacy campaign, which includes capability-building workshops directed toward the promotion of anti-corruption practices and good governance in the Philippine health sector.

Representatives and key players from five sectors were targeted to participate: (a) local governments, (b) health regulators, (c) social health insurance, (d) commercial enterprises, and (e) medical practitioners.

I'm sure other sectors and players, like the huge health NGO community, will get jealous why they will not be invited  in this activity. But the organizers are facing a budget constraint and can accommodate only a limited number of participants. It is a by-invitation only event and not open to the public.

Former National Treasurer and former UP NCPAG Dean Leonor "Liling" Briones will be one of the few speakers. The bulk of the activity will be the workshop among the participants.

I remember there was one meeting by MeTA Philippines, about the result of the WB-funded assessment of government procurement of medicines for selected hospitals (LGUs, DOH-affiliated, and the AFP hospital). Some of the figures presented were harrowing, as some government hospitals have procured at 10x or higher the given drug reference price. So if people think that central procurement by government of medicines and other medical supplies will result in lowering of prices, think again, it can be the opposite. The corruption culture in the government is still alive and kicking and so, cost maxmization instead of minimization, is what usually happens. The thieves and corrupt officials in various agencies will have little leeway to siphon off money to their pockets if they will procure at low prices, so the tendency to bloat the prices of procured medicines and/or other medical supplies.

Promulgating the rule of law -- the law against stealing and robbery in government and putting guilty parties to prison -- is the main solution to this and related problems. But this is easier said than done. So I hope that certain solutions and check-balance mechanisms that are more easily implemented, can be extracted from among the participants in this forthcoming forum.
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See also:
Health Transparency 1: MeTA Forum January 2009, January 26, 2009
Health Transparency 2: CHAT Discussion and Debates, June 15, 2009
Health Transparency 3: MeTA Forum January 2010 (Prevention vs. Medication), January 27, 2010
Health Transparency 4: Drug Promotions and Government, September 03, 2010