Health Transparency 2: CHAT Discussion and Debates

Last January 19-20, 2009, the Medicines Transparency Alliance (MeTA), an international NGO funded by UK’s DFID, WHO, other multilateral agencies, conducted a civil society organizations (CSO) mapping workshop in Manila. Invited were NGO and CSO leaders who have some track record in contributing to health policy discussions in the past, especially in relation to the new cheaper medicines law (RA 9502).

After the 2-days workshop, the CSO leaders who were there agreed to form a coalition among themselves. The goal is similar to MeTA’s – pursue medicines and health transparency among CSOs that have interest in public policy discussions. About 25 NGOs were represented there, including Minimal Government Thinkers. Then there were several meetings to draft the proposed charter of the coalition, as well as the draft action plan. MeTA international secretariat will provide some funding for the Philippine CSO coalition.

A few months later, the Coalition for Health Advocacy and Transparency (CHAT) was formally created, this time including other NGOs that were never part of the original 25 or so NGOs last January 19-20.

CHAT has a google groups where members can post many things – seminars, articles, etc. I think the discussion list has about 40+ members, am not sure.

I am among those who frequently post some of my short papers. Then some left-leaning NGO leaders reacted to my papers. The discussions were very long. Their postings though are in Filipino, not in English. I would have wanted to post some of their long discussions here, but this blog has a number of foreign readers who do not understand Filipino language. And I’m not in the mood to translate those kilometric postings in Filipino into English.

Among the articles I posted in the discussion list was about the new report released by the International Policy Network, “Keeping it real: combating fake drugs in poor countries”, authored by Julian Morris, Philip Stevens and Julian Harris. The paper is posted in the IPN website (www.policynetwork.net) and in our website, http://www.minimalgovernment.net/media/keepingitreal.pdf.

Among the figures cited in that report were the following:

1. WHO estimates that counterfeit drugs constitute up to 25 per cent of the total medicine supply in less developed countries (LDCs).
2. about 75 percent of imported counterfeit drugs come from India, according to one European Commission estimate; and China is also a significant producer of counterfeit drugs.
3. Fake tuberculosis and malaria drugs alone are estimated to kill 700,000 people a year.

One participant in the list questioned the sources of those data. Below are the data sources as contained in the annex references of the IPN report:

On #1 above: Page 26 of the Report: World Health Organization Factsheet No. 275, refers to a US FDA estimate: “The United States Food and Drug Administration estimates that counterfeits make up more than 10% of the global medicines market and are present in both industrialized and developing countries. It is estimated that up to 25% of the medicines consumed in poor countries are counterfeit or substandard.” http://www.who.int/mediacentre/factsheets/2003/fs275/en/ [accessed 6th March 2009]

On #2 above: Pages 9 and 26: One set of figures from the European Commission showed 75 per cent of counterfeit drugs being imported from India, home to around 22,000 small drug producers, many of which are informal (Bate, 2008). -- European Commission Taxation and Custom Union (TAXUD) statistics, 2005.

On #3, the authors explained in page 23, Appendix, their Statistics calculations:

The World Health Organization has previously calculated that approximately 200,000 malaria deaths per annum could be prevented if the medicines available were of acceptable quality.

This figure was calculated using statistics from the Africa Malaria Report 2003, and a paper on the quality of antimalarial drugs in Africa. The calculations assumed that there were £1 million annual deaths from malaria, with only half of these victims being diagnosed and receiving any treatment at all. Of these half a million receiving treatment, a fifth were estimated to have been resistant to chloroquine and sulfadoxine-pyrimethamine, leaving 400,000 lives capable of being saved through treatment (given existing levels of coverage). The study asserted that, according to the research in The Quality of Antimalarials – A Study in Selected African Countries, up to half of antimalarial drugs in some areas were substandard, and therefore up to half the 400,000 preventable deaths were due to substandard products.

We believe this figure can now be considered conservative. First, resistance to chloroquine and sulfadoxine-pyrimethamine could be removed from the equation, due to the wider dissemination of artemisinin-based drugs. This alone would increase the figure to 250,000 deaths. Second, as explained on page X of this report, drug resistance is significantly exacerbated by fake drugs, with increasing levels of drug resistant malaria along the Thai-Cambodian border attributable to the widespread substandard drugs in that region. Many deaths from drug resistant strands of disease can therefore indirectly be attributed to fake drugs.

According to WHO data, there were 9.3 million new cases of tuberculosis in 2007. Global coverage of DOTS (Directly observed treatment, short course) is said to be 94 per cent, with half of untreated sufferers expected to die. Data on levels of fake tuberculosis drugs is scarce, yet one reliable study (Laserson, 2001) of six countries showed levels of fakes at 10 per cent. By these figures we assume that around 900,000 tuberculosis sufferers are at risk from fake drugs, half of whom (450,000) will die due to the ineffective treatment.
Our total figures for malaria and tuberculosis therefore show 700,000 deaths attributable to fake drugs. It must be noted that due to paucity of reliable data, these are rough, yet conservative, estimates.

Still, that person thinks the above estimation are just hearsay or “haka-haka” in Filipino. Well, if a person or group of persons' mind is too poisoned with biases, no amount of explanation should be able to convince them. A similar situation could go like this:

Person A: I think Gloria Arroyo and family made xx million pesos in kickbacks on the aborted ZTE-NBN project alone.
Person B: why do you think so? how did you arrive at such figure?
A: because of the following considerations...
B: those are just hearsays, haka-haka, bulung-bulongan. Gloria and family did not steal any money from that project.

Another NGO leader advocating drug price control suggested that only like-minded people should become members of the CHAT discussion list. This means only those who favor more state intervention in health and medicine pricing like price control, issuance of CL, etc., should be there, and those who question those provisions should be kicked out of CHAT.

This NGO leader was not there last January 19-20 2009 when MeTA, with the help of some European Council (EC) staff, convened the CSO mapping workshop-seminar. The organizers who spent time and money for that workshop, wanted diversity, not monotony, of perspectives among CSOs and NGOs on medicines transparency. What this NGO leader wants is both price control and thought control.

The discussion list owner and moderator posted and explained that under the CHAT charter, it says:

". . . While bound by a common advocacy, CHAT recognizes the independence of its member organizations and respects the individual positions that may be taken regarding specific issues…. CHAT respects the independence & integrity of each member-organization.”

The same NGO leader noted that during the DOH advisory council meeting on price regulation last June 5, DSAP had one voice, PHAP and PCPI had one voice each, while civil society groups have different voices. It is a valid observation. But if we realize that civil society groups should include not only the left-leaning or militant groups, they also include non-political groups like homeowners association, rotary clubs, badminton clubs, cycling clubs, poetry association, etc. Any voluntary organizations, political or non-political, so long as they are not part of any government machinery (local, national or multilateral), can be considered as civil society organization. Such diversity of perspectives is an important characteristics of the concept of civil society.

There was also another posting with innuendos that I do not wish to be harshly criticized in the papers that I post in the discussion list. Far from that, I actually wish more left-leaning guys to debate with, openly and frankly. The triumph of left-leaning public policies in the government is partly due to the absence or weak voice of the free marketers, the believers of free enterprise, capitalism and individual liberty, to square off in various public debates with the advocates of more government, more taxes, more forcible collectivism and socialism, implicit or explicit.

It still escapes my comprehension why despite all of us in the list wishing to have cheaper medicines, many still cannot criticize or attack the Philippine government for imposing plenty of taxes and fees as if medicines are just like hamburger or beer or cigarettes that must be slam-dunked with as many taxes and fees as possible.

I posted my article last May 2008 entitled “Parallel importation vs. free trade" with a single and clear message: If we really wish more competition among pharma companies (innovators and generics alike), if we really wish to bring down medicine prices, we should have 500 or 5,000 or more pharma companies slashing each other's throats in fierce competition here,and not just about 140 pharma companies, both domestic and multinationals (combined PHAP and PCPI members minus drug store-members). And all taxes and fees on medicines should be abolished.

What's wrong with abolishing taxes and fees on medicines, responsible for making drug prices in the Philippines about 20 percent more expensive, that supposedly militant NGOs cannot publicly and strongly advocate? Could it be that many supposedly militant NGOs receive tax money, directly or indirectly from governments and multilateral institutions like WHO, WB, UN and USAID?

If so, such NGOs cannot really be considered as non-government organizations but partial government organizations (PGOs) or government-funded organizations (GFOs), partly or fully. Dr. Robert So of the DOH's NDP-PMU explained it to me one time when I asked him if the DOH also proposed that Congress should also cut or abolish taxes on medicines when they were deliberating the cheaper medicines bill before it became a law. Dr. So said, "Yes, we did raise that issue with them, the Congressmen laughed at us. DOH gets its funding from tax money, Congress is always on the look out where to further raise taxes. And for a government agency that lives off on taxes to demand tax cut is ironic." Dr, So suggested that it is a very valid issue and that NGOs are the "right" entities to push that advocacy. Of course the assumption here is that NGOs do not receive funding from government, whether national or multilateral government bodies, to make them more effective should the tax-hungry legislators and BIR bureaucrats get back at them.

The long and sometimes emotional debates in the discussion list is inevitable. When MeTA organized the CSO mapping workshop last Jan. 19-20, they wanted diversity, not monotony, of perspectives among CSOs that they invited. I was invited by Klara Tisocki of the EC, then helping MeTA. Some EC guys and the DOH already noted our divergence from the "dominant" perspective, our critical analysis of some provisions of then Cheaper medicines bill before it became a law. That's why they invited me.

So if MeTA and CHAT respect diversity, to encourage the sprouting of more ideas from more heads, then the CHAT discussion group alone is already a success. Let people and NGO leaders with varying perspectives on advancing medicines transparency -- transparency not only by the pharmaceutical companies, but also by drug stores, by the government, by the NGOs themselves, etc -- voice out their opinions and perspectives.

Counterfeit Drugs 2: IPN Report on Fake Drugs in Poor Countries

Early this week, the International Policy Network (IPN, www.policynetwork.net),  a think tank based in London, released its new report, “Keeping it Real: Combating the spread of fake drugs in poor countries”. The 28 pages long paper is also co-sponsored by 18 international think tanks from 18 countries, including Minimal Government Thinkers.

The new Report has some figures that can be shocking to patients. Among these are the following. One, fake tuberculosis and malaria drugs alone are estimated to kill 700,000 people a year. That’s more than 1,900 deaths per day and equivalent to four fully laden jumbo jets crashing every day. Two, the WHO estimates that counterfeit drugs constitute up to 25 per cent of the total medicine supply in less developed countries (LDCs). Three, 68 percent of artesunate (anti-malaria) drugs in Laos, Myanmar Cambodia and Vietnam contain insufficient active ingredients, rendering them less effective, if not totally useless, in curing the sick. Four, about 75 percent of imported counterfeit drugs come from India, according to one European Commission estimate; and China is also a significant producer of counterfeit drugs.

These figures are significant because the new “Cheaper Medicines Law” (RA 9502) has a provision legalizing “parallel importation” of locally-patented medicines, and the premise of this provision is that cheaper medicines to be imported will come from India, home to some 22,000 small drug producers, many of whom are informal.

Since the foreign manufacturers (Indian, Chinese, others) are different from the wholesalers, importers and local retailers, i.e., they are not one and the same company but several different companies, tracing of who will be accountable if the imported drugs are counterfeit or substandard that can result to adverse effects to the patients, will be difficult.

One of the dangers of taking fake drugs is failure to provide effective treatment. The Report says “as fake drugs usually contain insufficient bioavailable active ingredient, a patient who believes he is addressing his disease is in fact going untreated. The disease thus progresses, often leading to death, especially in children and the elderly.”
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I attended this morning a round table discussion on "Quality issues in delivery of health care services: A Policy perspective” at the AIM Conference Center. The event was sponsored by the Health Policy Network (HPN) project of the Center for Legislative Development (http://hpn.cld.org) and was attended by mostly NGO leaders. A 30-page long paper entitled “Equity Issues in Access to Quality Health Care: A Policy Perspective” by the event organizer was also distributed to the participants.

Access for all to quality health care. This is a vision dreamed by almost all people in the world and is thus perfectly rationale. But resources are limited, the supply of well-trained doctors and other health professionals, the supply of good quality hospitals and clinics with sufficient laboratories and diagnostic instruments, the supply of safe and effective medicines and vaccines, are limited. While the demands for such health services and medicines are unlimited.

This is where the initial problem of access to quality health care arise. Add the fact that some people are too irresponsible to take good care of their own body and that of their own family, like those who drink and smoke heavily, take illegal drugs and fatty foods excessively, live in dirty places and do not observe personal hygiene, get into frequent fights, have sedentary and promiscuous lifestyle, etc.

Then add the fact that many governments think that medicines and health care are just like any other commodities like beer, hamburger and movies that must be slapped with multiple taxes and fees. That government corporations engaged in health insurance are accountable to the President and top politicians, and not to private citizens who were coerced to contribute to the health insurance funds.

One concept that was emphasized by the HPN is that for health care to be accessible, first it must be made available and second, it must be affordable. That is, available + affordable = accessible. While this may be correct in many cases, it does not mean that this will lead to “quality” health care which is the ultimate goal of all those public policies that people are talking about.

Take the case of those medicine warehouses managed and owned by some local government units (LGUs). During the MeTA forum last January in Manila, a World Bank-Philippines staff showed – complete with pictures – some of those medicine warehouses by big cities and provinces, where rats, garbage, useful and expired medicines are mixed in one room, often with no stable temperature control, some do not even have a thermometer to monitor room temperature.

Here, those medicines are available. They are more than affordable, they are distributed free. The poor patients in those LGUs therefore, have “access” to medicines. But do they get “quality” medicines that can cure them from their illness and diseases? Probably Yes, but probably No, and some may have contracted new diseases and complications if they happened to take substandard, expired or garbage-contaminated drugs.

It is not enough that there should be “more government budget for health care” as demanded by many sectors in society. Money can buy us subsidized or free medicines, safe and counterfeit alike, and money can also give us lazy and irresponsible government personnel who dispense expired and contaminated drugs.

More than bigger government taxation, regulation and intervention in health care, what is needed more is individual and parental responsibility for preventive health care, plus a competitive business environment where private health care providers and medicine producers can compete with each other in providing the safest and most reliable drugs and health care services to the people with varying health needs and varying financial resources.

Meanwhile, a physician friend thanked me for my paper on counterfeit drugs. She said that "there is a need to strengthen regulation and implement/add requirements to ensure product quality."

For me, more than regulation and government accountability, I want to see more corporate responsibility, that medicine producers and sellers should be directly accountable for all the products that they sell, no one else will be answerable should some things screw up later. Because counterfeit drugs is a very serious and criminal offense. A patient who waits for the medicine to cure him is actually waiting for his illness to mutate and evolve into a more dangerous disease because the medicine that he took was a fake or substandard.

And this is a big issue in parallel importation. If company A imported a cheap but countefeit medicine and the patient here died or developed a new diseases, that company should not say, "Oh I didn't know it was counterfeit, I only bought it from wholesaler X which he got from manufacturer Y in India. You should run after them, not me."

Whoever brought in the medicines, they alone should be accountable. If something bad happens to the patients who bought and took the drugs they sold, the importer and/or seller alone should go to the prison bars and pay indemnity to the affected patients, no one else. BFAD can only do so much, or it can even be possibly corrupted by some pernicious importers. Counterfeit or substandard drugs are sold dirt cheap because there was very little or zero research and innovation involved. By selling cheap, that alone will appeal to many poor patients, especially those who pinned their hopes in the "cheaper medicines law".

If corporate accountability is very clear and transparent, then I think counterfeiting can be drastically minimized. BFAD then will focus its limited resources and manpower on regulating those food and medicinal products produced and sold by enterprises which have hazy brand integrity.

* Counterfeit Drugs 1: On the Growing Fake Drugs Worldwide, December 21, 2007

Foreign Aid 3: Bob Geldoff and More Aid

July this year, Presidents and Prime Minsters from the US, UK, France, Germany, Japan, Italy, Canada and Russia held a G8 summit meeting in Scotland, UK, to discuss more foreign aid, global warming, etc. Bob Geldoff (and Bono and other rock stars) organized the "Live8" series of rock concerts in major cities of the said 8 countries. Their mission: pressure the G8 leaders to commit "more aid", "debt write-offs", to many African countries, to "make poverty history".

One free-market group in London, the International Policy Network (IPN), organized the "Global Development Summit" (GDS) on June 28. I was one of the panel speakers then, it was my first time to see London and UK, thanks IPN :-).

A day before the conference, I revised a famous song (IPN Exec. Director Julian Morris helped me) by Bob Geldoff in the 80s, "I don't like Mondays", and here's what we produced, below. We sang it on stage before the formal conference started.

Original song:

I don't like Mondays
(by Bob Geldoff, Boomtown Rats band)

The silicon chips inside her head
that switched to overload
and nobody's gonna go to school today
she's gonna make them stay at home
and daddy doesn't understand it
he said she was as good as gold
and he can see no reasons
cause there are no reasons
what reasons do you need to be shown
oh-woh-woh-woh

Tell me why -- I dont like Mondays
Tell me why -- I dont like Mondays
Tell me why -- I dont like Mondays
I wanna shoooooot, the whole day down!

Our revised song:

I don't like more aid

The G8 leaders are planning more aid
and that would mean, more taxes
and nobody's gonna go to shops today
they're gonna slash your take home pay
and Blair doesn't understand it
he said he'd wipe out poverty
and he can see no reasons
cause there are no reasons
what alibi you need to be shown
oh-woh-woh-woh

Tell me why -- i dont like more aid
Tell me why -- i dont like debt relief
Tell me why -- i hate protectionism
I wanna shoo-oooooot
The monopolists! :-)

(Chords pattern: C-G-F-G// Am-G, F-G)
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See also:
Foreign Aid 1: MDG Goals = More Debt Addiction, October 26, 2005
The Circuitous and Leaky Process of Foreign Aid, November 03, 2005