Health Spending 6: Health/GDP Ratio 2010

In my blog post the other day, On Inequality and Inclusive Business in HC, I wrote:

On government health spending, I think the ADB, WHO, UN, etc. data on PH public health spending is understated and wrong. They usually count only DOH + PhilHealth spending. They do not include some or all of other govt spending such as:

1. LGUs, with provincial and city health centers and hospitals. Manila City alone has six city-owned hospitals.
2. Philippine General Hospital (PGH), budget about P2 billion a year, part of the UP annual budget; hence, it is not counted as health spending but education spending…. 

This table is from the World Health Organization (WHO)  which I copied today. It says that the Philippines’ health spending / GDP ratio as of 2010 was only 3.6 percent.

Table 1. Philippines Basic Health Stats, from WHO 

  
source: http://www.who.int/countries/phl/en/

I posted the above observation (in italics) in the email loop among members of the Medicines Transparency Alliance (MeTA) Philippines, where an official of the WHO West Pacific Regional Office (WHO-WPRO), Ms. Klara Tisocki, is among the members.

Klara was kind enough to reply. She said, 

Regarding your comments  please note that WHO collects health expenditure related data in countries via the  national health accounts (NHA).  NHA constitute a systematic, comprehensive and consistent monitoring of resource flows in a country’s health system for a given period. NHAs use classification schemes, which are designed to be compatible with those practiced internationally; most importantly, the System of national accounts (SNA), to make cross-national comparisons possible.  

The International Classification for Health Accounts (ICHA) is a comprehensive system which classifies NHA into four dimensions: Financing sources (FS)-contributions by different actors; Financing agents (HF)-entities who manage health expenditures; Providers (HP)-entities that provide health care services and goods; and Functions (HC)-types of health care activities. You can read more about NHA at WHO webpage: http://www.who.int/nha/what/en/index.html  

More specifically  regarding the Philippines health expenditures these are collected via the Philippines National Health Account  (PNHA)  (which in turn reports to WHO for inclusion of Philippines data in WHO databases).   

The methodology and current statistics of PNHA are available on the website of  Philippines National Statistical Coordination Board  http://www.nscb.gov.ph/stats/pnha/.  

I would also like to refer you to the technical notes,  http://www.nscb.gov.ph/stats/pnha/technotes.asp on sources of data for the Philippines health financing, with regard to  your assumption that WHO, ADB, UN etc. count only DOH and Philhealth spending.  In these notes you will find the detailed description of Data Sources and Estimation Procedures as approved by NSCB Resolution No. 8 Series of 2011, that shows  what data  from which sources  are included under the different sectors and you can see the wide range of data sources considered.  

I thanked Klara for her reply as it provided useful links. From the NSCB link, here are the numbers:

Table 2. Philippines Health Expenditures by Sources of Funds

source:  http://www.nscb.gov.ph/stats/pnha/.

Socialized Healthcare 7: Degnan and Wagner on ICIUM and UHC

Healthcare is a very important issue for many people around the planet. That is why emotional arguments are often linked with quantitative and political discourses. The belief or motto that "health is a right and an entitlement from the state" often clouds if not erases the other side of the equation that health is also a personal and parental/guardian/civil society responsibility.

Yesterday, I attended a seminar at the Asian Institute of Management (AIM) by two eminent speakers from Harvard Medical School (HMS) and World Health Organization (WHO) consultants.

Dr. Ross-Degnan, Sc.D. (left photo), an Associate Professor at the Department of Ambulatory Care and Prevention (DACP) at HMS and Director of Research at Harvard Pilgrim Health Care, spoke on Improving Medicines Access and Use: Highlights from the International Conference on

Improving Use of Medicines (ICIUM 2011).

Dr. DegNan co-founded the International Network for Rational Use of Drugs (INRUD) in 1990, a global network of academics, health managers, and policymakers involved in developing and testing interdisciplinary interventions to improve use of medicines. He is a consultant at the WHO on issues related to access to and appropriate use of medicines, and pharmaceutical sector monitoring and evaluation. 

The second speaker was Dr. Anita Wagner (above, right photo), an Assistant Professor in the Department of Ambulatory Care and Prevention (DACP) at HMS and Harvard Pilgrim Health Care. She has a doctorate in epidemiology from Harvard School of Public Health and a doctorate in clinical pharmacy from the Massachusetts College of Pharmacy and Allied Health Sciences. For the WHO Collaborating Center in Pharmaceutical Policy, she leads the global Medicines and Insurance Coverage (MedIC) Initiative. Yesterday, she spoke on Universal Coverage and Medicines: Why Focus on Value?

A staff of Dr. Kenneth Hartigan-Go of AIM, David Teh, sent me the powerpoints today. Thanks David. Dr. Degnan's presentation is about 30 slides, I will show only about half of them below.

Improving use of medicines (IUM) I think is the other term for rational use of medicines (RUM). The latter is used here by the DOH and even by WHO Philippine Office. Right, even if medicines are heavily subsidized by the government, or even freely available, a patient should not over-dose or over-extend taking the medicines simply because they are cheap or free. There are serious long term adverse effects like anti-microbial resistance (AMR) where the body or a disease has gotten used to certain medicines and treatment and simply multiply or evolve into more dangerous diseases even if the patient is taking the necessary medications. The chart on supply and demand of medicines by Dr. Degnan is nice. I think it's simple enough.

Dr. Degnan gave a background about the ICIUM, it holds the conference every seven years. So the next conference would be sometime in 2018. And from 2003 to 2007, there was marginal improvement in policies and implementation of countries to improve use of medicines.

Below are the series of recommendations for each sector or stakeholder. I like the one mentioning the role of think tanks. We don't have much of such stuff here in the Philippines. We instead have dozens or hundreds of advocacy NGOs and people's organizations and cooperatives with definite positions on certain issues that are often not refined or updated with the changing times.

Then I like the mention or emphasis on multi-stakeholder collaboration, the unintended adverse effects of government intervention in pricing of medicines, like the current drug price control and mandatory 20 percent discount to senior citizens and persons with disabilities (PWDs).

Transitions 3: Lolo Angel Mendoza of AGAP

There are three things in life that are certain: death, taxes and change. Deaths allow us to recall and remember a person in his/her lifetime, if he/she has been kind to us, to other people, or not. It is this prospect of death that may perhaps be the best "regulator" of human behavior. As much as possible, people do not want to remembered as bad when they depart from this planet.

Among those people who have been kind to his friends, family and the rest of humanity, is Angelito "Lolo Angel" Mendoza (1946-2012), the head of the Ayos na Gamot sa Abot Kayang Presyo (AGAP) or Good Medicines at Affordable Prices. AGAP is a big coalition of various NGOs, from labor to community to health NGOs, and some known individuals like former Senator Wigberto "Bobby" Tanada.

Lolo Angel here in a planning workshop by the leaders of member-NGOs of the Coalition for Health Advocacy and Transparency (CHAT), sometime in January 2010. I'm seated in front of him and former Bulacan Governor Obet Pagdanganan.

I have known and met Lolo Angel, as well as many leaders of the biggest health NGOs in the Philippines more than three years ago, when the Medicines Transparency Alliance (MeTA) organized the "CSO Mapping and Workshop for META-Philippines", January 19-20, 2009, at Diamond Hotel, Manila. After that two-days seminar-workshop, the participants agreed to form a huge network or coalition of various NGOs that will advance more transparency in medicine pricing and public policy. So already big coalitions like AGAP, the Cut the Cost Cut the Pain Network (3CPNet) and WomanHealth have become members of that new coalition, which we later called the Coalition for Health Advocacy and Transparency (CHAT). It would be the civil society arm of MeTA Philippines.

These big NGOs were also among the major advocates that pushed for the changes in the country's Intellectual Property Code (IPC) and the enactment of the Cheaper Medicines Law of 2008 or RA 9502. Minimal Government Thinkers was not a major participant in the debates prior to that law. I was just writing in this blog, in the online magazine http://thelobbyist.biz, and some op-ed papers on health issues and my critique of certain provisions of the bill that later became a law. Somehow I got noticed by Ms. Klara Tisocki, the convenor of the CSO Mapping by MeTA and she invited me to that big workshop.

Photos below, during the visit by leaders of MeTA Jordan and MeTA Zambia with MeTA Philippines. The foreign visitors met with member-NGOs of CHAT. Further below, in one of the seminar-meetings by CHAT, May 2011. Gov. Obet beside Lolo Angel.

Lolo Angel had a big lump in his throat, has throat cancer. His voice is coarse and low. I would admit that I could hardly understand him when he speaks, but the man was friendly and hard working. With his disease and frail body, he still managed to attend various meetings and seminars by MeTA Philippines, CHAT, AGAP and other groups.

When we met in some of those meetings and seminars, my favorite greeting to him was "Lo, tagay na tayo!" (Pal, let's have a drink). And he would smile and giggle. Knowing that he cannot drink because of his various medications, I would keep teasing him, "Lolo, mag beer na tayo!"

My position on various public health policy issues is very often contrary to the position of AGAP and other member-NGOs of CHAT. They support compulsory licensing (CL), exhaustion of rights or "parallel importation" and other IPR-tweaking policies in RA 9502, I don't. But in the debate on imposing drug price control in mid-2009, Lolo Angel, AGAP, me and a few other NGOs took the same position of not supporting it. Lolo Angel's alternative to drug price control is more parallel importation and allow those patented but cheaper medicines from India, etc. to be brought in. While the alternative that I advocated was more competition, allow more pharma companies, local and foreign, innovator and generic producers, to come in.

Photos below, various CHAT meetings and seminars, May 2011, held at the PRRM building in Quezon City.

Below, the only photo I have in my computer where Lolo Angel was looking straight to the camera. To his right, were Cecile Sison and former Gov. Obet Pagdanganan. Cecile and Gov. Obet are currently the Secretary and President of MeTA Philippines.

It is sad to see another friend passing away. I knew that he was sick and weak, but I did not realize that he would be departing soon. The last time I saw him was last month, during the AGAP forum with former DOH Secretary Alran Bengzon last February 16, 2012,  Generic Drugs Philippines 3: Dr. Alran Bengzon on Medicines. He looked weak but could still talk and smile.

Lolo Angel, thank you very much for the friendship.
Thank you for the various discussions. We did not share the same position on certain issues, but it was the process of exchange, the civility and respect for different ideas that mattered.

I will miss you.
Rest in peace, my friend.

* See also Transitions 2: Ninang Telly Dakila, February 07, 2011