UHC 18: DOH Budget, Healthcare Deregulation and PharmaWealth

After I posted UHC 17: First, Second and Third Lines of UHC for the Poor in the Advisory Council loop last week, July 30, DOH USec Madz replied that DOH budget is presented as DOH proper which is smaller and DON family which is bigger because it includes the fund of National Nutrition Council, PoPCoM, corporate hospitals PHC,Lung Center and NKTI.

Leonie Ocampo of PPhA also replied,

Thanks Nonoy. I know it is not easy to be done, but if we want to be serious in looking after the health especially of the poor who can not afford to buy their medicines, ways to ensure they get the right medicines (quality, safety and efficacy assured) must be done. As I write this comment I know someone is dying because of;  

1. medicines taken are not the right medicines for the condition, in short NOT the best choice for the condition but given because it is what is available. 

2. medicines taken maybe are what are needed as determined by the doctor but the quality is questionable; counterfeit, substandard, fake, spurious and falsified but purchased by LGU or a government agency because they are the cheapest. ( price is not only the consideration in buying medicines anyway) 

3. medicines are right and chosen right but not used right because of lack, no or misinformation  given to the patient and . . .  many more reasons.  

RESULT : GAP between the clinically-tested effects of the medicines and the actual effects when used by the patient happen. Is this not a GOOD WASTAGE of the people's money?This is why the PPhA and I am supporting the DOH to really put its IRON HANDS on this.

I thanked USec Madz for her reply. I checked the DBM’s Budget of Expenditures and Sources of Financing (BESF) 2014, and here’s what I got.

Source: http://www.dbm.gov.ph/wp-content/uploads/BESF/BESF2014/B12.pdf

So DOH’s regular plus special purpose funds was P51.05 billion in 2012, much larger than other DOH presentation saying they only have P42 billion last year. The infusion of P14 billion for PhilHealth last year, or one year before the elections this year, explained such huge jump in 2012 budget.

The combined regular fund + special purpose funds this year is P52.56 billion and P82.77 billion next year, or an increase of P30 billion over this year’s budget. That increase is huge, larger than the regular budget of the DENR (P23.7 billion this year and P23.91 billion next year) or DOJ (P10.9 billion this year and P11.6 billion next year).

The deregulation of health insurance that I mentioned in my earlier paper refers to allowing people to have health insurance  but it does not mean that it should be PhilHealth only. People, especially those in the formal sector, should have the freedom and choice to opt out or not contribute to PhilHealth if they wish to, so long as they get another health insurance provider – an NGO or corporate HMO, an LGU, a private health foundation, and so on..

I also thanked Leonie as her perspective as a pharmacist can inject new perspective, a wake up call for many sectors who only focus on "cheaper medicines" as the single most important consideration in incorporating government medicine procurement with UHC policy.

Also last week, July 29, I attended a forum on "Designing Competition Reforms in Developing Countries" at the Phil. Institute for Development Studies (PIDS), Makati. DOJ Assistant Secretary and a friend, Geronimo "Indian" Sy mentioned in his presentation that a local pharma owned by a Congressman is able to supply medicines to many government hospitals and there might be anti-competition acts there.

He did not stay long after his talk though. I spoke during the open forum and supplied the "missing info" referred to by ASec Sy. I said that it's PharmaWealth owned by the family of former Cong. Ferjenel Biron. I added that an anti-competition act is possible because as a Congressman approving, raising or reducing the budget of government hospitals and other agencies, the legislator has the advantage in "winning" a medicine supply contract with many DOH hospitals. I saw the data presented during a UHC forum at the AIM the week before that.  PharmaWealth can supply amlodipine 10mg for only P0.35 a tablet to some government hospitals, and sell at P2+ or P3+ per tablet to other government hospitals. 

UHC 17: First, Second and Third Lines of UHC for the Poor

Later today, I will attend a round table discussion on Health System Shapers (HSS), Patients and Consumers Sector, at the Department of Health (DOH) main office. The goal of this and related fora is to further fine tune the government’s universal health care (UHC) goal.

Last week, I also attended the two-days (July 25-26) “Policy Dialogue on UHC and Access to Medicines “ held at the Asian Institute of Management (AIM) in Makati. Here are two of the definitions or presentations about UHC.

This one is from DOH UnderSec. Madeleine “Madz” de Rosas Valera in her presentation, “The Philippine Response to Universal Healthcare and Access to Medicines 2013”. She added that UHC is one of four major social investments of the government to help the poor. The other three are public education, housing and conditional cash transfer (CCT).

And this one is from Dr. David Lee of Management Science for Health (MSH) in his presentation in the same forum last week, entitled “Medicines as Part of Universal Health Coverage: The Global Dialogue”

Pondering on UHC, I think the health sector already has among the monster budget in the country today. Consider the following:

1. Proposed DOH budget for 2014, P80.2 billion, from P50.5 B* this year and P34.0 B in 2012

http://www.dbm.gov.ph/wp-content/uploads/NEP2014/XIII/DOH.pdf

2. projected PhilHealth revenue 2014, about P80 B, from about P62 B this year and P47 B in 2012. (Revenues almost equal Benefits payment per year)

3. PGH budget, P2+ B, from P2 B this year

4. AFP hospital, P1.5 (?) B, from P1.3 B this year

5. PNP hospital, Veterans hospital, etc.

6. Other state universities' hospitals

7. PCSO, PAGCOR, SSS, GSIS, etc. health spending

9. Provincial, District, City, Municipal hospitals **

10. Provincial, City, Municipal, Barangay health centers

11. WHO, WB, ADB, UN agencies, multilateral grants

12. USAID, JICA, KOICA, CIDA, EU, etc. bilateral grants

* I saw the DOH presentation last year for its 2013 budget, they were spending on a P42B approved budget, now it has been revised to P34 B? What happened to the P8 B? Can an approved budget still be slashed? Weird… will ask around why.

** Total number as of 2013: (a) DOH hospitals 60, (b) LGU hospitals 584,

(c) Rural health units (RHUS) 1,285, and (d) Barangay health stations (BHS) 962. The nearly 600 LGU hospitals alone, I think they will have at least P50 billion budget next year.

Should be P300+ B next year alone? And that’s for government spending alone.

I am wondering if there was any study conducted by the UHC study group (UP Manila), Health Policy Development Program (HPDP, UPSE + UP Manila + other colleges?) or other groups, detailing how much really is spent by the public sector alone yearly, on healthcare?

It seems none, except that every year, there is belief that there is  "not enough money, give more money, raise more money, to public health."

Meanwhile, there are various private and civil society spending on health charities. PHAP Foundation gives about P100+ M a year , Unilab another P100M? other PCPI-affiliated pharma. Zuellig Foundation, Rotary Foundation, GMA Kapuso foundation, ABS-CBN foundation, St. Lukes Foundation, MMC Foundation, etc.

I think ALL foundations and private charity organization have health spending in one way or another. Plus extra spending during calamities, like individuals donating money or medical products and devices.

So we are talking of possibly P500+ billion health spending in one year alone?

And many people still think that health spending is still "not enough". hmmmm...

The first line of UHC for the poor are the RHUs, BHS, and LGU hospitals. The second line will be the DOH hospitals, Philippine General Hospital (PGH), other state universities’ hospitals, AFP hospital, other departments’ health facilities. Plus the charity emergency/wards of private hospitals. That is for outpatient services (have fever, or headache, stomach ache, then go home after consultation) and wards in case of confinement.

PhilHealth should be considered as a third line in UHC of the poor. Yet PhilHealth is the main discussion point when people talk about UHC.

PhilHealth is NOT a healthcare provider, unlike those RHUs, BHS, LGU hospitals. PhilHealth is only a health financier, for those who are hospitalized, and assuming that they were not technically disqualified, say they forgot to pay the premium last month or a few months back. Or they are unmarried couple.

So the focus on expanding PhilHealth coverage may be a secondary consideration compared to improving the healthcare delivery of those RHUs, BHSs and LGU hospitals.

As an advocate of minimal government involvement, in healthcare in this case, I maintain that PhilHealth membership should not be made mandatory and obligatory for all people. What should be made mandatory is that all people, children especially, should have health insurance – whether from private charity organizations and foundations, or private HMOs, or some health NGOs, or LGU schemes and hospitals, or from PhilHealth.

Senior Citizens Discount 4: Distortion in Consumers' Perception of Drug Prices

(Note: The original title of this paper was "Health Transparency, More on Senior Citizens Drug Price Discount".)

There will be another meeting, the 16th meeting of the DOH Advisory Council on the Implementation of RA 9502 (Cheaper Medicines Law of 2008) next week, February 13 at the DOH. I have told the Secretariat that I will join the meeting.

I think the new Department Order regarding the sharing of burden of the mandatory 20 percent discount for medicines of senior citizens will be shown to us members of the Council. Or has it been officially issued already, I don't know.

In my blog post last December on this subject, there were two comments there, one from Leonie Ocampo, the President of the Philippine Pharmacists Association (PPhA) and from an anonymous individual who owns a small drugstore in the province. See below:

(1) ... Drug price regulation or expanding he MDRP list, as had always been my personal and the PPhA POSITION, THIS WILL NOT HELP. The first list did not give the expected result; no increase in the number of users which means only the regular users of the SKUs in the list benefits from the initiative and those who have NOT used said medicines continue not to avail of them even at 50 or 70% price reduction because in the first place, these people do not have the money to buy the medicines. Other ways to improve medicine access must be explored BUT THIS MUST BE DONE WITHOUT JEOPARDIZING THE MEDICINES QUALITY. We are open to help how this will be done.

-Leonie Ocampo

(2)  As a small independent drugstore in the province, I would like to add that the senior citizens law is being EFFECTIVELY USED by the giant chain drugstores as a LOYALTY and PREDATORY pricing program. Since they have the advantage of the “economies of scale”, they can easily “force and coerce” the drug distributors to subsidize this “expense discount” or else they will not buy. Because of this reason, the giant chain drugstores capture more or less 100% of the sales from senior citizens, without spending a penny! Unfortunately (also) for the small independent botikas… this not only means LOST SALES from the seniors, but they also loss the LOYALTY and PATRONAGE of the very influential sector in the local community! A double whammy!

-Anonymous

I developed this new graph below showing what happens when the smaller drugstores in small municipalities in the provinces will stop selling some drugs at a loss, particularly those medicines often demanded by the senior citizens. The mandatory discount under RA 9994 or Expanded Senior Citizens Act is 32 percent (20 percent original discount + 12 percent VAT) and only a small portion will be shouldered by the drug manufacturers, the bulk of the burden will be shouldered by the small drugstores. Government takes little or no burden as such loss is not tax-credited. 

In graph A, before the expanded mandatory price discounts to senior citizens is implemented, there are four sellers of a particular drug often demanded by senior citizens. Mercury Drugstore (they control about 60 percent of the total drug retail business in the country) and three small, town-specific drugstores. They may have slightly different prices for the same drug with the smaller ones selling lower than the dominant player Mercury. These are represented by points A, B, C and M.

After the expanded mandatory price discounts, the three local drugstores are still around but they have stopped selling some medicines often demanded by senior citizens to prevent losses. Only price M by Mercury is left, still at the same level as chain stores keep only one price for each product for all their branches nationwide. But the quantity has expanded from Q1 to Q2. 

What the anonymous commenter above argued is that they may prevent losses by not selling certain medicines often demanded by the senior citizens, but they suffer further lower revenues as the senior citizens who may be buying other medicines, say vitamins for their grandchildren, will purchase these in the same store, ie, Mercury or other big chain drugstores (Watsons, Rose, etc.).

The above graph is hypothetical but it shows another negative effect of government price intervention on small businesses. The other negative effect is the inconvenience to senior citizens themselves. If drugstore A selling at price A is just a few blocks away but it has stopped selling the medicine that they need, then they will have to travel to farther, perhaps in the neighboring town or city where there is a Mercury or other big chain drugstores.


I hope that this law will be amended in the next Congress. The main goal of that law is to help the poorer senior citizens purchase their needed medicines, fine. But the law did not make a distinction between the richer senior citizens with their poorer cohorts. Many senior citizens are rich or have ample savings, have PhilHealth and private health insurance, they do not need that discount much. The ones who need a discount are the poorer ones, those who worked at the informal sector. 

There are actually many government programs towards this end. Like the rising budget of the DOH, additional funding for PhilHealth from the new Sin tax law and higher monthly contributions from those working in the formal sector, and higher budget for local healthcare by the local government units. Forcing the private players (drug manufacturers, drugstores, drug importers, hospital pharmacies, etc.) to give that discount otherwise the government will go after them and cancel their license to operate (LTO) or business permit is wrong.

So a new legislation to correct this mistake is needed. I am not sure though how ready the major players and stakeholders can be in deflecting legislators' grandstanding and political harassment. Finding less costly alternative schemes to protect the poorer senior citizens will make this work more palatable to the legislators.

For the meeting next week, we were asked what topics we wish to be included in the agenda. I suggested that requests for price hike for some drug molecules that were put under the mandatory 50 percent price cut through the "voluntary price reduction" or politically twisted as  GMAP, should be be considered and granted. Why? 

So long as cheaper generic products for the same molecule are available for the consumers and patients, meaning they have the option to buy other drugs, let the innovator drugs be priced high if they want.

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See also:
On Senior Citizens Discount, August 10, 2009 
Senior Citizens Discount, Part 2, November 03, 2010 
Drug price control 5: Mandatory discounts and acronym politics, March 21, 2011 
Senior Citizens Discount 3: Sharing of Mandatory Discounts on Medicines of Senior Citizens, December 14, 2012

CSOs and State 16: The Integrity Initiative

Government is force and coercion. It is an institution created by men and women mainly to protect themselves, their families and friends, their properties, from bullies among the population. It was a good "social contract" where people surrender a portion of their individual freedom to the government, like the "freedom to revenge" and physically attack those who committed physical aggression against them and their properties. Government and its courts, justice and police system is supposed to do that job, to penalize those who disrespect other people's right to peaceful living.

But governments since then have been expanding and getting larger to monster institutions. Rule of law was supplanted by rule of men, and some bullies, thieves and other criminals have captured government power so they can become bigger bullies protected by the government itself and its armed forces. Corruption and plunder is among the byproducts of this situation. Another is large-scale human rights violations, imprisonment if not murder of those who protest dictatorial and despotic governments.

In order to minimize or avoid this situation, government itself created certain offices and mechanisms for self-policing and self-regulation. Thus, the separation of power among the Executive, Legislative and Judiciary branches of government, fiscal and oversight function of opposition political parties, and creation of anti-corruption Commissions, Bureaus or Task Forces within the government. But these offices did not do their function in many countries like the Philippines and thus, corruption has become the norm rather than the exception in many countries and governments. 

Non-government mechanisms and initiatives have sprang up recently in many countries like the Philippines, to help fight government corruption. The approach is different than the usual anti-corruption campaigns. Instead of pressuring government to limit corruption from within, the move is to pressure private enterprises and individuals to stop bribery with government offices and even to report corrupt and extortion practices by certain government officials.

This is the thrust of a new group called the Integrity Initiative (II). I have attended a talk by II Chairman, Ramon del Rosario of the Phinma Group of Companies last month. It was held at the Asian Institute of Management (AIM) in Makati and was mainly sponsored by the Pharmaceutical and Healthcare Association of the Philippines (PHAP) and its partner companies, NGOs and government offices like the DOH.. I liked his talk, short (15 minutes or less), extemporaneous and direct. He said that from an initial 100 company-signatories in 2010, II has grown to more than 1,500 signatory companies. They are now piloting two procedures. One is an Integrity Assessment where companies self-declare certain practices to avoid or minimize corruption with government, and two, an Integrity Validation to be done by a third party and check if those self declaration by a signatory company are correct or not.

During the open forum, I spoke and praised this initiative as truly civil society. It's a unilateral action by the private enterprises and groups themselves to start cleaning up their own ranks first, then demand that government should clean its ranks too. This will be a good branding for company-signatories and have obeyed the processes of II. Thus, II-affiliated companies can "brag" or openly declare that they are doing their businesses in transparent manner and comply with certain government regulations. This can be considered as a trademark by which other companies (suppliers and buyers) and ordinary consumers can hold on and expect that what those companies say are indeed true. A pressure from the outside by a united group of companies from different sectors or fields of business can exert substantial change in government.

I also suggested that while there are industry associations in each sector or industry, some of those associations do not have their own code of ethics and self-regulation mechanisms to avoid unethical marketing and advertising of their products and services and hence, cheat on their consumers. So II can possibly create committees to represent the different sectors and industries that can exert if not impose a code of ethics for member companies in each committee. 

I cited a story of an anesthesiologist friend who complained that they caught one local pharma who sold a counterfeit or substandard anesthesia to one hospital. An anesthesia, if in good standard and effective, is supposed to take effect within minutes to a patient. So for a patient to undergo surgery, he is supposed to feel numbed and be asleep within minutes before the knife will slice his/her tummy or other body parts. But the patient was wide awake, did not get numbed, and it is impossible to do the surgery otherwise the patient will be shouting in deep pain. So the surgeons and anesthesiologists have to scamper for a new set of anesthesia before the surgery can proceed. Surgery done. After that, they reported the incident to the FDA through a very confidential letter, and the pharma company later knew of such letter complaint, meaning they have a "mole" within the FDA and threatened to sue the complaining physicians. 

There were other comments from the audience like those from Leonie Ocampo of the Philippine Pharmacists Association (PPhA). Later, Doc Virgie Ala, the director of DOH-NCPAM, came to represent DOH Assistant Secretary Madz Valera who was supposed to give a talk too in that event, but was not able to come due to a sudden Senate Committee meeting that she has to attend. Doc Virgie expressed support for such civil society initiative like the II, as it would be easier for government offices to reduce corruption if there is such initiative from the private sector.

Civil society organizations (CSOs) and State, not just market and state, is a good initiative to limit government power and coercion. CSOs should be independent of government whenever possible, and not just extension of government like what many NGOs, media and academic people are doing. CSOs should be independent of government funding too, in order to ensure such organizational and philosophical independent from the state.

Meanwhile, PHAP Executive Director Reiner Gloor wrote about that event, I just saw it recently, paper elow. Photos here, he's rightmost. Doc Virgie Ala is to my left. Cecile Sison and former Gov. Obet Pagdanganan of MeTA Philippines, Leonie Ocampo to my right. Lower photos, Mon del Rosario of II and Phinma, and Doc Virgie Ala of DOH-NCPAM.

http://www.bworldonline.com/weekender/content.php?id=62191

The Integrity Pledge

Posted on 05:40 PM, November 29, 2012

Medicine Cabinet -- Reiner W. Gloor

IN 2003, world leaders adopted the United Nations Convention Against Corruption and designated Dec. 9 of each year as International Anti-Corruption Day in a bid to promote a culture that values ethical behavior.

Believing that corruption undermines social progress and results in inequality, the Aquino Administration adopted a platform of government that embraces integrity in public leadership. Early this month, President Benigno S. C. Aquino III. issued Proclamation 506 declaring Dec. 9 as National Anti-Corruption Day. In the proclamation he signed, the President said that corruption undermines the institutions and values of democracy and ethical values as well as jeopardizes sustainable development and the rule of law.

The drive to promote integrity has also been undertaken by the private sector recognizing that the government cannot do it alone. In response to the government’s campaign on good governance, the Makati Business Club (MBC), together with several other organizations, launched the Integrity Initiative (II), a multi-sectoral campaign that seeks to ultimately eradicate the corruption that has worsened poverty and stunted “the development of a competitive business environment that operates on a level playing field.”

Drug Price Control 31: Cancer Drugs and CWF

Among the members of the DOH Advisory Council (AC) on the Implementation of RA 9502 (Cheaper Medicines Law of 2008), and in our civil society health network Coalition for Health Advocacy and Transparency (CHAT), there is only one NGO leader who persists on lobbying for continued drug price control, the leader and founder of the Cancer Warriors Foundation (CWF), James Auste.

I can understand James' main concern, to save the lives of more and more children with cancer, and it is a noble goal. I myself have two young kids, aged only 6+ and 2+ years old. If anyone of them will get sick, I immediately become troubled but I try to stay calm as their illness are often not serious -- not dengue or similar fatal diseases. So I share with his concern.

But the means that he often advocates -- using politics and more government coercion -- is something that I definitely do not share with. Just three days ago, he posted in the Advisory Council members' email loop and said,

AMING PROPOSAL--TO EXPAND THE MDRP O MRP TO INCLUDE MIRACLE DRUGS LIKE TEMODAL NA EXORBITANTLY UN ACCEPTABLE UNCONSIENCABLE PRICED SA PINAS! ( CAN PROVIDE DATA FOR OTHER DISEASES)

TO SUGGEST AN AMENDMENT SA  CHEAPER MEDS LAW TO INCLUDE BRAIN CANCER! KASI ANG SURVIVAL RATE AY NASA 10%! DAHIL LANG DI MA ACCES ANG GAMOT! 

I replied to the email loop and argued this way:

Lousy argument James.

First you said "miracle drugs" meaning you recognize that no other drugs before were miraculous enough to cure patients, so they die more quickly.

Then you demonize those miracle drugs as if wishing that they were not invented, or were not brought to the Philippines in the first place.

It is possible that there are other anti-cancer drugs more "miraculous" than Temodal that are available in other countries abroad but not available here, precisely because the politics of envy is strong here, of wanting but demonizing revolutionary drugs.

Even local generic manufacturers like Unilab or Pharex who have the capacity to mass manufacture generics of off-patent medicines may shy away from doing so. At P100 per tablet of innovator drugs, the local generics can produce and sell at P50 or P55 and both camps will have their own markets and buyers. With MRP and drug price control, the local generics would find that they are now the expensive seller, so they have to push their prices further down, assuming there is enough leeway, or abandon selling such, even temporarily.

MRP and price control is killing competition. Where there is little or no competition, an economy can easily degenerate to socialism. See if healthcare is fantastic in socialist North Korea, Vietnam or China. But one problem with wishing for health socialism is that even socialist Vietnam and China now allows more players, allows more capitalism and the profit system, even at a limited scale.

Do not demonize the guys that give patients more modern treatment that improve their chances of survival. Demonize instead the taxation of medicines, demonize the absence of competition, demonize socialism.

Another member of the AC, the President of the Philippine Pharmacists Association (PPhA), Ms. Leonila "Leonie" Ocampo also replied.

Dear All,

I hope we wont be like Canada that because of Price regulation, many Anti cancer drugs are no longer available that they have to import these from the U.S. and Europe; in effect cost became higher. This is one concern being tackled in the global organization of Pharmacists (FIP) ; the Pharmacists being one key player in making the medicines available to the public.

Other means to lower cost, subsidy or whatever may that be could be the option to be used.

Again, the primary beneficiaries in the current price-regulation initiative  are the people who have the money to buy, but those who do not have continue not being able to access the essential medicines they need.   

Let us all be realistic. Let us also all work . . . that  practices in the use of medicines will be corrected, from procurement down to patient monitoring. Optimum benefits are NOT experienced by the patients because they get not only non-quality medicines but also non-quality services. Let us work together that GAPS existing now between the potential effects(efficacy) of medicines versus the actual effects(effectiveness) experienced by the patients will be closed to allow OPTIMUM OUTCOMES to happen. Many factors are to be looked into, in this situation and I am asking your support to PPhA for its programs addressing this issue with the ultimate end in mind . . . OPTIMIZE HEALTH OUTCOMES OF PATIENTS USING MEDICINES.

We remain, not in favor with price regulation. There are many options for cost-effective medications. We only need the more relevant policies and their right enforcement.

It's good that Leonie shared her observation about the case of Canada. Goivernment price dictatorship via price control simply did not work and will not work, if their goal is to allow more poor people to have access to more life saving medicines.
----------

See also:
Drug Price Control 27: Letter to Sen. Pia Cayetano, May 15, 2012
Drug Price Control 28: On Cong. Biron and Sen. Villar Bills, July 14, 2012
Drug Price Control 29: MRP Attempt Over Anti-Leptospirosis Drug, August 16, 2012
Fat-Free Econ 22: Three Years of Drug Price Control Policy, August 30, 2012 
Drug Price Control 30: Reversing the Policy on AC Resolution in 2009, September 14, 2012

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).

PH Pharmacists 5: PPhA Convention 2012, Day 2

Yesterday afternoon, I attended the 2nd day of the Philippine Pharmacists Association (PPhA) National Convention at the University of Santo Tomas (UST) in Manila. I skipped the morning session because I attended the "Online Onsite" program of interaksyon.com at the Enterprise Center, Ayala Avenue, Makati City. I spoke in an informal setting, about the conflict with China over Scarborough Shoal, the Spratly Islands, at the West Philippine Sea or South China Sea, and the interaksyon guys were tweeting my talk, feeding me questions from twitter and from other guys on the site which I also answered. Here's my presentation there,  http://interaksyon.com/assets/documents/interaksyon_online_onsite.pdfinteraksyon.com

Thus, I was not able to listen to the presentations of four good speakers like Dr. Lagrada of PhilHealth, Joey Ochave of UL, John Ware of WPPF, and Ms. Marilyn Tiu of the Board of Pharmacy.

I was not able to leave Makati early, I wanted to hear Dr. Midha's presentation about bioequivalence and related subjects. I came late, poor me. But I was able to hear the presentation by a good friend, John Chang, the President of FAPA, then by Leonie Ocampo.

John talked about the evolving roles of pharmacists: Traditionally from compounder (of drug molecules) to medicine selling/dispensing to counselling + information, to patient care and pharmaceutical care. This is a good evolution of roles. Towards the latter part of his talk, John showed a quote something like "There's no future in (medicine) dispensing, it can be done via the internet, by the machine, or hardly-trained personnel".

There is truth to this. Many pharmacies and drugstores -- especially those owned by the government (Botika ng Barangay or BnB, supported by the DOH), or private non-chain drugstores -- are manned by non-pharmacists, some even have zero formal training in pharmacy. They could be any political appointee by the Barangay or Village Chairman.

So it is possible that many pharmacists are over-educated (mind you, they have to pass a board and licensure exam by the government after hurdling 4 years of college education) if their work will just be limited or focused on drug dispensing and selling.

John also discussed about a debate in some countries where physicians complain or charge that "pharmacists act like physicians", and the reverse of the argument, that "physicians act like pharmacists." It's about the division of labor between the two on drug prescription vs. drug dispensing. John said that there should be complementarity of function between the two because the goal is the same -- patient care. Nice point there, John.

I don't have photo of John and Leonie during the convention, but I have one during the CGDA Conference in Taiwan last November. From left: Nancy Tacandong of FDA, John Chang, Leonie Ocampo, me and Joey Ochave.

The presentation by Leonie was good, lots of good data for the Philippines, like the following:

1. In community pharmacy, about 60 percent of the pharmacy business is controlled by the biggest chain with 800+ outlets nationwide. (That's Mercury, who else -- me)

2. About 40 percent of the business by 5,000+ outlets from different companies.
-- 70 percent of this 40 percent are from five chain pharmacies (That's Rose, Watsons, Med Express, The Generics, who's the 5th? -- me).
-- 30 percent of this 40 percent are from single branch pharmacy operations (The BnBs and Botika ng Bayan or BNB are not included in this 40 percent? -- me). The practice of pharmacy here is mainly dispensing, almost nothing else.

3. Hospital pharmacy constitutes 10 percent of the total pharmacy business. And this is dominated by 10 big hospitals (Makati Med, St. Lukes, Medical City, PGH,...)

Then Leonie discussed some unfavorable practices of the profession:

- Poor implementation of the "no prescription, no dispensing" rule;
- Poor storage of medicines practices,
- Medication counselling is not practiced;
- Sale of medicines unsupervised by trained pharmacists in non-traditional outlets (like those walking house to house carrying medicines in hand bags, selling drugs in public markets, etc. -- me)

She noted that "Pharmacists appear overeducated and underutilized". Thus, there is big role by the PPhA being the main (and only) professional association of Filipino pharmacists. PPhA is the umbrella organization of 10 affiliate organizations and 82 local and provincial chapters.

The various initiatives, projects and networking by PPhA were discussed by Leonie. I won't mention them here, I think her presentation will be made available in their website soon.

In relation to the top killer diseases in the Philippines and worldwide, about 2/3 are from non-communicable diseases (NCDs), medicine and lifestyle counselling will be an important role for pharmacists. What good are the most effective drugs made cheaper via drug price control and coercion policy, or even freely available via government of hospitals and assistance to the poor, if the patient will continue their unhealthy lifestyle like over-drinking, over-smoking, over-eating fatty and salty food, over-sitting and sedentary life?

Identification and monitoring of counterfeit and/or substandard drugs is also an important function for pharmacists. We ordinary folks will not be able to detect such, especially if we go to lesser known or even known for notoriety pharmacies, and worse from non-traditional outlets like "sari-sari" or variety stores, those sold on house to house marketing, etc.

Again, it is refreshing to hear that many of public health problems have private solutions, relying little or zero on politics and politicians. Health is mainly personal and parental + civil society responsibility.

* See also  PH Pharmacists 4: PPhA Convention 2012, Day 1, April 27, 2012

PH Pharmacists 4: PPhA Convention 2012, Day 1

Upon the invitation of the President of the Philippine Pharmacists Association (PPhA), Ms. Leonila "Leonie" Ocampo, I attended yesterday the afternoon activity, also the formal opening ceremony, of the PPhA National Convention 2012, held at the University of Santo Tomas (UST) in Manila. There was a poster and product exhibit in the morning at the conference venue.

I was amazed at the big crowd, more than 2,000 pharmacists from around the country came, the biggest turnout so far. I will post photos later.

Here is the program for the Opening Ceremony.

I was able to see the procession, then heard the opening message of Leonie and the keynote speech of Dr. Kamal Midha, the presentation of plaque, then I left. I will come later today, afternoon session as I have a talk in the morning on the Spratly/Scarborough Shoal, or the dispute in the West Philippine Sea or South China Sea, depending on which country you are standing on.

The welcome reception yesterday was sponsored by the United Laboratories (Unilab or UL) and its VP, Mr. Chito Sta. Maria, would give the message. UL is a giant pharma company here. Although it is a generic manufacturer, its annual sales is larger than the combined sales of #s 2 to 4, all innovator companies (GSK, Pfizer and #4 Wyeth, I think), it has lots of resources to give food, prizes, entertainment and other perks to the convention participants and organizers.

Dr. Midha's talk focused on rational use of medicines (RUM), the characteristics of medicines that should reach the public, and the importance of bioequivalence testing especially for generic drugs. He used the WHO definition of RUM -- right needs of a patient, right dosage, right time, and at affordable price.

There are six characteristics of medicines for the public, he said: Safe (adverse effect is avoided), Effective, Patient-centered, Timely, Efficient and Equitable. In particular, Quality, Safety, Efficacy and Affordability are all required characteristics.

He also discussed the problem of counterfeit medicines and how the public, with the assistance of pharmacists and other health professionals, can detect and avoid them. He said that Council of Europe has certain guidelines to help along this line, like all medicines should have 13 digits barcode.

Bioequivalence is important -- pharmaceutical equivalence, bioavailabilities after administration of the same molar dose under the same condition would show essentially the same effect as the innovator drugs.

I was actually expecting that Dr. Midha would give a technical presentation, like what are the strict processes required before bioequivalence can be declared or stamped on generic drugs that are newly introduced. Or the problem of antimicrobial resistance (AMR) that are related to irrational use of medicines. But nonetheless, his presentation was clear.

I was happy to see again yesterday two friends whom I have met during the Taiwan conference last November, the President of the Federation of Asian Pharmaceutical Associations (FAPA), Mr. John Chang from Malaysia, and FAPA Past President, Dr. Soo Ja Nam from S. Korea. PPhA Past President Normita Leyesa was also there of course.

What I find impressive in the PPhA Convention is the absence of high government officials -- say the DOH Secretary, or WHO Regional Director or Representative, or PhilHealth President -- as speakers, something that is so common in many private sector- or NGO-organized events like this one. Instead, key leaders of the profession, especially the Presidents (and past President) of the three international organizations (FIP, FAPA and WPPF) were given prominent roles to speak in the convention.

This is the way to strengthen and professionalize civil society organizations (CSOs) like the PPhA. To stand on their own, discuss matters among themselves, and rely less on certain political favors that high government officials would give them.

More stories and photos later...
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See also:
PH Pharmacists 1: Convention in Naga, April 06, 2011
PH Pharmacists 2: Patient Rights and Responsibilities, April 08, 2011
PH Pharmacists 3: Public Health and PPhA 2012 National Convention, April 16, 2012

PH Pharmacists 3: Public Health and PPhA 2012 National Convention

The practice of pharmacy -- linking chemical sciences with health sciences, compounding and dispensing medicines and pharmaceutical products for effective and safe use by patients -- is an important aspect in public health, or more specifically, in personal health. And since healthcare is first and foremost personal and parental/guardian responsibility, not much government responsibility, the skillful advice of pharmacists when to use medicines, how, at what dosage and timing, etc., or even when not to use medicines (e.g., do not take paracetamol + ibuprofen on empty stomach) is important in promoting personal healthcare.

Like other health sciences, pharmacy is both a science and a community practice. As a science, a pharmacist deals with pharmaceutical microbiology and parasitology, physical and manufacturing pharmacy, quality control, pharmaceutical biochemistry, plant chemistry, a country's medicinal plants, and so on.

As community practice, a pharmacist deals with pharmaceutical calculations, hospital/clinical/community  pharmacy, dispensing and medication counseling, pharmacology, clinical toxicology, pharmaceutical jurisprudence and ethics, pharmaceutical marketing and entrepreneurship and so on.

I saw in wikipedia that there are 11 different types of pharmacy practice areas, including internet pharmacy and veterinary pharmacy, http://en.wikipedia.org/wiki/Pharmacy.

In the Philippines, the sole national organization of these professionals is the Philippine Pharmacists Association (PPhA, http://www.philpharmacists.org/). I am fortunate to befriend the past and current Presidents of PPhA, Ms. Normita Leyesa and Ms. Leonila "Leonie" Ocampo, respectively. I get new perspectives from them in some public health issues and debates, ranging from rational use of medicines (RUM) to pharmacy practices to Botika ng Barangay (BnB) to drug price control, among others.

The PPhA will hold their annual national convention this year at the UST in Manila. This event attracts more than 1,500 participants per year as the various lectures and networking are useful in the practice of their profession.

Last year, in the 2011 National Convention of PPhA, Leonie inivted me as one of the speakers in one of different panels, I spoke on "Patient Rights and Responsibilities: Patients/Consumers Perspective". It was the biggest crowd I ever spoke to, a big auditorium full of health professionals, a bit scary for me then :-)

On another note, the PPhA is pushing for a new Pharmacy Law. I saw one bill, the proposed "Philippine Pharmacy Act", SB 2163 authored by Sen. Francis Escudero,  http://www.senate.gov.ph/lisdata/97098332!.pdf.

The goal of such proposed legislation is to professionalize further the practice of pharmacy in the country, so that the staff who face the patients and their guardians in drugstores and pharmacies are indeed well-trained and updated about pharmacy as a science and as a community practice. This is a good objective.

But I notice that there are many strict regulations to be imposed. This can be a double-edged material for both the professionals and the public. For the former, they will be compelled to remain updated in the new knowledge about their profession. But for some small drugstores and drug outlets including those owned by the government like the BnB and Botika ng Bayan (BNB), strict and costly requirements may force them to hire unlicensed and less-trained pharmacy professionals in their drug outlets. And public health may be compromised on certain cases.

The theme this year is direct and clear, "Best pharmacy practices for quality and safety." I wish the PPhA officers and members a successful convention.
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See also:
PH Pharmacists 1: Convention in Naga, April 06, 2011
PH Pharmacists 2: Patient Rights and Responsibilities, April 08, 2011

RUM 3: On Combining Drug Molecules and Alaxan FR

After I posted RUM 2: SARAH, Drug Dependence and announced to several players and leaders in the Philippine health sector, focus shifted about drugs advertising and the molecular combination of paracetamol + ibuprofen of Alaxan FR. So I emailed the other day Dr. Suzette Lazo, a friend and Director of the Food and Drugs Administration (FDA, http://www.fda.gov.ph/) via our CHAT googlegroups, as well as Dr. Nazarita Tacandong, another friend and FDA Deputy Director. I wrote,

Hi Docs Suzette, Nancy,

When Doc Delen de la Paz asked during the DOH Consultative meeting on RUM, "Is it advisable to combine paracetamol + ibuprofen (Alaxan FR) in the first place", I did not ask for her answer but I can see that her implied answer is No.

Doc Isidro Sia also gave the warning of not taking that drug on empty stomach as there is high possibility of adverse health results, suggesting that the combination of those 2 molecules can be tricky.

Another physician friend commented today,

"In response to your question in your blog, it is irrational to combine paracetamol and ibuprofen in my professional opinion. This is an example of fixed dosed combination. But United Lab may have some scientific data to show efficacy, but I have never seen this. I wonder if BFAD then allowed this based on science or based on other reasons."

That's 0-3 score disfavor for Alaxan FR molecular combination. I am no physician nor pharmacist so I have to ask you this question, why FDA allowed such combination given the high use of that drug by the public?

Doc Suzette gave a reply, below. She gave me permission to post her reply in this blog. Meanwhile, here are some of the ads for Alaxan FR, a very popular pain reliever here mainly because of its endorser, Manny Pacquiao.

Noy, this drug has been approved by the FDA since the 80s. The requirement is that for fixed-dosed combinations to be approved they must be compliant on a number of things: show synergy (of efficacy), stability of components in combination, etc. So as this was approved, Alaxan must have complied. Of course, fixed dose combinations get rather contentious sometimes because of differing opinions, which may not hold much water unless supported by evidence. An important issue is if there's a safety problem here? Are (we) seeing cases of drug-related morbidity related to use of the drug? There's no data so far from the people who are criticizing it so where do we go from here?

For your info there are far worse preparations that have been approved and these things sell too. FDA is in the direction of working towards cleaning up the bundle of approved drugs but this wont happen overnight.

Suzette 

PH Pharmacists 2: Patient Rights and Responsibilities

(Note: this is my article today in thelobbyist.biz)

Patients have the right to receive considerate, respectful and compassionate care regardless of age, gender, religion, nationality, sexual orientation or disabilities, from hospitals and other healthcare institutions they go to. But patients have the responsibility to provide complete and accurate information about their full name, address, health and medical history, present condition, past illnesses and related information when required.

These are among the topics that we discussed yesterday in Day 2 of the 3-days National Convention of the Philippine Pharmacists Association (PPhA) held at the Capitol Convention Center, Camsur Watersports Complex (CWC), Naga City, Camarines Sur.

The convention center was fully packed with possibly 1,500 people in the audience. I was one of three speakers yesterday morning. I talked on the “Patient Perspective” while Dr.. Eleonor Almoro, an OB-Gyne specialist andand faculty member of St. Lukes College of Medicine, talked on the “Physician Perspective.” Ms. Leonila Ocampo, current President of the Association talked about the PPhA Declaration of Patient Rights.

I thanked Leonie and Ma’am Mita Leyesa, past President of PPhA, for inviting me to this big Convention. I have known them for about two years now, they read my papers and articles including my book Health Choices and Responsibilities, that is why they invited me to be among the speakers in their event.

Patient rights and responsibilities refer to a set or bill of rights that a patient is expected to get from a hospital and its health professionals. Other patient rights include: (a) Right to receive care in a safe environment free from all forms of abuse, neglect, or mistreatment; (b) Right to be told the names of their doctors, nurses, and all health care team members providing healthcare; and (c) Right to have a family member or person of their choice and their own doctor notified promptly if admitted to the hospital, and so on.

The other patient responsibilities include: (a) To ask questions when patients do not understand information or instructions. Related to their treatment plan. If they do not follow the treatment plan, patients are responsible for the outcomes; and (b) Participate actively in their pain management plan, inform their doctors, nurses, pharmacists, other team members of the effectiveness of their treatment, and so on.

Each hospital and healthcare facility has, or is supposed to have, its own set of patient rights and responsibilities, This is important as it clearly delineates the distribution of responsibilities between the patients (and their guardians) and the hospital and health facilities management and health professionals. In a sense, there is a strong assignment of personal responsibility in healthcare and treatment of patients.

Talking about personal (and parental) responsibility of healthcare, the National Statistics Office (NSO) released the Death Statistics 2007 sometime middle of last month. It showed that the top 4 diseases were responsible for nearly 50 percent of all deaths in the country in 2007. These are: (1) Heart diseases: Coronary, cardiovascular, heart failure; (2) Cerebrovascular diseases: Brain dysfunction, hypertension, stroke; (3) Cancer: lung, liver, prostate, 200+ types; and (4) Pneumonia: Lung inflammation due to virus, bacteria, fungi, parasites. The 5th killer disease is Tuberculosis.

These are mostly lifestyle-related diseases. Gone are the days where the top killer diseases in the country are polio, malaria, dengue, flu and so on.

So, is “more government responsibility” in healthcare feasible?

Technically YES. All government spending is a political act. Whether the public debt is as high as Mt. Apo, if politicians will decide to increase spending on any particular sector, they can. But is it feasible without further long-term damage to fiscal situation and future spending on healthcare and other social services?

The answer is NO. Here are the outstanding debt of the national government: from P2.2 trillion in 2000, up to P3.4 trillion in 2003, up to P3.8 trillion in 2006, then P4.4 trillion in 2009, and P4.7 trillion as of end-2010.

The total budget in 2010 was about P1.7 trillion. Or our public debt is now more than 3x the total expenditures for the year. It’s a number that we cannot really be proud of.

Out of those trillions of pesos of public debt, how much are we paying each year?

From P227 B in 2000 to P470 B in 2003, P854 B in 2006, P622 B in 2009 and P670 B last year. There were lots of maturing debts that have to be paid middle of last decade. After that, debt payment somehow declined but still at a high level of close to P700 billion.

Interest payment constitutes about 40 percent of those annual debt payment. Almost P300 billion in interest payment alone in 2010, What does it mean?

It means that for every P5 of total government expenditure, P1 goes to interest payment alone. Principal amortization takes away more than P1 of that. So that ALL the sectors combined – healthcare, education, housing, agriculture, public works, social work, justice system, police, armed forces, the judiciary, congress, the various constitutional commissions like Comelec and COA – will have to fight it out with the remaining less than P3.

Increasing borrowings and bloating the public debt for whatever new programs, therefore, will be counter-productive as it will only mean less resources even for existing and continuing programs.

I added in my presentation, patient rights with respect to the pharmacists. This include the right to confidentiality of patient records, and the right to proper advice in rational use and non-abuse of medicines, especially if medicines are to be distributed free by government and other civic organizations.

On the issue of drug-switching in particular, some patients’ have the tendency to switch arbitrarily to the cheapest generic to get savings. Pharmacists should be able to explain to patients about the issue of bio-equivalence, pharma equivalence and related issues. Getting the cheapest generic drugs available is understandable, but if patients will experience some adverse effects later if the switched drug do not contain the necessary ingredients that a particular patient’s “bio-markers” will need, then other health problems will occur later.

Someday, pharmacists will be more integratedl within the health care system with more patient care skills, and not just selling and dispensing medicines.

PH Pharmacists 1: Convention in Naga

This afternoon, I am going to Naga City, Camarines Sur, Bicol region. There is an on-going Philippine Pharmacists Association (PPhA) National Convention there, today until Friday. Tomorrow morning, I will be one of the panel speakers and I will speak on "Patient Rights and Responsibilities: Patient perspective".

I thanked Ms. Leonie Ocampo, the current President of PPhA, and Ma'am Mita Leyesa, the immediate past President of PPhA, for inviting me as one of their speakers. I kidded them that since the title of my book is Health Choices and Responsibilities, and I will speak on Patient Rights and Responsibilities, I can just copy-paste some of the things that I wrote in the book and present to the audience :-)

I have known Ma'am Mita (2nd from right) and Leonie (4th from right) since two years ago, at the various health fora and at the DOH Advisory Council on Price Regulation. They read my papers on health policy, they said they like my ideas. This picture I took from their website photo gallery.

They know how subversive my mind and ideas are, on the role and misrule of certain government interventions, on the potentials and limits of markets. They are risking their professional stature for inviting me as a speaker because I might turn my subversive mind on them :-)

See you PPhA guys tonight and tomorrow.
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I wrote this last August 25, 2010:

A Night with Filipino Pharmacists

In the various discussions on drug price control policy of the Philippine government, like at the DOH Advisory Council on Price Regulation, I have met some of the top leaders of the Philippine Pharmacists Association (PPhA). I have befriended them, and would occasionally ask some data from them, which I used for some of my articles on the subject. 

Last Friday, August 20, the PPhA celebrated its 90th anniversary and appreciation night, and a day before that, I was invited by its current President, Mrs. Leonila "Leonie" Ocampo, to join them. Leonie is a good friend and I have asked some data from her on the price-controlled drugs from her drugstore chain. So when Leonie invited me, I immediately said Yes.

They gave a special award to several personalities that night, like the immediate past President, Dr. Normita Leyesa, and DOH USec Alex Padilla. Top officials of some drugstores, big and small, were also there.

In this picture, Leonie beside me, 3 officers and members of PPhA, and Ms. Leyesa at extreme right. In the dinner table, I have also met some academics -- Deans and faculty members of the College of Pharmacy of some universities here.

The event was held at the Bayanihan Center of United Laboratories (UL or Unilab), the biggest pharma company in the country, a local firm, with sales probably equivalent to the combined sales of the 2nd, 3rd and 4th biggest pharma companies here, all multinationals -- GSK, Pfizer and... I forgot the 4th one. It was the first time that I set foot on UL compound too. From the size of the compound alone, UL is indeed a giant corporation in the pharma industry. Here, a picture of Mr. Jose Campos, UL founder.

I am thankful to Leonie, also Ma'am Normita, for the opportunity to join them that night.