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

FDA Watch 2: Inspection of cGMP Compliance

A friend from the pharma industry here in Manila commented on my article last week, Competition, sans coercion, will bring drug prices down . He wrote,

Hi Nonoy,

I fully agree with you that it is competition and not price control which can sustainably reduce drug prices. The government's role is to level the playing field so companies can compete. The problem now is there is no regulatory level playing-field. The FDA conducts cGMP audit and ensures compliance (which it should) among local drug manufacturers, but it does not even inspect facilities in other countries like India. I find this reckless... I have visited India to meet various companies and look at their facilities. A lot of Indian companies have excellent facilities, some with USFDA, UKMHRA and EMEA certifications even. However, these companies are also complaining because quite a number of companies which will never pass any cGMP inspection are able to register and sell their products in the Philippines. At the very least, the FDA should inspect those coming from non-PICS countries to ensure cGMP compliance and thus ensure a level playing field. To their credit, FDA has long wanted to conduct such audits, but for whatever reason they have been unable to do so. The FDA needs our support so they can perform their functions without fear.

As to GSK, I am happy with their current thrust of lowering their drug prices, but note that it was initially not voluntary for them (as with the rest of PHAP) as the threat of MRP was used against them. In any case, competition has become very stiff in the pharma industry, which is good and is what should be. The private sector continues to find ways to have products that are low in price but which do not compromise quality. As we have shown, it's doable. However, we are still waiting for government to do its part through PhilHealth. Everyone agrees that the next inflection point in pharma pricing is when PhilHealth uses its power (and money) as a third-party payor. It too is doable. All it takes is a firm resolve and working with stakeholders who can help them.

I thanked my friend for allowing me to post his comments, minus his name and affiliation. The mad rush for "cheaper medicines at all cost" can often backfire as we might be getting super-cheap but super-ineffective drugs. I read somewhere a comment that "the most expensive drugs are those that do not work or cannot cure."

My friend added that "Technically, it's not parallel importation as many of the products which have been allowed to enter without cGMP audits are already off-patent or not patented here at all. They're also not the brands owned by other companies."

So, what keeps the Food and Drugs Administration (FDA) from conducting wide compliance inspections of certificate of Good Manufacturing Practices (CGMP)?

I remember during the 3rd MeTA-Philippines Forum last January 2010, FDA Director, Dr. Nancy Tacandong, shared during the open forum that they wanted to implement bio-equivalence testing for many drugs, but they got a temporary restraining order (TRO) to implement such. Although she did not mention publicly the party/ies who requested the TRO, I assume those are the guys who are importing or locally manufacturing just anything cheap drugs which are most likely candidates to be either counterfeit or substandard.

I have repeatedly argued that to encourage more competition and hence, cheaper products -- medicines, food, cell phones, shoes, etc. -- government should respect market segmentation by competing players in each sector and sub-sector. Those players that produce really new and more useful products as a result of endless innovation and R&D, should be allowed to price their product at any level they wish. They have the right to recoup their huge investments, and they also have the right to commit business suicide if they price their new products too high so that only a few will buy. What is important is that consumers, the patients especially, should have lots of choices. From the most expensive to the cheapest drugs.

* See also FDA Watch 1: BFAD Strengthening Bill, May 06, 2009