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 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

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.