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.
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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

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

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 

PhilHealth Watch 7: Deregulate PhilSick

(Note: Check my previous discussions on the "PhilHealth Watch" series as backgrounder:

Part 1: Claims vs. reimbursement, August 25, 2010
Part 2: Contributions vs. Service, September 24, 2010
Part 3, Market failure vs. Government failure in health insurance, October 13, 2010
Part 4: P110 B excess money, November 04, 2010
Part 5: Healthcare and Civil Society, May 06, 2011
Part 6: Bogus Claims and Robbery, June 15, 2011)

Last Thursday, October 6, there was an interesting forum on the Senate Bill amending the PhilHealth Charter organized by MeTA Philippines, inviting CHAT's NGO leaders. The presenter was Dr. Kenneth Hartigan-Go,  Executive Director, Zuellig Center for Asian Business Transformation, AIM Center for Development Management. and former Secretary of MeTA Philippines. The audience were varied -- from health NGOs, research NGOs (like IBON and MG Thinkers), WHO, PhilHealth, PHAP and a few multinational pharma, and the Phil. Pharmacists Association (PPhA).

Dr. Ken mentioned several issues about PhilHealth and the government-run health insurance system. Among them:

1. Still high out of pocket (OOP) spending,
2. Poor premium collection and poor insurance coverage,
3. Little funds for preventing and primary healthcare,
4. Some effects of devolution of healthcare to LGUs,
5. Accountability of PhilHealth administration
6. High OOP partly due to less essential if not useless health products like cosmetics, vitamins, even unnecessary hospitalization,
7. Possible rise in premium contribution by 3.5 percent or 5 percent for those in the formal sector,
8. Mapping of informal sector by the LGUs.
9. Goal of reducing OOP to 20 percent of total health expenditure (THE) by 2020,
10. Others.

The exchange among participants were rather very spontaneous and lively. I like the term "PhilSick" because one can "enjoy" getting PhilHealth reimbursement only if he/she is already very sick and confined in a hospital. If one is not confined in a hospital, he/she cannot file for claims and reimbursement.

After listening to various exchanges, my time to speak and I focused on the following:

1. We are already double- or triple-taxed on health: (a) income tax and consumption tax (VAT, etc.) to help finance the DOH, its retained hospitals, hospitals and healthcare by LGUs, (b) PhilHealth mandatory contributions, and (c) getting a private health insurance via health maintenance organizations (HMOs) and other schemes.

2. For me personally, the most useless is (b), PhilHealth. I have been working for the past 25 years or so, been contributing to Medicare before (it went bankrupt) now PhilHealth, and I've never been hospitalized all those years. My family members are supposed to be my "dependents" but my wife also has work, so she is also a PhilHealth member. When she gave birth, she was hospitalized of course, she claimed on her membership and the reimbursement was small, something like 1/7 of the total hospital bill.

3. With due respect to the PhilHealth guys in the room, PhilHealth is simply a monster bureaucracy that tends to behave like most bureaucracies - they exist mainly for themselves. See for instance how secretive it is with regards to the perks and bonuses of its Directors, how defensive and jealous it is in limiting membership of the Board to a few, mostly government officials too, people. The regulated sectors and players like the physicians and hospitals, are out of the Board. I also have personal experience in queueing for 2-3 hours just to file for claims, or another 2-3 hours just to get a membership data record (MDR). PhilHealth wants contributions to be sent to them in minutes (one can text his contribution to the bureaucracy) but members have to wait 2 to 3 months or more to get the reimbursement at a smaller amount compared to total hospital bill.

4. Many in the formal sector have to get a private insurance. If I have a persistent fever or bad cough, I cannot just go to any DOH hospital for they are far from my office; I also cannot file for claims with PhilHealth as I don't get hospitalized. I use my HMO card and it's convenient and useful.

5. To attain "universal healthcare" (UHC), it is important that people should have health insurance, whether government-run or private or NGO- or cooperative-managed. Thus, UHC should not mean government health insurance monopoly.

6. Thus, contrary to the advocacy of many in the room asking for bigger but a "reformed" PhilHealth, I think a better alternative is to deregulate the health insurance industry. PhilHealth will not be abolished, it can be retained as a government health insurance corporation but no longer a monopoly and membership to it will no longer be mandatory and by coercion. If PhilHealth sees that they are no longer attracting the public, it will be forced to become efficient and be more sensitive to their contributors and clients.

Personally, I would like to see PhilHealth be privatized and/or abolished, but that's not a realistic scenario. A more realistic one is the deregulation and demonopolization of the health insurance sector. Allow private firms or NGOs to compete among themselves in providing healthcare to the people, both in the formal and informal sectors.

In Switzerland, workers can get a health insurance via their labor union, or the company-sponsored one, or through their village and neighborhood association, etc. So people have many choices in getting healthcare that is tailored for them. There is no PhilHealth-like government insurance monopoly where people are mandated and coerced to become members, even if they are not happy with the amount of forced contribution and its service. See here, Healthcare competition 1: Switzerland, August 28, 2010.