Stem Cell 1: PhilHealth to Cover SCT?

I was following the stem cell treatment (SCT) controversy in the Philippines recently.  The Philippine Medical Association (PMA) and the Philippine Society of Stem Cell Medicine (PSSCM), both headed by Dr. Leo Olarte, vs the 21 other specialized medical societies. The former group says stem cell treatment can cure many diseases, the latter camp says it is not true, that stem cell is proven only for bone marrow transplant and blood-related cancer, I think, and that stem cell in other diseases are still under clinical trials.

But one problem came up when DOH Secretary Enrique Ona has generally sided with the PMA-PSSCM camp and even castigated the 21 medical societies for questioning the latter. Sec. Ona is an Honorary Chairman of PSSCM.

Today, I posted this news story from the Philppine Star and posted in the MeTA Philippines email loop. The images I got from the web, I just added them here.

http://m.philstar.com/314191/show/9e9e9bca3e86ccb9a19ca1f3e38608c9/

By Mayen Jaymalin
 MANILA, Philippines - Ordinary people may eventually have the chance to undergo expensive stem cell therapy.  

Health Secretary Enrique Ona said the Department of Heath (DOH) is looking at the possibility of including stem cell therapy in the benefit packages of the Philippine Health Insurance Corp. (PhilHealth) if the medical sector accepted it as a standard care.  

“Our dream is that when this type of therapy already has a standard of care, its cost will definitely go down. By then, hopefully, (PhilHealth) can offer it already,” Ona said.            

He expressed belief that stem cell therapy has the potential to cure diseases such as cancer, autism, diabetes, stroke, liver disease, spinal cord injury, Alzheimer’s disease and Parkinson’s disease....

Stem cell treatment soon to be covered by PhilHealth? Even if it's still under clinical trials for many diseases? And such treatment is not cheap, many practitioners there charging 6 digits, even 7 digits for their rich patients.

If this will push through, ubusan ng pera yan. What's next, PhilHealth will raise the annual premium of members because funds are running out fast? 

If we want UHC, government, the DOH and LGUs in particular, should focus on primary healthcare, in fighting communicable and infectious diseases, and childhood diseases. If people want stem cell treatment and risk their lives and money for the promise of miracle, let them spend their own money, why drag along pooled fund, especially that people are forced, coerced and arm-twisted to contribute to that fund by law?

A lot of distortions in healthcare and other social issues are often initiated by the government itself.

I just hope that such PhilHealth plan will be junked. Or they want another public clamor against it, ala anti-pork barrel robbery movement?

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Three members of the Council commented:

(a) From Leonie Ocampo of PPhA:

How sad of our DOH to be supporting an initiative and/or treatment not proven by clinical trails yet, more so planning to even put this into the Philhealth benefit package. 

Philippines with its limited resources must FOCUS in the MUST DOs in health care delivery. A lot of problems from procurement, handling and storage, distribution, prescribing, dispensing, administration and monitoring of patients are still into a lot of problems and need government attention to manage and control with the right structure and processes; then here is the department tasks to put all of these in place going to something not proven yet . . wow, I could imagine how much of the people's money will be wasted again. 

Yes, I agree with you Noy, FOCUS should also be given first and foremost on primary health care . . . right structure, right processes, right people and the right resources identified and provided. Let's stop talk, talk and talk but let us start to act in the right direction, sa tuwid na daan. You know what I mean.

(b) From Doc K

Dear all, Doh did not say at anytime that phic will cover stem cell.  Sec Ona has not sided with any groups. Pls do not believe all newspaper reports. Ask why these misleading news are surfacing over the last month.

(c) From Doc Delen:

Dear Nonoy,

Very well said!!!  I totally agree with you!  Really, the priorities of this government is something that we should question.  They are not looking at the needs of the vast majority of the Filipino which can be easily addressed if we put our money on public health and primary health services.  Primary health care is an approach that is not being espoused by the DOH when in fact PHC continues to be the backbone of good health strategies.  Secretary Ona, whose experience is very hospital based, prioritizes tertiary care and hospital centered care which is more expensive.  Certainly, if the government's budget for health is directly given to primary care services, improving the local health center facilities and making health care, including medicines, more available and accessible, then we do not have to have Philhealth that still screens what can be supported or not.  People will now patronize the health centers and exercise their right to health.  This will improve their health seeking behavior and  know that they can avail of services immediately.  They need not wait for their condition to worsen, which is what is currently happening, necessitating a tertiary care consult.  Then, eventually, we can have more healthy people who can now be more productive and contribute more to the economy of the country (but of course there should also be concomitant changes in the economic and political spheres as in providing decent and justly paid jobs, humane housing conditions, good nutrition, good education, etc).

It is appalling that Secretary Ona can think of stem cell therapy first to be included in a Philhealth package before he thinks of improving our basic health care services.  Stem cell therapy is very new and still under study and we should not deceive the people and worse, make money from them as indeed this is a very expensive intervention.  And to use our people's money for this is truly something we should not allow!

Thanks Nonoy for your very good insights on this issue.

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See also:

UHC 18: DOH Budget, Healthcare Deregulation and PharmaWealth, August 08, 2013 

Drug Price Control 37: Four Years of the Policy, August 16, 2013

UHC 16: Dialogue on UHC and Medicine Access, AIM July 25-26

The Department of Health (DOH), Philippine Health Insurance Corporation (PHIC or PhilHealth), FDA and the AIM Dr. Stephen Zuellig Center for Asian Business Transformation (AIM ZCABT) will hold a policy dialogue tomorrow and on Friday, on “Universal Health Care and Access to Medicine” at the Asian Institute of Management (AIM), Makati City.

I received the invite only today when the DOH National Center for Pharmaceutical Access and Management (NCPAM) extended the invite to all members of the DOH Advisory Council for the Implementation of RA 9502 (Cheaper Medicines Law of 2008). Thanks to Mhyanne Dioso, the chief “workhose” of NCPAM for the Advisory Council, aside from NCPAM Director, Doc Virgie Ala.

The main objective of the seminar is “to identify the gaps and solutions in ensuring universal access to medicines in the Philippines” and hence, contribute to attaining universal health care (UHC) or Kalusugan Pangkalahatan.

The DOH’s budget has been rising big time in recent years: from only P18.9 billion in 2008, marginally rising to P23.7 billion in 2009 and P24.6 billion in 2010. When the PNoy Aquino government came, the DOH budget jumped to P31.8 billion in 2011, P42.1 billion in 2012, to P52 billion this year. Next year, the DBM-approved budget that was sent to Congress is P87 billion, or a P35 billion jump over this year’s budget.

A big portion of such huge jump in the proposed spending next year will be used to cover more poor households in PhilHealth insurance system, as the President said in his State of the Nation Address (SONA) last Monday. And medicine procurement by DOH hospitals and other agencies will likely get a big boost too.

Please note that public health spending in this country does not only come from the DOH. There are also the LGUs through their provincial, city and district hospitals, provincial and city/municipal/barangay health centers. Then other government agencies like the AFP Hospital, Veterans (under the DND) hospital, PNP Hospital, UP-PGH, PCSO ambulances and health charities, and so on. And almost all departments and agencies have their own in-house clinics for the healthcare of their employees and their dependents. There is huge public spending in healthcare and many people do not realize it, so they ask for more subsidies through the DOH and PhilHealth.

Back to the forum tomorrow. Among the speakers will be DOH Secretary Enrique T. Ona, DOH UnderSec. Madeleine “Madz” Valera, PhilHealth President and CEO Alexander “Alex” Padilla, FDA Dir.- General Kenneth Hartigan-Go, and Mr. Deejay Sanqui of IMS Health.

I hope that Sec. Ona will give an overview of the big DOH budget next year seeking approval by Congress. It seems that the “creeping re-centralization” of healthcare is no longer creeping but already hopping. Healthcare is among those functions by the national government that were devolved and decentralized to the LGUs under the Local Government Code of 1991.

I also hope that PhilHealth President Alex will not announce another round of hike in annual premium, especially for those in the formal sector. PhilHealth hiked plans to hike the premium from 2.5 to 3.0 percent of the basic salary of those working in the formal sector just a few years ago. The premium of OFWs has been raised from P900 to P1,200 per year and the sponsored program, the poor, from P1,200 to P2,400 per year, but the poor do not pay this amount, the LGUs and/or the DOH do.

My advocacy for minimal government in healthcare does not include healthcare for pediatric diseases and infectious diseases for both children and adults. I support further DOH and LGUs spending for these two types of diseases. But I do not support more government subsidy for NCDs for adults. If people have money to buy lots of fatty/salty food and drinks, lots of alcohol and tobacco products, or nice flat tv and DVD players and become couched potatoes, and they become sickly later, they should also have the money to buy private health insurance to augment their PhilHealth insurance. To say that they have no money for their own healthcare while they can spend for those food, drinks and smoking, is simply “palusot” and must be checked.

PhilHealth I think, should prioritize issuing automatic membership card for all poor children, say 6 years old and below. If DOH and LGU resources cannot support automatic coverage for older children and parents from poor households, then other agencies like DSWD, PCSO, UP PGH, private charities and foundations can come in. But usually LGU hospitals provide universal coverage for their local residents, young and old alike.

Tomorrow afternoon panel discussion will be on “Innovating and Improving Access to Medicine via Good Governance” with Tarlac Gov. Victor Yap, Gov. Alfonso B. Umali, Jr. of ULAP, Ms. Esther Go of Medilink, and Dr. Peter Glen Chua of FDA as speakers.

The role of LGUs is important in this aspect as lots of waste if not corruption in medicine procurement and distribution happen at the LGUs level. Many LGUs do not have the proper training and expertise in the proper storage and dispensation of medicines given free to their local residents.  

On Day 2, July 26, there will be a panel discussion on “4Ps of Financing Pharmaceuticals”: Rational Pricing, Tailored Procurement, Strategic Purchasing, and Risk Pooling, with four speakers:

Dr. Melissa Guerrero of DOH-NCPAM, Mr. Bienvenido Bautista of PITC Pharma, Inc., Dr. Dennis Ross-Degnan of Harvard Medical School, and Dir. Carlos Da Silva of AHMOPI.

NCPAM has a big budget for medicine procurement for “drugs entitlement” on certain diseases like breast cancer. PITC Pharma is the state’s chief drug importer and wholesaler for the various DOH-sponsored Botika ng Bayan, Botika ng Barangay, and other DOH agencies.

I am curious about the lectures on various topics like the ASEAN Pharma Harmonization, Anti-Microbial Resistance (AMR), Drug Price Referencing, PPP to Improve Access to Medicine, and PHIC and PCB 2. The  speakers will be Ms. Joyce Cirunay of FDA, Dir. Virginia Ala of DOH-NCPAM, Mr. Alex Haasis of NCPAM, Dr. Anthony Faraon of Improving Access to Medicine Project, and Dr. Francisco Soria of PHIC.

We shall have an ASEAN Economic Community (AEC) in 2015 or less than two years from now. The ASEAN Free Trade Area (AFTA) will mature, meaning zero tariff for all imports from any ASEAN member-countries, except perhaps for poorer economies Myanmar, Cambodia and Laos who might slap import tariff on some imported products from other ASEAN countries.

Singapore is the regional headquarter of many innovator pharma companies, not only because it is a regional financial center at par with Hong Kong, but also it strictly respects IPR like patent and trademark. Thus, IPR-busting policies like compulsory licensing of new and patented medicines, and drug price control are not done there. An ASEAN harmonization plan will consider this disparity in IPR and drug pricing policy. Many ASEAN countries like the Philippines, Thailand, Indonesia, Malaysia and Vietnam have laws allowing CL or similar schemes, and drug price control policy. Singapore does not have such policies.

Another learning experience for me in the next two days in health economics and public policy.

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See also:

Socialized Healthcare 12: Nurses, Doctors and Other Resources, March 03, 2013

Socialized Healthcare 13: On Inequality and Inclusive Business in HC, March 19, 2012  

Socialized Healthcare 14: Over-extending Government Role in Health, May 22, 2013 

UHC 15: On DOH Plan to Recentralize Healthcare, June 27, 2013

UHC 15: On DOH Plan to Recentralize Healthcare

The quest for government-initiated and centralized universal health care (UHC) can be dizzying for all sectors -- patients/public, private healthcare professionals and providers, government health agencies, the legislature and everyone else. This is because when government centralizes or almost  monopolize healthcare, competition, price differentiation, market segmentation and service innovation is often sacrificed or killed.

A famous physician, expert and consultant on UHC and NCDs, also a friend, Dr. Tony Leachon, posted this story from GMA News the other day, in his fb wall,

PNoy to push for less controversial health programs in last half of his term

In a speech during the Department of Health's (DOH) 115th anniversary celebration, Aquino said his administration is determined to attain its goal of universal healthcare for all Filipinos by 2016….

"Last year mayroon tayong Sin Tax, mayroon tayong Responsible Parenthood, ngayon naman ho ay pakikiugnayan ng mas hindi masalimuot ang ating pakay," he added. Aquino, in his speech, said his government was able to enroll some 20 million more Filipinos to the national health insurance program during his first three years in office.

He also boasted of his administration's efforts to expand benefit packages for Filipinos suffering from heart diseases, aside from those with "catastrophic diseases" such as breast cancer, prostate cancer and acute leukemia.

The president likewise pledged to build more new health facilities in far-flung regions of the country, and the rehabilitate old hospitals.

"Hindi tayo titigil hangga’t may mga kababayan pa rin tayong ni hindi nakakakita ng espesyalista sa tanang-buhay nila. Kaya naman sa huling dalawang taon ng ating administrasyon—binawasan ho ako ng isang taon, siguro ‘yong writer ko po ay gusto na ring lumipat ng trabaho—target nating i-upgrade at gawing mas moderno ang 7,325 na mga ospital, klinika, at pagamutan," he said. DOH Secretary Enrique Ona, meanwhile, said his department will propose a law that will facilitate the efficient delivery of health services to distant towns in the country. 

"Kami ay nahirapan nang husto na ipaabot sa ating local health units 'yung tulong ng DOH kasi devolved ang ating health system down to the towns. Sabi namin, pag-aralan on how we can improve the devolution of healthcare," he said in an interview after the event. 

He likewise said he wants a legislation that will "improve the governance" of public hospitals under the DOH.

Among the comments raised by Doc Tony's friends were the following:

(a) Do not neglect the human resource aspect of modernizing health facilities, otherwise we willl have ghosts running our hospitals.

(b) Maldistribution and unemployment of healthcare professionals are serious issues.

(c) There is an over-supply of nurses and there is maldistribution of doctors, maybe even an under-supply of physicians.

(d) Start an Advanced Practice Nursing/ Nurse Practitioner program. Can be piloted with a very good nursing program. It will provide job security and provide additional primary care providers especially in underserved areas.

(e) "Hindi tayo titigil hangga’t may mga kababayan pa rin tayong ni hindi nakakakita ng espesyalista sa tanang-buhay nila." -- Why do the people need to see a specialist? Specialist in what? Why can't they be seen by primary care physicians or nurses? If nurses are trained to render primary care... agree ako jan.

I commented that the move now by the DOH is towards more nationalization and recentralization of public healthcare. But centralized programs often result in centralized expectations and centralized disappointment. Then I asked Doc Tony since he has worked in both private and public hospitals and other healthcare facilities, what are the efficient incentive systems that encourage HC professionals to provide really caring service to patients, so they get well and become economically productive.

Doc Tony replied that HC professionals should be compensated well to stay with a well planned career plan.

That is precisely my point. Very often in government hospitals and HC facilities, the doctors are paid flat rate, whether they see 20 or 200 patients a day, the pay is the same. So the tendency is to provide quickie prescription, little or no patient counselling, then call the next patients after 3 or 5 minutes. When government centralizes, nationalizes and monopolizes healthcare, service differentiation, market segmentation and service innovation is often sacrificed or killed. Government service is meant to uniformize, harmonize and monotonize the public, and sub-optimal health outcome is the result.

In the food sector, there is zero government carinderia or restaurant, zero government supermarket or talipapa, zero or little government farms, and yet people are eating. There are various products for various people with various budget and needs. Service innovation, price differentiation and market segmentation allows the various food producers/sellers to meet with certain food consumers.

In contrast in the health sector, (1) there are tens of thousands of government rural and barangay health centers, (2) tens of thousands of government-sponsored botika, (3)hundreds of government hospitals (DOH, LGUs, PGH, AFPMC, etc.), (4) there are free medicines and entitlement programs for the poor, (5) drug price control policy, (6) mandatory price discounts to senior citizens and persons with disabilities (PWDs), (7) government health insurance monopoly, and health problems are not declining but rising. Expectations rise, disappointment and discontent rise. Centralization and monopolization is wrong.

In another thread, there are good experiences in private-provided healthcare like the case of Dr. Meo Santos-Cao. She said, 

when I had my practice here in Laguna (up to 2006). I did not even register as provider with PhilHealth. I always made sure that this fact was clear to my patients. They paid me directly, usually before discharge from the hospital, but sometimes upon post-hospitalization check-up in my clinic if they had difficulty raising money. And since I didn't have to wait for 3-6 months for PhilHealth to pay me, I always charged much lower than other MDs here.  

I practiced general med. I did minor surgeries, checked on pregnant women and assisted normal deliveries. While it's customary for those services to be provided by specialists (surgeons and OB-Gyne), I had no qualms doing those because I was capable, had training and licensed to practice. In so doing, I gave patients an alternative to expensive services of specialists. In 2005, OBs charged 15k for a normal vaginal delivery, part was paid for by PhilHealth and the bulk out-of-pocket. Whereas, I charged only 6k for the same service, all out of patient's pocket. Malaki pa rin ang natipid ng pasyente. The important point here is that patients must know that they have options and that they cannot be held hostage by the prevailing system. Bottom line pa rin, as Marco pointed out, patient and provider must agree on the service and its cost.

I like the stories that Doc Meo shared, it's about private contract between a service provider (her as a physician) and service consumer (the patients) with no tertiary or external intervention (the state like PhilHealth, especially). The result is fine. If the patients are not happy, no need to rally or demonstrate in the streets to demand that the state should regulate Dr. Meo Cao or whoever. They simply refuse to come back, tell their friends that Dr. Cao is a lousy doctor. But this did not happen, they keep coming back, meaning they are happy with the services provided by Dr. Meo Cao.

Another physician friend also shared that "...with unjust compensation, doctors would opt not to operate lalo na kung difficult cases, the new Philhealth scheme doesnt take into account case difficulty. Di ka na properly compensated, mas malaki pa risk sa license mo, pagod ka pa. I dont think this is in the best interest of the patient. It takes forever for Philhealth to pay the MD and hospital, and only an instant to disqualify patients na may minor delinquencies sa continuity ng payment."
http://funwithgovernment.blogspot.com/2011/10/philhealth-watch-9-physicians-talk.html

On another note, I changed the subject of this thread from "Socailized Healthcare" to simply UHC. See also:

Socialized Healthcare 11: Private Health Insurance and HC Vouchers, November 16, 2012

Socialized Healthcare 12: Nurses, Doctors and Other Resources, March 03, 2013

Socialized Healthcare 13: On Inequality and Inclusive Business in HC, March 19, 2012  

Socialized Healthcare 14: Over-extending Government Role in Health, May 22, 2013

Health Spending 6: DOH's Proposed 2013 Budget

Government healthcare spending is among the biggest items in the national budget. Such spending is not limited to the budget of the (a) Department of Health (DOH) but also to (b) state universities like the PGH under the UP budget, (c) DND and DILG for the AFP and PNP Hospitals, (d) PCSO, PAGCOR which give away ambulances and provide hospitalization coverage to some poor people, (e) other Departments and national government agencies, (f) local governments with their respective city/district/provincial hospitals, (g) charity groups, corporate foundations, company spending, and so on. See my previous discussion here,  Healthcare Competition 9: Deregulate Further the Supply of Healthcare.

That is why I think the estimated national health spending of around 3.8 percent of GDP is understated. I think that ratio refers only to DOH and other national government spending for health. If we include all the above mentioned offices and institutions' spending, it should easily reach 5 percent or higher.

Anway, I attended the DOH budget presentation at the Senate last September 04. Below are some of the powerpoint slides presented by DOH Secretary Enrique Ona. Thanks to Mercy Fabros of WomanHealth who posted the presentation to our CHAT discussion group.

From P42 billion this year to P53 billion next year or a jump of P11 billion in one year. Percentage wise, the DOH along with the DSWD budget have among the highest, if not the highest, growth rate next year.  The Office of the Secretary (OSec) and the HFEP are the biggest items.

See the huge spike in DOH budget, rising by about P9 billion a year on average from 2010 to 2013. Allocation for sponsored program or subsidies for poor households to become PhilHealth members, is the main explanation for this huge jump. This function should have been done by the local government units (LGUs) but many of them  are not doing their job, so the DOH has re-centralized this function. Healthcare is among the services that were devolved and decentralized from the DOH to the LGUs when the Local Government Code (LGC) of 1991 was enacted. But recently, the move has been towards re-centralization.

Tobacco Tax 7: DOH on NCDs and Tax Hike

The Department of Health, along with WHO, officially recognizes the increasing risks of non-communicable diseases (NCDs) and since many of these are directly or indirectly caused by smoking, it is naturally expected to support proposed legislations raising the taxes on tobacco. I also think that very few people in this country ever oppose such move. I support it myself 100 percent. I think the debate is limited only on the level and rate of increase that should be taken.

DOH Sec. Enrique Ona made a presentation at the House of Representatives' Committee on Ways and Means last February 21, 2012, about the proposed hike in tobacco taxes. Below are his slides.

Upper right: as societies develop, death from infectious diseases decline while death from lifestyle-related and NCDs increase. There is clear recognition that people's unhealthy lifestyle increases the risk factors for NCDs. I have no question with these data and observations.

Below, incidence of death due to NCDs is the same in South East Asia including the Philippines, as that of the global average -- around 60 percent of total deaths. I have no question with these data except this observation: "tobacco use, unhealthy diet and physical inactivity... Disadvantaged sector is most affected."

The poorer and disadvantaged sector is now smoking more, eating more healthy food, and becoming more physically inactive. Which may imply that (a) they are earning more but spending more money on smoking, (b) they are earning more and eating more, but the unhealthy food, and (c) earning more and can afford to be more physically inactive. There are contradictions here. But we proceed.

Below: diseases of the young Meaning more young people are fat if not obese, more young people are smokers. Poorer countries are more susceptible to NCDs. This implies that people in the developing world are more sedentary, more addicted to fatty food, more smokers, more drunkards, and so on.

Now look at bottom right slide: "Lifestyle related disease is not a disease of affluence... One reason for greater death rates in the poor is that the poor smoke much more than the rich." I think there is a contradiction here. The poor are victims of NCDs because they smoke more than the rich, so why are they victims? Did anyone put a gun on the heads of the poor telling them to smoke one or two packs a day or more, otherwise they will suffer physical beating, or their heads will be blown away? I'm sure there is none.

My main critique of such analysis is that it acquits the poor of having more personal responsibility in running their own lives. If they smoke more, if they drink more, if they eat more fatty food than vegetables and fruits, and so on, they are victims of some "external forces" and hence, government must bail them out from such irresponsibility.

If government will say to the people, "Don't worry much being irresponsible to your body, when you get sick, I will take care of you", then we will have more smokers, more gamblers, more fat people.

Below, the poor have little or no access to prevention due to their low education. Is this an acceptable reason or alibi to acquit people of being irresponsible about their body? Maybe, but maybe not.

Now look at bottom right slide: DOH budget is P40 billion, but smoking related expenditures is 10x that at P400 billion. If the problem is this big, then perhaps raising the tax on cigarettes is not the answer, but outright banning of cigarettes, to close down all tobacco manufacturing plants, to disallow the planting of tobacco, etc.

The DOH is aware that outright banning of smoking is impossible to implement. If the demand is there regardless of the prohibitions by the government, then supply will find its way towards the consumers. Thus, certain leeway must be allowed for people to smoke. It's their own lives. Like people who do risky sports (rock climbing, cliff jumping, race car/motorcycle drivers, etc.)

Below, a study done in 1999 estimating that tobacco-related expenses and loss of productivity from 4 out of 40 smoking-related diseases, was P46.4 billion a year. That was a big amount then.

A study on tobacco control program in Thailand.

Table below shows that Philippine cigarette taxes are not exactly low or "among the lowest in the region. Of the 9 S.E. Asian economies, Philippine taxes are 4th highest.

Again, I reiterate my support to a hike in tobacco taxes in the country. If a 1,000 to 10,000 percent increase can be fully implemented and cigarette smuggling can be fully stopped and controlled, I will support that move then. Being a non-smoker ever since, I have no love affair with cigarette or cigar. But I think the probability that the government can fully control cigarette smuggling is as high as the probability of an average Grade schooler passing an exam on partial and differential calculus.  Thus, higher tax rates can only mean higher incidence of smuggling.

Many smokers will not be comparing Philippine tobacco prices vs. Singapore or Malaysia prices. Rather, they willl be comparing cigarette prices before and after the tax hike.

I wish the DOH and other groups and individuals pushing for tobacco tax hike, to be successful in this campaign. I also support a unitary or single tax rate to apply to all cigarette products. But more than government intervention via higher taxation to reduce smoking incidence, it is more important to remind people over and over again, that healthcare is first and foremost their own personal responsibility, not government's, especially for lifestyle-related diseases. Thus, the need for the government to step back in subsidizing personal irresponsibility via higher budget for NCDs. Infectious diseases and pediatric diseases remain dangerous that claim many young lives until now. That's where the bulk of our tax money for health should go.

If people have the money to buy a pack or two of cigarettes a day, then they should have the money to buy private health insurance on top of their PhilHealth membership which will soon become more expanded. Or at least save money for their future costly healthcare.
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See also:
Tobacco Tax 1: Telecom and Medicine Taxes Too, September 15, 2009 
Tobacco Tax 2: Higher Tax + Corruption = Lower Revenue, June 06, 2010
Tobacco Tax 3: When Supply is Killed But Demand Persists, November 15, 2010
Tobacco Tax 4: Finding the Optimum, Not Maximum Cigarette Tax, May 26, 2011
Tobacco Tax 6: On Cigarette Smuggling, February 27, 2012.

Lifestyle Diseases 13: Curbing and Preventing NCDs

This is the 2nd and longer paper sent to me today by a cardiologist friend, Dr. Tony Leachon. He is calling on many government agencies, and individuals themselves, to curb non-communicable diseases (NCDs). The photos below I added just for entertainment purposes only, they are not part of Tony's original paper.
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Why do we fail in curbing and preventing NCDs?

Anthony C. Leachon, M.D.

The modern world has given us tremendous know-how, yet avoidable failures continue to plague us everywhere, in healthcare and government, in law, and in finance. And the reason is quite simple and obvious. The volume and complexity of things that we are doing, far exceeds our capacity to properly deliver and achieve it- consistently, correctly and safely.

In 1970’s, the philosophers Samuel Gorovitz and Alasdair MacIntyre published a short essay on the nature of human fallibility that I read two weeks ago and haven’t stopped pondering since. The query they sought to answer was why we fail at what we set out to do in the world. One reason, they said, is “ necessary fallibility” – some things we want to do are simply beyond our ability and capacity. We are not perfect and all knowing. Even enhanced by iPhones,iPads, technology, our physical and mental powers are limited. Much of the world and universe is- and will forever remain – outside our understanding and control.

IGNORANCE and INEPTITUDE

There are clear realities, however, in which control is within our reach. We can do coronary artery bypass grafts, lap surgeries, laser eye therapies and many more. In such realms, Gorovitz and MacIntyre pointed out, there are two reasons that we may nonetheless fail.

The first is IGNORANCE- we may err because science has given us only partial understanding of the world and how it works. There are skyscrapers we do not yet know how to build , typhoons we cannot predict, heart attacks we still haven’t how to stop. The second type of failure the philosophers call INEPTITUDE – because in these cases, the knowledge and awareness exist, yet we fail to apply it correctly; like smoking – we know it’s bad for our health and yet smokers allow themselves to suffer and die prematurely. This is really absurd.

According to Prof. Antonio Dans et al in the Lancet article, Feb 19, 2011, chronic non-communicable diseases or NCDs (stroke, heart disease, cancer,diabetes, and COPD) is a major public health problem in the Philippines and in the South East Asia. Southeast Asia faces an epidemic of chronic non-communicable diseases, now responsible for 60% of deaths in the region. The problem stems from environmental factors that promote tobacco use, unhealthy diet, and inadequate physical activity. Disadvantaged populations are the hardest hit, with death rates inversely proportional to a country's gross national income.

Families shoulder the financial burden, but entire economies suffer as well. Death and disability from NCDs can exert an economic burden in 2 ways: indirectly, through loss of productivity and income, and directly, through household spending on chronic medical care, often of catastrophic proportions.  These preventable conditions can cause major drain on the economy because of avoidable morbidity and mortality.

Developing countries have not only the double burden of communicable and chronic disease, but many also experience the simultaneous challenge of health-system reform. Without universal access to care, well-integrated health services, and strong leadership in public health, response to the above challenges will be inefficient. In such circumstances, the greatest health gains could come from structured preventive strategies.

The success of any healthcare system despite the low financing for health from public funds, is related to a unique and innovative unique healthcare spending but the overall living condition in the country. The goal is to provide quality healthcare for all at a minimum cost to society by relying on a combination of public and private service delivery, but  even without a national insurance system. The Philippine government will play a key role. Preventing diseases will be the top priority by every government agency and LGU and not only the Department of Health.

Health is everyone’s accountability. Thus our government through inter agency collaboration will promote healthy lifestyle and prevent perennial killers  like coronary artery disease, strokes from hypertension, cancers, diabetes and COPD  and other tobacco related illnesses by ensuring a healthy environment, good health conditions, and heavy penalty for smoking in public places, should  take a high priority.      

                               

A Look into our Healthcare System

If we put all our health services in a continuum, with promoting health on the one end and mitigating sickness on the other, we will realize that, all the incentives of healthcare system now respond to signals from sickness. Why should health insurance be focused mostly on sickness? We have a present system as one that pays for procedures not cures; interventions not outcomes; transactions not transformations. We "penalize” doctors for providing cost-effective care that promotes health but we reward them for interventions regardless of outcome, redundancy, and waste.

Multi sectoral approach needed

Although attempts to control non-communicable diseases are increasing, more needs to be done. Health-care systems need to be redesigned to deliver chronic care that is founded on existing primary health-care facilities, but supported by good referral systems. Surveillance of key modifiable risk factors is needed to monitor the magnitude of the problem and to study the effects of interventions. All branches of government and all sectors of society have to get involved in establishing environments that are conducive to healthy living. Inaction will affect millions of lives—often, the lives of those who have the least in life.

Philippine Health Care – quo vadis ?

The Health for the Filipinos is not about extending insurance coverage and deciding who to pay for health care, and how much – important as those things are, it makes no sense just to figure out a better way to pay the bills for a system that is dysfunctional, ineffective, and broken.  We also have to change the health care system itself, beginning with a sharp new emphasis on prevention and public health.

Perhaps we can convene a meeting with the medical societies, for a start.  DOH Secretary Enrique Ona agrees with the suggestion to shift the focus of DOH from sick care to health care; The DOH will take the lead in addressing ignorance and ineptitude in healthcare and will communicate with  all government agencies to contribute their share on health.

Health is not only the accountability of DOH it is our accountability as citizens. But, our government leaders should step up and think of creative ways to improve our condition.

We can ask DepEd, DOST, and CHED to insert preventive health education modules into the academic curriculum ; we can ask DPWH,DILG, MMDA and LGU heads to clean up the streets and clear the waterways to prevent killer floods and the  presence of Dengue Fever, leptospirosis, diarrhea and other water borne and vector borne illnesses; We can ask the DENR to help implement the Clean Air Law to prevent COPD and cardiovascular diseases and plant trees every day to prevent massive flooding that lead to aforementioned diseases ; We can ask the DPWH, MMDA  and the LGUs to create better roads to prevent the surge of vehicular accidents; We can talk with Department of Finance, Bureau of Internal Bureau, Department of Budget Management , Senate and Congress to help the physicians to lobby for higher sin tax for tobacco and alcohol; We can request the Communications Group to help DOH inform, influence, and inspire the nation that there is still hope for every Filipino.

We need a summit where President Noynoy Aquino together with his cabinet, government agencies, all health organizations, private sector, NGO’s  and related  societies  for a National Commitment, a declaration that our healthcare system values prevention, wellness, rapid diagnosis and early treatment. It will hasten things if a draft can be shown to the body during that meeting. The DOH Secretary may then seek the support of his colleagues in the Human Development Cluster and may document their support in a formal signing event, with no less than PNoy as the leading health champion. The medical societies plus PHA, PHAP, PMA etc. may also sign a similar document as proof of their support.

A PPP (Public Private Partnership) Executive Committee may then be formed to formulate the work plan. This same committee may do the monitoring of performance by the PPP components and publish in the newspapers on a monthly basis. The DOH together with the other agencies can fund this project with the Private sector group volunteering whatever it is that they think is their best contribution towards the attainment of the programs’ objectives.         

We must realize that wellness and prevention must be truly comprehensive if it is to really succeed.  It is not only about what goes on in a doctor’s office.  It encompasses workplace wellness programs, community-wide wellness programs, building bike paths and walking trails, getting junk food out of our schools, making school breakfasts and lunches more nutritious, increasing the amount of physical  activity our patients and those individuals at risk.

We view this change in mindset as our opportunity to recreate Philippines as a genuine wellness society – a society that is focused on prevention, good nutrition, fitness, and public health. But, just as important, it will hold down health care costs by creating a sharp new emphasis on disease prevention and public health.

  

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See also:
Lifestyle Diseases 6: Personal Care against NCDs, October 14, 2011
Lifestyle Diseases 7: Drinking and Healthcare, October 18, 2011
Lifestyle Diseases 8: WHO and the NCDs, December 08, 2011
Lifestyle Diseases 9: Overeating and Food Poisoning, December 24, 2011
Lifestyle Diseases 10: Financing Healthcare vs NCDs, December 30, 2011

Drug Price Control 21: Illegalities in the Implementation of the Policy

A fellow NGO leader in our health NGO federation, the Coalition for Health Advocacy and Transparency (CHAT0, suggested that CHAT and perhaps MeTA Philippines should conduct a seminar or forum assessing the drug price control policy of July 2009, implemented in mid-August 2009. I suggested that there may be no need for it, for the following reasons.

1. The DOH Advisory Council on Price Regulation has been transformed already to Advisory Council on Healthcare. The DOH itself through the NCPAM, has implicitly recognized that price control did not achieve its goal, but there is no explicit and official assessment yet, none that is available publicly and online at least,

2. The two pharma associations, PHAP for the innovator companies and PCPI for the generic companies, have spoken repeatedly, that the policy is wrong. Their latest position papers were presented in a big forum during the 2nd Generics Summit last September 7-8, 2011, organized by the DOH itself.

See my discussions of the PCPI data here, Drug Price Control 19: Why is the Policy not Withrawn Yet, and PHAP presentation here,  IPR and Medicines 16: Wikileaks and the Cheaper Medicines Law, November 08, 2011.

3. The other industry and professional associations, like the Philippine Hospital Association (PHA), the Philippine Pharmacists Association (PPhA), have also spoken on several times saying that the policy is wrong.. The Philippine Medical Association (PMA) have also spoken against it.

4. The various drugstore chains (Watsons, Mercury, The Generics) and the Drugstore Association of the Philippines (DSAP) were also very vocal in not supporting the policy.

5. Various data from IMS, the main source of DOH itself in designing the policy, showed that prices of many drugs in various molecules, including those slapped with price control, were falling.

6. Former DOH Secretaries Alran Bengzon and Quasi Romualdez have also spoken against the policy. Alran spoke during one of the Advisory Council meetings, said that they at the Medical City (he's the President of the hospital, I think) are in the business of healthcare, not drug retailing. The policy has affected the pricing of various healthcare services of the hospital.

7. During the various meetings of the Advisory Council on Price Regulation at least since June 2009, none of the members there except representatives from the Cancer Warriors Foundation (CWF) and somehow from the Cut the Cost, Cut the Pain Network (3CPNet), supported the policy.

8. PhilHealth and PITC representatives, being government agencies, have a relatively neutral position on the matter. Their mother agencies are either the DOH or the Office of the President (OP), that's why.

9. The Chairman of MeTA Philippines, former Gov. Obet Pagdanganan himself, has also spoken against the policy even if initially he supported it.

But since it was a government coercion through the Senate (then Sen. Mar Roxas), the DOH (through former Sec. DOH-que), DTI and the OP, all private players have to sheepishly obey. When things were finally settled by late July 2009, the Presidential election was less than 10 months away, and Gloria Arroyo would be giving the last of her 9 State of the Nation Address (SONA) that month. It was hours before or after the last SONA of Gloria Arroyo, July 27, 2009, that EO 821 or the real maximum retail price (MRP) order, was signed. But MRP was politically twisted and officially called as Maximum Drug Retail Price (MDRP).

See this comparison that I made. It shows that the criteria used by the DOH has zero basis in the law or its IRR.

And here are two more illegalities, they may be minor or major items. One is the illegal use of MDRP not MRP (which then was coined to mean "Mar Roxas for President", so OP used MDRP), and the introduction of new term, GMAP.

The third illegality is the absence of reporting by the DOH (twice a year to the President, once a year to Congress) assessing the policy, and such assessments should be made public.

The tongue twisting of MRP into MDRP and GMAP -- both are illegal terms, both are nowhere to be found in RA 9502 or its IRR -- is additional proof that the policy in 2009 was all about politics and politicians, especially the May 2010 elections.

The DOH was lucky that none of the affected players sued it in court. Well, it was difficult to fight government then because the DOH position was heavily supported by then President Arroyo and then Sen. Mar Roxas, a powerful Senator and a Presidential candidate of the Liberal Party at that time.

I have no "axe to grind" against the DOH for re-discussing these issues again. In fact, I am thankful to the DOH because they knew perfectly that I am an advocate of less government, that I never supported drug price control from the start, and yet they kept inviting me to different meetings of the Advisory Council on Price Regulation, now Advisory Council on Healthcare. It's just that the DOH need to recognize once and for all, that the policy is wrong, that the longer that it keep implementing a wrong policy, the more that it allows the damage to the investment environment of the country for multinational investors in general, and the innovator companies in particular, to linger further. Enough of continued illegalities of the policy.

So may I call again on the DOH-NCPAM and DOH Secretary Enrique Ona -- Withraw the drug price control policy, recommend to President Noynoy Aquino to throw away EO 821 issued by former President Arroyo.

Drug price control 3: Cost containment and long-term costs

(Note: this is my article yesterday at thelobbyist.biz. Original title of this paper was "S-T health cost containment vs. long-term costs")

Singapore – Short-term health containment measures by governments like drug price control , have long-term costs to patients and the public. This is mainly in the form of non-launch or launch delay of new and more powerful, more disease killer drugs and vaccines by the innovator pharma companies, to countries which have price control, compulsory licensing and related policies.

That was the conclusion of a paper presented by Prof. Julian Morris, a professor at the University of Buckingham in London, and President of the International Policy Network (IPN), also in London. A number of leaders of free market think tanks from China, India, Malaysia, Thailand and Indonesia also came.

I attended the Think Tanks’ IPR meeting held yesterday at Hyatt Hotel here in Singapore. The other speakers in the meeting-seminar were Philip Stevens, previously with IPN and now an independent consultant, Dr. Amir Ullah Khan, Dean and Director of Research, Bangalore Management Academy in India, and myself.

My presentation was entitled “Politics of health cost containment: Philippines” and I talked among others, the country’s year and a half experience in drug price control since it was imposed in mid-August 2009. I went to the DOH website and found these quotes from Sec. Enrique Ona’s speeches.

“…after the results of our monitoring showed that volume of sales appears to NOT have significantly gone up for the drugs that we have targeted and that the poor --- the lower income brackets of our society --- still cannot access and afford the medicines despite major price reductions.”
-- Speech at PHAP Assembly, August 26, 2010,

“..noncommunicable diseases (NCDs) already dwarf the burden of TB, malaria and HIV/AIDs combined…we find ourselves with the least capacity to confront the high costs and demands for long-term care and more specialized services for these lifestyle diseases.”
-- Health Partners’ Meeting, September 14, 2010,

So, if drug price control policy did not attain its objective – making effective branded drugs by some multinational pharma be more affordable to the poor, even if there are cheaper generics available for the same drug molecules – why was the policy not withrawn to remove the business and health uncertainties it has created?

Related to the paper by Prof. Morris, the long-term damage to the Philippines’ health and foreign investment climate has been set. New, more disease-killer but patented drugs will be made available in Singapore, Hong Kong, S. Korea, etc. but not in the Philippines. Producers of such more effective drugs will delay bringing them to the country until perhaps the patent is about to expire. So Filipino patients desperate to get such new drugs and treatment will have to travel to other countries where those new drugs are available because there is no threat of price control or compulsory licensing there.

On the second statement, if communicable diseases like TB, malaria and HIV are no longer the main killer diseases in the country, rather the “lifestyle diseases” are, why should government pour huge tax money and dictate drug prices on treatment against lifestyle diseases?

Note that most of the drugs covered by price control were for lifestyle diseases: anti-hypertension (like amlodipine and telmisartan), anti-cholesterol (like atorvastatin), anti-diabetic, anti-biotic, some anti-cancer. It seems that no drugs against TB, malaria and HIV were included in the price control

Now that policy is hardly discussed in the country anymore. People and industry players, from multinational to local pharma, drugstores, hospitals, and consumer groups and the public have accepted that the supposed short-term cost-containment measure has become a long-term form of intervention.

The focus of public discussions on the health sector is how to attain universal health care (UHC). Government focus is for PhilHealth membership to really reach 85 percent of the population, vs. current coverage of only about 30 to 35 percent, even after Philhealth has been around for the past 15 years or so.

I have attended a number of seminars and conferences in Manila recently on UHC, especially those sponsored by MeTA-Philippines, the Coalition for Health Advocacy and Transparency (CHAT). I notice that private health insurance players were never invited as among the speakers.

For me, health cost containment can be attained better if people will be encouraged to purchase their own private health insurance on top of mandatory Philhealth membership as most killer diseases are now lifestyle-related.

Why? People who have lung cancer or throat cancer due to heavy smoking, those who have liver cancer due to heavy drinking, or those with bad hypertension and high cholesterol due to sedentary lifestyle and over-eating, should not pass the high cost of their treatment to the public and other Philhealth members, including those who take care of their body carefully. Because that would mean regular hike in the mandatory contributions to Philhealth. Those patients can draw from the Philhealth fund and from their private health insurance, in order to reduce out of pocket expenses.

Indeed, short-term cost containment by governments often produce long-term costs that will ultimately hurt patients and the public themselves.