Health Transparency 12: MeTA Philippines Dynamism

Two weeks ago, I attended the Council meeting of the Medicines Transparency Alliance (MeTA) Philippines, September 19 afternoon, at the Unilab's Bayanihan Center Annex. It was a good meeting, lots of topics discussed from many participants, including new members of the expanded Council. The meeting was presided by MeTA Philippines Chairman Roberto "Obet" Pagdanganan.

I like the expansion in membership of the Council to cover more private and health professional associations. I think some if not all of those professional organizations are also happy to belong to this big alliance with one important goal -- to have more transparency and accountability among various players, public and private, in the medicines manufacturing, distribution, retailing, dispensing and policy making.

There were several items on the agenda, among which are the objectives for Year 1 of MeTA 2, that officially started yesterday, October 01, 2012, up to September 30, 2013. See the five goals below. The quarterly activities including their respective budget starting this 4th quarter of 2012 were clearly discussed by MeTA Phils. Secretary General, Cecile Sison.

Aside from conducting studies on certain health and medicines policies of the Philippine government (DOH, PhilHealth, FDA, etc.), there will be a national forum once a year, a quarterly discussion series, as well as regular quarterly meetings.

MeTA, implemented in the Philippines and six other developing countries,  is actually a unique if not strange NGO. It is a non-government organization but funded by government, the UK Department for International Development (DFID), program and project monitoring is done by the World Health Organization (WHO) in partnership with an international NGO, the Health Action  International (HAI).

Its membership is multisectoral -- from the multilaterals, the national government, health and research NGOs, industry associations, and health professional organizations. From what I observed since I joined the MeTA network through CHAT since 2009, I think the multistakeholder or multi-sectoral approach in dialogue and consensus building is working.

With the huge public debt by the UK and many other European governments and the fiscal bleeding and economic uncertainties that come with it, it is safe to assume that while this project is good, it is highly possible that the UK government will stop funding it in the future. So alternative funding sources have been identified and will be in place next year.

Among these are the incorporation with SEC as a non-stock non-profit organization that has corporate and legal identity to accept grants and donations from various sources, public and private. Another is the collection of annual dues from members: P20,000 for corporate members like industry association and professional organization, P10,000 for associate members like a pharma company or drugstore chain, P5,000 for civil society coalitions like CHAT, P5,000 for individual members, and P2,000 for associate members from civil society. Minimal Government Thinkers will fall under the last category and will pay P2,000 next year.

These rates are actually low considering the various research activities, regular discussion fora, regular meetings and community work each year. Well, there are donations to come, both in cash and in kind, from various sources.

The current officers of the MeTA Philippines Council are:


ROBERTO M. PAGDANGANAN Chairman
JOSE MARIA A. OCHAVE Vice Chairman
CECILIA C. SISON Secretary-General
NORMITA D. LEYESA Treasurer
ALBERTO G. ROMUALDEZ, JR Senior Adviser
REINER W. GLOOR Trustee
KENNETH Y. HARTIGAN-GO Trustee
PAULA MAE B. TANQUIENG Trustee


The corporate members at the moment are:

1. Pharmaceutical and Healthcare Association of the Philippines (PHAP)
2. Philippine Chamber of the Pharmaceutical Industry (PCPI)
3. Drugstores Association of the Philippines (DSAP)
4. Philippine Medical Association (PMA)
5. Philippine College of Physicians (PCP)
6. Philippine Society of Experimental and Clinical Pharmacology (PSECP)
7. Philippine Pharmacists Association (PPhA)
8. Association of Philippine Medical Colleges Foundation, Inc. (APMCFI)
9. Philippine Hospital Association (PHA)
10. Private Hospitals Association of the Philippines (PHAPI)
11. Coalition for Health Advocacy and Transparency (CHAT)

No government agency, national or multilateral, is a corporate member

All of the above have the power to vote and be voted while associate and individual members do not have such rights and power. The latter can attend and participate in the various meetings though. Fair arrangement.

I am excited to see this development and dynamism. Someday MeTA Philippines can evolve into a largely privately-funded and sustained organization. Which is the essence of civil society -- a state of society where the citizens are mature, free and responsible enough to manage their personal, household and community lives via more volunteerism and the least government coercion involved.
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See also:
Health Transparency 7: DOH Advisory Council, CHAT, June 04, 2012
Health Transparency 8: Advisory Council on RA 9502, June 11, 2012
Health Transparency 9: Physician Misdiagnosis, Dispensing Medicines, July 20, 2012
Health Transparency 10: Depoliticizing Health, Corporatizing Government Hospitals, September 18, 2012
Health Transparency 11: MeTA Philippines and Multistakeholder Process, September 19, 2012

Fat-Free Econ 18: Healthcare Corruption and Physician Entanglement

* This is my article yesterday in TV5's news portal,
http://www.interaksyon.com/business/38886/fat-free-economics-healthcare-corruption-and-physician-entanglement
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For every well-meaning government regulation to help the poor, loopholes are created that make them worse than before. Creating new regulations or new subsidies to correct the previous loopholes will only generate new ones. This is proven in the case of some government hospitals and physicians.

My friend Ted who owns a small drugstore wrote to say that in a number of government hospitals, some physicians require their patients to buy medicines only from a particular drugstore. The prices of those drugs in that pharmacy are several times more expensive than in other drugstores. The difference goes to the physicians, their partner medical representatives and the drugstore.

Ted says the doctor asks the patient to come back after buying the drugs. If the medicines are bought elsewhere – the receipt does not come from the specified drugstore, there are no initials by the med rep at the bottom of the drug packaging, or other schemes – the doctor would tell the patient to return them and buy only from the specified drugstore. Ted calls this scheme “doctor’s deal.” A doctor friend describes this formally as “physician entanglement” with med reps and/or drugstores.

Here are examples of drugs. Note that prices under the entangled scheme are multiples of those subject to no such scheme:

	Entangled	Free	Multiple
1. cefuroxime 750mg vial (pheoronix)	420.22	39.00	10.8 x
2. cefazolin 1g vial (hazolin)	350.00	38.00	9.2 x
3. hyosine (gastrine)	80-85.00	21.00	3.8 – 4.0 x
4. omeprazole 40mg vial (merazol)	580.00	204.00	2.8 x

Below are the receipts showing that these are actual figures. For Phoerenix, one receipt from a Quezon City drugstore dated December 08, 2011 prices the medicine at P39 each, and the second from a Calamba, Laguna pharmacy dated May 26, 2011 prices the same drug at P420.

For Hazolin, one receipt from the same Quezon City drugstore dated December 01, 2010 has a unit price of P38, while a second receipt from Imus, Cavite dated September 7, 2012 has a price of P350.

For Gastrine, one receipt the same Quezon City drugstore dated August 31, 2010 prices the medicine at P21 each, while a second receipt from a Pagbilao, Quezon drugstore dated December 1, 2010 prices the same drug at P80 a unit.

The purpose of having a government or taxpayers’ funded hospital is to allow the poor to have access to healthcare at low or zero cost to them. Cool in theor,y but does not happen in reality, as the above cases show. A poor person is forced to buy expensive medicine at a particular drugstore to enrich certain government physicians and their partners.

There is a related study on this subject published in 2009, An Unhealthy Public-Private Tension: Pharmacy Ownership, Prescribing, And Spending In The Philippines by Chris D. James, John Peabody, Orville Solon, Stella Quimbo, and Kara Hanson. Here is the Abstract:

Physicians’ links with pharmacies may create perverse financial incentives to over-prescribe, prescribe products with higher profit margins, and direct patients to their pharmacy. Interviews with pharmacy customers in the Philippines show that those who use pharmacies linked to public sector physicians had 5.4 greater odds of having a prescription from such physicians and spent 49.3 percent more than customers using other pharmacies. For customers purchasing brand-name medicines, switching to generics would reduce drug spending by 58 percent. Controlling out-of-pocket spending on drugs requires policies to control financial links between doctors and pharmacies, as well as tighter regulation of non-generic prescribing.

This is a serious issue, although the data was for 2007-2008. Take this table for instance. Out of the 166 customers interviewed buying from a doctor’s pharmacy, 52 percent said they bought at a drugstore that was recommended by their government physician. This is more than twice the incidence for public doctors who do own or are not linked to a particular drugstore.

From the patients' and consumers' perspective, this is wrong. As consumers, our "vested" interest is more choices, more options; not less, not monopolization.

And while it is often said that some pharmaceutical companies - innovator or generic - would give gifts or donations to government hospitals and/or doctors, there are also cases of drugstores giving donations to government hospitals and/or doctors. The result is the same: the beneficiaries’ drug prescription behavior is somehow influenced by the donors. So even if the prices of the donor drugstores or pharmaceutical company are higher than competitors, patients buy from them.

One would ask, why do some government physicians do this? Government doctors are not earning enough. They get a fixed salary, so some "moonlighting" can be expected. It is no different from University of the Philippines faculty members - like Orville Solon and Stella Quimbo, the two local co-authors of the paper mentioned above - doing research and consulting work with the World Bank or World Health Organization or US Agency for International Development, or wherever, to augment low salaries in UP.

It could be one reason why some physicians stay long in government hospitals. They can make more money there than in moving to private clinics and hospitals. This is not to say all doctors in government hospitals engage in this practice. There are some who have the "vow of poverty and pure public service" in their hearts and minds.

Many government physicians do not spend much time on each patient. There are just too many patients seeking free or cheap consultation. But the salary of the government physician is fixed, whether they see 20 or 100 patients a day. Perhaps those patients who bought from the doctor’s family-owned drugstore would get longer consultation time, to compensate for the higher cost of the medicine that the patient had to fork out. Or perhaps the same doctors would give their cell phone numbers to those “generous” patients, who can text them and ask more questions and advice even if the physicians are already outside the clinic or hospital.

I have yet to see data to back up these claims, but they are highly probable.

Nonetheless, the above cases would point to one thing: if certain free market avenues are stifled through more government intervention, one can expect loopholes and circumvention of regulations to happen somewhere.

That is why more government subsidies and freebies in healthcare will not achieve “universal healthcare.” If services are provided free - or at a heavily subsidized rate - then demand will always be larger than supply. The result will be medicine and healthcare rationing. People may get free X-ray or some other diagnostic test, but they will have to wait for hours or even days to get the results. In Canada and other rich European economies, some patients have to wait for weeks, or even months, to get appointments to see a specialist.
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See also:
Health Transparency 6: Physician Protectionism, May 19, 2012
Health Transparency 10: Physician Misdiagnosis, Dispensing Medicines, July 20, 2012

Fat-Free Econ 14: Traffic, Car-pooling and LTFRB, June 21, 2012

Fat-Free Econ 15: IMF and Freedom From Debt, July 01, 2012

Fat-Free Econ 16: Coal, Climate and Government, July 17, 2012

Fat-Free Econ 17: SONA, the Budget and Debt, July 22, 2012

Health Transparency 9: Physician Misdiagnosis, Dispensing Medicines

Note: I originally posted this last Monday, expanding this today to include some updates...
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July 16, 2012

I posted this last night in my facebook wall to help a friend of mine....

Seeking advice from lawyers and physicians: A good friend of mine has been sick, almost 3 weeks fever, they consulted 3 physicians, they all gave different diagnosis. A 4th doctor said he shd be confined. The family felt robbed by the 3 previous doctors. Any remedial action?

A friend commented why sue doctors for having different opinions. I replied that suing a doctor is a last resort due to the high costs and legal hassles involved. That is why I was asking other remedial measures/actions. For now, the immediate concern is how the patient can recover, 19 days of fever. They hope the 5th doctor can give a more correct diagnosis.

This is how the disease has dragged on, as narrated to me by the wife of the patient. Well, she's my friend too.

July 4, wife bought him to The Medical City Satellite clinic in Antipolo. Had fever for about 3-4 days already. Doctor advised him to have CBC, urine test, Xray. After 30 mins the 2 tests were released and he was asked to take antibiotics for his UTI. He was asked if he has allergies, there is none. Next day, wife took the XRay results.

Patient still suffering from high fever, brought him back to TMC clinic. Again cbc tests, but doctor had an emergency and results was never read. Wife had limited money at that time, was told another doctor can see them but then she/he will ask for another consultation fee. Wife got pissed because they already paid the previous doctor w/o prescribing them and interpreting the tests results.

So they looked for another doctor in a different clinic. Come Sunday, rashes in the patient's body mostly from tummy. And still suffering from fever. Wife thought those rashes were reaction from the Med he was taking.

Come Monday they went to Clinica Antipolo and decided to have another blood tests before seeing new doctor. Wife explained to the doctor what transpired in their consultation at TMC Clinic. Gave her all the previous and present tests results . And the rashes have come out almost all of his body. Doctor said those were measles. She advised wife to stop giving patient those antibiotics and instead to take Vitamin C with Zinc and Paracetamol if with fever.

The fever continued and so paracetamol was given to him every 4 hours. Last Friday, wife noticed that in his personal urinal, he only peed few from the previous night. So come Saturday monitored all his water intake and his Urine. From the 5 glasses that he drunk the whole day he ony peed only about half glass.

Wife was alarmed, called up his doctor that told them earlier that it was measles, advised them to have another urine and blood tests. At this time, patient was already weak and manas na sya. So after results was released this morning, new doctor from Clinica Antipolo advised her to confine the patient. New doctor said that those rashes weren't measles but instead Stevens-Johnson, wife was shocked.

Two of my friends made these observations:

1. Erwin, a physician: "Mukhang nag ACUTE RENAL FAILURE."
2. Arnel, a lawyer: "If legal remedy, none, based on the facts; consultation lang naman, at humingi ka ng second opinion."

I thanked them and others who pitched in short advice.
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July 20, 2012

The wife posted this yesterday in facebook, patient still in the hospital:

Confirmed he's suffering from Stevens Johnson. His case is a severe allergic reaction from taking antibiotics. He is now under close supervision from his 2 doctors....


The steroids made him awake for more than 24 hours. And so we ask the doctors to give remedy for his being awake. He had his 8-hour seep after given half of the sleeping pills. The first time I've seen him sound asleep. I enjoyed my sleep too :-)


Finally, he was able to eat his complete meal. No more struggling from pains, no more fever. I think he is on his way to recovery :-)

So it's a clear misdiagnosis or medication error by the first doctor from The Medical City who prescribed the antibiotics. Perhaps if the same doctor saw the patient the next day, he could have advised to discontinue the antibiotics but as the wife narrated above, that doctor attended to an emergency case of another patient.

Adverse drug reaction (ADR) is an important issue in healthcare and pharmacovigilance. Drugs can heal, but drugs can also kill. I briefly wrote about it here,  Counterfeit Drugs 4: Drugs Can Kill.