PhilHealth Watch 12: Assistance to Leptospirosis Patients

* This is my article yesterday in the online magazine,
http://www.thelobbyist.biz/perspectives/less-gorvernment/1348-philhealth-and-leptospirosis-patients
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Contribution to the Philippine Health Insurance Corporation (PhilHealth) is not strictly considered as a tax, similar to Pag-IBIG (housing), SSS and GSIS contributions, as they are dedicated funds and are not incorporated in the National Internal Revenue Code (NIRC).

But there is one thing that makes them very similar to ordinary tax measures: they are mandatory, obligatory or forcible payment to the government. Whether one believes in PhilHealth, SSS, Pag-IBIG or other mandatory contributions or not, these contributions are automatically deducted to one’s monthly pay. So that fixed income earners have no choice but to pay for these three mandatory contributions each month, on top of the monthly withholding personal income tax.

The Department of Health (DOH), the mother agency of PhilHealth, announced last week that

(P)ersons in areas affected by the heavy southwest monsoon rains and diagnosed with leptospirosis shall be automatically covered by the PhilHealth, including non-members…

According to PhilHealth Circular 39 series of 2012, non-members living in these flood-stricken areas shall also be accorded the benefits due the PhilHealth Sponsored Program members/beneficiaries. For non-members less than 21 years of age whose parents are neither member, one parent shall be automatically covered.

Being automatically covered as PhilHealth Sponsored program members mean that they shall not be required to pay premiums and that they shall be considered members for the period from August 1, 2012 to July 31, 2013, with a number card. This privilege shall be applicable for all admissions starting 7 August to the end of this month.

This would sound unfair to regularly-paying PhilHealth members as their contributions that can be considered as additional “health tax” are being used to support people who do not contribute to the fund. There is already the DOH budget that is partly financed by their regular tax payment (income tax, VAT, excise tax, import tax, etc.), or local government units that are financed by internal revenue allotment (IRA) and local taxes, that are supposed to help these people.

There is validity in this argument. Many regularly paying members in the formal sector complain that when they or their dependents are hospitalized, PhilHealth share or deduction to total hospital bill is sometimes small, that PhilHealth can be “stingy” to them who religiously pay monthly for many years while PhilHealth can be gallant in paying the hospitalization bill of those who do not contribute to the fund.

I share the above opinion. But I also recognize that leptospirosis, being an infectious and lethal disease, can be very costly to the poor whose houses are already submerged in floodwater for many hours or days. So social contribution like PhilHealth assistance can be a great support for these poor people.

The DOH reported that “a total of 2,471 leptospirosis cases were reported nationwide from January 1 to August 18 this year. This is 62% higher compared to the same time period last year (1,522 cases). There were 121 deaths…. hospital admissions of Leptospirosis in Metro Manila from August 5-22 already included 783 cases and 34 deaths.”

There is lesson for the government here in the light of endless budget deficit (revenues are lower than expenditures) and ever-rising public debt. The limited funding of the DOH and local government units’ healthcare programs should be focused on dealing with infectious or communicable diseases as well as children’s diseases. There are many infectious diseases that remain lethal until now aside from leptospirosis: dengue, malaria, menningococcemia, hand foot and mouth disease (HFMD), typhoid fever, cholera and many others.

Using taxpayers’ money and the health tax or PhilHealth mandatory contribution to treat lifestyle-related diseases by non-members is not fair. No one put a gun on people’s heads so that they should over-drink or over-smoke or over-eat or ovet-sit. Engaging in the said activities will hasten the onslaught of various type of diseases like cardiovascular, cerebrovascular, malignant neoplasm or cancer various types, tuberculosis and diabetes.

The implication for the above case is to further deregulate private health insurance schemes. If people can afford to consume high volume of alcoholic or tobacco or fatty food and drinks, then they should also have the resources to purchase additional private health insurance on top of their PhilHealth mandatory membership. This dual health insurance should drastically reduce their spending should they get hospitalized or become more sickly someday.

The important point is that DOH budget, PhilHealth fund, and LGUs’ health spending should be concentrated in dealing with various infectious and pediatric diseases. And even to help people with physical or mental challenges like the blind, the deaf, crippled, autistic and related cases.

Taxpayers and PhilHealth members who regularly pay their taxes and mandatory contributions would not feel being cheated this way.
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See also:
PhilHealth Watch 6: Bogus claims and robbery, June 15, 2011
PhilHealth Watch 7: Deregulate PhilSick, October 09, 2011
PhilHealth Watch 8: Alternatives to PhilSick Monopoly, October 13, 2011
PhilHealth Watch 9: Physicians talk about PHIC, October 16, 2011
PhilHealth Watch 10: Hospital Bill Deductions, December 29, 2011
PhilHealth Watch 11: Is PHIC an Insurance Company?, June 12, 2012

Drug Price Control 29: MRP Attempt Over Anti-Leptospirosis Drug

Today, the drug price regulation or control policy in the Philippines is exactly three years old. It was implemented August 16, 2009. No cake nor cigar for this wrong policy.

Yesterday, I attended an emergency meeting of the Advisory Council for RA 9502 (Cheaper Medicines Law) at the DOH. There were some proposals to impose a maximum retail price (MRP) on doxycycline, a drug against leptospirosis, a common disease during heavy flooding that submerge thousands of houses for hours or even days.

Here is the background as I gathered during the meeting and in small talk after. During typhoon Ondoy (see  Climate stupidity 18: Warming causes more storms and less storms, Typhoon Ondoy Photos) three years ago, and in other severe flooding after that, several people died due to leptospirosis, an infectious disease coming from animals, especially rats' urine that mix up with dirty water and enter the human body via the mucous or wound or infected drinking water.

Once untreated, the virus can cause first flu-like symptoms (fever, chills, headache, etc.) later on meningitis, damage of the liver or other internal organs, and later, can result in death. The DOH was peppered with questions if not blame, during the leptospirosis outbreak then. So this time, before any outbreak would show, the DOH wanted to be ready.

So during the heavy flooding last week caused by southwest monsoon or "Habagat", then another heavy flooding early this week due to typhoon Kai-tak (local name "Helen"), many people tried to stock up on doxycycline as a precaution. A friend of President Aquino was said to have complained to him why the price of the drug was high, more than P50 or even more than P70 a tablet, when it should be cheap. The President asked the DOH about it.

Then the Director of DOH NCPAM, Dir. Virginia Ala herself got a call from a physician in Marikina, a city that often gets heavily flooded, why the price of doxycycline in Mercury Drugstore was more than P50 when it should be around P10 only. People began to wonder if there was a sudden jack up in the price of doxycycline from around P10 to P50+ or P70+, or even P160+. If that was so, some people suggested to put the drug under price control or MRP.

The DOH wanted to explore other proposals aside from imposing a new round of MRP, hence the need for that emergency meeting. Well, I got the notice of meeting only one day before the meeting, that's how urgent the meeting was for the DOH. I admire the DOH, especially Assistant Sec. (ASec) Madeleine "Madz" Valera for her trust in the inputs of members of the Advisory Council, as well as the consensual nature of the Council.

The meeting was initially chaired by former DTI UnderSec. and now PITC President, Ma. Lourdes Baua. DTI is the co-chair of DOH in the Advisory Council. PITC is an attached agency of the DTI. Then ASec Madz came to preside as Ms. Baua went to another meeting. She just came from a meeting with DOH Sec. Enrique Ona, and was later called out again for another meeting with the Secretary.

I noted during the meeting that the date was rather good as it was (almost) the 3rd year anniversary of MRP implementation. Dr. Rustico Jimenez, the President of the Private Hospitals Association of the Philippines, Inc. (PHAPI) noted that it was the DOH or other government agencies themselves that alarmed the public about leptospirosis and hence, alarmed the need for doxycycline. In his observation, more people died of pneumonia, gastro enteritis, other diseases during and after flooding than lepto. ASec Madz said that it might be true, but many people are at risk of lepto due to the rather high number of casualty from the disease in previous flooding.

There were several suggestions that came out on what the DOH should do to limit public alarm over lepto and other water-borne diseases. The DOH observed that many individuals and civil society groups were distributing medicines to flood victims especially in evacuation centers. The DOH suggested that since non-rational use of medicines (RUM) is becoming common, like not all people can take a particular medicine for a specific disease, medicines donation should as much as possible be coursed through its central office, its provincial offices and attached hospitals.

I suggested during the meeting that since many people would give their donations to civil society and charity organizations than to government, call it distrust of government in one way or another, medicines donation should be done with the presence of health professionals for proper dispensing to patients. Doxycycline for instance should not be given to pregnant women and children, especially those below eight years old.

Reiner Gloor suggested that in times of emergencies, if it is possible that drugstores can give the doxycycline and PhilHealth will reimburse later. I don't remember what the guy from PhiliHealth said in reaction to this. But  for members who are qualified for the out-patient benefit package, I think this is possible and a good proposal. If a member is kept out of hospital, takes medication and recovers at home, PhilHealth spending will be lower and hence, it will benefit.

One good outcome of the meeting was that no one suggested that doxycycline be put under MRP. No one suggested to expand drug price control policy. Here's one reason, from some of the materials distributed during the meeting.

Doxycycline, Pesos per 100 mg capsule, Muntinlupa:

Brand Name	Drugstore Name	Price
1. Vibramycin	Watsons Mercury	169.75 168.75
2. Doxin	Asian Hospital Medical Center Muntinlupa Watsons, Mercury, South Star, Rose	145.25 103.62   74.25
3. Doxicon	Rose Pharmacy Shopwise Pharmacy Watsons	58.10   56.00   49.25
4. Dyna-doxicycline	Mercury, South Star	53.00
5. Drugmakers	Middle Town	5.00
6. Mydoxy	The Generics Pharmacy	2.00

source: DOH.

So if people will suggest imposing drug price control, they would most likely be targeting Vibramycin. But why would people insist on vibramycin with its almost P170 price per capsule, when other brands at a much lower price, P49 or P5 or even P2 are available. Although I think that the P2 drug would have been snapped up by some hoarders, to be sold at a higher price via black market in still submerged towns and villages in Laguna or Cavite, Bulacan, Pampanga, Bataan, etc.

A note on groups that oppose and support the MRP policy...
As far as I can recall in previous Advisory Council meetings, those who are explicitly against government drug price regulation or control are:

1. PCPI, Philippine Chamber of Pharmaceutical Industry, local generic manufacturers and distributors, drugstores,
2. PHAP, Pharmaceutical and Healthcare Association of the Pilippines, mostly multinational innovator companies, big drugstore chains like Mercury,
3. PPhA, Philippine Pharmacists Association,
4. PHAPI, Priv. Hospitals Association of the Philippines, Inc.
5. DSAP, Drug Store Association of the Philippines, small and non-chain pharmacies and drugstores,
6. AGAP, Ayos na Gamot sa Abot-kayang Presyo coaltion
7. MGT, Minimal Government Thinkers.

Those with soft or implicit opposition are
8. PMA, Philippine Medical Assocation,
9. Mercury, Watsons, The Generics
10. MeTA, Medicines Transparency Alliance, Philippines.

Those who explicitly support price control
1. CWF, Cancer Warriors Foundation.

Those who have no explicit position but only follow their mother agencies:
1. PITC Pharma, DTI
2. PhilHealth, DOH
3. FDA, DOH
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See also:
Drug Price Control 23: Greece's Pharmacy Nightmares, January 13, 2011
Drug Price Control 24: Forcing Drug Firms to Report Payment to Doctors, January 24, 2012
Drug Price Control 25: Top 10 Articles on Google Search, April 03, 2012
Drug Price Control 26: Conflict of Interest in Drug Price Regulation Legislation, May 13, 2012
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

RUM 7: Leptospirosis and Doxycycline, August 12, 2012
Warming Hysteria: Typhoon Ondoy Flooding, September 28, 2009

RUM 7: Leptospirosis and Doxycycline

Leptospirosis and other water-borne diseases are very common during heavy flooding where tens or even hundreds of thousands of houses are submerged in water. People have no option but to walk in dirty waters and hence, risk getting any of these diseases.

Like treating infectious and pediatric diseases, I grant that there is government role in dealing with this kind of disease outbreak. I am no health anarchist, unlike some other shades of free marketers. I post below two articles, one a DOH advisory posted in facebook today, the potentials of doxycycline in dealing with lepto and related diseases, but also its limits. There is rational use of medicines (RUM) here, it cannot be used by (a) pregnant women, (b) children below 8 years old, and according to wiki, (c) "taking doxycycline with food and dairy products may decrease the amount of medication absorbed."

I am also posting portions of Reiner Gloor's article on the subject, to show healthcare-based civil society role in dealing with this and related diseases.

(1) DOH Advises Public on Drug Prices

Press Release - 12 August 2012
by Department of Health (Philippines) on Sunday, August 12, 2012 at 8:34am ·

Health Secretary Enrique T. Ona today provided some pointers for the general public in purchasing doxycycline and other drugs and medicines, in the light of the expected surge in leptospirosis and other diseases due to flooding caused by the southwest monsoon.

“We want the public to be able to make informed decisions and get the best prices on doxycycline and other drugs and medicines”, Ona said.

Doxycycline is an antibiotic that is currently recommended to prevent leptospirosis among those with increased risk of exposure.

The Department of Health has already distributed free doxycycline for rescue and relief teams and residents in evacuation centers. Individuals with similar risk should consult a physician prior to intake.

However, doxycycline does not totally protect against leptosirosis. "Those who will develop fever even after taking doxycycline should go to their doctor for examination. Doxycyclin is not recommended for pregnant women and children below eight years of age," Ona explained....

At present, the price of generic doxycycline 100 mg capsules varies from P2.00 to P 15.00 depending on the manufacturer. Generic doxycycline 100 mg capsules are available in government hospital drugstores and commercial drugstores.


(2) Health during disasters

Medicine Cabinet -- Reiner Gloor
Posted on 05:55 PM, August 09, 2012
http://www.bworldonline.com/weekender/content.php?id=56533

RECENT extreme weather disturbances have recently resulted in loss in lives and property in Metro Manila and the rest of Luzon.

The Pharmaceutical and Healthcare Association of the Philippines (PHAP), through the PHAPCares Foundation, earlier called on its members to again extend help to victims of massive floods in Metro Manila and affected Luzon provinces. Last week, the PHAPCares Foundation turned over P500,000 worth of medicines to National Disaster Risk Reduction and Management Council (NDRMMC). In coordination with our government partners, we intend to roll out a medicine donation caravan to assist the disaster victims....

Realizing that people are physically and emotionally vulnerable to health risks during calamities, PHAP, through the PHAPCares Foundation, signed a Memorandum of Agreement (MoA) with the NDRRMC to renew the industry commitment to provide needed medicines during calamities. The aim of the "Gamot Agad Program" is to deliver essential and life-saving medicines to victims at the quickest possible time alongside the other equally crucial relief items such as food, water and blankets.

Under the MoA, industry members will provide the government P50 million, or P10 million annually, for the next five years worth of life-saving medicines for use during disasters and emergencies.

Dr. Posadas said that common medicines needed during these times are those that afford remedies to common ailments such as anti-pyretic/analgesic/anti-inflammatory medicines, decongestants and expectorants, anti-diarrheal/oral rehydrating solutions, antibiotics and topical medicines for wounds.

One common rule to remember is that medicines should be kept in a secure container that will shield them against the elements. One simple way is to put these medicines in a plastic container, tightly sealed to protect the medicines, especially from moisture and dirt. Aside from the medicines, some basic medications for wounds like alcohol, hydrogen peroxide, betadine, cotton, scissors, dressing tape, gauze, topical antibiotics and elastic bandage are useful....
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See also:
RUM 3: On Combining Drug Molecules and Alaxan FR, February 03, 2012
RUM 4: Dealing with Drug-Resistant Diseases, April 24, 2012
RUM 5- Cheaper Medicines and AMR, May 08, 2012
RUM 6: Pharmacovigilance and ADR, July 20, 2012