UHC 22: Shortage of Doctors in the Philippines

A friend, Dr. Tony Leachon of UP College of Medicine, also practicing at Manila Doctors Hospital, posted this article in his fb wall last week, and it attracted lots of healthy and useful comments from his fellow physicians. I believe more people should be able to read this useful exchange. This is long, 4,600+ 7,300+ words, 10 16 pages, enjoy.
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Tony Leachon
PMA warns of worsening shortage of doctors. http://www.abs-cbnnews.com/nation/01/30/14/pma-warns-worsening-shortage-doctors

Emmanuel 3D- Dispersal, Diffusion, Dedication

Daniel Most patients in the provinces can't afford doctors. The government thought universal healthcare through the PHIC will solve it. It just solved half the problem.

PHIC doesn't even pay for OPD consults. What, wait for these patients to be sick enough to be admitted for insurance to start paying for it? By then the healthcare cost could already skyrocket.

Ted The ratio should be 1 physician per 1000 persons. If we are 95million and we have 130,000 licensed isnt 1.3 doctors per 9,500 population? We definitely need more doctors! I believe PPP will be a major solution as many of the doctors are in the private sectir.

Iris Hopefully UPCM Return Service will help and that these new MDs will be encouraged to stay.

Minerva  This issue definitely needs a comprehensive analysis that considers demographics, changing practice patterns and healthcare access. Most existing estimates of the shortage of physicians are based on simple ratios. These estimates do not consider the impact of such ratios on patients’ ability to get timely access to care and do not quantify the impact of changing patient demographics on the demand side and alternative methods of delivering care on the supply side. We are at the threshold of collaborative practice which could be expanded to include the use of healthcare teams of physicians, nurses, midwives. Telehealth is another option to address timely access to care in remote areas. Improving allocations for physicians in government, both national and local as well as improvement in facilities through local government emphasis on health agenda is a must while we review the Local Government Code.

As an educator engaged in organized medicine, I believe we should also shift some of our focus in teaching medicine and include health informatics, leadership and management of change, medical socio-anthropology and immersion in public health issues in research, in elective rotations and as part of case scenarios in medical subjects so that medical students will have a grasp of the real world that they will face after medical school.

Ted  If each private doctor accepted or was assigned few poor families in consult and treatment under their care and Philhealth paid for their servicrs, would that lessen the problem?

Daniel  PHIC calls it capitation but its only paid to the RHU doctors, which in most cases, the poor patients won't even find in their clinics.

Adrian It might be time to consider Dr Domingo's proposal for a national matching system. That will ensure a career for doctors, while addressing distribution issues.

Philippine Navy and Sangley Point

A friend in facebook, Dr. Aileen Baviera, an academic in UP and researcher on foreign policy and military affairs, rode a Philippine Navy chopper yesterday and took photos, posted in facebook. I have seen Sangley Point from a distance via commercial plane, but I have never been there. Nice photos.

The skyscrapers of Manila-Makati-Pasay-Paranaque, seen from Sangley Point, Cavite.

Not many battle ships anchored there that day. Maybe the other ships are in Mindanao, Palawan, and near the Spratlys, Scarborough/Masinloc areas.

That long stretch is a runway, for the Air Force, I think.

The Navy headquarters in Roxas Blvd, Manila. I read that the government intends to lease or privatize this area, good move. Huge amount of money can be realized from that scheme. Any move to modernize the Armed Forces of the Philippines (AFP) should be funded from the privatization of some DND/AFP assets and land, and not resort to raising taxes or more government borrowings.

Our public debt is rising by P400 to P450 billion a year, with or without any economic crisis. It's a pathetic and ugly fiscal situation. It should not be worsened by more public borrowings to pursue certain social or military goals. Privatization is the mdiway solution.

See also: 
External threat and the Navy, January 06, 2011 
Privatization 8: Government Debts: Military Camps and Spratly Issue, June 20, 2011 
China Watch 16: Scarborough Shoal, Spratlys and Citizens Action, May 01, 2012

Economic Liberalization via Charter Change, the FEF Statement

Investments and job creation is not a crime that must be restricted by governments. The Philippine Constitution, ratified in 1987 or 27 years ago, is nice except that it explicitly limits or bars foreigners from owning certain assets and businesses in the country. Some sectors are limited to either 40 percent maximum equity ownership by foreign investors, some are outright off-limits to foreign investors.

I believe that the PH constitution needs to be revised and amended. In addition, I wish to see a Constitution that is 10 pages max. Very few details, mostly motherhood statements. All details -- like the minimum age for a candidate to run for Congressman/woman, for Senator, for President; what sectors to be reserved only for Filipinos, etc. -- should be done via legislation. That way, there is no need to clamor for frequent changes in the charter. People can lobby for new legislation or amend an old law without affecting the entire constitution.

Below is one statement calling for charter change.
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FEF Statement of Support to the move of Speaker Belmonte to amend the economic provisions of the PH Constitution

CHACHA NOW!

STATEMENT BY THE FOUNDATION FOR ECONOMIC FREEDOM

February 3. 2014

 We, the Foundation for Economic Freedom, support the move by Speaker Feliciano Belmonte Jr. to amend the economic provisions of the Constitution to include the phrase “unless provided by law” to the foreign ownership restrictions in the Constitution in public utilities, land, mass media and advertising, educational institutions, and development  of natural resources.

We believe that vesting on Congress, rather than the Constitution, the power to determine the restrictions in foreign ownership will send a strong signal to foreign investors that the government will level the playing field by opening up the economy as conditions permit.

We believe that opening up the economy to foreign investors is necessary to increase  Foreign Direct Investments (FDI) in the country, which remain one of the lowest in the ASEAN.

Poverty and hunger levels have remained unchanged despite the country’s 7.2% economic growth.  To attain “inclusive growth,” the country must boost investments by liberalizing foreign ownership  rules in order to generate employment and reduce poverty.

The country also risks being left out of the Trans-Pacific Partnership (TPP), an economic grouping of nations intended to boost trade and investments among member countries, if it does not amend the restrictive provisions in the Constitution and give foreign investors equal treatment as local investors.

Opening up the economy to more foreign investors, especially in strategic industries where foreigners are presently prohibited from owning a majority, will help improve competition, increase consumer welfare, lower prices, raise productivity, and generate technology transfer.

While the Constitutional amendment will not immediately liberalize the economy, it will provide an evolutionary path to making the necessary changes as needed.  The Belmonte proposal represents a practical political solution that provides the “key” to opening up the economy.

We urge President Aquino to reconsider his stand about not amending the Constitution and allow Congress to pass the Belmonte bill in time for a national referendum in 2016.  The millions of poor and unemployed are looking up to his government to live up to his promise of inclusive growth.

Plane Delays and NAIA Bureaucracy

* This is my article yesterday in thelobbyist.biz.
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A fried posted last January 27 one of his travel nightmares when he came home from Norway.

Another shameful episode at the Ninoy Aquino International Airport…. our plane was supposed to touch down at 1155AM but we had to go on circles for 3x of 15 minutes each because of the queuing problem in the run way. On the third round the Pilot of flight TG 620 had to make an emergency landing at Clark because our plane almost run out of fuel. I was both angry and ashamed as I heard all the side comments and complaints of the passengers especially those foreigners who just came for a business meeting today but had to miss out. We touched down around 3:00PM after yet another prolonged wait at the Diosdado Macapagal International Airport (Clark) because it took them more than half an hour to give us the go signal to take off after refueling! 

If we have only one runway that is functional how can we accommodate all those planes that come to our airport. How can we attract Tourists and Investors to come if this is the kind of infrastructure we have to offer. Why can't we just give up the Ninoy Aquino International Airport and build a more respectable and world class airport in Clark Field! The area has enough space for several runways….

Sabi nung British na katabi ko magagaling daw ang mga Pinoy professionals na katrabaho niya, nasisira lang daw tayo sa palpak na patakbo ng mga politiko at technocrats sa gobyerno! NAKAKAKAHIYA TALAGA TAYO!

Amen. I can only commiserate. So far I have not experienced a nightmare like that. 

Airlines want to economize fuel cost as much as possible so they can bring down their fares. If an airplane is made to wait for 10 minutes or more in the air, that should be several thousands of pesos of wasted fuel with no additional revenue. But the airline cannot bill the government through NAIA for such additional costs. Govt can only charge lots of taxes and fees on airlines but will not share with additional costs due to govt inefficiency or stupidity.

These days, each airline has to consider 4 factors in their pricing. (a) fare by competitor airlines on same routes, (b) domestic passengers taking the bus and RORO instead, for those going to Bicol, Samar, Leyte, Aklan, Capiz, Antique, Iloilo; (c) taking the boat direct from Manila pier to many provinces in Visayas-Mindanao, or (d) postpone the trip and not fly if the fares are high. So airlines must economize on many things especially fuel to give low fares as possible and attract more passengers. Like low fares to passengers who have no check in baggage. Lighter plane load, fewer fuel consumption. If they check in baggages, extra fee for 10 kg bag, 15 kg bag, 20 kg bag, etc.

Here comes government, occasionally causing wasteful use of fuel by airlines and not assuming responsibility for its inefficiency. Government could have mitigate the additional costs by allowing deductions in landing fee, take off fee, etc. for each minute delaying the landing of an airplane. But govt does not think that way, kabig lang ng kabig, shameless collection of endless taxes and fees.

Another thing. The queuing of airplanes and allowing faster landing and taking off can be done with more modern technology. In HK, I noticed that one runway can accommodate one landing every 30-40 seconds on average, then on the other runway, planes take off every 30-40 seconds too. At NAIA, I notice that queuing is every 45 seconds or more for each landing, another 45 seconds or more for each take off. Maybe there are suppliers of new air navigation technology, but they can’t sell unless they give bribe to NAIA bureaucrats?

Government taxes and fees in the airline sector, passed on to the passengers: Aviation security fee + Excise tax and VAT on fuel products and fuel surcharge + VAT on overall plane ticket. There are also implied taxes in the plane fare like common carriers tax (CCT), gross Philippine billing tax (GPBT), or a franchise tax, on top of corporate income tax, etc. Then there are landing fee, take off fee, baggage handling fee, etc. Airlines pass all of these to passengers.

Plus: travel tax for international passengers (essentially a hold up, highway robbery as there is zero service given to passengers), airport terminal fee (and the airport does not even give free drinking water/fountain, passengers have to pay extra to buy bottled water).

Some big airports abroad also divert plane landings but only during emergencies, like very bad weather, or some risks in landing like one airplane has nearly crash landed and left debris on the runway. But not for reason of "Sorry guys, 12 planes on queue ahead of you, you are #13, so feel free to waste fuel for several minutes, or land at the next non-busy airport."

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See also: 
On airport terminal fees, April 05, 2010 
Plane fare fees, January 14, 2011
Airline oligopoly 1: Philippine AirLines, September 16, 2011 
Migration and Freedom 13: Travel Tax Robbery, December 06, 2011
On Airport Terminal Fee, December 09, 2011 
Tax Cut 12: Removing Taxes on Foreign Airlines, April 02, 2012

Middle Earth, the Middle Class and Growth

I like the play of words here: hobbit and habit, Middle Earth and middle class, JRR Tolkien and equilibrium theorists. Article written by my former prof. at UPSE, a math econ, institutional econ, econ history specialist, Dr. Noel de Dios. Bottomline: the need for rule of law.
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Adventure and fantasy -- not to mention Peter Jackson’s fabulous visual effects -- explain much of the recent popularity of J.R.R. Tolkien’s novels and characters, especially their movie incarnations. If one only looks very closely, however, one may also find a small parable relevant to Philippine society.

Tolkien’s Middle Earth is threatened by occult superpowers that seek total domination through their mobilization of brainwashed masses. Little resistance is offered, however, for lack of social cohesion. Human warrior-kings have been corrupted by petty divisions and their narrow ambitions that blind them to an imminent common threat. Dwarves, on the other hand, devote their lives to compulsive wealth-seeking in underground mines. Meanwhile the seraphic, almost-divine elves are only half-committed to this world and already have their eyes trained on the next.

In the end, however, Good still triumphs over Evil and Middle Earth is saved because the One Ring of Power is entrusted to the most unassuming and unambitious of creatures -- hobbits who have neither the desire nor the use for it. (Game theorists will be pleased to note the implied role of credible commitment.) Special meaning attaches to the nature of the hobbits themselves, who are moved neither by dreams of power, fame, exorbitant wealth, nor heavenly reward. Their concerns focus instead on the mundane: orderliness, security, peace, the freedom to attend to one’s own business and to secure one’s own (pipe-smoking) comfort. Embodying Adam Smith’s virtues of prudence, justice, and benevolence, the hobbits (in short) stand for civilisation and the bourgeoisie -- the middle class of Middle Earth.

In what sense can this be a parable for today? Like Middle Earth, if Philippine society is to progress, it too must ultimately hand over power to its middle class. Or more precisely, it must aim to reach the point where the majority of its people become middle class and are sufficiently numerous to set the tone of both polity and economy. (This insight is nothing new, by the way: the work by Easterly and Acemoglu, among others, shows the close causal association between the size of the middle class and economic growth.)

The strength and size of the middle class matters because it is the natural constituency for many of the factors known to make for economic growth and development. The most obvious fact is economic: a large middle class constitutes a diverse market that acts as a magnet for both domestic and foreign investment. It allows the domestic economy to escape the tyranny of Engel’s Law and produce diverse and higher value-added goods and services beyond food staples.

Bong Mendoza's Political Poetry

Below are three of the various short poems and septons by a friend, Dr. Amado “Bong” Mendoza of the UP Political Science Department. Posted yesterday and today, reposting them here with his permission. My short comments after each poem.

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(1) self-rule, anarchy and leadership

there is without doubt
greater demand for
than supply of good leaders

for leaders, what's the recipe?
mix vision and charisma?
courage and resolve?

no equilibrium in sight
we should eventually learn
to lead ourselves.

Right Bong, but anarchy to mean "zero authority" and "zero government" is a pipe dream, a fiction. I like the example of many village associations. They provide roads/drainage/flood control construction and maintenance, garbage collection, street lighting, security, fire truck/control, village park and multipurpose hall, etc. They have elected officials with term limits, have appointed or hired staff and bureaucrats. They have their own internal revenues like the annual dues, car sticker fees, household ID fees, etc. It is one classic case of self-government, minarchy, and it is working. People who are not satisfied with how the village fund and security is being managed, can move out and go to another village, or plot to change the leadership of the village.

(2) why do we obey so-called leaders?
t'is the key question in political philosophy

They're elected, they're the best
men of virtu
slaves not to fortuna's
shifting fickle tides

Karl Marx said they owned us
Robert Michels declared
They do what we can't do, daily, 24/7!

(I acknowledge my intellectual debts to Aristotle, John Locke, Niccolò Machiavelli, Karl Marx, and Robert Michels.) 

We obey so-called leaders because we are forced to do so. There are laws, armed forces and prison system by the state that forced us to obey them. True democracy should mean the least coercion. Someone thinks he's got a very bright idea. In a democracy with least coercion, he should be able to finance it without coercion, and not forcing me and you to finance his bright idea. The fact there it needs coercion and legislation means that 99 percent, it is a stupid idea.

(3) what's a CAP?
collective action problem
there's one when people
do not help each other
constitute a community

why this behavior?
we do compete or cooperate
the stronger instinct seems to be
consistent with our best lights.

bakit di magtulungan?
mga tao sa lipunan
sadya bang
mas malakas
pagnanais na
isulong ang sarili
isulong ang interes?

kailangang magtulungan
para mabuo, ating pamayanan.

(c) 2014 Amado M. Mendoza, Jr.

Collective action is often hidden, especially from the eyes of central planners. Some people focus on producing or spreading knowledge, they do not produce a single kilo of food. Some people produce food, they contribute little or nothing in producing knowledge. They exchange somewhere, the knowledge producers have food, the food producers have knowledge for them and their kids. There is collective action there, and it benefits humanity.

Thailand Politics and the Monarchy, Part 3

A friend, Dr. Amado "Bong" Mendoza, Prof. of UP Political Science, wrote a brief but good analysis of the Thai political crisis. He gave me permission to post it here; photo from his fb wall. My comments below his article.
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Oh, Thailand

Dr. Bong Mendoza

February 01, 2014

While we had delightful face-offs in Manila's Chinatown, there are dangerous ones going on in Bangkok.

Thais cast their ballots in polling stations today hopefully to form a new government after Prime Minister Yingluck Shinawatra dissolved parliament in the face of vociferous opposition last year.

The cause celebre?

Yingluck's parliamentary majority rammed through an amnesty bill that, among others, would allow Yingluck's older brother, former prime minister Thaksin Shinawatra to go home from exile in Dubai.

The proverbial straw that breaks a camel's behind!

Elections in democracies are supposed to settle rivalries between political factions; that is, decide which camp will lead a nation. However, these elections may not be able to accomplish that due to several complications.

The opposition's strategic objective: the ouster of the "Thaksin regime"

Opposition tactics: blocking of major Bangkok intersections; occupation and paralysis of government ministry buildings; calls for Yingluck's resignation; calls for take-over by a reform council before elections are held; election boycott; blocking of candidate registration--all resulting in failure of elections and failure to constitute parliament and a government.

This latest crisis is part of the continuing struggle roughly between pro-Thaksin and anti-Thaksin forces. Said contest started in 2006 when then prime minister Thaksin was ousted by a royally-endorsed coup. A few decidedly inept military men (including one, General Samak, who cannot decide what his job was: general, prime minister, or television cooking show host?) were at the helm until a civilian politician from the Democrat Party took over.

Thaksin fled the country in 2008 to avoid cases filed against him in court.

However, he retains strong support and loyal Red-shirts clashed with pro-government Yellow-shirts in 2010.

In 2011, the rival political factions arrived at a modus vivendi upon the election of the Pheu Thai government led by Prime Minister Yingluck Shinawatra. Eventually, the peace was roiled by the railroaded amnesty bill.

Thus in Thailand, we have minorities who try to impose their wills. We have majorities abusing their numbers. King Bhumibol, who had influentially shaped the course of Thai politics for several decades, is old and sickly. The military top brass can mount another coup. Question is how long can the generals man the household before the civilians assume power once more.

The eventual death of Bhumibol will be a game changer. His heir apparent is a wastrel. The Crown Princess is respected but she has to hurdle the gender bias before she could be named head of state and monarch of Thailand.

Bhumibol is also a very tough act to follow. The 1932 Revolution may have ended absolute monarchy in Thailand. In the early years of his reign, during the government of a military dictator, Bhumibol may have had little power and was no more than a ceremonial figure. However, military rivals for leadership begun to seek his blessings.

The English academic Duncan McCargo have noted the active political involvement of Bhumibol through a "network monarchy" working through the Privy Council. The network's political cachet was supposedly threatened by the rise of Thaksin. The network's capacity to exercise power is based partly on Bhumibol's popularity and strict control of his image.

Bhumibol's power is largely based on mystique. He is reputed to do things. We will never know how these are done since he works behind the scenes.

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The Thaksin camp has its set of sins and corruption, so does the anti-Thaksin camps, from the monarchy to the traditional Bangkok-based political elites. The problem of the anti-Thaksin camps is they can NOT win any election. Since 2006 ouster of Thaksin, all four elections including the last 2011 elections were won by the Thaksin camp. That is why the opposition including the Democratic Party, campaigned for mob rule, bring down the Yingluck Shinawatra government without elections, and their unelected "People's Council" will rule for two years without election. 

Mob rule, no respect for the rule of law, the Thai constitution. The problem with mob rule policy is that assuming they succeed in bringing down the Yingluck government without election, the next months, if the Thaksin camp can also mobilize millions of supporters, there will be another round of paralyzing rallies and change of government. Mob rule is ugly and not advisable.

On the monarchy. Its "holiness" should be damaged by now among many rural residents who are mostly pro-Thaksin. The monarchy and Thaksin are both populists, giving away various subsidies and freebies to buy political support, bloating the Thai public debt. But it seems that Thaksin was the better populist than the monarchy, his family and business cronies.

Not that I am pro-Thaksin and his corruption and populism. I am for the rule of law, in Thailand and elsewhere. If a government is corrupt, then bring it down and change it via constitutional processes like elections or impeachment or similar schemes. Mob rule is rule of men and the opposite of rule of law.

The snap election was held yesterday. Here is one news story, it is ugly. Preventing other people to vote, and still call themselves as democrats, people's representatives? They are mini-dictators who are not in power yet, and they want to be in power sooo bad.

http://www.interaksyon.com/article/79951/thai-protesters-block-voting-in-chaotic-election

BANGKOK - Opposition protesters prevented voting at thousands of polling stations in Thailand on Sunday, triggering angry scenes in the capital over an election that plunged the strife-racked kingdom into political limbo.

Despite weeks of mass street demonstrations aimed at forcing her from office, Prime Minister Yingluck Shinawatra was widely expected to extend her billionaire family's decade-long winning streak at the ballot box.

But the disruption to voting means that the results are not expected for weeks at least, and there will not be enough MPs to convene parliament and appoint a government until new elections are held in the problem areas….

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See also: 
Thailand politics and the anti-globalists, November 20, 2008 
Thai politics and the Monarchy, December 04, 2008 
Killings in Thailand and Military Crackdown, April 16, 2009 
Rule of Law 4: On Thailand Crackdown, April 18, 2009 

Thailand Politics and the Monarchy, Part 2, January 14, 2014

MeTA 15: Forum 2014 on Healthcare Ethics and Transparency

The Medicines Transparency Alliance (MeTA) Philippines will hold its annual forum this year with a timely theme, Transparency and Ethics in Healthcare. Things that are expected of various players and professionals in the health sector -- pharma companies, drugstores and pharmacies, hospitals and clinics, doctors and pharmacists, etc. And patients and the public too, we should have our own "code of ethics".

Here is the provisional program as of January 25. I removed the time slots to focus on topics and speakers. Lunch time is indicated, so readers can see which ones are morning and afternoon sessions.

The Mexico City Principles (MCP) is a set of ethical conduct adopted by APEC member countries for the pharmaceutical sub-sector several years ago, held in Mexico City. As shown in the program above, there will be a high-level multistakeholder panel discussion on the adoption of MCP in the Philippines and a call for voluntary codes of business ethics from different sectors and players. 

Day 2 morning, there will be foreign speakers who will talk about global developments in regulating medicines promotion (Tim Reed, Executive Director, HAI Global), regional trends in ensuring transparency in pharmaceuticals policy (Klara Tisocki, Team Leader-Essential Medicines and Health Technology, WPRO), and the way forward for the Good Governance for Medicines (GGM) Program (Deirdre Dimancesco, WHO Geneva). 

In the afternoon, two special topics that have great impact on healthcare in the Philippines - health promotion and sustainable funding, will be discussed by speakers from  HealthJustice  and the AIM.

Participants will come from various sectors and represent all stakeholders in the dialogue about health, medicines and transparency.  They will have opportunities throughout the forum to participate in open forums, ask questions and articulate their positions and perspectives through the stakeholder workshop.

They will be given links to all forum documents, including studies and researches cited in the presentations, as well as reference materials on transparency, ethics in health, addressing corruption in health and related topics.

Meanwhile, I have changed the title of this thread from "Health Transprency" to simply "MeTA" as this thread is mainly about MeTA fora and activities.
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See also:
Health Transparency 11: MeTA Philippines and Multistakeholder Process, September 19, 2012 
Health Transparency 12: MeTA Philippines Dynamism, October 02, 2012 
Health Transparency 13: MeTA International Visit to Manila, April 16, 2013 
Health Transparency 14: IMS-CHAT Meeting, April 18, 2013, Friday, July 12, 2013 

Drug Price Control 36: Advisory Council, James Auste and China, July 12, 2013 
FDA 6: Business and Modernization Plan, July 17, 2013