[FINISHED]

[Slide 3]: Objectives of the session

Discussion on the principles of primary health care, including the processes, issues, and challenges in the
pharmaceutical sector, from regulation and supply to financing and use

[Slide 4]: WHO

World Health Organization (WHO)
● United Nations (UN) agency specifically dedicated for health
● Made up of 8,000 public health workers from all over the world with an emphasis on diversity
(different nationalities and different backgrounds)
● At the headquarters in Geneva, the essential medicines department is made up of different
groups:
a. International Nonproprietary Names (INN)
b. Prequalification - similar to FDA work for UN
c. Policy - work on pricing, patent, trade,
substandard/spurious/falsely-labeled/falsified/counterfeit (SSFFC) products, good
governance, medicines, and traditional medicines
d. Health technologies - medical devices
● Set the international standards and cascaded down to country level through the regional offices
● Philippines is located in the West Pacific Region, not South-East Asia
○ Philippines is good because structures are already in place and functional (DOH & FDA)

[Slide 5]: WHO Policies and Programs

Public health policies that shaped the world
● 1948: WHO Constitution- “Health as complete state of well being”
○ When colonizers left the colonized countries, the latter were placed into a not very good
condition since their previous systems were patterned on the mother countries of the
colonizers.
■ Example: There was nothing in the public health system after the world war.
Americans previously opened puericulture clinics since their concept of public
health was sanitation. After the war, this system disappeared.
○ In Europe, health is totally free because it is the government’s responsibility to pay for
your health.
● 1950s: Golden era of chemotherapy- Discovery of antibiotics
○ Rise of pharma industries
○ Ultimate goal/desire of a pharmaceutical company - to earn money
○ Generally, the biomedical philosophy was accepted - “For every ill, there’s a pill”
● 1970s: Alma-Ata Declaration
○ Supports the idea of health for all
■ Current tagline of Philippine DOH: “All for health towards health for all”
- Time before realizing that “health for all” should be the goal: 50 years
○ Brought about by the demand for comprehensive primary health care
○ Alma-Ata is focused on primary health care
○ Health has social determinants, so everything has to be considered in order to bring
about proper health.
■ Examples: Education is necessary to achieve proper health. A proper source of
water is necessary to ensure eradication of diarrhea. The presence of trash cans
is necessary to prevent littering.
 ○ When Alma-Ata had been popularized, the Philippines was awarded by the UN and WHO
as the first country in the whole world to implement primary health care.
■ Year of launch: 1978; Year of award: 1979
○ Because of Alma-Ata, community-based interventions increased since health was
previously very facility-heavy.
■ “Hospitals” are the first to come to mind among Filipinos when it comes to health,
even though there are many things one could do as an individual or as a member
of a community.
● China’s barefoot doctors
○ Similar to Doctors in the Barrio
○ There are doctors who literally walked barefoot in the mountains to reach far-flung areas
to serve others.
● Comprehensive primary health care was criticized
○ Countries have different stages of development. Even if a goal is desirable since it is
ideal and right-based, the systems and conditions in place in a country should be
considered.
○ Which should come first: development or health?
■ There are countries that decided to compromise health and work on
development, violating many human rights in the process, and only fixing the
problem when they reached a certain level of concern.
■ But there are countries like Cuba that worked on right first, then human
development, and lastly, on progress.
■ The Philippines is a confused country. There is no clear focus on either
development or health.
○ If selective primary health care, what would be left? “GO-BIFF” (Growth monitoring, oral
rehydration salts, breastfeeding, immunization, free education, family planning)
● 1980s: The World Bank became stronger
○ Goal of World Bank: give loans to countries
■ Countries are encouraged to get loans. But whenever countries get these, there
are conditional items as in the Structural Adjustment Program (SAP) that leads to
privatization of health services. So, services that were previously free are now
being paid for.
■ rom the perspective of the banker and banking institution, these are methods that
improve your efficiency.
○ Health should not have the same principles as business. Otherwise, the patient may be
deprived of the desired health outcomes. Still, giving health services for free is not
feasible since this would be too expensive.
● Devolution: movement from centralized to decentralized system.
○ Previously, the DOH had a say on the barangay level. However, this power was later
transferred to the local chief executives.
● 2000: Milennium Development Goals
○ Previous target was 2015, but nothing happened. Deadline was extended to make it
comprehensive, resulting to the SDGs (Sustainable Development Goals).

[Slide 6]: Declaration of Alma-Ata

● September 1978
● Alma-Ata is in Kazakhstan. The document was named after the place where the meeting was
held.
 ○ Similar example: Mexico City Principle- This is a provision that tells us how to do ethical
marketing for drugs, how to have ethical relationships with healthcare professionals and
medical representatives. The meeting was held in Mexico City.
I. Emphasizing the idea of health as a fundamental human right
○ Universal - for all (not based on gender, social demographic profile, ethnicity, language)
○ Inalienable and indivisible- your right to health is inseparable from you as a human being
○ Interconnected- if you violate a person’s human right, you are essentially violating the
human rights of other people because health is a social phenomenon
- Example: If you deprive poor people with TB of their medicines, eventually, TB
will catch up to all of us.
[Slide 7]:
II. Social inequity- there is disparity between and within countries
○ A concern for all countries
○ The Philippines is a glaring example of social inequity. More Filipinos are entering the
Forbes list, but at the same time, more Filipinos are growing poorer.
○ Ultimate aim in economic development: Increase number of people in the middle-income
group
■ Once you hit the critical mass of the middle-income, you will be able to improve
the general purchasing power of the country, the economy will improve, creating
more opportunities which will allow you to pull up people from the lower strata.
■ More people are now in the middle-income class in the Philippines (but the
critical mass has not yet been reached).
● Example: Flights and gadgets are more affordable.
[Slide 8]:
III. New International Economic Order
○ Globalization - opening up of country borders in order to have full advantage of the
market
■ Problem with globalization: rich countries become richer but poor countries
become poorer
■ Characteristic of poorer countries which appeal to rich countries
● Natural resources
● Cheap labor
● Market size (larger population)
○ Many agreements made in the World Trade Organization were in favor of richer countries
- accumulating loans given to poor countries
○ Going against globalization results to isolationism.

[Slide 9]:
IV. Right and Duty of the Individual to Participate in the Health Process
○ The health care system starts in the individual (self-care), particularly since health is
interconnected.

[Slide 10]:
V. Government responsibility - difficult to determine the extent of what is enough

[Slide 11]:
VI. Primary health care definition:
○ Spirit of self-reliance and self-determination: one of the end goals of primary health care
is to enable a person to have total control of his life and health.
 ○ Education does not immediately translate to attitude and action.

[Slide 12-15]:
VII. Primary health care aspects:
○ Promotive, preventive, curative, and rehabilitative
○ Primordial prevention - taking action for an anticipated problem
○ Service delivery network - health services should be part of a bigger group (referral
network) rather than working independently
■ Government should design a referral network
■ Challenge to Filipino pharmacists: convert drugstores from point of sales to point
of healthcare

[Slide 16]:
VIII. All governments should formulate national policies, strategies and plans of action to launch and
sustain primary health care as part of a comprehensive national health system and in
coordination with other sectors. To this end, it will be necessary to exercise political will, to
mobilize the country’s resources and to use available external resources rationally.
○ Political will example: Duterte’s stance on things

[Slide 18]:
X. All countries should cover this declaration. It says a lot about how people and governments
should be working towards health.

[Slide 19]: Shortcomings at Present

● Inverse care
○ The vulnerable population, despite being poor and having the most health needs, still do
not receive health support.
○ With those who are rich and not vulnerable, everything is so accessible to the point that
they spend for non-essential services (e.g. nose lifting, liposuction).
○ Those who need more get less. Those who need less have more.
● Impoverishing care
○ Access to health tends to puts you in a state where you are not financially fluid.
■ Example: If you are a minimum wage earner and the sole earner of family, and
then someone gets sick, you have to let go of your other basic necessities (food,
housing, etc).
○ Low-middle income families are also affected and are pushed below the poverty line
○ It is the government’s responsibility to provide you financial risk protection.
■ Mechanisms include social health insurance.
● Fragmented and fragmenting care
○ Example: A patient with 5 comorbidities have 1 doctor for each condition/disease. They
prescribe separately. The patient now has been feeling a lot of side effects, problems,
and complications, probably from antagonistic effect.
■ Medication reconciliation is best done by the pharmacist.
○ Solution to fragmented care: Interprofessional Education (e.g. CHDP)
○ Fragmented programs in DOH
● Unsafe care
○ Swiss cheese model
○ Protocol/ system
● Misdirected care
 ○ Overspecialization of practice = inefficiency

In this problem (shortcomings at present), we have a role to play.

In the medication pathway, the pharmacist is situated in the middle.
Doctor prescribe -> Pharmacist dispense -> Nurse administer

[Slide 20]: Levels of Prevention

● Primary Prevention
○ If you are predisposed, you have to proactively prevent all risk factors that are modifiable.
■ Example: Immunization to prevent acquiring an endemic disease (full blown) in
where you live
○ “Herd immunity” - there are people in the community that are not immunized but will not
develop the disease because the transmission chain is broken. You are in the middle of
many people who are protected by immunization. Coverage rates target should be met.
○ Philippines is one of the countries which have the lowest Expanded Program on
Immunization rates.

● Secondary prevention
○ Early detection
○ Prognosis is lower when detection is late
○ Disease screening
○ How to have people access screening methods in terms of geography and cost

[Slide 21]
● Tertiary prevention
○ We don’t want you to deteriorate, we want you to go back to your normal functionality
● Primordial prevention
○ Tackling the risk factor before it even reaches the individual
○ Make it impossible to access
■ Example: Tobacco ban by the govt to prevent lung cancer. (Primary prevention
would be not smoking)

[Slide 23]
● SEARO and AFRO are the most vulnerable populations
○ Because of the social and demographic profile of the people there

[Slide 24]
● DALY - Disability Adjusted Life-years
● Double burden of disease - A country has to face both acute, communicable diseases and
chronic, noncommunicable diseases.

[Slide 25]
● DDD - Defined daily doses
● The role of the pharmacist will be highlighted in the future since drug usage will only increase.

[Slide 26]
● There is a problem of innovation.
○ There are fewer and fewer new drug entities,
 ○ The few that do get to the market are being sold at excessively high prices.
○ Pharma companies are getting back not on the cost of their research but rather on the
cost of their marketing.
● WHO recognizes a need for an incentive system for research but not at the expense of the
patient
○ It is the public sector (universities) that make the initial investment in terms of drug
development
○ They pass it on to pharma companies since it is the companies that have the money to
really do research
○ Public sector ends up paying for something that they have already paid for in the first
place
■ Like double jeopardy

[Slide 27]
● Highest consumers: high-income countries, because they have resources
○ But it is the low income countries that are in need

[Slide 28]
● Alimentary tract medicines: highest consumption in low income countries because of the burden
of communicable disease there
● CV medicines: highest consumptions in high income countries because it is very likely that they
can purchase their medicines while low income countries cannot
● Mental medicines: highest in high income countries because psychological diseases are more
common there

[Slide 29]
● There is an increasing medicine consumption for all countries regardless of income level.

[Slide 30]
● Low income countries are still using branded medicines over generics.
○ Spending almost 300x more than what is needed

[Slide 31]
● TPE - total pharmaceutical expenditure
● The high income countries spend the most on drugs.
○ Low income spend the least, not because we are healthy and do not need the medicines.
We need the medicines as well, but we cannot afford them.

[Slide 32]
● THE - total health expenditure
● Almost ⅓ of THE goes to TPE
○ The role of pharmacy in public health is justified. We have to make sure that this large
expenditure is properly carried out.

[Slides 33-35]
● Comment on tables:
Read them and appreciate their sense
Develop critical thinking; Don’t memorize, just appreciate the sense, identify problems, and come
up with solutions
 ● High income countries contribute highest percent of global pharmaceutical expenditure, but they
don't have much of the health burden; Health burden is in the low-middle income countries and
low-income countries.

[Workshop]
● Instruction: Draw the structure of the Philippine health system from the national level up to the
community of the individual.
● General idea from produced outputs: Very complex and complicated health system
● Possible scenarios given the complication:
1) [Illness?]
2) Problems in coordination, transparency, accountability
● Criticism #1: There is a very strong private sector in the Philippines.
There are non-health structures as well that are not really health organizations but they do help,
for they do influence health.

[Slide 36]
● Republican government
● Bicameral legislature
● Independent judiciary
● 18 administrative regions, 81 provinces, 144 cities, 1,490 municipalities, and 40,028 barangays.
● Effect of decentralization: So much power at the lower levels

● Comment on workshop output: WHO doesn’t overrule government because government is

sovereign; We heavily influence them but we are not above them.

● Annual growth rate: 1.7%

● Population: 102 million
● Life expectancy: 69
● We are already classified as an aging population. (High population of people less than 60 and
less than 50 years)

The Philippines
● GDP / Capita (PPP) 2: $ 6982.40
● Annual mortality (2011): 5.2 per thousand with 498, 486 registered deaths
○ Death sex ratio: 1.37
■ More deaths in males than females
■ 52-56% of deaths are male deaths in Philippines
○ Cardiovascular disease as leading cause
● IMR (2011): 12.8 deaths per thousand livebirths
○ Bacterial sepsis (16.5%)
○ Pneumonia (12.5%)
○ Respiratory distress (10.0%)
● MMR (2011): 0.8 per thousand livebirths
● IMR and MMR: Sensitive indicators of the health status of the country
● Many countries already have 0% MMR and IMR per thousand
○ Finland: There was one case of maternal death. It became a scandal because they
believe that that death was not a warranted death.
 ● Human resources
○ Number of physicians: 3.56 per 10,000 population 2
■ Physicians are urban-centric and most are specialists.
■ Not evenly distributed
○ Number of pharmacists: 4.19 per 1,000 population 2
○ Hospital beds: 1.2 per 1,000 population2
■ In Fabella, 3-4 women share a bed
○ Doctor consultation: 2,254 per capita
● Health expenditure
○ Public VS Private Share of total health expenditure
■ Public (35.3%); Private (65.7%)
■ The private sector is very strong in the Philippines (65.7%)
■ If we fix the public sector, it is only 35.3%. There is much more improvement
needed for the private sector.
■ External quality assurance: Similar to unknown testing → DOH sends samples to
diagnostic testing centers
● Passing rate: < 50% for microbiology; <30% for parasitology
● Most of the time your diagnosis will be wrong in the Philippines → Wrong
therapy → Unsafe care
○ Total health expenditure per capita (PPP): $ 328.9
○ Total health expenditure as a share of GDP: 4.7%
○ Composition of total health expenditure
■ Out-of-pocket: 53.7%
■ General government: 20.3%
■ Social health insurance: 14%
■ Other private: 3.4%
■ Private prepaid plans: 8.6%

The Philippine Healthcare System: Reforms over the Years

● 50s and 60s: Centralized health system

○ Department of Health is responsible for health delivery from the highest level to the
lowest
● 70s: Partially decentralized
○ Regional health offices for Region I, II, III
○ Later called CHD (Center for health development)
○ The idea is that the central office (in Manila) was too far to monitor other areas in the country →
Mini-DOH in regions
 ● 80s: Primary health care
○ District health care → district hospitals
○ Before: All hospitals are financed by the department of health
○ Now: Supervised by regions but financed by the DOH
● 90s: Devolution of health systems
○ What happens below is because of the local government
○ DOH’s role: Guidelines, standards, policies; they will come in only when requested
○ This also allowed regional offices to focus on health issues relevant to their area.
○ IRA: Internal revenue allotment
■ Money is no longer held by the DOH, nasa local units na
■ Allocation of funds depend on the local chief executive → Varying salary of health
workers
● 1998: Health Sector Reform
○ DOH RO → Provincial → Municipal/City → Rural/Urban health centers → BHU
○ Hospitals: Specialty hospitals → Regional (~72 retained by DOH) → Provincial → District →
Municipal → City
○ 1980s: Joined together, DOH also regulated hospitals (public and private)
○ PGH’s budget comes from the UP budget → training center for UP students
■ Most of UP’s budget is used by PGH
● 2002: Fourmula ONE
○ For better health outcomes
○ More responsible health systems
○ Equitable health care financing
○ Thrusts
■ Financing -- increased, better, and sustained
■ Regulation -- assured by quality and affordability
■ Service delivery -- ensured access and availability
■ Governance -- improved performance
● 2010: Kalusugang Pangkalahatan

Pre-devolution (Before 1983 Re-organization)

● Budget appropriations are with the Central Office (CO)
● Separate implementation of PH and hospital services
● Top to bottom approach
● DOH-CO has the administrative and technical supervision over all DOH personnel at the field
level

EO 851S 1985
● Integration of PH and hospital services
● Technical and administrative supervision of all vertical programs placed under the Integrated
Provincial Health Offices (IPHO)
● Piloting of District Health System
● Budget directly released to IPHO and District Health Offices

RA 7160 (Local Government Code of 1991)

● Transfer of personnel, assets, and liabilities from DOH to the local government units (LGU)
● Fully autonomous LGUs that manage local health services
● DOH with new functions
 ○ Regional Field Offices (RFOs) as Technical Resource and Health Human Resource
Development Centers
● Problems encountered
○ Irrational distribution of the IRA
○ Inadequate provision of health worker compensation and benefits
○ Technical fragmentation

● 1992, upon implementation of LGU Code

● Budget: P 4.2B was devolved, P 6.01B was retained to maintain organic staff
○ However, more should be given to the local units

Health Sector Reform

● Increasing private sector presence in the health sector (privatization)
● Decentralization (Devolution)
● Focus on efficiency (rather than equity)

Philippine Health Agenda

● Aquino Health Agenda (AHA)
● Guarantee 1: All life stages & triple burden of disease
○ There should be care from womb to tomb
● Guarantee 2: Services are delivered by networks that are… (There should be referral systems)
○ Fully functional
○ Compliant with clinical practice guidelines
○ Available 24/7 & even during disasters
○ Practicing gatekeeping
○ Located close to the people
○ Enhanced by telemedicine
● Guarantee 3: Services are financed predominantly by PhilHealth
○ Universal Health Coverage (UHC) is not equated to PhilHealth
○ PhilHealth as the gateway to free affordable care
○ Simplify PhilHealth Rules
○ PhilHealth as main revenue source for public health care providers
[Slide 48]
● In 2013: 316 licensed manufacturers, 411 traders, 4770 wholesalers and distributors and 27,826
retailers.
○ Look at the discrepancy between the number of retailers and the number of pharmacists.
● In June 2014: 20901 products with market authorization for human use, 739 for veterinary use,
408 vaccines and biologicals, 97 traditional medicines, and 35 medical gases.
○ Developed stage
○ Are medicines really accessible in the PH?
● Pharmaceutical exports comprise 0.08% of total export value (2015).
○ Our other meds reach Europe.

[Slide 49]
- Top player in the pharmaceutical market? Dominated by foreign firms in terms of sales but by
volume, it is dominated by many players (?).
- 3.2 B
- Big Rx market- 13.6% antimicrobials

Some of our health system’s vertical programs:

- NTP (National Tuberculosis Program)
- TB
- HIV- national
- EPI- expanded program on immunization (vaccines)
- Parasitism
- Mass drug admin (praziquantel, albendazole)
- Medicine access program for DM and HTN- supposedly free drugs

[Slide 50]
- Problem of generics law: There should not be branded and generic medicine; rather, it should
be innovator and generics.
- When patent expires, generics can be made. What happens currently is that generics place
their own name. They claim to be premium, as they are not too expensive or cheap and have
a name
- There should be no branded generics.
(ex: Paracetamol- Biogesic- generic drug that you might mistake for the innovator, thus
thinking that it is more effective than the others but it is not. It is just the same as paracetamol
produced by company X)
- Unibranded
o Pharex and Rhea
o Ritemed (no med reps, go to consumers directly; main focus before- rural area
(started here); now- consumer in commercial alta (Rich person can also buy our
product. Strategy: Rural population and urban rich population; no med reps needed)

[Slide 51]
Unilab is now in other countries, such as Vietnam and Indonesia.

[Slide 52]
 - Go to website of DOH-NCPAM.gov.ph (National Center for Pharmaceutical Access and
Management)
- Who regulates the drugs? FDA
- 9711
- Pharmaceutical legislation- cheaper medicines act
o Purpose: pull down prices
o Many instruments here: compulsory licensing, shortening the patents, negotiated
procurement, whole procurement- revisit these laws.)
- Please go back to the Philippine Pharmacy Act.

Assignment: Go back to this PMD

- Our PMD (Phil Medicine Policy) was PNDP before (Phil National Drug Policy)
- Mnemonics before: PQRST- outdated already
- Now: SARAH (since 2011)
- S- Safety, Efficacy, and Quality (SEQ)
- Affordability and Availability
- R- Rational Drug Use
- Accountability and Transparency
- H- Health Systems Support
-
[Slide 53 onwards]
- Elements
- What does the government do per pillar? You will feel that pharmacists have many roles. (eg in
SEQ, availability, etc)
[Slide 54]
- Projects:
- Drug price reference index-
o System that puts together all drug pricing procurement prices of hospitals- use leverage to
negotiate with pharma companies (minimum and max price)
o Mechanism to lower cost or at least prevent abuses from pharma companies
- How are drugs priced? (Pharma companies)
o Sometimes one place has a discount, but in reality, the price in another place is increased
to compensate for it.
- EDPMS
- Drugstores are required to submit the prices of the drugs.
o E.g. Mercury- annual
o Why? So that you will know how they are priced
o SRP of medicine
o In other countries, when you apply for FDA marketing authorization, the price of the drug
is placed in the application form of the drug. If they approve the drug, the price written
during application is its only price. In PH, we don’t do that.

[Slide 56-60]
- RUM
- So many developments now
- Due date: 2011, 2016
- New PMP made (Phil Med Policy) and changing from PQRST à SARAH
 - New: CHANGE (Not yet released)
o Difference from SARAH: No health system support because available in all ______;
Added partnerships, health literacy, and people empowerment
o Biggest PH problem according to us: Misinformation

[Slide 61]
- Lastly, pricing in PH- free pricing (dangerous because no control)
- Effort of the govt under the Cheaper medicines act
o MRP (Maximum Retail Pricing)- voluntary
o GMAP (Government-mediated Access Price)- done once only but this year something will
be released
- Price negotiations- Yes
- EPR
- In reality, we should have no problem to access, but availability does not equate to accessibility.
- We have so many products. What’s troubling us is many are me-toos, copies, non-essential
drugs so these numbers do not necessarily reflect the accurateness of their quantity.

[Slide 62]
- System of pharmaceutical supply
- How does medicine flow from the time they were discovered until they reach the patient? Look at
the diagram.
- Do not share the materials in these slides as they are not yet published.
- 40 countries
- In PH: ID problem and contribute to the solution.