written on 31.08.2010

Interview with Esperanza Cabral, Former Secretary, Department of Health (DOH)

The new Government took office on the 1st of July, but we would like to hear about your experience as Secretary of Health. You took office at a particular time (January 2010) when the industry was still dealing with the first round of the MDRP price reductions and while you were in office the industry went through the second round of voluntary price cuts. Can you give to our readers an overview of the situation when you took office, and what were your priorities while you were Secretary of Health?

The Cheaper Medicines Act was already in place at the time that I became the Secretary of Health, and there had already been the first round of mandatory price reductions last August 2009. So when I came into office, the government, particularly the legislators, were looking at the second round of price reductions. At that point I felt that voluntary price reductions would be much better than mandatory ones, so that is what we tried to do. We talked to the chief executives of the pharmaceutical companies and asked them whether they would be willing to reduce their prices on certain drugs voluntarily, rather than come up on the mandatory drug reduction list and many did. So in March we were able to bring up a list of drugs for voluntary price reduction. After that, there was no more time while I was in office for a third round of voluntary price reductions; it is now left to the new Secretary to do that if he wants to. I felt that forcing the drug companies to reduce drug prices was a last option; that if it was possible to do so by talking to each other and understanding the other’s point of view then we would come to a more satisfactory situation.

We are now one year from the first MDRP and we can see the effect. Most of the industry defines the results as “negative” because it has simply made medicines less expensive for those that could already afford them and did not actually achieve the objective of making medicines more accessible for the poor. As both a doctor and someone who has worked in both the public sector, what is your perspective on the results of MDRP? Do you feel MDRP has achieved the objective of increasing access to medicines?

Yes, I would say that it has. The industry may be right that the very poor that cannot afford medicines are still not able to afford medicines that they need. However, there are many people who were struggling before, a group in-between rich and poor, who could only afford SOME but not ALL of their medicines before the MDRP. These people have benefited from the MDRP because now they can afford the medicines they are prescribed. So I think it is unfair to say that the Cheaper Medicines Law has not improved access, because it has. It may not have improved access perfectly or completely, but they have improved it to a significant extent. I have many patients that tell me they are very happy because for example, the medicines that used to cost 100 PHP per pill and which they could afford to buy only 5 of, now costs 50 PHP per pill and they can afford to buy 10.

Besides this increase in access which happened in the last year, what would you say have been the main evolutions that you have witnessed over the course of your career, not only in the public sector, but also as a doctor?

Since the late 80s when the generics law was passed until now, there have been many changes in the complexion of the pharmaceutical industry. Before, almost all the drug companies in the Philippines were innovator companies, but now there are many generic companies. There used to be only one generic company at that time, and that was United Laboratories! But now there are many players who import active ingredients or finished products, that have made generic medicines available here. Because of that, I think the problem now is of quality assurance, to be sure that the products that are in the market are of good quality. There have been significant price reductions and therefore competition increased. The worry now is if all the products that are in the market are of acceptable quality.

Counterfeit drugs are also an issue, but they are a different concern not related to the prices of legal medicines.

One of the changes that is planned to happen soon, is the Universal Healthcare, which President Aquino is pushing for in three years. Do you think this is a feasible objective?

He certainly will have to try! I am not sure he will achieve universal healthcare in three years, but we cannot fault him for trying and we should in fact encourage him. The other aspect of Universal Healthcare is that once everyone is insured, we have to assure that the coverage is significant. At the moment even if you are insured by the government the support value of the coverage for the average in-patient is less than 30% of the total medical bill. So that is another thing that has to be addressed. There are many other issues that have to be addressed as far as universal health coverage is concerned. Even if we succeed in insuring all families in the Philippines, it does not mean to say that we are covering them completely, or even to a significant extent.

When you were Secretary of Health, you pushed for some advocacies, some of which were met with controversy, for example herbal and natural medicines, the reproductive health bill, as well as a campaign against smoking. Which of your advocacies would you like to see the new Secretary of Health continue? And why is it important to continue them? Which one should be made the first Priority?

All of them! That is the reason they are my advocacies, because I feel they are important! For me, the first priority should be population development. I am an advocate of passing a reproductive health law in order for people to have access to information so that they can make intelligent decisions and for those that cannot afford to exercise those decisions on their own, they should be able to get help. I just feel that this is a very important cross cutting issue that affects EVERYTHING.

It affects the individual. It affects the family. It affects the nation.

And if we do not do anything about it, it is going to hinder the development of our country. The population of the Philippines is really booming; too much! Already, we are not able to support this number of people in the Philippines properly.

Concerning herbal products, naturally the producers were affected by my order to translate the phrase “No Therapeutic Claims Approved” into the national language. But, if you look at the administrative order that I passed, all it does is address truth in advertising. It does not prevent anyone from selling these products, what we want is to take certain steps so that a person buying the product knows what he is buying and is not banking on myths and misconceptions because of the strong misleading advertising that food supplements have been getting away with.

In fact there have been previous regulations on this, and just a few months before I became the secretary and put out the order, the FDA put out warnings against food supplements saying that consumers should be aware of what they are buying and there are no therapeutic claims that are proven for this drug. The controversy was really just around the translation of the English version of “no therapeutic claims approved” to the national language! If you are sincere in wanting something good to come out of your product, you should be the first to make sure that what you are selling is understood by the buyer.

Before joining the department of health you were the Secretary of Social Welfare and Development. How did this previous experience shape your priorities in the DOH?

As I have said before, I believe all Secretaries of Health should have a stint in the Department of Social Welfare and Development (DSWD). This is because even though we are doctors and even though we are part of a helping profession, there is a different perspective, particularly by clinicians and specialists who become Secretaries of Health. Who are these doctors that become Secretaries of Health? They are the prominent physicians with large practices full of patients who can afford to pay. We have no idea of what is happening outside and my stint at the DSWD influenced all my activities in the DOH; this perspective of the poor.

Maybe a non-doctor could become a good Secretaries of Health, but on the other hand, a doctor has certain advantages coming into the position that a non-doctor may not have, or may have to learn over a period of time. It is like becoming the owner of a bus company if you do not know how to drive, you do not know if the drivers are fooling you or not!

Do you have any advice that you would like to give to the new Secretary?

The new Secretary must have a heart for the poor and focus on those who are disadvantaged, marginalized and vulnerable to risks. His primary duty is to help his people. He is no longer a surgeon; he is the Secretary of Health.

Where would you like to see the Philippines Pharmaceutical and Health Care sector move in the coming years?

There are very many things that need to be taken care of as far as health is concerned, but the problem is that every election period, you hear people campaigning that health and education are their priorities, and then as soon as they get elected health and education go to the back burner and its infrastructure that becomes the priority. But growth needs to have a purpose. Why do you want to grow? Who should benefit from this growth? Everybody must benefit from it. Not just the rich people who do not need the benefit.

Something that we have seen is that a lot of the medical community goes to work abroad here. How do you feel about this so called “brain drain”? Is it helping or hurting the Philippines development?

I am sad and sorry that many of us need to go abroad to find better opportunities. I look forward to the day when we can take care of our own. Some of them go abroad, and then come back, but not enough. For example, in my graduating class in medical school, there were 75 of us. Nearly everybody, say 70 of us, went abroad, and only 5 came back. So out of a class of 75, there are about 65 of us working abroad, and only 10 working in the Philippines. This is a big gap. It is a little better now, maybe 50/50, but this is not because doctors no longer want to go abroad, it is because the opportunities abroad narrowed. If the opportunities were wide open, then 80-90% of graduating classes would be abroad.

As far as nurses are concerned, the Universities take advantage of this desire to go abroad, so they put up nursing schools and hundreds of thousands of Filipinos go to nursing school. They graduate and take the test to go abroad, and many do not pass it, and as a result there are 200 000 nurses unemployed in the Philippines. And there are many vacant positions for doctors, nurses, and midwives in the rural areas, but no one wants to go there! They would rather be unemployed, and you cannot blame them. There are security problems and poor opportunities for personal growth or professional satisfaction there.

On more of a personal note, our readers are always curious to know how is it adapting to public life? How do you, as someone with an impressive career behind you to balance a public, working and professional life with a personal life?

Public life, if you are a private person, and you are suddenly thrown into a situation where everything is of interest to very many people, can be off putting, and you need to adjust, it is part of the job.

I can tell you that in the Philippines, it is much easier for a woman to balance professional life and family life. Why? Because there are other women who are there and on whom we depend to pick up some of the functions we normally would be doing. So we need to be very grateful to all of our domestic help because without them it would be very difficult. Also we have to be grateful to the close family community (the aunts, the uncles, the grandparents,) because nobody can do it alone.

And in the Philippines it is just that much easier to get help from everybody. We are doing this all on the shoulders of other women.

Do you have a final message to the international readers of Pharmaceutical Executive?

I would like to see the Philippines take its place in the world health community that it deserves. I think that and for reasons that are ours, we are not taking our rightful role in the world and we can be.

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