Philippines Pharmaceutical Situation 2009 WHO Household Survey on medicines

Dennis B. Batangan, M.D., M.Sc.

Noel Juban, M.D., M.Sc.

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© World Health Organization 2009

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ACKNOWLEDGEMENTS

We are grateful to the Department of Health for their permission to conduct the study. We

would also like to thank the directors and heads of provincial health departments in all six

regions who endorsed the study.

This document has been produced with the financial assistance of the Department for

International Development (DFID), UK. The Department of Health of the Philippines

Republic, the World Health Organization and the Medicines Transparency Alliance have

provided technical support. The views expressed herein are those of the authors and can

therefore in no way be taken to reflect the official opinion of the Department of Health of

the Philippines Republic, the Department for International Development (DFID), UK, of the

World Health Organization and of the Medicines Transparency Alliance.

Conflict of Interest Statement

None of the authors of this survey or anyone who had influence on the conduct, analysis or

interpretation of the results has any competing financial or other interests.

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Table of Contents

LIST OF TABLES........................................................................................................................................V

LIST OF FIGURES......................................................................................................................................V

ACKNOWLEDGEMENTS........................................................................................................................... II

EXECUTIVE SUMMARY ...........................................................................................................................VI

1. INTRODUCTION...............................................................................................................................1

2. THE PHILIPPINES BACKGROUND .....................................................................................................1

2.1. Health sector...........................................................................................................................1

2.2. Pharmaceutical sector ............................................................................................................2

3. METHODOLOGY ..............................................................................................................................6

3.1. Overview .................................................................................................................................6

3.2. Selection of geographic areas and reference public health care facilities .............................6

3.3. Selection of households..........................................................................................................7

3.4. Selection of respondents ......................................................................................................10

3.5. Data Collection......................................................................................................................10

3.6. Data Entry .............................................................................................................................10

3.7. Data Analysis.........................................................................................................................10

3.8. Limitations of the Study........................................................................................................10

4. RESULTS.........................................................................................................................................12

4.1. Characteristics of surveyed households ...............................................................................12

4.1.1. Respondents .................................................................................................................12

4.1.2. Household characteristics.............................................................................................13

4.1.3. Household expenditures...............................................................................................14

4.1.4. Household socio-economic status ................................................................................14

4.1.5. Household Morbidity ....................................................................................................15

4.2. Geographic access and availability of medicines..................................................................18

4.2.1. Proximity to health care facilities .................................................................................18

4.2.2. Sources of care in case of acute illness.........................................................................18

4.2.3. Opinions about geographic access and availability of medicines.................................19

4.3. Affordability of medicines.....................................................................................................19

4.3.1. Cost of medicines for acute and chronic illnesses ........................................................20

4.3.2. Medicines social coverage ............................................................................................21

4.3.3. Opinions about affordability of medicines ...................................................................21

4.4. Medicine at home.................................................................................................................21

4.4.1. Number of households with medicines found and the medicines found ....................22

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4.4.2. Sources of medicines found in households ..................................................................22

4.4.3. Labeling and packaging of medicines found in households..........................................23

4.4.4. Antibacterials found in households ..............................................................................24

4.5. Use of medicines during acute and chronic illnesses ...........................................................25

4.5.1. Prescribers of medicines in case of acute illness ..........................................................25

4.5.2. Reasons for not taking medicines prescribed for acute illness ....................................26

4.5.3. Reasons for not taking medicines prescribed for a chronic disease.............................27

4.6. Opinions about quality of care..............................................................................................27

4.7. Opinions about pricing and quality of medicines .................................................................28

4.8. Opinions about generic medicines .......................................................................................29

5. DISCUSSION...................................................................................................................................30

6. CONCLUSIONS...............................................................................................................................32

BIBLIOGRAPHY ......................................................................................................................................34

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LIST OF TABLES

Table 3.1: Reference health care facilities and households, by region ...............................................7

Table 4.1: Education and Gender of Respondents ............................................................................13

Table 4.2: Characteristics of surveyed households ...........................................................................13

Table 4.3: Monthly household expenditures in PHP .........................................................................14

Table 4.4: Prevalence of acute and chronic conditions.....................................................................16

Table 4.5: Reported symptoms of acute illness.................................................................................16

Table 4.6: Reported chronic Illness....................................................................................................16

Table 4.7: Travel time to health care facilities...................................................................................18

Table 4.8: Sources of care for an acute illness...................................................................................19

Table 4.9: Opinions about geographic access and availability of medicines.....................................19

Table 4.10: Cost of prescriptions for a recent acute illness.............................................................20

Table 4.11: Monthly cost of medicines for chronic diseases...........................................................20

Table 4.12: Opinions about affordability of medicines ...................................................................21

Table 4.13: Most frequent categories of medicines found in households......................................22

Table 4.14: Frequently reported antibiotics found in the households............................................24

Table 4.15: Reasons for not taking prescribed medicines for acute illness ....................................26

Table 4.16: Reasons for not taking medicines for a chronic disease as prescribed ........................27

Table 4.17: Opinions about quality of care......................................................................................28

Table 4.18: Opinions about pricing and quality of medicines .........................................................28

Table 4.19: Opinions about generics ...............................................................................................29

LIST OF FIGURES

Map of the Philippines........................................................................................................................... vi

Figure 3.1: Household Sampling .............................................................................................................8

Figure 3.2: Household Clusters ...............................................................................................................9

Figure 3.3: Representation of household clusters in each surveyed area..............................................9

Figure 4.1: Gender and age of respondents/health care decision makers...........................................12

Figure 4.2: Level of household expenditures in different survey areas................................................15

Figure 4.3: Prevalence of illnesses by socioeconomic status................................................................17

Figure 4.4: Source of medicines found in households..........................................................................23

Figure 4.5: Percentage of medicines found in households with both adequate label and

primary package, by source ..................................................................................................................24

Figure 4.6: Reasons for keeping antibacterials at home.......................................................................25

Figure 4.7: Prescribers of medicines in case of acute illness ................................................................26

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EXECUTIVE SUMMARY

Background

A field study to measure access to and use of medicines was undertaken in the

Philippines in 2008-2009 using a standardized methodology developed by the World

Health Organization.

Methods

The survey was conducted in six regions: La Union province in Region 1,

Pampanga province in Region 3, the city of Manila in the National Capital Region (NCR),

Palawan province in Region 4, Capiz province in Region 6, and Misamis Oriental province

in Region 10 (See Map below). In each region, six reference public heath care facilities

were selected among those participating in the Level II Facility Survey that was run in

parallel. Within defined distances from each reference public health care facility,

households were selected by purposive cluster sampling. A total of 1079 household

respondents were interviewed by means of a structured paper questionnaire that

gathered information on the socio-economic level of households, and collected data on

access to and use of medicines for acute and chronic conditions as well as opinions and

perceptions about medicines. Data entry was performed with EpiData software and

analysis with Excel.

Map of the Philippines

vii

Key results

Opinions and perceptions about medicines

Overall, respondents believe that the quality of medicines and services in their

public health care facility is appropriate.

Geographic access and availability of medicines

Indicators of geographic access to medicines suggest that the majority of

households are close to a heath care facility, both public and private. However,

availability of medicines is perceived to be more in the private facilities than the public

facilities. In general, people perceive that geographic access to medicines is satisfactory

in the sampled areas. The most frequent source of medicines in case of acute illness and

chronic diseases are still the private pharmacies or drug sellers and a majority of

sampled households consider that the needed drugs are available in the public health

facilities.

Affordability of medicines

Overall, indicators of affordability of medicines suggest that the price households

pay for medicines is an obstacle to accessing medicines. The average cost of a

prescription for acute illness was Php 485, and the monthly cost of medicines for chronic

diseases was Php 946. The penetration of medicines insurance coverage in the sample is

very low and recourse to borrow money or sell things to pay for medicines is

significantly reported.

Medicine use and medicines at home

Sixty nine percent of households have medicines at home suggesting possible

stocks for emergency use or left over from previous treatment. Sixty-one percent of

medicines found at home had appropriate labels and primary packages in good

condition.

Medicine use in acute and chronic illnesses

Over half of the medications taken in acute illness were self-prescribed or

prescribed by non-health professionals. The most frequent reasons for non-adherence

to treatment in both acute and chronic illnesses were improvement of patient’s

symptoms and incapacity to afford the required medicines.

Conclusions

Results of the survey raise equity issues in access to basic medicines. The facility

survey, which has been piloted concomitantly, is providing convergent signals on

availability and affordability of medicines in the same sampled area.

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In a context where the Philippines are now looking towards Universal Health

Care, strategies to achieve this ambition will have to take careful consideration of key

medicines availability and affordability at all level of health care. The definition of

adequate policies and mechanisms to tackle these issues will be part critical components

of the realization of Universal Health Care in the Philippines.

Studies such as the Facility and Household surveys can provide useful insights

and baseline assessment to technical and political leaders in the country. Their list of

indicators and variables might need to be more selective and harmonized with other

national surveys in order to provide the framework for a regular monitoring and

evaluation of medicines policies and interventions undertaken in the Philippines.

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1. INTRODUCTION

In 2002, World Health Organization (WHO) and Health Action International (HAI)

conducted a pilot study on medicine prices in the Philippines. A follow-up study by the

same organizations was published in 2005 entitled ‘The Price People Pay for Medicines’.

In addition to the series of studies on medicine prices, in 2008-2009 the WHO Level II

and Level III studies were implemented. The Department of Health (DOH) supervised the

study for Region 3 and the National capital Region (NCR) while the People-Managed

Health Services Multi-Purpose Cooperative (PMHSMPC) supervised the study in Regions

1, 4, 6 and 10. The study was conducted prior to the implementation of the maximum

drug retail price (MDRP) order (August 2009) and during the early implementation of the

cheaper medicine law (October 2008).

The core indicators used to monitor national medicine policy are classified into

three levels. Level I involve core structure and process indicators while Level II focuses

on core outcome or impact indicators. Level II includes access to essential medicines and

rational use of medicines utilizing a systematic survey on health facilities and

households. On the other hand, Level III deals with the indepth assessments of specific

components of the pharmaceutical sector such as pricing, traditional medicines, HIV/

AIDS, regulatory capacity, drug supply, and trade-related aspects of intellectual property

rights (TRIPS). This study limited the scope to Level II and Level III indicators, particularly

focusing on the systematic survey on health facilities and households, and pricing of

medicines.

2. THE PHILIPPINES BACKGROUND

The Philippines is a large-sized country, covering an area of 299, 764 km2. It is

divided into 17 regions, 80 provinces, 138 cities, 1,496 municipalities, and 42,025

barangays. As of the last census in 2007, the Philippine population numbered 88, 574,

614, with a population density of 295 per square kilometer. The Philippines is a lower

middle income country with a nominal GDP of US $1,745 per capita.

Life expectancy at birth is 64 years for males and 70 years for females. The

country's population is predominantly young, with the 0-14 year age group representing

33.8% and those aged 65 years and above comprising only 4.4%.

2.1. Health sector

In 2007, the total expenditure on health was Php 234,320,986. Approximately

3.8% of the GDP is spent on health. Of the total expenditure on health, 31% is

government expenditures. The remaining 69% of total expenditures on health is private

expenditures, with 54% being out-of-pocket expenditures.

Under Republic Act (RA) 7875, a national health insurance program for all

Filipinos was instituted in 1995. In the same year, the Philippine Health Insurance

Corporation (PhilHealth) was established for this purpose. As of the first quarter of 2010,

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PhilHealth reported that over 20 million Filipinos were covered by their insurance policy,

majority of which were employees in the private sector. (1) Medicines delivered during a

confinement episode are covered by Philhealth till a defined ceiling. With regards to

outpatient services, however, only day surgeries, dialysis and cancer treatment

procedures such as chemotheraphy and radiotheraphy are included in a member’s

benefits. (2)This leaves out a considerable portion of acute and chronic illnesses for

which most patients seek outpatient consultation.

The country’s public health care system is a devolved one. This was introduced in

1991 upon the passage of Local Government Code. This placed the burden of delivering

basic services for health and implementation of health programs on the local

government units. Based on their catchment areas, health facilities could either be

barangay health stations, rural health units, district hospitals, provincial hospitals or

regional hospitals. Hospitals can also be classified according to their service capability,

under which there are 4 levels. Level 1 is an emergency hospital that provides initial

clinical care and management to patients requiring immediate treatment, as well as

primary care on prevalent diseases in the locality. Level 2 is a non-departmentalized

hospital that provides clinical care and management on the prevalent diseases in the

locality. Level 3 is a departmentalized hospital that provides clinical care and

management on the prevalent diseases in the locality, as well as particular forms of

treatment, surgical procedure and intensive care. Level 4 is a teaching and training

hospital (with at least one Accredited Residency training Program for Physicians) that

provides clinical care and management on the prevalent diseases in the locality, as well

as specialized and sub-specialized forms of treatment, surgical procedure and intensive

care. The Department of Health provides oversight in all these levels, acting in a

governing role rather than in an implementing capacity.

2.2. Pharmaceutical sector

National Medicines (Drugs) Policy

The National Medicines Policy (NMP) of the Philippines was created under

Memorandum Order No. 133, 1987. Its implementation, as well as plan that sets out

activities, responsibilities, budget and timeline was put in place by Administrative Order

No. 46 s. 1998 and the Department of Health’s Department Order No. 32, 1994. No

update of the national medicines policy is currently present.

In 2008, a significant addition to the medicines policy of the Philippines was

made thru the signing into law of Republic Act (RA) No. 9502. Officially known as the

“Universally Accessible and Quality Medicines Act of 2008”, this act amended the

Pharmacy Law (RA No. 5921), the Generics Act of 1988 (RA No. 6675) and the

Intellectual Property Code (RA No. 8293). Under the new law, drug manufacturers are

required to make available unbranded equivalents to their branded products. This is

concert with the amendment of the intellectual property code which allowed

manufacturers to experiment, produce and register patented drugs before the

expiration date of the patents. As such, marketing of generic drugs can be done

immediately after patent expiration. Another significant change that the act imposed

was the power to set price ceilings on drugs in the Philippine National Drug Formulary

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Essential Drug List. This mandate has been used by DOH to negotiate or set significant

price reduction with/to some pharmaceutical companies in 2009 thru the Government

Mediated Access Price (GMAP- 18 molecule, 45 branded products) and the Maximum

Drug Retail Price (MDRP – 5 molecules) initiatives

Regulatory system

A formal medicines regulatory authority, funded through the regular budget

from the government, is likewise in place. Republic Act (RA) 3720 and RA 9711 afford the

legal provisions for establishing the powers and responsibility of the Food and Drug

Authority (FDA), the main medicines regulatory authority in the country. The FDA

provides information on legislation, regulatory procedures, prescribing information,

authorized companies, and approved medicines. Transparency and accountability in the

regulatory body is promoted by the Norms of Behavior for Officials and Employees of

the Department of Health (DOH Administrative Order (AO) 2007-042) and the Code of

Conduct and Ethical Standards for Public Officials and Employees (Section 12 of Republic

Act No. 6713).

Legal provisions for marketing authorization also exist. These are provided for by

RA 3720. Upon request, the FDA issues a list of all registered medicines products.

Further information on medicines registered in the country can be publicly accessed at

the bureau of patents and from published materials such as the Philippine

Pharmaceutical Directory (PPDr) and MIMS. As of November 2009, a total of 22,981

medicines have been registered. Manufacturers, wholesalers, distributors, importers

and exporters of these medicines are regulated through the Revised Regulations for the

Licensing of Drug Establishments and Outlets (DOH AO 1989-056).

A quality management system with an officially defined protocol for ensuring the

quality of medicines is in place. Medicine samples are tested for medicines registration.

The Food, Drug and Cosmetic Act (RA 3720), FDA Act of 2009 (RDA 9711) and Special

Law on Counterfeit Drugs (RA 8203) provide the legal framework for these activities.

Regulatory procedures are also in place for ensuring the quality of imported medicines

under RA 3729 and RA 6675.

In the Philippines, legal provisions for the licensing and practice of prescribers

and pharmacies are in place. Prescribing by generic name is obligatory in the both the

public and private sectors under the Generics Act of 1988 (RA 6675). Generic

substitution is permitted in both public and private pharmacies. However, no incentives

to dispense generic medicines at public or private pharmacies exist.

Provisions in the medicines legislation covering promotion and/or advertising of

medicines also exist. Guidelines on Advertisement and Promotions to Implement the

Generics Act Of 1988 were outlined in the Department of Health’s Administrative Order

1989-065. This document, however, like much of the legal policy for the regulation of

the pharmaceutical sector, is yet to see a more current update.

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Medicines supply system

The Government Procurement Policy Board (GPPB) provides oversight not just on

the procurement of medicines of the Department of Health but also on the procurement

by other government offices. In 2005, the Philippine International Trading Company

(PITC) Pharma Inc. was created under Executive Order (EO) No. 442 to be the lead

coordinating agency to make quality medicines available, affordable and accessible to

the greater masses of Filipinos. PITC Pharma Inc.I is the main buyer and supplier of drugs

for the Department of Health and the Botika ng Barangay (BnB). The BnB refers to a drug

outlet, carrying OTC drugs and 7 prescription drugs, managed by a legitimate community

organization (CO), non-government organization (NGO) and/or the Local Government

Unit (LGU). This program was conceptualized with the hope of making cheaper

medicines more available to the public. Guidelines for the establishment and operations

of Botika ng Barangays and Pharmaceutical Distribution Networks have been established

(AO No. 144, s. 2004). Public sector medicines procurement is limited to medicines on

the national EML.

RA 7160, otherwise known as the Local Government Code, has devolved health

services to local government units, with each level procuring medicines on their own.

Medicines are therefore procured at every LGU level, 85 provinces, 1800 municipalities

and 75,000 barangays across the country. Also, within the DOH systems, the 72 hospitals

under its jurisdiction are separate procuring entities. The purpose of such devolution

was to make the procurement of medicines more locally responsive. However, an

unavoidable effect of this system is a fragmented procurement system that is harder to

regulate and audit.

Procurement of medicines in the public sector is guided by RA 9184, or the

Government Procurement Act. Under this law, bidding is the default mode for

procurement but other mechanisms such as shopping and negotiated purchases can be

undertaken. The practice of emergency purchases however is rampant in all level of the

health care system.

With regards to drug distribution, the Pharmaceutical and Health Association of

the Philippines (PHAP) reported that as of 2008, drugstores, majority of which were

private chain stores, were still the leading channel of distribution (89.25%). (3) On the

other hand, government hospitals only held around 3% of the distribution of medicines.

Medicines financing

In 2009, the total expenditure for medicines including supplements was

approximately PhP 110 billion. Only 12% of this value was government expenditure.

There is a national policy to provide some medicines free of charge (i.e. patients do not

pay out-of-pocket for medicines) at public primary care facilities. The following patients

are entitled to receive medicines for free: patients who cannot afford them, children

under 5 years of age, pregnant women and elderly persons. No fees are supposed to be

charged at primary care facilities and prescribers in the public sector never dispense

medicines.

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PhilHealth serves as the country’s public health insurance. It covers for the cost

of medicines. This insurance, however, has a cap and is limited to the inpatient settings.

As stated earlier, outpatient benefits are limited to day surgeries, dialysis and cancer

treatment procedures leaving out a large portion of acute and chronic illnesses for which

patients seek outpatient service.

The Philippines is just starting a pilot on a national medicine price monitoring

system for retail/patient prices.

There are official written guidelines on medicine donations that provide rules

and regulations for donors and provide guidance to the public, private and/or NGO

sectors on accepting and handling donated medicines.

Rational use of medicines

The Philippines' National Drug Formulary (PNDF) is defining the national Essential

Medicines List (EML). It was last updated in 2008 and is being used as basis for public

sector procurement. The national formulary committee of the Department of Health is

responsible for the selection of products on the national EML and is updated in cycles

regularly. Antibiotics, injections, narcotics and psychotropic drugs, according to law,

should never be sold over the counter without a prescription. However, the actual

enforcement of this law is weak.

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3. METHODOLOGY

3.1. Overview

This study was conducted using a standardized methodology developed by the

World Health Organization. (4) The household survey measuring access to and use of

medicines was conducted in six (6) regions. In each region, six (6) reference public heath

care facilities were selected among those participating in the Level II Facility Survey that

was run in parallel. Within defined distances from each reference public health care

facility, households were selected by purposive cluster sampling. (See Figure 3.1) A total

of 1079 household respondents were interviewed by means of a structured paper

questionnaire that gathered information on the socioeconomic level of households, and

collected data on access to and use of medicines as well as opinions and perceptions

about medicines. Data entry was performed with EpiData software and analysis with

Excel.

3.2. Selection of geographic areas and reference public health care facilities

The six geographic sites included in the study were La Union province in Region

1, Pampanga province in Region 3, the city of Manila in the National Capital Region

(NCR), Palawan province in Region 4, Capiz province in Region 6, and Misamis Oriental

province in Region 10. From each of the six geographic sites, six public health facilities,

fifteen private facilities/drug outlets, and one warehouse were selected. The six public

health facilities were composed of one public hospital which should be the largest

facility with general public outpatient services in the area and with a medicine

dispensing unit, one primary or rural health center or lowest level public health facility;

and four health facilities randomly selected from all middle level public health facilities.

The fifteen private facilities / drug outlets were composed of three private, non-

governmental or mission health facilities; and twelve private drug outlets closest to each

public health facility included in the survey.

For each of the previously mentioned geographic sites, the sample of reference

facilities was identified by first selecting the main public hospital. An additional five

public medicine facilities (e.g. hospital medicine dispensaries) per survey area were then

selected at random from a list of all public health care facilities expected to carry a full

supply of essential medicines. The WHO methodology calls for selecting 30 households

per public health care facility participating in the health care facility survey. Households

were then selected purposively.

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Table 3.1: Reference health care facilities and households, by region

Region Facility Public

Hospital

Health

Care

Center

Households

BACNOTAN DISTRICT HOSPITAL 30

BANGAR 30

Caba Medicare & Community Hospital 30

ITRMC 30

NAGUILIAN DH 30

1

Northern La Union Maternity & Children's Hospital 30

A. MABINI H.C. 30

DIMASALANG H.C. 30

JOSE REYES 30

LANUSA HEALTH CENTER 30

SAN SEBASTIAN H.C. 30

NCR

V. FUGOSO 30

DIOSDADO MACAPAGAL 30

JOSE B. LINGAD 30

PORAC DISTRICT 30

R.P. RODRIGUEZ HOSPITAL 30

ROMANA PANGAN DISTRICT HOSPITAL 30

3

ROSARIO MEMORIAL 30

AMH 30

ONP 30

Quezon Medicare 30

Quezon RHU 30

Roxas Medicare Hospital 29

4

SPPH 30

Bailan District Hospital 30

DAO DISTRICT HOSPITAL 30

DUMARAO RHU 30

MAMBUSAO DISTRICT HOSPITAL 30

Roxas Memorial Provincial Hospital 30

6

Tapaz District Hospital 30

BAL. RHU 30

CMH 30

INITAO DISTRICT HOSPITAL 30

MCH 60

10

NMMC 30

Total 1079

3.3. Selection of households

The WHO methodology calls for selecting 30 households for each public health

care facility participating in the health care facility survey. The largest urban area, the

National Capital Region, contributed for one sixth of the households. A similar

contingent of households came from each of the six administrative areas.

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In accordance with the WHO methodology, households were selected

purposively as follows. The reference health care facility was the central reference point;

the first two households were selected randomly in opposite directions and in clusters of

five households defined as follows: two clusters were within a 5km radius from the

facility, two clusters were between 5 and 10 km from the facility, and two clusters were

beyond 10 km. In each reference facility, a total of thirty households were selected as

illustrated in Figure 3.1. Overall, there were 1,079 households surveyed for the six

geographic sites. After completing an interview with the respondent of the first

household of each cluster (or scheduling one for a later time), data collectors skipped

several households before selecting the next household. Not every household was able

to participate in the survey; in such cases, the next household was chosen as a

replacement.

Interviewers were trained to use judgment in selecting households. General

rules of thumb applied were:

• Households should not be next to each another;

• Households should not be excluded if respondents are not immediately

present but an appointment can be scheduled to interview them later in

the same day;

• Households should have an economic status that is generally

representative of the area in terms of dwelling condition, size,

organization of the household premises, and water supply.

Figure 3.1: Household Sampling

P u b l i cF a c i l it y

> 1 0 k m

5 - 1 0 k m

< 5 k m

P u b l i cF a c i l it yP u b l i c

F a c i l it y

> 1 0 k m

5 - 1 0 k m

< 5 k m

One household in survey =

In the Philippines, 1079 households participated in the survey. Figure 3.2

presents the actual distribution of households in each cluster. Households were equally

distributed across three clusters defined by the distance of households to reference

health care facilities

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Figure 3.2: Household Clusters

Figure 3.3 presents the percentage of households per cluster in each of the six

selected regions. The profile of each cluster of households was similar with regards to

region representation, save for NCR and Region 3 where majority of the households

were located >10 km and <5km from the health facility, respectively. The major urban

area accounted for about two in ten households in each cluster.

Figure 3.3: Representation of household clusters in each surveyed area

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3.4. Selection of respondents

Interviewers were trained to use judgment in selecting respondents.

Respondents were selected if they met at least three of the following criteria:

• Main health care decision maker

• Most knowledgeable about health of household members

• Most knowledgeable about health expenditures of the household

• Most knowledgeable about health utilization by household members

• Designated care giver for sick household members

3.5. Data Collection

In 2008, the data gathering for the study was done by the Department of Health

(DOH) Team led by Dr. Robert So and Dr. Dennis Quiambao for Pampanga and Manila.

Then in 2009, data gathering was continued by PMHSMPC Team in Palawan by Dr.

Ramon Docto of Palawan State University, in Capiz by Prof. Leo Quintilla of U.P. Visayas,

in Misamis Oriental by Dr. Chona Echavez of Xavier University, and in La Union by Prof.

Arjay Arellano of U.P. Baguio. The research team was led by Mr. Mikael Navarro who is

the research coordinator, Ms. Bernadette Guillermo who is the data management

coordinator, and Mr. Johnny Lucion.

3.6. Data Entry

Survey data were entered by a team of data entry persons. EpiData software was

used for data entry. Data entry was checked by entering twice a percentage of the

questionnaires using the double data entry functions of Epidata; erroneous entries and

potential outliers were verified and corrected as necessary through data cleaning.

3.7. Data Analysis

Household Epidata records were merged into four files for analysis. Files were

imported into an Excel workbook containing macros and formulas that automatically

generated tables and figures of the report.

3.8. Limitations of the Study

Several limitations and difficulties were observed during the conduct of the

study, which may produce undue bias in the data collected. Interpretation of the data

should be done with the following in mind:

Sample representativity

• The WHO Level II core outcome indicator survey is designed to obtain relevant

information from a simple-as-possible data collection process and small sample

size. More precise results needs larger samples but they are costly, time

consuming and require a more complex logistic infrastructure. Therefore, a

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balance between what is desirable and what is feasible becomes the issue with

the sample size. The best sample size will be the smallest one that will result in

estimates with the desired degree of precision.

• The survey has been designed to provide a picture of the national pharmaceutical

situation in a country. The regions and facilities selected cumulatively represent

the national situation. The sample sizes used are statistically not large enough to

make inter-facility comparisons. For patient care indicators, for example, a

minimum sample size of 100 would be necessary in order to make comparisons

between facilities. This survey uses a sample size of 30. However, providing that

majority of the data is collected and the results are statistically different,

comparisons between geographic regions can be made. Regional comparisons

may be of interest where there is especially wide variation or contrasts,

particularly with a group of related indicators.

• Looking at the education and characteristics of the surveyed household, the

poorer households may have been underrepresented in the sample

Potential bias

• Recall bias. One month recall of events might not capture hospitalization,

catastrophic events or other significant events that have occurred during the year.

• Interviewees were informed of the nature of the study focus on medicines and

may have paid more details for expenditures related to medicines, hospitalization

and less on the other components of family expenses.

• The questionnaire used for this survey was written in English. Although the

interviewers were trained on how to use this in the local setting, a questionnaire

that’s translated to the vernacular, with appropriate validation, may facilitate the

information gathering process and produce more reflective data.

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4. RESULTS

4.1. Characteristics of surveyed households

Understanding the characteristics of surveyed households is critical to assessing

their representativeness at the national level. Interpretation of survey results depends

on the location, size, composition and socio-economic status of households, as well as

characteristics of respondents and morbidity of the population included in the survey.

4.1.1. Respondents

Respondents are selected by data collectors because they are the household

health care decision makers. Therefore, the gender, age and education of respondents

provide information about the characteristics of the main health care decision makers in

households. The profile of respondents is an important consideration in the

interpretation of the opinion questions of the survey.

Figure 4.1 presents the gender and age of respondents. Women represented the

large majority of respondents (66%). Over two thirds of respondents were between 25

and 50 years old; 22 percent were male, and 43 percent were female. Three in ten of the

respondents were over 50 years old, 10 percent were male and 20 percent were female.

Figure 4.1: Gender and age of respondents/health care decision makers

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Table 4.1 presents the highest level of education reached by respondents. Ninety

eight percent (98%) of respondents went to school. Seventy percent (70%) of

respondents completed secondary school with twenty eight percent (28%) continuing to

studies beyond secondary school. The level of education was comparable between male

and female respondents. This is higher than the national statistic reported in 2008 which

showed that only 41% of the population completed secondary school or pursued studies

beyond secondary school.

Table 4.1: Education and gender of respondents

All Male Female

Number of respondents 1074 361 713

No formal schooling 21 2.0% 14 3.9% 7 1.0%

Some primary school 91 8.5% 24 6.6% 67 9.4%

Completed primary school 200 18.6% 49 13.6% 151 21.2%

Completed secondary school 141 13.1% 59 16.3% 82 11.5%

Completed high school or equivalent 310 28.9% 85 23.5% 225 31.6%

Completed college/university 293 27.3% 121 33.5% 172 24.1%

Competed post-graduate studies 14 1.3% 6 1.7% 8 1.1%

4.1.2. Household characteristics

Table 4.2 summarizes the characteristics of the surveyed households. It is worthy

to note that the mean number of children per household with children in this survey is

only 2 while for households with the least spending capacity have 3. Compared to the

National Demographic and Health Survey of 2008, this value is closer to the fertility rates

of the wealthiest quintiles (fertility rate = 1.9) than the poorest quintile (fertility rate =

5.2). (5) As such, the poorer households may have been underrepresented in the current

household medicines survey.

Table 4.2: Characteristics of surveyed households

4- week spending/person (PHP)

All < 700 701-

1000

1001-

1499

1500-

2000 > 2000

Number of households 1079 154 156 135 173 143

Total population 5234 857 795 697 780 534

Mean household size 5 6 5 5 5 4

Percentage of households with

children 56% 62% 56% 61% 53% 42%

Mean number of children per

household with children 2 2 3 3 2 2

Mean number of children under 5 yo

per household with children 1 1 1 1 0 0

Mean 4-wk household total

expenditures 6,638 1,767 4,460 6,502 7,933 12,824

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4.1.3. Household expenditures

The medicines survey collects direct information on food and health

expenditures. Providing an actual value of 4-wk total expenditures is optional. Recall

period of total and health expenditures include the four previous weeks. Recall period of

food expenditures is limited to the previous week: food expenditures results have been

adjusted to take into account the difference in recall period. Discretionary expenditures

are calculated as the difference between total 4-wk expenditures and 4-wk food

expenditures. In the Philippine survey, most respondents provided their actual 4-week

household spending.

Table 4.3 presents the mean and median of household expenditures collected in

the Philippine survey. The mean is the average value, sensitive to outliers, whereas the

median is the 50th percentile, i.e. the value below which 50% of the values are

positioned. The large difference between means and medians of expenditures displayed

on the table is due to the presence of extreme outliers at the higher ranges of

expenditures.

Table 4.3: Monthly household expenditures in PHP

Number of

Respondents Mean Median

4-wk hh total expenditures 761 6,638 5,500

4-wk hh food expenditures 1055 5,253 4,000

4-wk hh discretionary expenditures 761 1,600 1,300

4-wk hh health expenditures 1079 1,130 160

4-wk hh medicine expenditures 1071 441 100

4-wk hh hospital expenditures 1072 524 0

4-wk hh voluntary health insurance

expenditures 1069 60 0

4-wk hh other health expenditures 1071 113 0

Seventy percent (70%) of the respondents chose to provide an actual amount of

total household expenditures. In this group of 761 respondents, the median value of

total 4-wk household expenditures was Php 5500.00.

4.1.4. Household socio-economic status

Socio-economic status is a key attribute of households, influencing their options

and decisions about health care. Socio-economic status was estimated by collecting

information on expenditures/income and assets of households.

The medicines survey identifies poor households in two ways:

• by asking respondents how much their household spent over the past four

weeks: this question is optional.

• by asking respondents to match their household expenditures with one of

five pre-defined ranges

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Most respondents provided their actual 4-week household spending. For this

reason, this report displays socio-economic status in wealth quintiles defined by the

level of 4-week household expenditures: < 700 PHP, 701 to 1000 PHP, 1001 to 1499 PHP,

1500 to 2000 PHP, and over 2000 PHP.

Figure 4.2 shows the distribution of household clusters by band of expenditures,

i.e. by the socio-economic level selected by respondents. Region 6 showed to be the

more affluent with more than 50% in the 1500 PHP and above level of expenditure with

Region 10 with the smallest proportion for the same categories combined.

Figure 4.2: Level of household expenditures in different survey areas

4.1.5. Household Morbidity

Information about household morbidity were obtained by asking respondents if a

member of the household had acute illness within two weeks preceding the survey and

if a member of the household has a chronic disease. If that is the case, data collectors

collect health data on the youngest member with a recent acute illness and on the

oldest member with a chronic disease. They also ask how many members had a recent

acute illness or have a chronic disease.

Table 4.4 presents the prevalence of illnesses in surveyed households. About one

third of the sampled households were free of current health problem (34%). On the

other hand, thirteen percent (13%) of sampled households reported both acute and

chronic conditions. About two fifths (40%) of households disclosed one or more recent

acute illnesses, and an equal proportion (39%) reported one or more chronic diseases.

Acute illnesses and chronic diseases were reported equally often. This means that there

is an expenditure related to health and medicines purchase for 40% of the households

-16-

surveyed. The cost of this will always be a part of the weekly household budgeting if

there is adherence to treatment for household with chronic illness.

Table 4.4: Prevalence of acute and chronic conditions

Table 4.5 presents symptoms of recent acute illness as perceived by respondents.

Cough, runny nose, sore throat, and earache were the most common reported

symptoms. Fever and headaches were also common. Accidents which may need more

resources are less frequently reported.

Table 4.5: Reported symptoms of acute illness

Symptoms Frequency

(n = 427)

Percent

Cough, runny nose, sore throat, ear ache 265 62.1

Fever, headache, hot body 229 53.6

Pain, aches 67 15.7

Difficulty breathing, fast breathing 34 8.0

Others 30 7.0

Diarrhea, vomiting, nausea, could not eat 27 6.3

Thirst, sweating 20 4.7

Could not sleep 11 2.6

Bleeding, burn, accident 7 1.6

Convulsions, fits 5 1.2

With regards to chronic conditions, chronic diseases are documented as they are

recalled by respondents. Table 4.6 presents reported chronic diseases. The most

frequent reported chronic diseases were hypertension, asthma, arthritis and diabetes.

These conditions require regular intake of medications, at times, multiple drugs and in

combinations as in the case of hypertension and diabetes.

Table 4.6: Reported chronic Illness

Chronic Illness Frequency

(n = 488) Percent

Hypertension, high blood pressure 244 50.0

Asthma, wheezing, chronic difficulty in 90 18.4

At least one chronic disease

Yes No All

145 290 435 Yes

13% 27% 40%

272 372 644

At least one

recent acute

illness No 25% 34% 60%

417 662 1079 All

39% 61% 100%

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breathing

Arthritis, chronic body pain 83 17.0

Diabetes, high blood sugar 78 16.0

High cholesterol 62 12.7

Others 61 12.5

Heart disease, heart attack consequence 42 8.6

Ulcer, chronic stomach pain 36 7.4

Tuberculosis 16 3.3

Stroke consequences 15 3.1

Epilepsy, seizures, fits 9 1.8

Cancer 6 1.2

Liver disease 5 1.0

HIV infection, AIDS 2 0.4

Depression 1 0.2

The figure below (Fig. 4.3) shows that the same proportion of households with

acute and chronic illness among those with the least spending capacity ( <700 PHP). For

those with >2000PHP spending capacity, the proportion with chronic illness is higher

(48%) while those with acute illness was lower (34%). This may be related to a better

living condition and higher lifespan (greater number of old members within the family)

for these household.

Figure 4.3: Prevalence of illnesses by socioeconomic status

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4.2. Geographic access and availability of medicines

Geographic access to public health facilities is an important indicator of equity in

access to medicines.

4.2.1. Proximity to health care facilities

The survey records the proximity of each household to different types of health

care facilities, using the time to travel as unit of distance. Facilities are classified into the

following categories: public hospital, private or NGO hospital, public health care center

or dispensary, private clinic or physician, traditional healer, private pharmacy, or drug

seller. For each facility, options to choose from are less than 15 minutes, between 15

minutes and 1 hour, and over one hour of travel time.

Table 4.7 displays the proximity of households to any health care facility and to

public health care facilities.

Table 4.7: Travel time to health care facilities

Number of Households Percent

Travel time to closest health care facility

Less than 15 min 958 89% Over 1 hour 20 2%

Travel time to closest public health care facility

Less than 15 min 791 73% Over 1 hour 39 4%

Eighty nine percent (89%) of the surveyed households was close to a health care

facility and seventy three percent (74%) was close to a public health care facility. Four

percent (4%) of the surveyed households had to travel more than 1 hour to reach the

closest public health care facility. Looking across the different levels of expenditures, no

major differences in the proportions were noted. The data suggest that for the majority

of the household surveyed, geographical access to a health care facility is not a problem.

However, others may contest this finding and cite mountainous areas or island

communities of remote distance to the center of a local community but this was not

captured by the sampled population for this survey. This can be explained by the

sampling procedure done.

4.2.2. Sources of care in case of acute illness

For acute illness the sources of care in case of acute illness are listed in Table 4.8.

Majority of households sought care and medicines either from a public hospital, public

health center or private hospital or clinic or physician. Others, though a smaller number,

would consider consult with a traditional healer or just go direct to the drug seller for

the medication. Merging the public facilities together and the private facilities together

and looking across level of expenditures, the private facilities remain to be the major

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Table 4.8: Sources of care for an acute illness

Sources of Care Frequency

(n = 210)

Percent

Public hospital 51 24.3

Public health center or dispensary 50 23.8

Private hospital, clinic or physician 49 23.3

Private pharmacy 40 19.1

Traditional healer 18 8.6

Drug seller 18 8.6

Friend or neighbor 12 5.7

Mission or NGO hospital 4 1.9

4.2.3. Opinions about geographic access and availability of medicines

Personal opinions are part of the survey. Table 4.9 presents the percentage of

respondents who agreed with statements related to geographic access and availability

of medicines. Eighty seven percent (87%) of respondents were satisfied with the location

of their public health care facility and are willing to use public health care facility given

more convenient opening hours. This is something positive in the sense that there is an

intention of use (willingness to use public facility) and being deemed easy to be reached

despite less than 50% availability of the needed medicines. This may be due to the fact

the public health facility especially health centers have been used more for

immunization and prenatal care of mothers rather than a place for consult for acute

illness. Even more, availability of medicines is a reality that most Filipinos have

experienced in the past. Thus, being seen by a health service provider can account for

the positive perceptions of service despite the belief that availability of medicines is

better in private health care facilities.

Table 4.9: Opinions about geographic access and availability of medicines

Agree

The public health care facility closest to my household is easy to reach. 87%

My household would use public health care facilities more if opening

hours were convenient. 85%

The public health care facility closest to my household usually has the

medicines we need. 45%

The private pharmacy closest to my household usually has the

medicines my household needs. 71%

4.3. Affordability of medicines

Affordability of medicines is a critical indicator of equity in access to medicines.

The level of medicine insurance coverage and the actual cost of medicines for different

conditions are important to consider when assessing medicines affordability.

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4.3.1. Cost of medicines for acute and chronic illnesses

Information about the cost of prescriptions for recent acute and chronic illnesses

was collected.

Table 4.10 presents the cost of prescriptions for acute illnesses. The average cost

of one prescription for acute illness was Php 485. The average number of medicines per

prescription was 1.75 (range: 1-5) and 52% with at least 2 medications.

Table 4.10: Cost of prescriptions for a recent acute illness

Number of recent acute illnesses 541

Number of persons with recent acute illness who took medicines 500

Number of persons with recent acute illness who paid for

medicines 427

Average number of medicines by prescription 1.75

Average cost of one prescription when not free-of-charge PHP 485

The medicines survey also collects information about the price of medicines

taken for chronic diseases. In this case, the monthly cost of each prescribed medicine is

recorded.

The average monthly cost of a prescription for chronic disease was Php 946 while

the average number of medicines taken for a chronic disease was 1.9, ranging from at

least 1 medication to as high as 9 medications per day. At least 50% had a minimum of 2

medications per day.

Table 4.11: Monthly cost of medicines for chronic diseases

Number of persons with a chronic disease 488

Number of persons with a chronic disease who take

medicines 461

Number of persons with a chronic disease who pay for

their medicines 277

Average number of medicines taken 1.9

Average monthly cost of medicines for chronic disease

when medicines are not free-of-charge PHP 946

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4.3.2. Medicines social coverage

The medicines survey also collected data regarding the percentage of households

who receive prescriptions free-of charge in case of acute illness and the percentage of

households who receive insurance coverage in care of acute conditions. Fifteen percent

(15%) of prescriptions for acute illness were obtained free of charge. Only 3% of

prescriptions for acute illness were covered by health insurance. However, this may be

due the fact that most acute illnesses were probably outpatient cases not presently

covered by national health insurance.

On the other hand, 40% of those who reported chronic illnesses were given

medicines free of charge. This was notably higher among households with a 4 week

spending per person <700 (46%) than among households with a 4 week spending per

person >2000 (25%).

4.3.3. Opinions about affordability of medicines

Table 4.12 presents the percentages of respondents who agreed with statements

related to affordability of medicines. Sixty eight percent (68%) of respondents agreed

that they can usually afford to buy all the medicines they need though the same number

had experience in the past of borrowing money in order to buy medicines. Seventy

percent (70%) of respondents agreed that medicines are more expensive in private

pharmacies than in public health care facilities. However, despite the perceived higher

costs at private pharmacies and the perceived possibility to get free medicines from

public health facilities (59%), continued patronage of private pharmacies (see 4.4.5) may

also be due to the fact that 31% of the respondents believed that they can get credit

from these establishments.

Table 4.12: Opinions about affordability of medicines

My household can get free medicines at the public health care facility. 59%

Medicines are more expensive at private pharmacies than at public health care

facilities. 78%

My household can usually get credit from the private pharmacy if we need to. 31%

My household can usually afford to buy the medicines we need. 68%

My household would obtain prescribed medicines if insurance reimbursed part

of their cost. 52%

In the past, my household had to borrow money or sell things to pay for

medicines. 68%

4.4. Medicine at home

Collecting information on medicines kept at home contributes to answering

questions on medicines people access and use, who prescribes them, where they can be

obtained, how much they cost and why people take or do not take them.

In each household, data collectors ask to see all medicines that are kept at home,

and record the name, source, reason for keeping each medicine, as well as the condition

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of their label and primary package. Medicines are entered in the data base with both

their actual and generic names, and a code derived from the 16th WHO Model List of

Essential Medicines. (6)

4.4.1. Number of households with medicines found and the medicines found

Sixty nine percent (69%) of households have medicines at home. Table 4.13 presents

the most frequent categories of medicines found in households by EML category. Non-

steroidal anti-inflammatory medicines (NSAIMs) and non-opioid analgesics were the

most frequently found medicines at home.

Table 4.13: Most frequent categories of medicines found in households

Categories N Percent

Non-opioid analgesics and NSAIMs 734 43%

Vitamins/minerals 173 10%

Beta lactam medicines 136 8%

Unclassified agents 134 8%

Antihypertensive medicines 112 7%

Respiratory tract medicines 98 6%

Antiasthmatic medicines and medicines for COPD 79 5%

Antibacterials other than beta lactam medicines 76 4%

Antidiarrheics 73 4%

Insulins/antidiabetic agents 38 2%

Antacids/other antiulcer medicines 38 2%

4.4.2. Sources of medicines found in households

Figure 4.4 presents the percentage of medicines found in households that were

obtained in different types of health care facilities. Only eight percent (8%) of medicines

found in households came from a public health care facility and 78% come from private

pharmacies or drug sellers. Even looking at the households of different level of

expenditures, the private facilities remains to be the main source of medicines, reaching

91% for those in the >2000 group.

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Figure 4.4: Source of medicines found in households

4.4.3. Labeling and packaging of medicines found in households

Labels of medicines found in households are considered acceptable by data

collectors if they include medicine name, dose, and expiration date. Similarly, the

primary package of a medicine is considered acceptable if it is an envelope or a closable

container which contains only one medicine.

Figure 4.5 presents the percentage of medicines that had an acceptable label and

primary package, by source of medicine.

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Figure 4.5: Percentage of medicines found in households with both

adequate label and primary package, by source

Overall, about sixty percent (61%) of medicines found in households had a label

in good condition and were in an appropriate container. Most of the medications may

lack the proper labeling when checked due to retail (by number of pill) purchasing.

4.4.4. Antibacterials found in households

Table 4.14 presents the most frequent antibacterials found in households, by

generic name and frequency. Amoxicillin was the antibacterial most frequently found in

households and this was followed by co-trimoxazole. Reasons cited for having

antibacterials at home were as standby for future use and because they were left over

from previous treatment (Figure 4.6).

Table 4.14: Frequently reported antibiotics found in the households

Antibacterials Frequency

Amoxicillin 99

Trimetoprim+sulfamethoxazole 47

Cephalexin 13

Cefpirome 12

Metronidazole 11

Antibiotic, unclassified 6

Cloxacillin 5

Doxycycline 5

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Rifampicin 5

Ciprofloxacin 4

Figure 4.6: Reasons for keeping antibacterials at home

216

47

84 85

0

150

300

Number ofantibacterials

found in household

Current treatment Left from pasttreatment

Anticipate futureneed

100% 22% 39% 39%

4.5. Use of medicines during acute and chronic illnesses

For each recent acute illness reported, data collectors record name, route of

administration, prescriber, and source of each medicine taken for this illness. Medicines

are entered in the data base with both their actual and generic names, and a code

derived from the 16th WHO Model List of Essential Medicines. In households with a

person diagnosed with a chronic disease, the data collector records the name of each

medicine prescribed to the person with a chronic disease, the condition for which it was

recommended, the number of days of supply usually obtained, the usual cost for one

month, and insurance coverage for every person with a chronic disease. Medicines are

entered in the data base with both their actual and generic names, and a code derived

from the 15th WHO Model List of Essential Medicines.

There is great variability in the coverage of the acute illness in the survey. It may

range from a simple pains, fever and runny nose to something like an accident that may

be very serious. As such, the response in the different questions on acute illness shows

the same variability.

4.5.1. Prescribers of medicines in case of acute illness

Figure 4.7 presents prescribers of medicines in case of acute illness.

Doctors/nurses were still the most common prescribers a third of the population self-

prescribed; meaning purchased their medicines based probably on their experience in

the past with the same conditions. This was also possible especially for medicines for

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colds, pain, and fever which are the more common forms of acute illness reported by

the respondents.

Figure 4.7: Prescribers of medicines in case of acute illness

4.5.2. Reasons for not taking medicines prescribed for acute illness

The medicine survey includes a list of possible reasons that could explain why a

person did not take prescribed medicines. If non-compliance is identified, this list is read

to the respondent who chooses yes if he/she feels this reason explains why the medicine

was not taken. Yes may be selected for several possible reasons.

Table 4.15 presents the number of persons with acute illness who did not take

the medicines as recommended, and the most frequent reasons chosen to explain non-

compliance. Improvement of the symptoms was the reported reason for discontinuance

of medications and treatment, followed by affordability. This will lead to incomplete

treatment which, in a context of an antibiotic course, can lead to resistance in the

future.

Table 4.15: Reasons for not taking prescribed medicines for acute illness

Reasons Frequency

(n = 110)

Percent

Symptoms have gotten better 83 75.5

Our household could not afford the medicines 40 36.4

Someone in the household decided medicines were not needed 35 31.8

Someone in the household chose a different treatment 31 28.2

Someone advised not to take medicines 23 20.9

Medicines were not available at the public health care facility 23 20.9

The place where medicines can be obtained was too far away 22 20.0

No one in the household could take time to obtain medicines 22 20.0

Sick person had bad reactions to medicines in the past 15 13.6

Medicines were not available at private pharmacy or drug seller 15 13.6

Others 9 8.2

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4.5.3. Reasons for not taking medicines prescribed for a chronic disease

Table 4.16 presents the number of persons with chronic disease who did not take

prescribed medicines as recommended. Same with acute illness, the most common

reasons for not taking medicines was improvement of symptoms being felt by the

patient. However, this was followed again by affordability since there cost is even more

an issue for maintenance for chronic illnesses.

Table 4.16: Reasons for not taking medicines for a chronic disease as prescribed

Reasons Frequency

(n = 106)

Percent

Symptoms have gotten better 70 66.0

Our household could not afford the medicines 56 52.8

Someone in the household decided medicines were not

needed

23 21.7

No one in the household could take time to obtain

medicines

23 21.7

Someone in the household chose a different treatment 21 19.8

The place where medicines can be obtained was too far

away

18 17.0

Medicines were not available at the public health care

facility

18 17.0

Sick person had bad reactions to medicines in the past 17 16.0

Medicines were not available at private pharmacy or drug

seller

16 15.1

Someone advised not to take medicines 15 14.2

Others 9 8.5

4.6. Opinions about quality of care

The medicines survey collects opinions of respondents about quality of care.

Statements describing opinions are read to respondents who are asked if they agree or

disagree. Data collectors are instructed to tick the option ‘do not know’ only if

respondents are not sure or do not want to answer a particular question.

Table 4.17 presents opinions of respondents about quality of care in their area.

Opinions of respondents about the quality of services in public health care facilities were

positive. However, there were also more respondents agreed that the quality of services

is better in private facilities as compared to public facilities. There is still this notion that

imported medicines are of better quality than locally manufactured medicines.

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Table 4.17: Opinions about quality of care

Agree

The quality of services delivered at public health care facilities in my

neighborhood is good. 73%

The quality of services delivered by private health care providers in

my neighborhood is good. 82%

Imported medicines are of better quality than locally manufactured

medicines. 59%

4.7. Opinions about pricing and quality of medicines

The medicines survey collects opinions of respondents about the pricing and

quality of medicines. Statements related to these attributes are read to respondents

who are asked if they agree or disagree. Data collectors are instructed to tick the option

‘do not know’ only if respondents are not sure or do not want to answer a particular

question.

Table 4.18 presents opinions of respondents about pricing and quality of

medicines. From the table, several information can be obtained. For one, respondents

are more conscious about the prices of the medicines they are buying and would asked

pharmacist for a cheaper drug with the same content (64%). They also believe that

health providers, both in public and private health facilities, take into account the ability

of their patients to pay when they prescribe medicines. Pharmacist is still seen as a

good resource person to ask about quality of medicines to be purchase. Trust in the

government in ensuring quality medicines in the market is also there (71%). And the

term ‘generic’ is a very common term for everyone.

Table 4.18: Opinions about pricing and quality of medicines

Agree

In public facilities, health providers take into account our ability to

pay when they decide which medicines to prescribe. 65%

In private facilities, health providers take into account our ability to

pay when they decide which medicines to prescribe. 57%

When I receive a prescription, I am comfortable asking how much

the medicines will cost. 77%

It is easy for me to find out how much medicines cost. 77%

Two identical medicines may be sold at different prices. 74%

I know where to find medicines at the lowest price in my

neighborhood. 76%

When I buy a medicine, I ask for the least expensive product. 64%

When a pharmacist recommends a medicine, I can be sure that it is

the best value for money. 57%

When a pharmacist recommends a medicine, I can be sure that it is

of good quality. 60%

-29-

Medicines of better quality are more expensive. 77%

There are places in my neighborhood where I would never buy

medicines because they sell medicines of poor quality. 41%

Our government makes sure that the medicines we buy are of good

quality. 71%

Different names may be used for the same medicine. 74%

I have heard the word “generic” before to describe a medicine. 95%

4.8. Opinions about generic medicines

Only a minority of respondents answered ‘do not know’ to the question related

to generic medicines. Table 4.19 presents the percentage of respondents who knew

about generics and agreed with statements related to generics. Of the majority of

respondents who heard the word ‘generic’ before, sixty seven percent (67%) believed

that generic medicines are of lesser quality and ninety percent (90%) believed that they

are less expensive than brand medicines.

Table 4.19: Opinions about generics

Agree

Number of respondents who heard the word "generic"

before to describe a medicine 1022

A generic medicine is usually lower in quality than a

brand medicine. 67%

A generic medicine is usually lower in price than a brand

medicine. 90%

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5. DISCUSSION

An important indicator of equity to access to medicines is geographical access to

the health facility. Some may presume that access to the facility may equate to access to

medicines. However, this is not always the case. In the Philippines, some public health

care facility does not have or have very limited supply of medicines. In the devolved

health care setting, most of medicines are procured by the local government and very

selected medicines are coming from the DOH central office. These from the central

office are mainly for specific programs like immunization, HIV, TB and malaria, where

procurement remains with the central DOH. A very small proportion (4%) of the

respondents in the study reported that they need to travel more than 1 hour to the

nearest health facility, public or private. Majority (87%) assessed the location the public

health facility as convenient and intends to utilize them more if opening hours are

convenient. This may be come applicable to the health centers that are only open o

daytime regular office hours.

Main source of medicines in the households comes from the private facilities

although perceived that the medicines from them are more expensive than the public

facility. The respondents equate quality with higher price. Also, some respondents

reported possibilities of credit with private pharmacies within their locality. Most of the

medicines found at home were from past treatment regimen which may imply non-

compliance to full duration of treatment regimen. This may contribute to the possible

emergence of antimicrobial resistance.

Looking at the reported average costs of medicine (when medicines is not given

free of charge) for an acute illness (PHP 485) and monthly medicines for the chronic

illnesses (PHP 946), these translates to spending 7% and 15% of the total household

monthly expenditure of PHP 6638. These two figures are also over the mean monthly

medicines expenditures of PHP 441. Moreover, there is negligible medicine coverage for

acute and chronic conditions from health insurance. This high cost of medicines can also

contribute to the non-completion or non-adherence to treatment protocol aside from

the relief of symptomatologies among patients. This non-adherence can now lead to

antimicrobial resistance and uncontrolled blood pressure and blood sugar levels among

hypertensives and diabetics. This leads to a use of antimicrobials with higher coverage

and cost and to complications in case of hypertension and diabetes which can be

catastrophic. In a study by Higuchi in the Philippines among diabetics, 70% of 160

patients had given up on diabetic care because of cost, not only cost of drug, but also

cost of transportation to the clinics and loss of daily wage of patient and companion.

This may also push families into impoverishments as seen in studies among developing

low- and middle-income countries. (7)

The Philippines has a high prevalence of lifestyle diseases particularly

hypertension and diabetes, both belonging in the 10 leading causes of morbidity and

mortality. However, the most common hypertensive medicines used by the

respondents are not compatible with the first line drugs recommended by current

practical guidelines for hypertension. This may be brought about by lack of strict

adherence of prescribing physicians to the established clinical practice guidelines. This

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can also be influenced by pharmaceutical companies which tend to promote more

recent molecules at higher price. In addition, respondents have high prevalence of self-

prescription which may not be congruent to the clinical practice guidelines.

Furthermore, less than half of all the prescriptions were from medical professionals.

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6. CONCLUSIONS

1.1 Conclusions

Accessibility

Among the sampled households, the geographical location of public health care

facilities seems not to be a significant factor hindering access to medical services.

Availability

Households consider that availability of medicines is higher in private health care

facilities compared to public health care facilities. This perception seems to be

confirmed by actual data collected at facility level in the Facility survey and by the origin

of the medicines found at home. Majority of medicines are obtained from private

pharmacies or drug sellers even if the prices are perceived to be more expensive

compared to medicines from public health care facilities.

Affordability

The average monthly cost of medications for chronic disease was Php 946. The

average cost of 1 prescription for acute illness was Php 485. Generic medicines are

perceived to be less expensive compared to branded medicines. Most frequent reasons

for non-compliance to medical treatment for acute and chronic diseases were

improvement of symptoms and affordability to buy the medicines. Medicines covered

by insurance for acute and chronic conditions were very negligible and recourse to

borrow money or sell things to pay for medicines is significantly reported.

Quality

Services in public health care facilities are perceived to be of good quality despite

the lack of medicine. There is a high preference for branded and imported drugs, in

terms of quality perception. Generic medicines are perceived to be of poor quality

compared to branded medicines. The interpretation of this perception has to be

considered carefully since consumers tend to favor brands whatever the sector.

However it is also well known that such perception may have behavioral impact on

purchasing habits. Imported medicines are perceived to be of better quality compared

to locally manufactured medicines.

Rational Use of Medicine

Most common hypertensive medicines found at home are not compatible to the

first line drugs based on current clinical practice guidelines for hypertension. Most of the

medicines found at home were from past treatment regimen.

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Less than half of all the prescriptions were from medical professionals with high

prevalence of self-prescription among the sample population. However, this was

reported for acute illness where the proportion of what looks to be minor illness

(running nose etc.) is high and which may further increase the trend.

Results of the survey raise equity issues in access to basic medicines. The facility

survey, which has been piloted concomitantly, is providing convergent signals on

availability and affordability of medicines in the same sampled area.

In a context where the Philippines are now looking towards Universal Health

Care, strategies to achieve this ambition will have to take careful consideration of key

medicines availability and affordability at all level of health care. The definition of

adequate policies and mechanisms to tackle these issues will be part critical components

of the realization of Universal Health Care in the Philippines.

Studies such as the Facility and Household surveys can provide useful insights

and baseline assessment to technical and political leaders in the country. Their list of

indicators and variables might need to be more selective and harmonized with other

national surveys in order to provide the framework for a regular monitoring and

evaluation of medicines policies and interventions undertaken in the Philippines.

.

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