Thursday, May 23, 2013

The Best Governance for Medicines ... is in Thailand

The Best Health Care System in the World? 

Here in the US, a lot of people have been convinced that we have the best health care system in the world.  For example, during the 2012 US presidential campaign, Politi-Fact reported,

House Speaker John Boehner, R-Ohio, says the health care law signed by President Barack Obama -- and upheld by the U.S. Supreme Court -- imperiled the nation’s health care system.

'Gov. Romney understands that Obamacare will bankrupt our country and ruin the best health care delivery system in the world,' Boehner said, during the July 1, 2012, edition of CBS’ Face the Nation.

Boehner wasn’t the only one making that claim on the Sunday talk-show circuit. On Fox News Sunday, Senate Minority Leader Mitch McConnell, R-Ky., added that the U.S. has 'the finest health care system in the world.'

More recently, as the Huffington Post reported,

Sen. Jeff Sessions (R-Ala.) charged Thursday that Obamacare is destroying the 'greatest health care system the world has ever known' and that it was 'horrible' for anyone to suggest Americans receive anything less than the best care, even though they die younger on average than people in many other countries.

'This is just one example of what happens in this country when people in Washington take on the arrogant view that they know how to fix the health care system -- one of the most massive, complex, marvelous systems the world has ever known,' Sessions said on the Senate floor.

One would expect that the greatest health care system in the world would have the greatest pharmaceutical industry in the world too.  In fact, as noted by Politi-Fact,  that is pretty much what Congressman Boehner asserted,

 Boehner’s office also noted that wealthy foreigners flock to the U.S. to receive care because of its cutting-edge facilities, and that the U.S. is among the leaders, if not No. 1, in medical research and pharmaceutical development.

Not the Best Governance for Medicines in the World

A recent article from the National News Agency of Malaysia will probably not get a lot of attention in the US, or other developed countries, but it does suggest another reason to be very skeptical about shouts of "USA Number 1" at least applied to health care.  The article's main point was:

The World Health Organisation (WHO) has praised Thailand for the world's best governance for medicine, Thai News Agency (TNA) reported.

Public Health Minister Dr. Pradit Sintawanarong, who is attending the 66th World Health Assembly in Geneva, Switzerland, from May 20-28, told journalists on Wednesday that the WHO has asked Thailand to co-organise a meeting on good governance for medicine, as the Thai Kingdom is considered the world's most advance in governance for medicine and should be a good example for other countries.

Dr. Pradit, who was invited by the WHO to open a meeting on Thailand's governance for medicine and health systems, held as part of the 66th World Health Assembly, acknowledged that the WHO has also asked Thailand to share experiences in another side meeting on 'Good Governance in the Pharmaceutical Sector:The Case of Thailand and Malawi'.

Again, a lot of people think of the US health care system as a model of the rest of the world.  Here is one little bit of data that maybe it should not be the model for "governance for medicine."  Of course, that phrase itself is almost never used here.  Its definition, however, should be instructive.

The World Health Organization has had a small "Good Governance for Medicines" program since 2004.  We first discussed it here in 2008  On the program web-site, its goal is defined:

contributing to health systems strengthening and preventing corruption by promoting good governance in the pharmaceutical sector.

Specifically the programme aims:
-To raise awareness on the impact of corruption in the pharmaceutical sector and bring this to the national health policy agenda
- To increase transparency and accountability in medicine regulatory and supply management systems - To promote individual and institutional integrity in the pharmaceutical sector
- To institutionalize good governance in pharmaceutical systems by building national capacity and leadership.

So if Thailand received recognition for having the best governance for medicines, the implication is that the US does not.

In fact, we and other dissidents have documented a host of problems with individual and institutional integrity in the pharmaceutical sector, lack of transparency and accountability in medicine regulatory and supply management systems, and actual corruption in the pharmaceutical sector.  Some of the most recent big examples on Health Care Renewal since December, 2012, include:
-  the CEO of drug and biotechnology company Amgen collected tens of millions of dollars while his company settled lawsuits alleging it gave kickbacks to doctors, pharmacists and others to use potentially dangerous medicines (post here)
-  Pfizer's 14 legal settlements since 2000, including settlements of allegations of fraud, illegal promotion of hazardous drugs, kickbacks given to physicians, bribery of foreign officials, etc.  The biggest was for $2.3 billion.  In one case, the company was convicted of being a racketeering influenced corrupt organization (RICO) (post here).
- Three settlements in the US by GlaxoSmithKline in 2012, of allegations including deceptive marketing to hide drugs' adverse effects, improperly preventing generic competition, and a $3 billion settlement for deceptive marketing and improper promotion of multiple drugs (post here).
- Eli Lilly settled allegations that it bribed foreign officials.  (In 2009 it pleaded guilty to criminal charges arising from deceptive marketing of Zyprexa) (post here)
- After making two settlements of overcharging the US government in 2007 and 2009, Sanofi settled US allegations of giving kickbacks to doctors (post here)..
-  The pharmaceutical paid "key opinion leader" who was most influential in promoting widespread use, and probably overuse of opiates, admitted it was all "misinformation" (post here).

See also our posts on bribery, kickbacks, fraud, crime, and corruption, not to mention deception, stealth marketing, conflicts of interest, institutional conflicts of interest, etc.

Participatory Democracy in Health Care

So good for the Thais for apparently doing much better with far fewer resources.  One reason seems to be that the government has made good governance for medicines, defined as above, a big priority:

According to the public health minister, the Thai government and his ministry have adhered great importance to good governance for medicine (GGM) and health systems and Thailand has also joined the WHO's campaigns on the GGM from the first stage, concerning the assessment of the situation and the installation of relevant systems.

I can also speculate that one reason they have done better is their conscious effort to enlist the public at large in discussing and setting the direction of their health care system.  For example, as we discussed in 2009,  Thailand has set up by law a National Health Assembly, with its stated goal to be:

an instrument as well as a learning process to develop participatory public polices on health and pushing for practicability.

Assemblies have been held yearly since 2008.  A detailed report on the 2008 assembly is here. [Rasanathan K, Posayanonda T, Birminghan M et al.  Innovation and participation in the first National Health Assembly in Thailand. Health Expectations 2012; 15: 87-96].  The most recent was in December, 2012 (look here.)  

Such a mechanism for broad public input into health care does not obviously occur in the US.  Instead, we have corporations spending billions on lobbying, public relations, stealth advocacy, and campaign contributions.  We have the constant interchange of top government and corporate health care leaders via the revolving door.

We do not have any significant public discussion of good governance for medicines, or anything like it.  (The few, rare exceptions about which I know are the recent Healthy Skepticism meeting on Selling Sickness, and the now yearly meetings organized by  Discussion of deception, conflicts of interest, crime and corruption affecting large health care organizations is muted and anechoic.  I know of precisely one course on health care corruption in any US medical, public health, or health administration school (look here, and its focus is on developing countries.)

Time to head to Bangkok?....  But if we all cannot... 

In the US, we will not have a chance of meaningfully improving our health care system until we start listening to unbiased health care professionals and academics (in particular, who have not been paid off by vested interests),  civil society organizations, and people and patients at large, and stop getting all our insight from corporate executives, their cronies, and their paid experts.  We will not have a chance until we allow discussion of all the problems, including bad leadership and governance, dishonest and deceptive practices, conflicts of interests, and outright crime and corruption.  We will not have a chance until we put our priority on patients' and the public's health, not the vested interests of those who have gotten rich off the current dysfunctional system. 



Anonymous said...

Amen.....I say....Amen.

Healthcarereforminsider said...

Thanks for sharing this, it's really interesting! Always good to gain a higher perspective by looking at how other countries tackle their healthcare issues. Do you think that putting priority on patients' and public's health is good enough? I would assume that people "say" their priority is patient and public health at all levels of the healthcare system. People don't necessarily come outright and say that they have trouble with "vested interests". Are we better off focusing on innovation vs. trying to change the broken and dysfunctional system through good governance?

Roy M. Poses MD said...

Putting patients' and the public's health has to be the first priority. Obviously, it is a lot easier to state that as a mission than to do it, but at least it needs to be stated.

Clearly transparency about conflicts of interests is important, and honored now mainly in the breach.

Finally, innovation, of course, does not always lead to good outcomes. And stating one is for "innovation" is even easier than stating one is for putting patients' and the public's health first.

Anonymous said...

Did you know that any form of publicity about a medical error is a crime in Thailand?
Did you know that most of your (accurate and incisive) postings here at "Health Care Renewal", in Thailand would put you in prison?
What should this tell us about health care quality in Thailand?

Roy M. Poses MD said...

Anonymous of 24 May, at 1:37,

Very interesting.

I know that there are issues about free speech in Thailand, particularly regarding any discussion of the royal family. However, I have not heard of particular problems affecting health care.

Do you have any evidence to support your assertions?

I know this blog has Thai readers, and none of said anything like what you said, to my knowledge, up to now.

I also know I was in Thailand in 2009, and gave a talk there to an agency of the Ministry of Health entitled, "Health Care Ethics, and the Role of Vested Interests and Conflicts of Interest in Health Research." The talk certainly dealt with the sort of content we publish on Health Care Renewal. The audience seemed appreciative, and no one came close to suggesting it was risky to say such things.

Jenni said...

Health care discussions always strike a nerve in me. Several of my loved ones have illnesses that make it impossible for them to obtain reasonably priced healthcare. They are turned away time and time again it has shaped the way I view the issue. I hope progress can be made but it seems congress is driven to repeal obamacare. I appreciated the information about Thailand. It's important to analyze other country's health care systems. There needs to be a way to withdraw the greed of insurance companies.

Ren said...

I live in Canada and I glad about our free health care system. I am so grateful to live here.