Botika ng Barangay not in poorest places despite GMA’s claim

First of two parts

If a minimum wage earner were to be stricken with diarrhea, relief can come cheap from the Department of Health’s Botika ng Barangay outlets, where a 2-milligram capsule of generic loperamide would cost only P1.05.  

The Botika ng Barangay (Filipino for village drugstore) price is vastly lower than what loperamide costs in commercial drugstores—P4.10 a tablet for generic and P14 for branded.

Launched by President Gloria Arroyo in 2001, the Botika ng Barangay, or BnB, program is the answer to poor Filipinos’ need for cheap medicine. But here’s the catch: There is not a single Botika ng Barangay outlet in some of the country’s poorest provinces and towns where they are needed most.

As of January 2009, there were 12,341 outlets, a long way from the 427 in 2003. But the program covers only half of the country’s 42,000 barangay or villages and suffers from poor implementation and conflicting priorities from top to bottom. As a result, the Botika ng Barangay program has wasted scarce resources while denying health-care services to the poorest areas it was meant to serve.

One example is the Autonomous Region for Muslim Mindanao (ARMM) which, besides having the least number of hospitals and barangay health centers, has the fewest Botika ng Barangay outlets, numbering 78 as of January. All the Botika outlets in ARMM are in Maguindanao, leaving the provinces of Basilan, Sulu, Lanao del Sur and Tawi-Tawi without any Botika ng Barangay outlet.

Way short of claim

This is certainly a far cry from what President Gloria Arroyo boasted at the inauguration of the 11,000th Botika ng Barangay in Camp Bagong Diwa, Taguig, on April 11, 2008: “Kalat sa buong Pilipinas ang BnB . . . Ang masa ang pangunahing nakikinabang dito sa mas murang gamot na ipinagbibili [The Botika ng Barangay program is scattered throughout the country. The poor are main beneficiaries of the cheap drugs being sold].”

In fact, data released by the Health department’s Pharmaceutical Management Unit (PMU) 50 a month later revealed that the then seven-year-old program had not reached Lanao del Sur, Tawi-Tawi, Compostela Valley, Siquijor, Batanes, Marinduque and Sulu, which are among the country’s poorest provinces.

The 2007 Botika ng Barangay list also left out 15 out of the top 40 poorest towns in the country.

The country’s fourth poorest town is Tangkal, Lanao del Norte, where 86 percent of the population lives below the poverty line, according to the 2003 data—the latest—from the National Statistical and Coordination Board.

A midwife mans the town’s solitary health station. A doctor visits only thrice a week due to travel difficulties. Villagers travel to neighboring Kolambugan town for hospitalization and other health services, as the health center is in need of repair. Both Tangkal and Kolambuham do not have Botika ng Barangay outlets offering cheap remedies.

Still inaccessible

This situation “runs counter to the goal of improving equity with regard accessibility,” said former Health Secretary Carmencita Reodica, who headed the first Botika ng Barangay prototype during the 1980s and made it her priority project when she became Health secretary in 1996.

The program, added former Health Secretary Jaime Galvez Tan, “falls below expectations [because] it’s not really reaching the poorest.” The problem, he said, is that “health interventions gravitate [to] where it is easiest to be implemented . . . Alam naman ng gobyerno ‘yan [The government knows about the problem with access to drugs].”

But the Health department’s Central Office does not have a direct hand in setting up Botika ng Barangay outlets, said Health Undersecretary Alexander Padilla and project executive officer of PMU 50. If there are no Botika ng Barangay stores in the poorest places, he said, it is the Health department’s regional centers for health development or community organizations and local government units that are responsible, since Botika ng Barangay outlets are set up on their initiative.

Minimum market size

A barangay has to have a population of at least 15,000 plus local government and community support before such a Botika ng Barangay could be set up there, said Botika coordinator in Central Luzon Marilu Malamug. The Department of Health then offers seed capital in the form of P25,000 worth of medicines. 

By next year, when President Arroyo leaves office, the Health department aims to establish 15,000 Botika ng Barangay outlets to benefit close to 21 million Filipinos. Padilla said the Health department is “right on track” since it has only 3,000 more to go to reach the target.

But equity in health could never be achieved if only a quarter of the country’s 80 million population would benefit from the program, said Marlene Bermejo of the Health Action Information Network (HAIN), a private organization conducting research on government health programs and services.

“Despite all of these efforts, there are only 18,000 barangays with botikas,” said Tan, referring to the Botika ng Barangay and the Botika ng Bayan, which is solely managed by the Philippine International Trading Corp. (PITC). It is the mother company of the PITC Pharma Inc., which procures drugs for the Botika ng Barangay program.

Not enough drugs

But even in communities with Botika ng Barangay, residents cannot turn to these drugstores for help for serious illnesses, such as malaria, influenza and tuberculosis, the leading causes of mortality and morbidity in the country. The Botika ng Barangay also does not have medicines for filariasis and schistosomiasis, two of the leading diseases in some poor communities in the Philippines.

Medicines sold in Botika ng Barangay drugstores consist mostly of over-the-counter drugs for minor illnesses, such as diarrhea, dehydration, stomach acidity, coughs and dizziness. When the program started in 2001, only two prescription drugs for bacterial infections were dispensed—cotrimaxole and amoxicillin.

It was only in 2005 when five prescribed drugs for three of the leading mortality diseases were included in the Botika ng Barangay inventory: metformin and glibenclamide for diabetes, metropolol and captropil for diseases of the heart, and salbutamol for respiratory ailments. 

“We do not [address] malaria, tuberculosis and AIDS in the BnB. We can only use so much resources,” Padilla said. He added that the Health department refuses to allow Botika ng Barangay outlets to carry medications for tuberculosis, currently the sixth-leading cause of death in the country, because “we don’t want people to start curing themselves.” 

Filipinos in need of medication for these diseases have to turn to private retailers, which offer a variety of more expensive, branded medicines they badly need, said Bermejo.                

A regional Botika ng Barangay coordinator, who requested anonymity, disclosed that some operators who procure their own stock sell some prescription drugs strictly prohibited by the Health department.

Customers’ needs

In 2006, the Commission on Audit discovered that several Botika ng Barangay outlets in Caraga and Metro Manila sold unauthorized medicines. Caraga operators disclosed that they were buying Alaxan and Ambroxol, among others, because these were demanded by patients who suffer from bronchitis, the leading disease in the region. 

Former Health Secretaries Reodica, Tan and Manuel Dayrit admit that under their administrations, the Botika ng Barangay outlets did not really address many diseases. “Yes, these problems existed in the past and continue to exist today,” said Dayrit, who headed the program in its early years in 2001 until 2005.

Tan had studied the type of medications available at community drugstores in his book Health in the Hands of the People. Referring to the Botika ng Barangay’s predecessor, the Marcos-era Botika sa Barangay, Tan wrote, “[They] sold anti-diarrheal drugs instead of promoting rehydration therapy or herbal medicines.”  Tan advocates tailor-fitting a Botika ng Barangay’s inventory to the diseases in a community where there are no doctors.

In the town of Pakil, Laguna, Botika ng Barangay outlets usually experienced stock shortages because the medicine supply does not match the demand of the community, according to a 2007 University of the Philippines Public Health study. Cotrimoxazole and amoxicillin, two main antibiotics needed in the town, were usually unavailable at the 11 outlets studied.

Pakil is not an isolated case. State auditors recorded that more than P1.5 million worth of Botika ng Barangay drugs had already expired between 2005 and 2007 nationwide because of procurement of “unsaleable” and the least requested drugs.

Reodica attributes the wastage of government resources to the weak logistics of the Health department regional units and the poor inventory and management of Botika ng Barangay operators. Alice Laguindanum, staff of the PMU 50, said it is not the Health department’s “problem” anymore once the drug packages are in the control of its regional units.

Lack of manpower

Part of the management problems in the Botika ng Barangay program is the lack of manpower. Only a supervising pharmacist is authorized to dispense prescription drugs in the Botika ng Barangay, according to a Health department administrative order issued in 2005. The Pharmacy Law, meanwhile, requires that a drugstore should have at least one pharmacist.

The World Health Organization (WHO) said in 2004 that only that one pharmacist looks after the medicinal needs of every 1,664 Filipinos. The ratio has most likely worsened, as more pharmacists are being lured by better pay and working conditions abroad, said Bermejo.

The nationwide ratio shows that 33 Botika ng Barangay outlets are assigned for every supervising pharmacist. In 2007, only 371 pharmacists or food and drug regulatory officers were supervising the 10,279 Botika ng Barangay outlets as well as other public and private drugstores. An independent monitoring done by Health Action Information Network in 2006, meanwhile, showed that each food and drug regulatory officers was assigned to regulate 212 public and private drugstores.

The shortage of pharmacists has hindered the establishment of Botika ng Barangay outlets in hard-to-reach areas like those in Region 12, which is composed of the Cotabato provinces, Cotabato City, General Santos City, Sarangani and Sultan Kudarat. “There are only few outlets [in remote locations] because pharmacists are not interested to supervise in far-flung areas,” said Lilia Milanes, the food and drug regulatory officers in Region 12.

During her term in the 1990s, Reodica looked for an alternative, setting up Botika ng Barangay’s near district hospitals and placed them under the supervision of the district pharmacist. Without a pharmacist’s advice, consumers resort to self-medication, posing a threat to the rational use of drugs, she said.

Major problem

Padilla said the lack of pharmacists is not really considered a “major” problem, since sell mostly over-the-counter drugs and only seven prescription drugs. “There are some functions that anyone can do, like dispensing a prescription drug,” he said.

But the Commission on Audit said the manpower problem has resulted in the expiration of prescription drugs in some regions. In Soccksargen, the commission said in its 2007 report, “more than half of the five prescription drugs sold at BnBs expired due to the non-availability of a supervising pharmacist who has the sole authority to dispense them.”

While the Bureau of Food and Drugs has so far never encountered cases of drug poisoning from the purchase of Botika ng Barangay drugs, Bermejo could not be certain that all drugs in all Botika outlets are safe, especially since hundreds of outlets sell drugs even without a special license to operate from the Bureau of Food and Drug. Also, bureau only has one testing center based in Muntinlupa City. This means all tests must be done in Metro Manila.

Padilla said the problems reported by the Audit commission have been addressed. “Wala na kaming nakikita na mga nag-eexpire ngayon ha [We have not come across expired drugs these days]. Kung meron man [If there are], not to the extent that huge government resources will be wasted,” he said.

It is now up to the local government units to deal with the “minor” problems of the Botika ng Barangay like licensing and monitoring, Padilla added.  He said the program, in the first place, is meant to engage the local governments in the delivery of health-care service.

“We don’t operate it [as if with] a remote control,” explained Padilla. The Health department central office, he said, is only in charge of training the operators, while local governments are the ones that can best assess the economic conditions of their area and the subsequent placement of Botika ng Barangay outlets.

Claiming that the program is disjointed from the overall delivery of health care service, Bermejo said: “Aside from its operational flaws, I feel that the framework in which the BnB is implemented is being overlooked.”        

Health spending down

Health spending experienced a steep drop under the Arroyo administration, forcing Filipinos to spend more for badly needed health services. In 2008, the total national government health spending of P253 per Filipino was 27.5 percent less than what was spent in 1997. Between 2000 and 2004, government spending on health fell from 41 percent to 30 percent of total spending, while out-of-pocket spending increased from 41 percent to 47 percent.

Meanwhile, community health worker Eleanor Jara could not forget a Botika ng Barangay outlet she saw in one of the poor provinces of Mindanao. She was with two representatives of the European Union studying the health situation of barrios ravaged by the ongoing war.

The Botika ng Barangay they came upon only had a single, small cabinet less than a meter high, containing very few medicines. At the time, no one was manning the drugstore. Confounded by the sight of the BnB outlet, the EU [European Union] representatives asked Jara, “What is this thing?”

“It’s [President] Arroyo’s BnB program,” she said.

To be concluded

(Editor’s note: The authors are senior journalism students of the University of the Philippines. This two-part report is an abridged version of their thesis, which was done under the supervision of UP journalism professor and VERA Files trustee Yvonne Chua.) –Jan Marcel Ragaza And Alliage Morales Vera Files, Manila Times