Kenneth Hartigan-Go, MD is the Acting Director General of the Food and Drug Administration of the Philippines, and was founding Executive Director of the Dr. Stephen Zuellig Center for Asian Business Transformation, where he is a non-resident research fellow, at the Asian Institute of Management.
Are you, like National Scientist Ernesto Domingo, a believer that universal health care is possible in the Philippines?
Yes, I believe that because there are models out there that have been successful. We can just follow or adopt. Business must moderate its greed for this to work.
Shouldn’t government, or a strong government, be the one to moderate its greed and moderate the greed of business? I mean capitalism is about greed.
I think if we are to rely solely on government, we are in trouble. I believe business is changing in that social responsibility is now part of the equation. The private sector has an unending capacity to renew itself and improve. Government is just there to implement rules, but my belief is government should not be too involved with intervening on the conduct of the private sector, but government must protect the public at large from unscrupulous groups that do not respect the rule of law. Self-regulation or voluntary compliance to sensible rules makes more sense for me. Government must, like in China, plan strategically with a generational perspective, rather than a one-year or five-year perspective. If you want a heavily interventional government, it becomes a top-heavy government, and you necessarily have to answer the question: where do you get the quality people to man all these positions in government?
Even so, assuming we have a non-interventional government, we still don’t have the people in government, right?
Well, we have to qualify what kind of people we want in government. We must attract people who are not just into crafting policy, because I think we have enough people who have the education and desire and skills to craft excellent policy. We don’t actually need more policy. We need people who actually want to implement programs, unafraid and unapologetic about continuing all the good programs of his or her predecessor. You will not trust a military general to command an army on the battlefield who has not implemented or experienced an actual battle plan. You cannot risk the lives of foot soldiers in his hands. It is the same with government agencies: appointments must be made on the basis of the implementation record or execution ability of the person who will enter a department or agency; you cannot just hire on the basis of brilliance, or even brilliance with policy.
There is some criticism that the current Department of Health may be too focused on medical equipment upgrades, rather than public health issues and policies.
To balance that off, people may be forgetting that in the area of health care, equipment is also not only necessary, but important in attracting medical doctors and nurses to stay in a poorly resourced area. There is obviously an over concentration of health workers in Metro Manila, and the efforts to upgrade medical equipment and facilities may actually be a good strategic plan of trying to balance the manpower concentration from metropolitan cities to far flung areas and improve clinical services. We also should not expect our doctors to want to be barefoot doctors. A tipping point of some sort is necessary in order to get people to want to relocate outside the centers like Manila and Cebu.
I read somewhere that you are excited about the 2014 UP medical students who are required to serve in the country for three years, why not hire from that pool of graduates?
I think you may be referring to the return service agreement of UP med graduates and actually 2014 is just the start of the program. They are not required to do service in the country: they are just required to stay in the country for the next three years and that is already interpreted as fulfilling the requirement for having studied in UP-PGH. Of course that opens many good and exciting possibilities for them and the country; but I also heard there are graduates who are also asking lawyers to look into the legality of the contract. I think the requirement is good and necessary, because taxpayers paid a lot to have them educated in the best medical school in the country; at the same time I also don’t want to overplay the possibilities, because the person can just stay in the country and take up ballet lessons, not practice medicine, and still that person has fulfilled the requirement already.
Is that enough for you, just staying in the country?
No, of course it is not enough. You took a slot from someone who may not be as academically gifted, but willing to serve in the rural areas, and we certainly prefer that student who is willing to stay in the Philippines to practice. The country spent a lot to get a student through medical school, the least he or she can do is actually put in service for three years, at the minimum.
Are you happy with Philhealth?
Yes, but our whole health policy is largely still curative, not preventive. We have to give more attention to preventive plans and mechanisms: hospitals should be the last part of the line of defense, or last part of the program. This is the reason there is optimism for private public partnerships, because it unburdens the government of some of the overhead and it can concentrate on other priorities and concerns.
On our part in Sunfu, we are skeptical about the private public partnerships because,for example in laboratory equipment, suddenly you have a capitalist entity inside a government hospital. Of course the push for the capitalist entity is to get the Return on Investment as early as possible, and we don’t want to be in a position where we will be tempted to push doctors and medtechs to keep using our laboratory equipment even if unnecessary or disadvantageous to the patient. The temptation to corrupt people will be high for a private entity that has a lot of investments inside a public health facility.
Okay, yes: but we can’t continue doing things the way they were done before and expect good results. We need radical solutions, which the late Quasi Romualdez was looking for when he became secretary of health. We need to change fundamentals, we have to sell to people the idea that the good of society is always part of the equation, that it is good business. The problem really is we don’t call out people who are corrupt, but maybe that is where education fails. Maybe this is where government should give reasonable timetables for reasonable ROIs, in order to moderate, as I said, the greed of the private sector.
Our company tends to believe in strong government: although worldwide, even the founders of Google have said, the medical industry is over regulated, and as a result, many people, innovators, refuse to go into exploring businesses and innovations in the area of medicine and health care. Maybe education is the solution?
If you mean sending government people to institutions of higher learning, I have seen the government send out a lot of people to study, here and abroad. I think it is only half the solution. The whole environment just doesn’t support the technology and radical initiatives innovative and out-of-the-box people bring into government, so people just largely give up. We need street-smart implementers. This was the approach of the late Quasi Romualdez as secretary of health, he got young people, brought them to Baguio, and told them to craft a reform agenda. When we got back: he said implement it. I realize, now that I am older, the hope is really in the young, not us the old. In your interviews, you should be going after the young, not us the old. Maybe you want to interview the old for inspiration, but the game-changers and possible game-changers will come from the youth. For one, the young have the trait still of being embarrassed, and that is necessary and important for us to move forward. We also need horizontal implementations and coordination among our planners: we are very vertical in the way we plan. We need people who are able to do interagency planning for our country to become more efficient. We lack this skill very much. At the moment, we are also very reliant on donors.
How about clinical trials? Is this something we want to attract? This is big business.
This question requires a complicated answer. There is a big business and health potential, but we are wasting it because of over regulation and our lack of technical capacity. There are groups against clinical trials. But if you look at the history of science and medicine, from research to animal trials to human trials, it is a long and expensive process. There are a lot of bureaucratic hurdles. There are of course the fake clinical-trials, which is really a market seeding operation, where a company gets to pay a doctor for prescribing drugs in the guise of a trial, but is actually only a technique for companies to give money to the dispenser of drugs in order for that person in authority to prescribe and get into the habit of prescribing their drugs. At a stroke of the pen, we think we have largely stopped this. We have disallowed this by issuing some guidelines and definitions of what is a legitimate clinical trial. Many companies are thankful for this, because they are no longer forced to go into this, because their competitors have stopped the practice as well. This is a way of bringing down the prices of drugs.
Now there are the legitimate clinical trials. We hope to post them in our website, those that are approved clinical trials. Clinical trials can be a good and legitimate way for our country to earn revenue, but more importantly for me, indigent patients get a chance to use drugs that they do not have a chance to try if they are not part of the clinical trials for say AIDS or cancer. In a certain country with quite an advanced economy, there are hardly any patients who are pharmaceutically naïve, meaning people whose bodies have not yet been used for some kind of clinical trial. We have groups here in the Philippines who are angry that people are being used as guinea pigs, but medicine really has to eventually be tried on people: this is done all over the world, in Singapore, Thailand, the United States. Some countries have been taking advantage of this, except their population is so small, and many or most have gone through clinical trials already; so they tell us, we should take advantage of this opportunity. If we have clinical trials here, and the drug gets approved, the approval time will also be shorter and cheaper, because it already went through our process here, and this is another way to bring down the prices of drugs.
The main problem is ethics, not clinical trials: self-regulation, and then regulation of professional societies are very important and crucial. Medical organizations should take away membership privileges or fellowships of medical doctors who cross the line. The government should not be the first and last organization disciplining professionals, yet many want government to do the job for them.
How about manufacturing drugs: do we have hope in becoming a smaller version of say India?
We don’t have hope in manufacturing. In drugs, we do not manufacture, we just compound. We don’t have the volume and scale of India. We just don’t have it. We also don’t have the critical mass of scientists, medical researchers, and professional managers. Sorry to sound so negative, but it is the truth. Our hope is to take care of our plant and marine diversity, and focus our effort in research on these. There is potential there.
Where do you get the motivation or inspiration to get things moving in government?
Anger. Dr. Manuel Dayrit, who was a great secretary of health, said you have to be detached to survive government and to get things moving. That is one way, but detachment may make you lose the sense of urgency. Outrage is a good motivation: it gets things moving.
Who were the teachers in medical school who inspired you?
A lot. I am afraid of mentioning some names, as there are so many of them. Dr. Nelia Maramba. She is a first-class scientist, a well-read professional, and a very good teacher. There is the late secretary of health, Dr. Quasi Romualdez. Of course our National Scientist, Dr. Ernesto Domingo is a great inspiration. There are many more.
Why quit from government after just two years of service? Maybe you should stay longer.
I don’t believe you have to stay long in government to do reforms. I believe in going in and doing good work as fast and as efficiently as possible. I also believe in the Chinese saying that you have to create a vacuum for people to move up. I gave myself two years, and my two years are up this October. The secret is simple, just listen to what people say about us: it tends to be accurate, what people in industry objectively share about their experience with us. We listen, and we try to adjust and institute improvements in the system. There are many problems, but we are trying to put our house in order. We try to implement innovations, we are trying to cut down regulations, and we are trying to continue good programs from the past. There is a lack of trust that things can be implemented, that positive things can be done, and we try to have that atmosphere inside the agency. But we must allow good people to move up, allow young people to have the opportunity. Political appointees usually look at building monuments, rather than generational planning. Not staying too long in government is a way of developing leaders also.
What are you going to be when you leave government? Are you going back to being a toxicologist? A medical researcher? A professional manager? A policy advocate? An institution builder for the Asian Institute of Management?
Hard to answer: but I will find out and I will tell you when I am finally out of government.
What is exciting you in the many fields you are involved in?
Nothing. Sounds jaded, but none at the moment.
Please share with our readers three books or authors that you learned from and maybe we can learn from as well. It can be related to your field, like medical books, but it doesn’t have to be.
If as a doctor all you read are scientific books of your field, it is the end of you: doctors must read outside their field. Malcolm Gladwell’s series of books I like very much: I found them helpful in seeing the world through the lens of anthropology, of how certain behavior shapes our decisions. The Tipping Point is the most interesting among his series of explorations. Rudy Gulliani’s biography I enjoyed very much. It shows a framework of working within government. His actions as mayor of New York were sometimes controversial, but were shown to be quite strategic and long-term in thinking and consequence. He is confrontational, but he used numbers to prove his arguments and explain why he took a certain approach, and not another. Tom Clancy’s Jack Ryan books are good. I am interested not in the conspiracies he unravels per se, but I like his fictional take that there is something more to what you see, and the protagonist shows a way of looking at the world in a different way. Of course it is too good to be true, but the novel way of looking at a problem, instead of being carried away by media or some hysteria, is a good way of finding solutions. It is good to be reminded that things are not always what they appear to be. Among local writers, Francis Kong I find to be inspirational and at the same time practical. He gave a talk to FDA officers. He touched the hearts of our people. He made a lot of sense: society should teach our people financial literacy, that people must be taught that money doesn’t grow from trees, and that there is an ethical dimension involved in issues about work and money.