University for me was a chance to start again, to be that adventurous individual my younger self hoped I could be. I know that after graduating I wouldn’t have the same chance as I would have had during university to explore and learn simultaneously and therefore, every summer I hope to learn, not just about healthcare, but about culture, language, art. I want to grow.

This is summer N^o1, and this is a blog detailing my three weeks at a hospital in Iloilo in the Philippines.

I thought I’d have been more nervous considering that this was to be my first international flight, and that I would be flying by myself. There were no queues at Manchester and I was checked in and parted with my bumblebee yellow suitcase quickly. We had a slight delay before take off which worried me as I had only a short layover at Doha. I had a row of seats to myself and so you would have thought that as it was an overnight flight I would have taken the chance to sleep. But no, my brain refuses to sleep while travelling so for most of the 8 hour flight I was in a circular state of state of slowly nodding off before my brain sent alarm bells ringing and I was then suddenly awake. Even though I didn’t sleep I had a lovely flight and didn’t realize why people despised long-haul flights so much.

Let me just give you some advice, you need at least two hours of a layoverif you have a connecting flight. The plane landed and I had managed to conceal myself among first class passengers and so got the first shuttle from the plane to the terminal. There was someone waiting with placard to direct me to the transfers desk. Impatiently waited to get through security and then asked someone which gate I was supposed to be. The reply? You need to run to the gate…they just announced the last call for passengers. I had to run…actually runthrough Doha airport and only just managed to get on my next flight to Manila.

This 10 hour flight made me realize why people hated long-haul. Some guy had stolen my window seat and so I was squished in the middle seat unable to stretch my legs or sit cross legged.  It was a NIGHTMARE.

 – If you have the time and money I would recommend breaking up the long haul flight so you can spend a few days somewhere extraordinary and explore.

I arrived in Manila and had a few hours to spare before my last flight to Iloilo. You can either take a shuttle bus (which is free but comes at irregular times during the night) or take a taxi to change terminals. I took the shuttle bus and it was lucky that I did. When I arrived at the Work The World house they explained that a student had paid 5000 pesos for a taxi to change terminals – it should have been a maximum of 500! If you do take a taxi, ask them to put the meter thing on, and if they refuse, don’t get in.

Sunday 23/06/2019

Last time I slept was Thursday night in the UK. Its now Sunday and I’m finally in the Philippines which is +8 GMT. The change in time zones, infrequent meal times, and anti-travel sickness tablets have messed my body up. My brain is of cotton and my GI system is wrecked – I’m either starving, constipated, or have eaten too much. I don’t even know. My stomach kills.

I arrived Iloilo in the early morning at 7am and it’s 29 degrees here. I was greeted at the airport by one of the main WTW house staff and we took a taxi to the house where I was given breakfast and a quick tour. One of the things that I noticed while in the taxi was how different the infrastructure was compared to the UK – they had brand new modern buildings right next to homes of rusty corrugated iron sheets.

I had a small nap but then stayed up until late to avoid jet lag. Breakfast is served at 6am on weekdays and supper at 6:30. I shared a room with 5 other girls and we were lucky that they had just installed air conditioning in. Bunks are covered in mosquito nets and the bathroom is spacious. We were the only room on that floor of the house and so had a lounge area outside it basically to ourselves which had a couple of sofas.

Monday

I miss the quietness of home. A house nearby was playing loud music when I managed to fall asleep and it was still on when I woke up. Also, effing birds I’m telling you, do they actually sleep? Shrieking throughout the night. One guy said that he was ready to roast the cockerel that kept waking him up at ungodly hours.

7:30 start where they took us newbies on a Jeepney to the hospital for an introductory presentation and tour. We were then back on a Jeepney and toured some local sights such as a church, a tourist shop, a small museum of the history of Iloilo, and the Department of Tourism to get information on where to visit during the weekends. During our Jeepney ride one of the staff stopped at a street food stall and bought us all one of these, well, I’m not quite sure what they were. They were a 

sort of mix between pancakes and Welsh cakes with a little cheese for filling.They were delicious. 

We then had Philippino food at a restaurant where they take all the newbies each week and we were not disappointed. Mango smoothies become the obsession of the WTW students and I tried things such as crispy aubergine. For someone who is quite fussy it’s absolutely lovely and there is something for everyone. Garlic rice was a group favourite.

Tuesday 

This was my first day of placement at the pharmacy and I was allowed to decide on my schedule for the next three weeks. Unlike medicine or nursing where you must complete at least one week in each department, in pharmacy you can choose just do one day in an area. This is both a blessing and a cause for headaches – you are exposed to multiple departments within a short space of time (yey!) but if you’re like me and want to know everything about everything it means that the planned ‘crash course in hospital pharmacy’ was about to get a little more intensive (not yey).

• Most of the pharmacy team are actually pharmacists with very few technicians.
• Most of the drugs dispensed here are ampules and vials.
• Daily prescriptions are dispensed – in the Philippines if an inpatient needs medication they must take a prescription (which has meds which will cover the next 24 hours) to the pharmacy to receive it. Only emergency drugs are given in the wards. There are advantages to daily prescriptions such as less waste but it does seem very time consuming to dispense items such as antihypertensive drugs daily – drugs that they will need for years instead just a few days.

CDs are kept in locked drawers instead of safes that are used in community and I was astounded by the fact that in the PHP Diazepam 5mg is classified as a controlled drug! In the UK it is a community fast mover!

To understand the health system I’ve read a few documents published by the Department of Health. Here are a few things that I’ve learned:

They don’t mess around when it comes to objectives – they aim high. A little too high maybe. One document states that one of their visions is that ‘Filipinos are among the healthiest people in Southeast Asia by 2022, and Asia by 2040’ (1). From what I have seen, if they manage this, it will be a miracle. Access to healthcare is a problem due to (a) a high proportion of out-of-pocket spending in healthcare, and (b) getting HCP to remote areas.

Out-of-pocket spending has contributed to over half of the current health expenditure of the Philippines, and the largest component of this way of financing was from the poorest individuals. This statistic is quite a…confusing one. The introduction of a ‘Sin Tax’ in 2012 meant that in only one year $1.2 billion was raised and split 80% to PhilHealth and 20% to the DOH. All this money should have been reflected in reducing the OOP expenditure but the value has barely decreased. 49.7% of the OOP financing was spent on medicines (2) which led to the implementation of the Generics Act and the Cheaper Medicines Act.

The high OOP spending posed a financial risk for already impoverished families and was tackled through the introduction of schemes such as ‘No Balance Billing’ (NBB). This scheme prevents hospitals from charging patients anything above what will be reimbursed by PhilHealth (2).  However, there are criteria that need to be met to be eligible for NBB – patients must have no means of income or an income which is insufficient to care for a family, if they are a sponsored patient, domestic workers, or senior citizens (3).

In 2016/17, the NHS cost £144.3bn (4), alcohol duties raised £11.6bn (5) and tobacco £9.1bn (6). The soft drinks levy is expected to raise £240 million – which is both good and bad in a health expenditure point of view (7), good as it caused 50% of manufacturers to reduce the sugar content of affected drinks, but this reduces the money received. However, if the UK were to propose a more widespread sugar tax which would include processed foods and sweets, how much would it raise andcould it be the future of NHS funding?

Access to healthcare is being tackled by deployment programs such as Doctors to the Barrios Program (DTTBP), Nurse Deployment Projects (NDP) and Rural Health Midwives Placement Program (RHMPP).

            In 1998, DTTB was launched by the DOH to try to redistribute healthcare so that it would benefit the rural population. Doctors would be sent for a period of two years to areas and afterwards they had the choice to stay if the desired to. However, their absorption into local area meant they they would receive less salary compared to their urban counterparts, and could be a reason as to why only 18% of the cohort chooses to stay (8). Leonardia et al (2012) found that among the participants the most important factor when deciding whether to stay or not was whether they had support from the local government – e.g. for infrastructure and supplies. Out of those who stayed, many left stating reasons such as they wanted to be with family or they left for career development. We have a similar problem in North Wales – a lack of community pharmacists. Two of the busiest branches that I know of have no permanent pharmacist and rely on locums – some which travel from areas such as Manchester in England (taking them a few hours to get here) and this lack of stability affects the whole team – many locums are not qualified to offer services such as smoking cessation or MURs, and paper work is left uncompleted.

Wednesday

Uneventful day at the main dispensary but I did notice something that I wish we had within community pharmacy in the UK. On a patients’ medication record it will state the patients admitting diagnosis – as quite a few pharmacy students have part-time jobs within community pharmacies it would be a great way for students to begin connecting to dots between diseases and drugs.

We all finished early and went to Guimaras island. Its just across the water from Iloilo and we crossed on one of those boats that you think you’ll only see in Thailand or something, kind of like a wooden catamaran.

We got there and all five of us squished into a little trike to get to Alobijod Cove. It was cloudy but warm there and it wasn’t humid like in Iloilo so we swam and pretended as though we were in a photo shoot. On the way back we stopped at a place called Pit Stop and had mango pizza (not nice, not sure if I actually like mango) and mango spaghetti – the spaghetti itself is not made of mango as I had thought but its just a mango sauce which tasted similar to sweet and sour.

Thursday & Friday

I was assigned to the Malasakit section of the main dispensary. I had no idea what Malasakit was and the main pharmacist of that section was more than happy to give a detailed explanation of what it was and the role of the pharmacy in the program. She was brilliant.  

The Malasakit section patients are usually from the outpatient clinic and they bring their prescription to the counter where the pharmacist will price the items. In the UK, the drug tariff is online but here they just print off a copy each month that has all the medications they have in stock. The patients/family members then go to the Malasakit center, bring back the prescription where they make a charge slip, dispense and release the medication. For inpatients, they give 24 hours worth of medication while for outpatients it’s 30 days.

• Does visiting the outpatient doctors improve medication adherence? 
• Does the PHP have GPs or just outpatient clinics?
• Botika ng Barangay vs pharmacy.
• Services offered by community pharmacists.

As you can see, I have a few unanswered questions and the internet is not always the best place to learn about culture. If you are planning on going to Iloilo and are interested in everything as I am, you could try get some experience within a community pharmacy. There are three pharmacies lined up opposite to the hospital entrance so I don’t think it would be too difficult.

She showed me booklet which had a tally of all the medications they dispensed and explains what each of the Malasakit fast movers were used for. One item that stood out was the rabies vaccine. Before going to the PHP my knowledge of rabies was probably the same as the general public – if you get bitten by an animal, go to the GP to get a shot or otherwise you might start foaming at the mouth.

Most were post-exposure prophylaxis and this item was a Malasakit fast mover – hence why they had an entire fridge dedicated to the vaccine!

The continuous augmentation of Animal Bite Treatment Centers (ABTCs) has led to the steady decline of human rabies cases from 455 in 1998 (10) to 150 in 2018 (11). The rate of infection has also decreased – the number of bites have increased but cases have decreased, which means that the centers have been able grant more of the population access to treatment.

• Animal Bite Pharmacological Treatment

PRE-EXPOSURE PROPHYLAXIS (PrEP) – as 51% of animal bites occur in children under 15 (9) the Philippines vaccinate all school children living in endemic areas.

RABIES IMMUNOGLOBULIN (RIG) is injected into and around the wound and so acts quickly to neutralize the viral antigens there.  It is made from components of human blood plasma – plasma is not collected in the UK due to the blood transmitted CJD that occurred in the late 90s and so is imported.

’What is Creutzfeldt-Jakob disease?

Immunoglobulins are in a worldwide shortage from what I gather but in the Philippines the use of both the RIG and vaccine is more common than just the vaccine itself with 17.2% of bites treated with only the vaccine, but 72.9% with the vaccine in addition to ERIG (9) – ERIG is the equine derivative.

POST-EXPOSURE PROPHYLAXIS (PEP) is given intramuscularly to the upper arm or into the thigh for younger children. The problem with vaccinations is that require more than one dose – non-immunized individuals will require four doses, and so completion rate is low at 59% in 2017 (9). This is strange as as of 2016, the government funds all doses of the vaccine and of the one RIG dose. Economic effect of non-completion of rabies vaccine?

Reading recommendation’The Green Book, chapter 27: Rabies.

• What is being done to reduce the number of bites?

Anti-Rabies Act of 2007 led to ’mass vaccination of dogs, database of registered & vaccinated dogs, impounding of stray dogs, education campaigns, and the provision of free PrEP to school children in high incidence areas.

The majority of Malasakit fast movers were related to cardiovascular issues e.g. amlodipine and captopril for hypertension, atorvastatin for hyperlipidaemia, clopidogrel for the prevention of atherothrombotic events. This pattern of dispensed drugs is reflected in the country’s leading causes of morbidity (#2 = hypertension) and mortality (#1 = ischaemic heart disease) (1).

The hospital relies heavily on old fashioned paper documenting which can make it feel as though you are in an office and not a pharmacy at times. Pharmacists usually spend most of the afternoon updating the pharmacy record to that it matches the ward record. The hospital is currently updating and expanding in order to accommodate the large intake of patients. However, if they were to invest in a centralized electronic system I believe it would change the status of pharmacists from secretaries to clinicians and allow them to fulfill their role and improve patient outcomes.

Thursday

Thursday is BBQ night at the WTW house. Their BBQ is suprisingly different to the UK and is so much better. Crispy shrimp will now be a requirement on every BBQ menu in our house.

On karaoke night, beware of individuals who will put all star by smash mouth on repeat and sing the ‘and they don’t stop coming’ remix. I mean its funny but gets annoying the third time round.

One of the external doors of the pharmacy has a poster raising awareness of counterfeit drugs. WHO found that 10% of drugs in low and middle income countries are falsified (12), and the Pharmaceutical Security Institute found that 193 of 673 pharmaceutical crime incidents occurred in the Philippines (13). The majority of sources originated from Pakistan – why? However, the poster isn’t just something that warns patients of some far away danger that occurs to a minority of individuals – falsified OTC drugs are being locally manufactured.

• Labels are not printed and applied to drug boxes as they are in the UK which means that pharmacists trust patients to decipher and understand the doctor’s orders. This trust is a stark difference between the culture in the UK – why is medication culture different? Is there more respect for HCP there or do they just care more about their health?

Weekend- I visited the Iloilo Museum of Contemporary Art which was an experience that pleasantly surprised me. ‘Modern’ art is not usually to my taste but the paintings and sculptures interested me.  One of my favourites was a sculpture by Daniel Dela Cruz titled Off With Her Headwhich was a depiction of a scene from Alice’s Adventures in Wonderland.

I had lunch at Nicolette which is this really cute bakery and cafe at SM city. They had a counter full of bread and pastries and they had this amazing idea where they had unbaked filled rolls on display, which meant that you could wait a bit and have them fresh and warm. Lovely and unbelievably cute.

Week one down, two more to go. I hope you found it interesting and please read my next post for the second part of my trip.

• Department of health. National Objectives for Health. Philippines 2017-2022. 2018 [accessed 20/07/2019]
• Oberman K, Jowett M, Kwon S.  The role of National Health Insurance for achieving UHC in the Philippines : a mixed method of analysis. Global Health Action. 2018; 11(1)
• Philippine Health Insurance Corporation. PhilHealth Circular 2017-0006. Strengthening the Implementation of the No Blanace Billing Policy (Revision 1) 2017 [accessed 20/07/2019]
• House of commons Library.  NHS funding and expenditure. 2017 [accessed 01/08/2019]. Available from:
• Office for Budget Responsibility.  Alcohol duties. London: Office for Budget Responsibility; date unknown [updated 01/08/2016]. Available from: https://obr.uk/forecasts-in-depth/tax-by-tax-spend-by-spend/alcohol-duties/
• Office for Budget Responsibility. Tobacco duties. London: Office for Budget Responsibility; date unknown [updated 07/05/2019]. Available from:  https://obr.uk/forecasts-in-depth/tax-by-tax-spend-by-spend/tobacco-duties/
• HM Treasury. Soft drinks Industry Levy comes into effect. 2018 [accessed 01/08/2019] Available from:
• Leonardia J, Prytherch H, Ronquillo K, Nodora R, Ruppel A. Assessment of factors influencing retention in the Philippine National Rural physical Deploymet Program. BMC Health Serv Res. 2012; 12: 411. doi: https://doi.org/10.1186/1472-6963-12-411
• Quiambao B. Perspectives on Rabies mAb Development: Example from Academic experience. US FDA Workshop on Rabies mAb July 17, 2017; Maryland.
• Health Intelligence Service. Field Health Service Information System : Annual 1998. Manila: Department of Health.
• Epidemiology Bureau. Field Health Services Information System : Annual Report 2018. Manila : Department of Health.
• World Health Organisation. Substandard and falsified medical products.. Geneva: World Health Organisation; 2018 [accessed 09/08/2019].  Available from: https://www.who.int/news-room/fact-sheets/detail/substandard-and-falsified-medical-products
• UNODC. Transnational Organized Crime in Southeast Asia: Evolution, Growth and Impact. Vienna: United Nations Office on Drugs and Crime;2019 [accessed 09/08/2019].