Time Sarawak has Health Services Management School

NEED FOR SETTING UP SCHOOL OF HEALTH SERVICES PLANNING AND MANAGEMENT IN SARAWAK.

Dr. Francis H. H. Ngu, , M.B.,B.S.(Malaya), M.H.P.(UNSW)

AUG.2009.

“--- in an advanced nation as we aspire to be, there should not only be expensive top end medical technologies and services available for the elite few, but there should also be accessible and equitably distributed medical care –“

“A Keadilan government, genuine about human capital development, will positively engage with the medical and allied professional stakeholders, and health related NGO reps, in medical services development; we maintain that getting competent professional advice in public decision making will reduce the chance of large scale public policy and project failures.” YB Dominique Ng, ADUN Padungan, extract of speech in DUN.

SUMMARY:

In the general context of high complexity and rising national health care costs, Sabah and Sarawak will need a large injection of public sector funding for new facilities and upgrades to achieve a “catch-up growth”. The disparity of service provision between E. and Peninsular Malaysia, and the growing accessibility problem following Privatisation Policy, aggravated in face of a stalled economy, need to be addressed by government. The public interests in medical care in Sarawak has been largely canvassed by a single political party, but in the last 2 years receiving some limited bipartisan support.

Devolvement and decentralization as part of needed structural reform was stated, (but left to future discussion).

In anticipation of the needs outlined, the implementing capacity of government must be beefed up quickly by training a body of health services planning and management professionals of multi-professional backgrounds. It is suggested that such a school be set up, at relatively low cost, to benefit the State and nation. The new HSM profession will help better inform political leaders and the wider community in the much needed dialogue on health care and social welfare issues in the decades to come.

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That no nation has it absolutely right attests to the complexity of providing health care services to nation states. USA spends double digits of its GDP on Health, but has been struggling with reforms even as you read this, as Obama tries to provide universal coverage for a large section of the lower socio-economic groups left out under market mechanisms. UK has its well established NHS, very tightly rationed, partly through GPs as controlling “gatekeepers.” Australia provides high quality universal coverage to its citizens at high costs, but not without funding constraints and deficiencies in practitioner

supply to rural and remote areas. The “socialist market economics” which power the rest of the Chinese economy, has left the greater part of the population not covered to receive affordable medical care.

Medical care is human resource and technology intensive, subject to great flux in a social-political environment undergoing ever more rapid change. The multi-disciplinary high-knowledge personnel teams have to be optimally engaged to deliver patient-care individual and community outcomes.

Health services delivery, based on whichever international models, has proven to constitute an increasingly larger part of the GDP. In Malaysia the public and private combined outlay of just under 4% of GDP is relatively low compared to some western nations. However domestic political and health care policy re-orientation in Malaysia may see the share by Health in the public sector jump by 50-100% in the medium term. The increased supply of Medical graduates at around 3000 a year nationally, will further create its own demands and in its wake, rising national health care costs, a sequel predictable by health care economics.

The health care needs and deficits of Sabah and Sarawak are quite staggering, as we have outlined in “Time to review medical care services in Sarawak”, which we went to press in April, 2008 and which we canvassed again in August 2008 (1):

“-----reiterating the following proposals:

1. Sibu, Miri and later Bintulu should be upgraded to Regional Referral Hospital status, providing a wider range specialist and sub-specialist services in 5-10 years, such as psychiatry ,cancer, cardiology, nephrology, urology, burns among others.
2. A few other divisional hospitals need to be upgraded to general hospitals with 5-6 basic specialist services, as expressed initially by Parti Keadilan Rakyat and later the BN MPs of Sarikei, Limbang and Kapit. The Sri Aman, Lubok Antu and Saribas population has also long been underserved.
3. State Government, Federal and Education Ministries must urgently and jointly address health services manpower issues, in view of the enormous upgrading of health services due to the people of Sarawak.
4. Attention should be paid to health services planning and management training to policy level, necessitated by a newly arising scenario of bipartisan recognition of the need to address severe medical care services deficiency.
5. There needs to be a systematic devolvement of decision making authority and responsibilities from central government to state government if the medical care needs of Sarawak were to be met in the decades ahead.”

“Parti Keadilan leaders in Kuching had during the 2006 State general elections campaign, called for the building of 3 standard polyclinics and 3 general hospitals around the growing Kuching metropolis within the next 10 years or so. They are to serve residents of Petra Jaya-Santubong, Pending-Samarahan-Asajaya and Batu Kawa-Padawan-Mambong respectively. Planning should start soonest—“ (1)

It is evidently clear that the medical care agenda is so massive that even if the present MOH planning and management machinery were to move entirely from KL to Kuching, it can barely cope with the needs of Sarawak, not to mention Sabah as well. Even the proposed second hospital for Kuching, whether new or converted from SIMC, will prove an enormous stress to the manpower capacity of the Ministry for the subsequent 3-5 years. (2)

Catch-up growth in the public health sector is mandated by both the disparity of development between Peninsular and E. Malaysia, and also by a large hiatus due to sharply reduced public sector health care infrastructural development as a result of the wider government Privatisation policy of the Mahathir era.

Large scale privatization of medical care replacing public sector financing is hazardous politically even with a highly robust and broad middle class economy; the ills are becoming increasingly apparent for a nation facing economic stagnation since the Asian Crises of 1997, increased income and social inequality and a drop in real disposable incomes as a result of world-wide inflation. Private and individual financing for medical care is feasible for some 20% of Malaysians nationwide, but even less for Sabah and Sarawak. Holding back public sector funding will prove more and more politically untenable for government. Sooner rather than later, this has to be a bipartisan recognition of the political realities of Health Care.

To meet the health service planning and management demands of the needed catch-up growth, the 2 East Malaysian states, with also the highest population growth among the states, must urgently develop their full health services planning and management competencies, this reasonably achievable within 5 years.

The jury may still be out on whether health care is economically productive, but to leave the planning and management of health care without the contribution from the disciplines of public policy, health economics, accountancy, general and business management, health and social statistics, engineering, architecture and design among others, would be irresponsible and even catastrophic. The current Sarawak International Medical Centre fiasco is a case in point.

The health services planning and management field (H.P./ H.S.M.) attempts to forge a multi-disciplinary approach to the optimal delivery of modern health care, including public health and epidemiology, social science, economics and accountancy, general management, demography, law and ethics, media and communications, research science among others, and aided by IT. Major fields of learning and related professions provide a facilitatory and enabling structural and management framework for the medical, nursing and allied professionals to apply best practice evidence-based medicine to patient care. Some of our finest professionals should be called to contribute to health care, which is challenging us with advancing new technology, rapidly rising costs and difficult bioethical issues.

The health service management professional may be trained through a diploma course or as a primary degree undergraduate course, or be drawn from other established professions like medicine, nursing, public administration, economics and management through a (post)graduate programme. Accreditation as a HSM professional would follow training specified by a profesional accreditation agency. Italics (2).

Malaysian central planning and educational authorities are lagging in awareness of the field of health services management (HSM). Limited exposure to planning and management is provided in the Master of Public Health programmes at local universities, rightly reflecting the over-riding importance of tropical communicable diseases before morbidity from lifestyle changes and the explosion of medical technology set in.

A couple of medical officers are sent overseas to do Dip. Hospital Administration or graduate H.P./HSM programmes annually. Their subsequent input into the health system is however curtailed by structural arrangements.

On return, they are appointed either as Hospital Directors or as officers in the Planning Department of the Ministry of Health in Kuala Lumpur. The Planning Department is however a misnomer, for it does not deal with the whole range of national health policy, structural issues, health service financing or holistic planning, but rather it engages in newly approved physical facilities and their design; even this, it is deficient in the post-commissioning evaluative phase processes which are invaluable in influencing subsequent physical projects.

Sarawak would make a national contribution if it were to start a School of Health Services Management, at Diploma, undergraduate and graduate levels in conjunction with reputable overseas partners, as are found at a couple of Australian universities.

The cost of setting up is rather minimal, as only small lecture rooms and tutorial rooms are needed, and much academic material may be sourced online. The greater operational costs relate to academic staffing and resource library. However a small to modest annual outlay of around RM$10 million is needed initially. The sum pales in comparison to the RM$350 million spent on the Sarawak International Medical Centre project, a giant fiasco which would have been wholly avoidable had the protagonists been exposed to proper professional HP/HSM advice.

The financial investment is small, but the returns to health care management and health sector efficiency and effectiveness would be enormous. HP and HSM training must proceed, notwithstanding the health care model adopted. It may be crucial to the long-term success of inevitable health care structural reform for Sarawak and Malaysia in future; it would greatly help the further development of both the public and the private health care sectors, including future health tourism ambitions as part of the services economy. Professionalism will be greatly enhanced at all levels from policy makers at national and state levels to middle rung managers of hospitals, large polyclinics, and local divisional and district health management. Italics (2)

There will be developed a common language to help bridge the communications gap between the medical and nursing professions with legislators, NGOs, political leaders, managers and administrators from other professions. Other professional fields engaged extensively with Health Care would also be duly benefited, these as the wider social spin-offs which are only partly tangible.

Certain basic principles will also be imparted to political leaders as reference points on which to base their political platforms in relation to health care policies. Among others, these relate to resource allocation issues, health services financing, evaluation of new technology, HRM in Health, quality assurance, etc.

A new core of HSM professionals will be borne to replace the only 3 Sarawak-borne doctors who benefited from such training, and all of whom have reached retirement age. There is need for a much larger group drawn from various professions, in addition to medical, who will articulate policy, needs, values, reforms, process and outcome issues,

and take a lead role in steering the health care delivery of Sarawak for the new century.

The emergence of a professional group will guide discussion of a range of health and social welfare issues and thus also help promote meaningful community participation and input into future health care and social welfare policies.

1 Ngu, F.H.H., ” Rational Medical Care Planning”, press-release Kuching, 7th Aug. 2008.

2. This author, in a discussion paper, unpublished, “A structural framework for DECENTRALISING MANAGEMENT OF HEALTH CARE SERVICES for SARAWAK.’