THE LOOMING MALAYSIAN HEALTH CARE DEBATE (PART 1.)

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

(This is written in the personal capacity of author, not necessarily reflective of the views of any organization or political party.
Writer has tried to balance, however imperfectly, public, political, health services planning and medical professional perspectives and interests, which are not always consonant with each other
.
Declaration of personal interests and possible bias : writer is the Head of the Health and Welfare Services Bureau, of Parti KeAdilan Rakyat in Sarawak.)

The recent announcement by the Minister of Health of a far-reaching reform for the nation, as the Health Care Financing System, is likely going to provoke a vigorous public policy debate, for which the following is an early warming up. This is a debate long overdue, a debate that should cut across all sections of Malaysian society.

THE CONTEXT :

The proposed healthcare reform takes place with the following being some of the major contexts relevant to the debate:

1. Historically, whether viewed from Malayan independence in 1957, or Malaysian Federation of 1963, the major structural Public Health Care Sector changes were the full federalisation of the Health Services of the States of Sabah and Sarawak within Malaysian Federal Health Ministry around 1970, proceeding into the 1980s, and, secondly, the general Privatisation Policy of the 1980s and 90s.

A major reform proposal by the Malaysian Medical Association for a National Health Commission since the 1970s, had been rejected repeatedly.

2. Malaysian government is constitutionally bound to shoulder the major part of providing health care for its citizens and funding thereof. Of further note, is the WHO Alma Mata Declaration which pledges Health Care for All by the Year 2000; Malaysia is a signatory nation.

3. The nation’s finances are under critical stress following the Asian Financial Crises of 1997 and the World Economic crises of 2008/9, other highly significant issues of National and State governance aside. The national debt is just above 50% of GDP, and the widening budget deficit of over 7%, of GDP which led to a Federal Government Minister warning that the nation may face Bankruptcy by 2019. Foreign Direct Investment has dropped to a historic low of below US $ 2 billion, with investment outflow more than twice the FDI inflow.

4. IN 2008, Malaysia spent about RM35 billion on healthcare, more than half of it in the private sector. The national healthcare expenditure represents slightly more than 4.7% of our GDP, with 2.2% coming from the public purse.

5. A dichotomy of Health Care, both in access and quality, has arisen and intensified, following Privatisation Policy, between those with access to high quality private care and those with full, partial or minimal access to public sector health care. This is reflective of the wider social dichotomy arising from income inequality that has increased steadily in Malaysian national life. The Gini co-efficient has risen over the years from around 0.40 to around 0.47.

6. The upper and middle middle classes are facing rising health care costs through expected higher private health insurance premiums and other own-pocket expenses, while the lower income groups and the poor face increasing rationing from congestion of and queuing for public sector service (this in spite of decanting to the private sector).

7. A serious dichotomy has arisen and intensified in the public sector health service
as well, with a much better developed tertiary and specialized services in the Klang Valley and a couple of other cities, and the laggard states of East Malaysia and elsewhere.

8. Malaysia remains a relatively low-wage, low-income economy wherein general world inflation and national inflationary factors impact on the expendable incomes of individuals and families. Public sector health care is thus an important part of what is a rather inadequate social safety net.

9. A Federal Coalition presiding over a highly centralized and long-lasting government, is fighting for electoral survival, in the face of mounting issues of governance, financial accountability and lagging economic growth.

10. An opportunity to learn from the cumulative experience of developed countries in health care over the decades, including a major over-haul in the British NHS currently; they provide an options looking glass for our own debate.

DESIRED PRINCIPLES OF RESPONSIBLE REFORMS:

In principle, any major healthcare reforms for the nation should be supported if they are based on all or most of the following, not necessarily ranked in order of importance:

1. Restating the core responsibility and major role of government in providing health care, or financing thereof; this holds for all responsible governments of developing and developed nations; a cardinal principle of governance should be the use of national wealth and income for material and social progress of citizens, including the appropriate provision of social welfare, of which health care is a major component.

2. The statement that a major goal of reforms is the universal, just and equitable access to health care, both across social (income) classes and diverse geographic regions ;

Health planning should be needs-based, to a large extent rational, and not overwhelmingly driven by political expediency.

3. A long term government pledge to steadily raise the government budgetary contribution from the current 2.2 % to around 4.5-5 % of GDP staggered over 10 years ; if the private sector expenditure were expected to rise to 2.5-3 % of GDP, it would increase national health care expenditure to around 7-8 % in 2021, from the current 4.7 %.

A budgetary commitment by government to healthcare is the essential measure of good and caring government, under-writing its constitutional role and ensuring progress in health care and social justice.

4. A firm government pledge to vastly improve both the scope and quality of service in the public sector as well as its geographical spread and rural reach; thus steadily reducing the dichotomy in quality of services provided by private and public sectors, and largely correcting the current imbalance of health care personnel vs. patients/population ratio;

5. Any new co-contribution by citizens should be take into account wages, real incomes, general inflation and poverty; the household threshold income defining poverty should be revised by cost of living realities, adjusted yearly or biannually
for inflation.

6. Establishment of a sound means-testing mechanism of eligibility of working age individuals and families for both free non-contributary health care and pharmaceutical benefits, as well as other social welfare benefits and subsidies;

7. A commitment to set up a comprehensive Pharmaceutical and Medical Supplies Benefits Scheme in around 2-3 years, so that medical practice which is evidenced based is better promoted;

8. Consolidating the unwieldy private health insurance sector, so that the number of insurance providers are reduced to 2 or 3 for efficiency, maintaining competitiveness and providing significantly better coverage for all age groups and all citizens, presence of morbidity irrespective;

9. Recognition that a sound public sector health care is the foundation of a progressive private health sector; health care tourism must compromise neither citizens’ health care needs, nor medical professionalism and ethics through over-zealous commercialization;

10. Appropriate integration of public and private care sectors, for fuller utilization of all resources of both sectors for better health outcomes of the public;

11. Consolidating the veritable achievements of Public Health (in relation to communicable diseases, maternal and child health, etc.), and emphasizing lifestyle health promotion through intensified inter-sectoral collaboration involving medical, educational, sports, media, legislative strategies, etc.

Primary and secondary prevention is where national health care cost containment would be truly achievable by government and the nation; it is at the same time beneficial to individuals and families;

12. Decentralising public sector health decision making to States and Health Care Regions, in particular the States of Sabah and Sarawak, which are sometimes not on the federal ministry radar screen sited at PutraJaya.

13. Increasing the pool of Health Services Planning and Management professionals in Malaysia, to provide a professional planning perspectives to future health care discourse which will feature more and more in Malaysia.

14. Urgent study on the optimal mix of health care personnel in view of a sudden enormous increase of trainee doctors, and the implications on training needs and standards as well as service hardware infrastructure.

15. Legislative, structural and educative response to develop a partnership of health care decision-making by government, professional providers and community (unions, employer bodies, health and welfare NGOs, health care clients). A participative structural framework must be the natural and just corollary to a co-contributary principle.

Indeed most of the above would need timely attention by any Malaysian government of the day, whether or not a co-contributary Health Care Financing System is put in place.

The above list is put forth as the core list of major policy considerations, though it is surely not exhaustive. There could be other large issues, especially about quality assurance for effectiveness and efficiency, practice safety, health information systems/IT, workforce issues/professional accreditation, traditional and complimentary health care, research and evaluation, etc.

These are subsets getting more and more technical, but will need exploration as well.


More instalments to come :
--
THE CASE FOR INCREASE IN GOVERNMENT HEALTH CARE EXPENDITURE..


INCOME THRESHOLD FOR CO-PAYMENT, QUANTUM, IMPACT.

INTEGRATION OF PUBLIC AND PRIVATE HEALTH CARE SECTORS

HEALTH CARE INSURANCE FUND (S)

THE PAUPER RESOURCE-RICH STATES OF SABAH AND SARAWAK

DEBATE ARISING ?