THE LOOMING MALAYSIAN HEALTHCARE DEBATE (PART 4)

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

MALAYSIAN NATIONAL HEALTH SERVICE ?
PUBLIC HEALTH CARE VS PRIVATE HEALTH CARE, CAN THE TWAIN MEET ?

From 1957 to the mid-1980s, public sector provided health care was over-whelmingly dominant, except for primary care, where GPs in towns take care of it virtually independent of Government.

The Privatisation Policy put forth in the mid-eighties has seen the steady growth of private hospitals; the private sector health sector now incurs slightly more than 50% of the national health care bill, or some 2.5 % of G.D.P.

With the growth of the private sector, the third party in health care has emerged in the form of many health care insurance parties.

The general practitioners who have so far practiced independently will be roped in by government to provide care for patients of government clinics, though much uncertainties of implementation remain.


PRIVATE HEALTH CARE

In a free market economy, there is a definite place for private care and private hospitals, but its limitations in providing health care for a nation must be well acknowledged.

Quite apart from the problem of affordability by the majority of citizens, health care can never be a commodity that fits in perfectly with free market. From the outset, the supply and demand basis of market does not work; in health care, experience has shown that supply creates demand in defiance of free market principles. The choice of consumers in the perfect market place is guided by free information flow and highly informed consumers; in healthcare, knowledge and information is tilted highly in favour of providers (medical profession, institutions). Few commodities in the market place command an emotive overweight as much as health care. Health care as a commodity, which left to pure market mechanisms, may completely overwhelm the financial means of the average individual and family.

Thus, even in developed and affluent countries, social mechanisms to fund health care have been intensified, this belatedly in USA, (and even in USA !), under Obama Presidency.

The Privatisation Policy in Malaysia did not reduce national health care cost, but merely transfer cost from the public to the private sector. Indeed, the higher standards of private settings, together with the liberal use of expensive modern technology and higher professional fees, drive up total health care cost of the nation. Not only are the hospital bills beyond the ability of 80% of the population to pay, health care insurance premiums will also prove intolerable to the majority, even the upper middle class families, as costs escalate.

The major ills of Privatisation have been well presented by various groups, notably Citizens’ Health Initiative and YB Dr. Michael Jeyakumar of the Socialist Party, and are acknowledged by writer for readers’ essential reference.


PUBLIC HEALTH CARE

Constitutional responsibilities aside, the State (government) will always have to assume the major continuing responsibility of providing health care for citizens. If a nation progresses reasonably well, it will mean shifting administrative mechanisms from straight forward government institutions (MOH) to some form of National Health Service, providing access for the whole population, and continually improving standards of care. The NHS put in place in “High Income economies” of developed nations in the last few decades have included a low co-payment from those who can comfortably afford.

MALAYSIAN NATIONAL HEALTH SERVICE ?

What the Malaysian Government has deferred for some two decades is a stated policy to put in place an NHS, which in time will be as good as any others. It has been detracted from an NHS by the Privatisation Policy, and even at this late stage is reluctant to refer to a “Malaysian National Health Service.”, perhaps for obvious ideological reasons. Thus instead of debating about the shape of and respective roles of stake-holders in the NHS-like proposals, we find ourselves in the tight corner debating medical co-contribution towards a Health Care Finance Plan which will essentially be the cornerstone of an NHS.

The apparent Policy ambivalence must first be resolved, and make no mistake, for an NHS to be an improvement of the pre-existing arrangements, government has to initially make a massive injection of funds into the health care sector, and not expect a slowed down budgetary contribution. A firm stated commitment of government in medium to long term in providing funding support for a Malaysian National Health Service is the major prerequisite to inspire confidence of all.

On the corollary, if it is not about setting up a National Health Service, tailored for Malaysia, the debate about Medical Co-contribution would be premature. Why should the public support co-contribution when it is not about an all round improved national health care system that provides universal and equitable access ?

An NHS for Malaysia will among others, have to be built upon:

1. Providing health care resources more equitably over all parts of Malaysia ( hence this writer’s series about Unmet Health Care Needs of Sarawak), otherwise the injustice from paying the same co-contribution and receiving much less or not at all !

2. The National Health Finance Fund will pay for all primary care (outpatients, family medicine) at GP clinics, with small co-payment for those who can afford (defined as per my Part 3 previously), and for specialist services via a GP/family medicine gate-keeping mechanism.

3. Comprehensive co-operation with GPs for primary care, and optimal cooperation between private specialists and government hospitals in cities and large towns, and private GPs and district hospitals in smaller towns.

4. Choice for the public to use private or public hospitals, with the Health Finance Fund making re-imbursement of a fraction of the fees incurred at a private hospital under a schedule of reimbursements.

5. A pharmaceutical and medical supplies benefit scheme .

6. A decision on whether it would be built on a fee-for- service or a capitation principle; or could there a world-first, in giving both providers and consumers a choice of either, through an A List of fee-for service and a B Scheme for capitation grants, cognizant of how each may potentially affect health care delivery;

The Minister of Health has thus to persuade all the stakeholders that the interests of all will not only be protected, but will be vastly improved in the long-term:

1. Persuading cabinet and parliament that such a system requires a massive injection of public funds initially over 2-3 Malaysia Plans, but will in the long term deliver better patient care and community outcomes, and be the eventual best mechanism for national health care cost containment; that health care cost containment does not arise at a macroscopic level at this stage of under-provision vs needs over large parts of the nation;

2. Engaging Pakatan Rakyat legislators in discussion and debate to reach a broad bi-partisan consensus on a matter of reform of such national gravity; a bipartisan select committee on health and welfare should become a permanent feature of Malaysian legislature;

3. Persuading the public that this is the way forward for universal access to health care to a high level if deemed clinically necessary; that there will be continual improvement and upgrading; that private centre care remains an option if preferred; eventual public co-contribution is better marketed as an investment in public sector health care in the long haul, not a stop gap for current fiscal difficulties;

4. Persuading the all important medical profession that there will be greater professional flexibility and satisfaction, with steady growth of incomes assured and not compromised; similarly persuading with openness and due mutual respect, other allied profession; a package of professional incentives should be negotiated;

5. Persuading states, especially Sabah and Sarawak, that an NHS though in many ways are another form of central “command economy”, the space will be widely opened up for decentralized decision making to promote system responsiveness and service efficiency, to the ultimate extent of establishing Sabah and Sarawak Health Care Commissions respectively;

6. Persuading the cabinet that for a Malaysian workforce trapped in a “low income” economy, and for large sections of the population underserved, especially in Sabah and Sarawak, the compulsory co-payment of medical care cost by wage-earners should be deferred until real median incomes are 2-3 times current levels; (see Part 3 previously);

7. Persuading the cabinet that the National Health Care Fund will need to be topped up by respective Government civil service departments, as part of their respective human resource operational costs, to finance Government commitment to virtually free health care for civil servants and dependents, as well for the increasing number of pensioners;

8. Persuading all stake-holders that henceforth, health care planning will grow out of the civil service bureaucracy represented by the Ministry of Health to a more professional level, befitting a developed nation, by the establishment of a Malaysian Health Care Planning Commission; such a Commission will embrace the stake-holders of health care more comprehensively than the MOH civil service bureaucracy. (Writer acknowledge that the germinal thoughts on this matter originate from a certain lead member of Malaysian Medical Association)

The Minister of Health has much more to do to receive various input from all interested sources; public hearing should be conducted. The Minister should put its own proposals on the table, as a prerequisite to any meaningful dialogue with any group in a spirit of partnership in health care that Malaysians are looking forward to.

Once the Minister has broad consensus from other stake-holders, it is he who will drive health care policy decisions in the Cabinet; the Minister of Health must be so equipped with all logical (and illogical !) arguments pertaining to all aspects of health care policy that he will not be the one driven by the vicissitudes of the Cabinet, especially its current budget deficit fixation.

Information sharing must be the basis of establishing that trust between stake-holders; and dialogues not be seen as merely an avenue to push through unilateral decisions.

“Public- Private :Can the twain meet” has not been adequately covered here, but will be covered subsequently as “Medical professional isuues and interests.”

The establishment of a Malaysian National Health Service as good as any other, is a logical extension of its considerable achievements in health care, unmet needs notwithstanding. It would not only put Malaysia on the world map for comparative health care system studies, but also provide it with the needed international reputation of high public standards, if Health Care Tourism were to successfully become an important services sub-sector of the economy.