MALAYSIAN HEALTH CARE DEBATE (PART 3)
Dr. Francis H.H. Ngu, M.B., B.S. (Mal.), M.H.P. (U.N.S.W.)
Sarawak.
EXAMINING DIMENSIONS OF MEDICAL CO-CONTRIBUTION:
BETTER SOCIAL SAFETY NET NOW ?
Background
It is well known that government provided health care in Malaysia is virtually free for outpatient primary care and minimal for inpatient hospital care. Pharmaceuticals are also generally free. Those in abject poverty are exempted from even the minimal payments. Overall, Malaysians pay for less than 5% of the health care costs to government.
Public advocate groups have persistently opposed changes to the arrangement, and to the Privatisation Policy, especially the privatization of government hospitals.
However, to move health care to the next and sustainable phase of development, a health care financing mechanism is likely to be rolled out soon. Employers and employees are likely to have to contribute, together with Government, to a health care fund which will finance health care.
No public hearing has been conducted to gauge community views. Few details are known, except that the very low income, the very poor and the elderly may be exempted from payment. Strong social resistance to medical co-contribution may be anticipated.
Comparative foreign models
Co-contribution is a feature of the National Health Service of several developed countries including UK and Australia. The government of social-democratic parties of these countries, have some 60 years ago introduced a wide range of social welfare benefits, including highly subsidized public sector health care.
Patients pay a minimal amount for consultation, and medication prescribed. The poor, unemployed and lower income are means-tested by the national social security or welfare system, and are exempted from any payment.
In UK the NHS makes annual capitation grants set against performance targets to providers (GPs) for providing care. In Australia, the Federal government re-imburses the providers (doctors, pharmacies) on a case by case basis, according to schedules agreed upon. The general practitioner’s are “gate-keepers”, patients receive specialist and hospital care only upon referral by GPs.
A few differences between Malaysia and developed countries should be born in mind:
1. Wage earners of developed countries have incomes 5-15 times of Malaysian wage earners. Thus basic minimum wage in Australia starts at around RM 40 per hour, with heavy loading for weekends and public holidays.
2. Generous income support are given to the unemployed or low income families, of up to RM 5000 per month for a family of 5 or 6. The income at which poverty level is set is thus very high.
3. The thresh-hold for paying personal income tax is also very high, at around RM 50 K annual income, or much more.
4. The government of these developed countries allocate proportionately far more than Malaysia to health care; in Australia total national health care expenditure is over 10% of GDP, in UK somewhat less, in Malaysia least and under 5% of GDP.
There are many more salient points for consideration, but suffice it here to state the above.
Level of health care provision
Malaysia is praised internationally for a very extensive primary care network; the national health outcomes from public health programmes including maternal and child health are most outstanding.
Yet from the relative under spending as suggested by the above comparisons with foreign developed countries, there must exist many gaps and deficiencies. This is indeed the case. This writer, admittedly writing from a political perspective, has set out the broad outlines of the unmet health care needs of the State of Sarawak alone (1). The same holds for Sabah, and possibly pockets in Peninsular Malaysia.
INCOME THRESHOLD FOR CO-PAYMENT, QUANTUM of PAYMENT
The debate about co-payment will surely revolve around the income or wealth level at which co-contribution becomes applicable, and for the higher income employees, at what percentage of the base salary.
Threshold income
The threshold income at which wage earners have to co-contribute surely has to relate to the income level below which poverty is defined.
The Selangor State government sets it at RM 1500 pm per family of 5, this before the withdrawal of fuel subsidies in 2008. A consumer association puts the figure at around RM 2000 pm.
A federal minister suggested that the threshold income for personal income tax
should be RM3000 pm. (RM 3.15 = US$ 1 approx.)
This latter would suggest that taxing a wage earner with an income of RM 3000 pm would impose some hardship on the latter. Enforcing co-contribution, by the same logic would be unfair at that income level.
The official Malaysian poverty threshold as set at around RM 800 p.m. for a family of 5, is grossly off the point. Taking into account home loan payments, transportation costs, and a series of other commitments, co-contribution should be considered at a relatively high threshold income, say RM 5000 pm or much higher.
It is estimated that only about 30 % of Malaysian wage earners take home RM 3000 p.m. or more.
If the threshold for co-payment is set at RM3000 p.m., only a third of the workforce will pay, at RM 5000 p.m. as threshold, perhaps just 10 % of employees will make co-payments.
This limits the amount of funds for health care from employee contributions.
The Quantum of Co-contribution
In foreign countries like Australia, they started from as low as 1% of base salary, rising to 2-3 % after many years of policy adoption.
Co-payment of 1% of salary of a RM 3000 wage earner is RM 30 pm., RM360 pa. or 1% of a RM 5000 wage earner RM 50 pm, or RM 600.
Taking this percentage amount or even more from an employee would be intolerable. It also raises the point as to whether the maximum contribution will be capped, and then the amount at which the cap will be set.
(The figures quoted above are purely for the discussion, and do not imply that writer supports co-contribution at RM 3000 or RM 5000 monthly as threshold income.)
Limitation of wage earner’s contribution
Thus the amount for the National Health Care Finance Fund that can be raised from wage earners or low-income self-employed is thus much limited. This is due to the inability of the Malaysian public due to poverty and to a low-income wage structures to make a substantial co-contribution.
Even a low minimum wage regime, long canvassed by labour unions, is not in place.
Employer and corporate contributions
If employer contribution is rated according to employee pay, the employer contribution is similarly circumscribed; the quantum of corporate contribution (voluntary or mandated) is also expected to be limited and not rising much annually, due to a nett national investment outflow and lackluster GDP growth.
Would government and industry however agree to a small Health Care Levy on excess profits (or as market bonanza from time to time), especially in the resource sector ? The social and economic debate on the hefty resource and mining tax is currently still raging in Australia; though the initial proposed levy is regarded by many as outrageously high, the general principle of it seems to have considerable support.
Are we prepared to look at all avenues of social financing mechanisms adopted overseas, or do we selectively pick one, namely medical co-contribution, and maintain a blind spot for other potential mechanisms ?
Other social security organisations
Contribution from EPF to the national health fund is controversial as EPF as the old age pension fund for wage earners as originally designed, is already undermined by house purchase and other withdrawals; SOCSO has however a treatment and rehabilitation component in design which are synergistic with health care.
Both EPF and SOCSO contributions are also rated according to employees’ wages, generally low as earlier stated. While EPF is savings and growth in concept, SOCSO and any medical co-contribution are non-refundable population risk insurance in conception.
MECHANISMS ; FUND MANAGEMENT
It remains unclear as to the structural arrangements to control and manage what will eventually be a large fund, or if there are other sources of funding, other than from Government consolidated revenue and possibly employee and employer co-contribution.
Will the Fund collect directly, to the burden of employers, or delegate collection to an existing agency like SOCSO ? Are there safeguards for abuse of public funds, not unfamiliar to Malaysians ?
HAS THE THRESHOLD FOR A BETTER SOCIAL SAFETY NET NOT BEING
CROSSED ?
Means testing
Wage income threshold is technically an easier method of determining the liability for employee contribution, however incomes of self-employed may be harder to ascertain with accuracy.
Moreover for a given wage threshold, the family needs and commitments may differ considerably. Thus a family in Sarawak with a relatively high total income of RM 12,000 say, may have a couple of children studying without loan or scholarship, in KL; minus the expenditure on their childrens’ education what is their expendable income ? And not forgetting essential car and house mortgages to pay.
Thus in developed social democratic countries, large bureaucracies have to be set up for determining the income and fundamental expenditures of families, to determine their eligibility to a wide range of social welfare benefits, including free health care.
If the Government of the day thinks it is time to introduce GST, abolish subsidies and push medical co-payment, then has the time not arrived to also introduce a more comprehensive social welfare system ?
Such a welfare system would have to be based on Means Testing for social welfare benefits, including free health care without being subject to co-contribution; this in a “High Cost Few Subsidies” economy, where the majority of the people will be not just in the “Middle Income Trap,” but effectively be in the “Low Income Trap”
This writer wish to refer readers further to his initial assertion in 2008, and to propose here that in 2010 and thereafter, setting up a proper Social Welfare System has become all the more urgent, including for all the other reasons previously stated in 2008. (2)
Health care issues inexorably lead to the over-arching issues of the economy, the basic principles underlining public policies and the wider political scenario. However, it may best to leave to the better rationale of individuals, rather than to canvass a particular line of political and social thinking here.
Ref.:
1. Ngu, UNMET HEALTH CARE NEEDS, SARAWAK, 2010, PARTS 1& 2. (Pt.3 Due) Tindak Malaysia blog.
2. Ngu, Social Welfare Article in the wake of the fuel price shock of 2008, reproduced at Tindak Malaysia blog. Also on N Francis Sarawakiana blog, April 2009, “Reproduction: Social Welfare Article.”
Wednesday, October 6, 2010
Wednesday, September 8, 2010
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.
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.
Monday, August 23, 2010
THE MABO RULING IN AUSTRALIA AND NATIVE CUSTOMARY RIGHTS OF SARAWAK
Dedicated to the First Sarawak Peoples, the brave indigenous peoples:
THE MABO RULING IN AUSTRALIA AND NATIVE CUSTOMARY RIGHTS OF SARAWAK
Francis H.H.Ngu, (non-indigenous Sarawakian and Malaysian).
“ A favourable Mabo decision by the High Court would free not only the Islander people and all Aboriginal people, but all the white people of Australia,” Eddie Mabo, initiator of the Mabo land case, prior to his death in 1992, five months before the historic Mabo decision.
Writer was in Australia doing a health services planning graduate programme in Sydney in 1982, when a Torres Straits islander and others gathered the courage and determination to take the Queensland State Government to court for denial of aboriginal land rights.
Eddie Mabo and others were defending the ownership right to their ancestral land at the northern tip of Queensland, handed down for generations according to Aboriginal legal traditions. In what was considered unwinnable, the High Court of Australia handed down an historic decision in 1992, over-turning the Terra Nullis principle, and recognizing Mabo and fellow islanders ownership rights to their own land.
At closer range , writer witnessed and continue to witness the equally courageous fight of the indigenous peoples of Sarawak for their land rights on Borneo island, and their economic rights associated with land. In spite of differences, there are compelling aspects of similarity which merit this simple narration.
The Aboriginals and the Torres Straits islanders are now acknowledged correctly as the First Australians. They represent perhaps the longest history of human civilization of some 40,000 years.
The Penans and other Dayak people of Sarawak are the First Sarawak people, and with the indigenous peoples of Sabah and of Malaya, the First Malaysians, though not generally so regarded by all of society as yet. To them, all Sarawak and Malaysian people ought to accord respect and honour, in that others later to come have been so congenially accommodated in this state and nation. Some indigenous people of Sarawak have a history of thousands of years of settlement and others a few hundred years.
There are outstanding common threads in the history and culture of Sarawak indigenous and Australian aboriginals, indeed many other indigenous peoples around the world. Apart from close kinship, what defines their existence and their culture is their sacred relationship to the land that they live on. Without ancestral land, lives and culture are in peril.
The Aboriginals live in perfect co-existence with their land from the tropical Torres Straits, to the vast desert scrubland of the continent, to the cold southern ranges. The Penans and others were, until their forcible displacement in recent history, an integral part of the Borneo ecosystem. As guardians of the Borneo tropical forests, they should perhaps also be accorded the honour of the First Environmentalists !
The close communal kinship of both groups in Australia and Borneo respectively, are enriched by unique cultures, a heritage of all mankind to be guarded, and nurtured not trampled upon by commercial interests.
The Aboriginal “dreamtime” is matched by rich Dayak imagery of folklore, both have walk-abouts, “berjalai” for adventure and opportunities in the case of migratory Sarawak Ibans.
Aboriginal paintings can be simultaneously contrasted and paralleled by Iban and Orang Ulu art on textile, both feature not only folklore but essential spirituality. Smart and effective hunting implements, the boomerang and the blow-pipe are well known respectively. One day in future, I hope, the Aboriginal didgeridoo may be merged with the Iban gongs and the Orang Ulu sapeh in a symphonic piece celebrating international indigenous friendship.
So the cultural list goes on, the rest well documented by learned anthropologists and sociologists. Suffice it to say that the rich cultural traditions and creativity can only inspire and benefit modern society. They are being constantly revived through elaborate ceremonies such as the Aboriginal coroboree and the Harvest Festivals of Borneo, the Gawai and Pesta Menuai.
Upon white settlement of Australia, the Aboriginals suffered for over 200 years from displacement, annihilation and cultural genocide through assimilation of the Stolen Generation. Land was taken over by immigrants mining and pastoral interests, as the principle of Terra Nullis states that Australia was no man’s land before white settlement and only the British Crown can lay claim on the whole continent. Aboriginals were to be confined to officially defined reserves. The historical facts of the ethnic persecution are well displayed at major Australian government museums, including the one at Perth, a commendable display of the conscience of a civilized nation among civilized nations.
The subjugation of Aboriginals haunted the 1982 Brisbane commonwealth games, as well as the bicentennial celebration of white settlement in Australia in 1988 respectively, so much so that PM Bob Hawke appeared on TV in tears to acknowledge, ”They have not been looked after (better).” PM Paul Keating, hailed the Mabo court ruling and went on to craft Aboriginal Reconciliation legislation and suggested a Social Justice package of socio-economic rights.
PM Kevin Rudd in 2008 went on to deliver an official apology on behalf of Government and Parliament for the maltreatment of Aboriginals including the Stolen Generation. Thousands of Australians, black and white, were moved to copious tears upon hearing the national apology. On that day too, Aboriginal elders also invited legislators into Parliament House, in a ceremony legitimizing the Australian Parliament even retrospectively after more than a century of Federation !
(Writer was in Australia and had the opportunity to watch live coverage of the event on ABC in 2008, at the same time thinking about the indigenous people of Sarawak.)
The NCR struggle of the indigenous peoples of Sarawak, in spite of the signal victories in court since the Nor Nyawai case, has a long road ahead, a Long Road of Freedom as Mandela said.
The Native Customary Rights of Sarawak natives, in place since the rule of the White Rajahs of Sarawak, have been traded away by the Dayak leaders of Sarawak in recent history. Large tracts of native customary right land were extinguished, and Dayaks displaced by logging and plantation interests all over the whole State, these documented by a hundred cases before Sarawak courts.
Weep, weep Sarawak for pushing the First Peoples of Sarawak to the margins of society !
The full restoration of NCR is now possible only with full and broad political change in Sarawak and Malaysia. The Land Code of Sarawak awaits to be re-written.
Thousands of white Australians rallied with the Aboriginals in their struggle; tens of thousands of non-indigenous Malaysians must also stand with Penans and other indigenous groups in their stuggle for land rights and social justice.
As the Mabo victory freed the non-indigenous Australians from the chains of lies and oppression, the ultimate victory of Penans and Dayaks will free all non-indigenous Sarawak people and all Malaysians from the shameful treatment of our fellow countrymen and women, the First Sarawakians and the First Malaysians.
The Dawn must come when the new Chief Minister of Sarawak will rise in the Dewan Undangan Negri of Sarawak in the year 2013 to tender the apology of the House to the First Sarawakians, and the Prime Minister of Malaysia will lead the Dewan Rakyat and Senate in the year 2013, in tendering the apology of the Malaysian nation to Dayaks and all indigenous people of Malaysia.
Then we can be proud as One People of Malaysia, all accorded social economic justice and freedom. Agi idup agi ngelaban ! (Iban- we strive for as long as we live !)
Thoughts on approaching Malaysia Day, 16th September 2010.
THE MABO RULING IN AUSTRALIA AND NATIVE CUSTOMARY RIGHTS OF SARAWAK
Francis H.H.Ngu, (non-indigenous Sarawakian and Malaysian).
“ A favourable Mabo decision by the High Court would free not only the Islander people and all Aboriginal people, but all the white people of Australia,” Eddie Mabo, initiator of the Mabo land case, prior to his death in 1992, five months before the historic Mabo decision.
Writer was in Australia doing a health services planning graduate programme in Sydney in 1982, when a Torres Straits islander and others gathered the courage and determination to take the Queensland State Government to court for denial of aboriginal land rights.
Eddie Mabo and others were defending the ownership right to their ancestral land at the northern tip of Queensland, handed down for generations according to Aboriginal legal traditions. In what was considered unwinnable, the High Court of Australia handed down an historic decision in 1992, over-turning the Terra Nullis principle, and recognizing Mabo and fellow islanders ownership rights to their own land.
At closer range , writer witnessed and continue to witness the equally courageous fight of the indigenous peoples of Sarawak for their land rights on Borneo island, and their economic rights associated with land. In spite of differences, there are compelling aspects of similarity which merit this simple narration.
The Aboriginals and the Torres Straits islanders are now acknowledged correctly as the First Australians. They represent perhaps the longest history of human civilization of some 40,000 years.
The Penans and other Dayak people of Sarawak are the First Sarawak people, and with the indigenous peoples of Sabah and of Malaya, the First Malaysians, though not generally so regarded by all of society as yet. To them, all Sarawak and Malaysian people ought to accord respect and honour, in that others later to come have been so congenially accommodated in this state and nation. Some indigenous people of Sarawak have a history of thousands of years of settlement and others a few hundred years.
There are outstanding common threads in the history and culture of Sarawak indigenous and Australian aboriginals, indeed many other indigenous peoples around the world. Apart from close kinship, what defines their existence and their culture is their sacred relationship to the land that they live on. Without ancestral land, lives and culture are in peril.
The Aboriginals live in perfect co-existence with their land from the tropical Torres Straits, to the vast desert scrubland of the continent, to the cold southern ranges. The Penans and others were, until their forcible displacement in recent history, an integral part of the Borneo ecosystem. As guardians of the Borneo tropical forests, they should perhaps also be accorded the honour of the First Environmentalists !
The close communal kinship of both groups in Australia and Borneo respectively, are enriched by unique cultures, a heritage of all mankind to be guarded, and nurtured not trampled upon by commercial interests.
The Aboriginal “dreamtime” is matched by rich Dayak imagery of folklore, both have walk-abouts, “berjalai” for adventure and opportunities in the case of migratory Sarawak Ibans.
Aboriginal paintings can be simultaneously contrasted and paralleled by Iban and Orang Ulu art on textile, both feature not only folklore but essential spirituality. Smart and effective hunting implements, the boomerang and the blow-pipe are well known respectively. One day in future, I hope, the Aboriginal didgeridoo may be merged with the Iban gongs and the Orang Ulu sapeh in a symphonic piece celebrating international indigenous friendship.
So the cultural list goes on, the rest well documented by learned anthropologists and sociologists. Suffice it to say that the rich cultural traditions and creativity can only inspire and benefit modern society. They are being constantly revived through elaborate ceremonies such as the Aboriginal coroboree and the Harvest Festivals of Borneo, the Gawai and Pesta Menuai.
Upon white settlement of Australia, the Aboriginals suffered for over 200 years from displacement, annihilation and cultural genocide through assimilation of the Stolen Generation. Land was taken over by immigrants mining and pastoral interests, as the principle of Terra Nullis states that Australia was no man’s land before white settlement and only the British Crown can lay claim on the whole continent. Aboriginals were to be confined to officially defined reserves. The historical facts of the ethnic persecution are well displayed at major Australian government museums, including the one at Perth, a commendable display of the conscience of a civilized nation among civilized nations.
The subjugation of Aboriginals haunted the 1982 Brisbane commonwealth games, as well as the bicentennial celebration of white settlement in Australia in 1988 respectively, so much so that PM Bob Hawke appeared on TV in tears to acknowledge, ”They have not been looked after (better).” PM Paul Keating, hailed the Mabo court ruling and went on to craft Aboriginal Reconciliation legislation and suggested a Social Justice package of socio-economic rights.
PM Kevin Rudd in 2008 went on to deliver an official apology on behalf of Government and Parliament for the maltreatment of Aboriginals including the Stolen Generation. Thousands of Australians, black and white, were moved to copious tears upon hearing the national apology. On that day too, Aboriginal elders also invited legislators into Parliament House, in a ceremony legitimizing the Australian Parliament even retrospectively after more than a century of Federation !
(Writer was in Australia and had the opportunity to watch live coverage of the event on ABC in 2008, at the same time thinking about the indigenous people of Sarawak.)
The NCR struggle of the indigenous peoples of Sarawak, in spite of the signal victories in court since the Nor Nyawai case, has a long road ahead, a Long Road of Freedom as Mandela said.
The Native Customary Rights of Sarawak natives, in place since the rule of the White Rajahs of Sarawak, have been traded away by the Dayak leaders of Sarawak in recent history. Large tracts of native customary right land were extinguished, and Dayaks displaced by logging and plantation interests all over the whole State, these documented by a hundred cases before Sarawak courts.
Weep, weep Sarawak for pushing the First Peoples of Sarawak to the margins of society !
The full restoration of NCR is now possible only with full and broad political change in Sarawak and Malaysia. The Land Code of Sarawak awaits to be re-written.
Thousands of white Australians rallied with the Aboriginals in their struggle; tens of thousands of non-indigenous Malaysians must also stand with Penans and other indigenous groups in their stuggle for land rights and social justice.
As the Mabo victory freed the non-indigenous Australians from the chains of lies and oppression, the ultimate victory of Penans and Dayaks will free all non-indigenous Sarawak people and all Malaysians from the shameful treatment of our fellow countrymen and women, the First Sarawakians and the First Malaysians.
The Dawn must come when the new Chief Minister of Sarawak will rise in the Dewan Undangan Negri of Sarawak in the year 2013 to tender the apology of the House to the First Sarawakians, and the Prime Minister of Malaysia will lead the Dewan Rakyat and Senate in the year 2013, in tendering the apology of the Malaysian nation to Dayaks and all indigenous people of Malaysia.
Then we can be proud as One People of Malaysia, all accorded social economic justice and freedom. Agi idup agi ngelaban ! (Iban- we strive for as long as we live !)
Thoughts on approaching Malaysia Day, 16th September 2010.
Monday, August 16, 2010
THE LOOMING MALAYSIAN HEALTHCARE DEBATE (PART 2)
Dr. Francis H.H. Ngu, M.B., B.S. (Mal.), M.H.P. (UNSW)
Sarawak.
THE CASE FOR INCREASE IN GOVERNMENT HEALTH CARE EXPENDITURE..
CUTTING BUDGET DEFICIT, CUTTING BUDGET FOR HEALTH CARE,
CO-PAYMENT TO FILL BUDGET GAP ARISING ???
It is evident that the timing of the proposal is awkward, following in the wake of botched government attempts to introduce the GST soonest and rapid withdrawal of multiple subsidies to shore up dwindling coffers, and a serious budget deficit. A major crises arising from the co-occurrence of national finance woes, health care woes and political woes has impacted on the Minister of Health to cap and even reduce government health service expenditure, while appearing to maintain or improve service.
Health care expenditure was targeted for reduction during the Great Austerity Drive of the mid-1980s, and is clearly targeted again in 2010. There has been a cutback of some 4.8% in the last budget, according to reliable sources.
It runs contrary to the 3rd proposal above (Part 1) to steadily increase government health care expenditure as percentage of GDP over 10 years to double to what it is at present. A total public-private health care expenditure of 7-8 % GDP is a shade higher than WHO recommendations for middling developing countries, but is at the lower end of developed countries. This is what it takes to qualify ourselves as a developed country in terms of health care after 2020.
At the current low levels of expenditure and serious public sector under-provision, Malaysia can hardly be said to be a nation continuing to make strides and progress when health care spending across the board were to be held back.
Such a proposal to increase health care expenditure would on the face of it sound lunatic, given the national indebtedness and poor fiscal shape! Read on.
The national indebtedness and fiscal deficit did not arise mainly from a chronically under-funded health care sector (under-funded, in terms of objective needs, citizen’s real life experiences and according to WHO recommendations), but to massive abuse and leakages of public funds, misallocations, mismanagement and wastage; and not let health care for citizens be the whipping target as the natural and acceptable sequaele.
Why not target the much larger defence expenditure at over 20 % of GDP for larger budgetary cuts ? A massive body of public discourse on corruption and cronyism, folly projects, overblown prices and costs and massive expenditure on defence hardware need not be re-canvassed here.
These are the roots of national indebtedness and fiscal woes which meager co-contribution in health care will do little to rectify.
NO SHORT-SIGHTED REFORMS, PUBLIC MUST NOT BE SHORT-CHANGED
HEALTH CARE COST INFLATORS:
In the event, health care needs requiring increased government expenditure arise from the following considerations:
1. Natural population growth of just under 2 %, much higher growth in Sabah from immigration;
2. Increasing population in the above 60 age groups, thus rising geriatric needs; in addition to a steadily changing population pyramid, slowly rising lifespans also impact on health care resources;
3. The impact of lifestyle diseases tending younger, and of neoplastic diseases (cancer) increasing in incidence as well;
4. High rates of road traffic accidents and industrial accidents/diseases; a major burden of disease is incidence and prevalence of mental illness in an industrial urban society facing different stress from different sources;
5. The growth of medical (doctors) personnel, as more Medical and Specialists posts will be filled; range and scope of service will expand faster with fast professional personnel growth; this is significant as professional personnel cost is a dominant component of recurrent health care expenditure;
6. Serious unmet hardware infrastructure needs in East Malaysia and elsewhere;
7. More outbreaks of traditional communicable diseases, and newer viral diseases;
8. The impact of subsidy withdrawal and GST introduction on domestic price inflation, both goods and services, to the health care budget;
9. Medical technology, which for Malaysia is largely imported, thus subject to international price pressures; the impact of imported inflation on medical and non-medical equipment and supplies.
10. Rapidly emerging new medical technologies, generally increasing health care costs.
A social need may be arising for fully or partly subsidized Nursing Homes in Malaysia in future, which the above proposal of 4.5-5 % of GDP does not cater for; this a most controversial matter best left to a later time for debate.
Similarly, rehabilitation facilities for the permanently handicapped is barely existent, however, this is largely within the founding mission of SOCSO.
Against these inflators of cost, the contribution from employers and employees, would be limited and rising slower than health care expenditure needs. This does not however, mean not thinking about co-contribution to a newly established national health finance fund. Considerations about co-payment will be dealt with in Part 3.
A BUDGETARY CUT REDUCES THE LOW PER CAPITA EXPENDITURE FOR HEALTH CARE EVEN MORE!
The cut-back on the chronically under-funded health care sector is as detrimental to the health and welfare of citizens, to their economic productivity, as it is morally and politically callous. If government cut-back, or reigning in of future budget outlays be the primary target of reform, then this reform is a no-go exercise in futility from the beginning, whether considered responsibly, rationally, professionally or politically.
Fortunately, it appears the Minister of Health is in support of greater government health care expenditure of up to 4 % of GDP, only that is shows up as a budget cut of 4% !
A steady government budgetary increase to 4.5-5 % of GDP, staggered out over a decade , is the responsible and sustainable way forward without critically affecting the budget deficit. With financial accountability and best practice, budgetary and fiscal prudence, colossal savings can be achieved elsewhere in the public sector; this even if government ignores the clamour from dissidents and oppositions, by just working on the Government’s own Auditor General’s Report published year after year.
This debate about long-term reform must be substantially re-geared !
A nation going forward must be able to deliver progressively better health care for all its citizens. A government budgetary commitment to health care is the essential measure of good and caring governance, under-writing its constitutional role and ensuring progress and social justice.
Sarawak.
THE CASE FOR INCREASE IN GOVERNMENT HEALTH CARE EXPENDITURE..
CUTTING BUDGET DEFICIT, CUTTING BUDGET FOR HEALTH CARE,
CO-PAYMENT TO FILL BUDGET GAP ARISING ???
It is evident that the timing of the proposal is awkward, following in the wake of botched government attempts to introduce the GST soonest and rapid withdrawal of multiple subsidies to shore up dwindling coffers, and a serious budget deficit. A major crises arising from the co-occurrence of national finance woes, health care woes and political woes has impacted on the Minister of Health to cap and even reduce government health service expenditure, while appearing to maintain or improve service.
Health care expenditure was targeted for reduction during the Great Austerity Drive of the mid-1980s, and is clearly targeted again in 2010. There has been a cutback of some 4.8% in the last budget, according to reliable sources.
It runs contrary to the 3rd proposal above (Part 1) to steadily increase government health care expenditure as percentage of GDP over 10 years to double to what it is at present. A total public-private health care expenditure of 7-8 % GDP is a shade higher than WHO recommendations for middling developing countries, but is at the lower end of developed countries. This is what it takes to qualify ourselves as a developed country in terms of health care after 2020.
At the current low levels of expenditure and serious public sector under-provision, Malaysia can hardly be said to be a nation continuing to make strides and progress when health care spending across the board were to be held back.
Such a proposal to increase health care expenditure would on the face of it sound lunatic, given the national indebtedness and poor fiscal shape! Read on.
The national indebtedness and fiscal deficit did not arise mainly from a chronically under-funded health care sector (under-funded, in terms of objective needs, citizen’s real life experiences and according to WHO recommendations), but to massive abuse and leakages of public funds, misallocations, mismanagement and wastage; and not let health care for citizens be the whipping target as the natural and acceptable sequaele.
Why not target the much larger defence expenditure at over 20 % of GDP for larger budgetary cuts ? A massive body of public discourse on corruption and cronyism, folly projects, overblown prices and costs and massive expenditure on defence hardware need not be re-canvassed here.
These are the roots of national indebtedness and fiscal woes which meager co-contribution in health care will do little to rectify.
NO SHORT-SIGHTED REFORMS, PUBLIC MUST NOT BE SHORT-CHANGED
HEALTH CARE COST INFLATORS:
In the event, health care needs requiring increased government expenditure arise from the following considerations:
1. Natural population growth of just under 2 %, much higher growth in Sabah from immigration;
2. Increasing population in the above 60 age groups, thus rising geriatric needs; in addition to a steadily changing population pyramid, slowly rising lifespans also impact on health care resources;
3. The impact of lifestyle diseases tending younger, and of neoplastic diseases (cancer) increasing in incidence as well;
4. High rates of road traffic accidents and industrial accidents/diseases; a major burden of disease is incidence and prevalence of mental illness in an industrial urban society facing different stress from different sources;
5. The growth of medical (doctors) personnel, as more Medical and Specialists posts will be filled; range and scope of service will expand faster with fast professional personnel growth; this is significant as professional personnel cost is a dominant component of recurrent health care expenditure;
6. Serious unmet hardware infrastructure needs in East Malaysia and elsewhere;
7. More outbreaks of traditional communicable diseases, and newer viral diseases;
8. The impact of subsidy withdrawal and GST introduction on domestic price inflation, both goods and services, to the health care budget;
9. Medical technology, which for Malaysia is largely imported, thus subject to international price pressures; the impact of imported inflation on medical and non-medical equipment and supplies.
10. Rapidly emerging new medical technologies, generally increasing health care costs.
A social need may be arising for fully or partly subsidized Nursing Homes in Malaysia in future, which the above proposal of 4.5-5 % of GDP does not cater for; this a most controversial matter best left to a later time for debate.
Similarly, rehabilitation facilities for the permanently handicapped is barely existent, however, this is largely within the founding mission of SOCSO.
Against these inflators of cost, the contribution from employers and employees, would be limited and rising slower than health care expenditure needs. This does not however, mean not thinking about co-contribution to a newly established national health finance fund. Considerations about co-payment will be dealt with in Part 3.
A BUDGETARY CUT REDUCES THE LOW PER CAPITA EXPENDITURE FOR HEALTH CARE EVEN MORE!
The cut-back on the chronically under-funded health care sector is as detrimental to the health and welfare of citizens, to their economic productivity, as it is morally and politically callous. If government cut-back, or reigning in of future budget outlays be the primary target of reform, then this reform is a no-go exercise in futility from the beginning, whether considered responsibly, rationally, professionally or politically.
Fortunately, it appears the Minister of Health is in support of greater government health care expenditure of up to 4 % of GDP, only that is shows up as a budget cut of 4% !
A steady government budgetary increase to 4.5-5 % of GDP, staggered out over a decade , is the responsible and sustainable way forward without critically affecting the budget deficit. With financial accountability and best practice, budgetary and fiscal prudence, colossal savings can be achieved elsewhere in the public sector; this even if government ignores the clamour from dissidents and oppositions, by just working on the Government’s own Auditor General’s Report published year after year.
This debate about long-term reform must be substantially re-geared !
A nation going forward must be able to deliver progressively better health care for all its citizens. A government budgetary commitment to health care is the essential measure of good and caring governance, under-writing its constitutional role and ensuring progress and social justice.
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 ?
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 ?
Tuesday, March 2, 2010
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