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 ?

Time Sarawak has Health Services Management School

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

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

AUG.2009.

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

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

SUMMARY:

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

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

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

FULL TEXT

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

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

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

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

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

“-----reiterating the following proposals:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Reproduction: Social Welfare Article

A plea was made at the peak of the Oil Crises in 2008 for a new Social Welfare Policy for Malaysia primarily to mitigate the hardship of Malaysians in the lower socio-economic groups from the oil price shock, though other macroeconomic considerations feature prominently as well.

While a few of the assumptions of the writer have clearly changed due to circumstances brought on by the subsequent global economic crises and the collapse of commodity prices, the central plank of social welfare as good public policy holds. If anything, the economic downturn makes such policy rethink all the more pressing. Nations in the Asian region, Singapore, China and Taiwan(China)have all beefed up welfare aid to the economically depressed. Australia on top of its institutionalised super-generous social security , was the first to give out handouts as a driving component of its stimulus package. A second handout is being given out around Easter, benefiting those with incomes of AU$100k per annum and below.

A fresh boost to social welfare in Malaysia, however weak comparative to neighbours, should be on the agenda.

Indeed a measure of the quality of public policy of any nation is the quality of its safety net provisions for the vulnerably disadvantaged. Social security would present a humanising side to mitigate the avariciousness of the unfettered free market.

In today's Malaysian Insider blog comment to an article "Malaysia to push economic reform", Professor Chan Chee Khoon of the Science University of Malaysia has timely called on government to address the wages and incomes issue, and institute minimum wage to spur aggregate demand.

This writer believes that social security is an essential policy tool to boost domestic demand, reduce petty crime, building of truly caring society and other desirable social objectives.

In the "Islamic Welfare State" of PAS, and Khalid Ibrahim's "Merakyatkan Ekonomi", one hopes the first seeds are now been sown which will in time bloom into a decent
Social Security system for Malaysia.

Francis Ngu


TEXT OF REPRODUCED ARTICLE
DR. FRANCIS NGU CALLS FOR MAJOR SOCIAL WELFARE POLICY INITIATIVE.

SUMMARY:

The abandonment of subsidy for fuel and even other subsidies will lead to severe and multi-sectoral repercussions yet to be fully realized, including stagflation, increased unemployment, social unrest, manifold increase in poverty and poverty related crime. At this crucial juncture, a long term social welfare policy programme should be put up, even belatedly, to mitigate quite disastrous spin-offs from the controversial policy of abandoning fuel and other subsidies. The implemention of a social welfare policy is proposed here as a major prong of a social justice reform programme, and to mitigate the effects of local and international economic slow down.

FULL TEXT:

In the midst of social anger and large and small protest actions of various groups, it is incumbent upon social welfare NGOs, political workers, scholars, professionals, leaders in the business and civil service, and legislators to begin an urgent debate and discussion on the medium and long-term socio-economic impact of a possible doubling of petrol price in the near term to around RM4 per litre.

Considering that fuel price would have risen 3-4 fold over a medium length period of 5-10 years, if the pump price approaches RM 4, and all the other essential goods see price rises to compound, the purchasing power of the Malaysian consumer will fast evaporate.

This is well understood and painfully felt by the public at large. The anticipated dive in consumer and investment confidence, and the drop in GDP is reflected in the opening bells of the KLSE on the morning of June 5th.

The concurrent effort in wages reform in the private sector, even though feeble, and the need to scale down foreign labour, add to the difficulties of various business sectors. Job creation will slow down, unemployment will worsen.

All taken together, a stark scenario of rapid inflation and slowed growth, in Malaysia and overseas, sets the ground for the worsening of poverty and increase in the poverty rate towards levels of 1970s, if not earlier. In its wake, social unrest and poverty related crimes. Without political will for reform, poverty eradication will be thrown into the ever distant future.

There is no doubt that Malaysia is facing a severe crisis, which, to the lower socio-economic groups, is far more severe than the 1997, Asian Financial Crisis.

Yet, ironically, the crisis to the average consumer, may not have to be so severe, or there need not even have to be a crisis at all ! This is because we are also in an unprecedented commodities boom! The export price of petrol has increased 10 fold from under US $20 to US $ 140 ! CPO is the mother of all golden crops now at some RM 3500 per tonne.

It only points to the fact that the nation’s wealth distributive mechanisms have failed miserably. The GINI index has risen steadily to 0.47.

For some 2 decades, government has resisted any notion of meaningful wage reform, including a minimum wage as a start. A systematic social welfare net has been denied to the lower socio-economic groups, even during the 1997 Asian Financial Crises. Such an institutionalised social safety net is not mentioned even as we face paying the full price of fuel on world markets.

The promoters of the denial mentality paint a glowing picture of pristine economic health against a fictitiously low unemployment and poverty rate.

The most prosperous nations of the world have poverty rates of 10-12 % against Malaysia’s poverty rates of 2-3 %. Unemployment rates of 4-5 % only occur in intolerably booming western economies. The claim that Malaysia has one of the lowest prices for fuel and essential goods should at least be balanced by the fact that wages in those other high cost countries are 5-15 times Malaysian wages. Again, in those high cost countries, annual income of RM 150K and below is considered low income in public policy debates; an annual income of RM 50K may already entitle a family to receive welfare assistance. The monthly social welfare payment to a poor family overseas may be 4-5 times the starting wage of a professional in us “lucky” Malaysia!

When we face the reality of prices in a globalised world, when subsidies are being dismantled, it is hoped that the denial and feel-good mentality will fade away. Otherwise, there can be no meaningful debate on public policy.

It is hoped that meaningful public policy debate will lead to meaningful public policy within the short term. We are now moving painfully away from a distorted market economy with multiple subsidies, but we are faced with a market economy where eventual removal of price controls is leading to inflation at a pace threatening the livelihood of many. Nearly all the first world free-market economies have solid social welfare systems put in place 50-100 years ago, both as a principal of social justice and also as an essential policy to safeguard social stability.

A Malaysian Social Welfare System must be set up soonest, and should be running before any further price rises in fuel and further removal of other subsidies. The compensation to vehicle owners is a queer cabinate invention, which does not address the rising cost of living for all consumers, especially the poorest who obviously may not even own a motor vehicle. A long-term social welfare programme must proceed alongside a more vigorous wage reform drive in the private sector and regulation of foreign labour. Personal tax cuts and refunds by significant elevation of the lower thresholds should also be considered.

Welfare as a social policy principle.
When the livelihood of a large segment of society is threatened to a level affecting social stability, the arguement for and against individual charity vs institutionalized charity becomes academic and should be put aside. The basic dignity of living is too serious a matter to be left to charitable whims of individuals, but must be effectively addressed by institutionalized welfare. Individual and community charity initiatives continue to grow ever stronger in countries with matured social welfare protection.

In these countries too, there is no proof of generalized economic malaise as a result. Fine tuned welfare programmes are nowadays tied together with skills re-training and with employment search for the healthy unemployed.

Social welfare recognizes the right of citizen to have a basic dignity of living and belonging to society, something so important to social peace and cohesiveness. It is further an instrument for providing a level playing field for all, and for individuals and families to realize their full potential. Human creativity and initiative may be suppressed and trapped by grinding poverty.

Last but not least, social welfare is an integral part of the programme of major political parties promoting people’s welfare using different terms such as social justice, democratic socialism, welfare state and others. It is now more apparent than ever before that a dose of welfarism is needed to survive the disaster caused in part by the globalised and ailing free market.

Social welfare is affordable. Although Malaysia is a mid-range developing country, the present commodities prices boom alone enables Malaysia to put in place a robust social welfare programme soonest. The present petrol price rise is saving the nation of a massive “subsidy”, which is really increased profit to Petronas. When the pump price is floated at international market prices, the profit increase to Petronas is RM 50 billion, more if world crude rises further. All other subsidies, if finally withdrawn, is estimated to save government another RM 50-80 billion. All leakages of subsidies, and to undeserving sectors, would have been plugged.

Certainly, much of the RM 50 billion or RM 100 billion earned by Petronas or saved by government, should be set aside for economic investment, especially public transport infrastructure. It is immediately obvious that even 10% of either sum is sufficient to launch the programme, 25 % of either will establish a good programme and 50% will send all the street protestors praising the government. Thus welfare aid is institutionalized at a level consistent with the economic strength of the nation.

Social welfare payments may be implemented within months.
Emergency Implementation.
Should it be necessary to reduce public panic, emergency implementation may be necessary, with all the pitfalls fully realized.
With the progress in electronic banking, there should not be difficulty to effect payment to all IC card holders with a bank account. Payment to minors should be through parents.
Payments to the poorest of the poor without bank accounts, may have to be separately dealt with, as well with some Sarawakians with no IC cards. Without means testing, this may mean a significant leakage to the small wealthy segment of society; however it should be a tolerable price to pay for staving off social unrest.

Long term Implementation.
Fine tuned long term programs will have to be based on Legislative Framework, Means Testing, Welfare Fraud Detection and Judicial Sanctions. If we can embark on space age ambitions and mega-projects, can we not establish an efficient and effective implementation network nation wide for social welfare within 1-2 years?

Social welfare to mitigate economic slow-down.
Malaysia is said to have negotiated its way out of the 1997 crisis by pump-priming the economy by spending on infrastructure, among other measures. The economic slow down this time round is dictated by rising cost of production and severely damaged consumer and investor confidence and anticipated dipping of export demand for manufactured goods. Tourism and related services may also be affected. A social welfare system spending of RM 20-30 billion alongside infrastructure spending will help maintain domestic retail and services demand and restore part of the business confidence.

Thus a social welfare system is justifiable in terms of public policy, affordable , technically feasible and even economically sound.