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 ?

The Column That Wasn

The Column That Wasn

An overview of the "Allah controversy"

Summary: Following a brief review of the current crises arising from a controversial Government ban on the use of the term ALLAH by non-Muslims, and ensuing court proceedings, this article quotes several responses from leaders in Sabah and Sarawak in addition. The spirit and letter of the Malaysia Agreement should not be forgotten in order to have full perspective in the debate. Possible repercussions in international relations and image are outlined, with particular reference to Indonesia. The article proposes major steps to restoring inter-religious harmony, beyond judicial decisions. In conclusion, writer appeals to a return to shared core values of all major religions.


There has not in my memory of recent history anywhere in the world where the word used to refer to God has given rise to such national controversy and attracted international attention. Against the backdrop of social change and political tension, Malaysia has gained an unenviable World First, a national passion promoted under the Mahathir regime.

Close on the heels of the 50th Anniversary of the Malayan Independence, a ban was gazetted by the Government for non-Muslims on Malaysia to use the term Allah in reference to God. The Government move was rather perplexing, saying that use of the Arabic word might offend the sensitivities of Muslims who make up 60% of Malaysia's 28 million population.

The ban was however overturned in court on December 31st, 2009, enraging certain sections of Muslims aligned to the ruling UMNO party. The High Court said it was the constitutional right for the Catholic newspaper, the Herald, to use the word "Allah". The Herald had faced the prospect of indefinite ban from publication for using the term Allah.

Protesters against the court ruling have apparently received implicit and explicit encouragement from statements of a few Federal Government Ministers and the decision of the Home Ministry to appeal against the High Court ruling. The Home Minister has in a rare departure from previous practice, granted permit for a mammoth demonstration by protestors; it has always been the contention by Malaysian Government that public demonstrations are “not our culture” and threaten public order. However, on the eve of the large demonstration,
the PM, the Home Minister and the Police (IGP) are reportedly making some conflicting and rather confusing statements.

The controversy is thus set to escalate. If of any help, the court has granted a government application for stay of execution of the High Court ruling pending the outcome of the Appeal by the Home Ministry, this consented to by the Catholic side.

For one, the former prime minister, Mahathir, said that the word Allah belongs to the Muslims, whereas the current PM is notably “uncommitted” on the matter. In sharp contrast, Mahathir’s activist daughter, Marina, says “It is not about God belonging to you, rather YOU belong to God.” She says that the constant battle for ownership of God is in quite wrong.

It is generally the contention of Government and some others that sections of the Muslim population in Malaysia would be easily confused over the usage of “Allah” by non-Muslims, insinuating that churches have used this as an excuse to convert Muslims out of their faith.

Mahathir further said that the term Allah may be used in such a way that could inflame the anger of Muslims, or in his own words, “they may use it on banners or write something that might not reflect Islam”, a statement condemned by Dr. Lim Teck Ghee et al. as wholly unworthy of the former PM.

TG Lim, in 2 separate articles at the Centre for Policy Initiatives website, reported in some detail the mass mobilization against the High Court ruling that has already spread to cyberspace in quite an alarming way in tandem with inciteful and intimidating articles in an UMNO controlled newspaper.

In a strident rebuke head on, an UMNO veteran, Tengku Razaleigh Hamzah says,” Umno is digging itself into an intolerant hardline position that has no parallel that I know of in the Muslim world.-- and the government it leads is taking up policy lines based on “sensitivities” rather than principle. The issue appears to be more about racial sentiment than religious, let alone constitutional principles.-- A nation is made up of citizens bound by a shared conception of justice and not of mobs extracting satisfaction for politicised emotional states.--Malaysia is a federation of sovereign entities, --it has come to be run habitually as a unitary state. We have to learn again how to be a federation.”(Concerns about federalism in the context of the “Allah debate” is also echoed by Sabah and Sarawak political leaders quoted later.)

“The Bible has been using Allah for hundreds of years, ever since they translated the Bible into Bahasa Malaysia/Indonesia. In fact, we have copies of a Bahasa-translated Bible published 200 years ago that used Allah”, says RPKamarudin. This being so, and surely for the 50 years of Malayan Independence, there has not been a significant exodus of Malaysian Muslims to embrace Christianity as this is legally not possible in Malaysia, in spite of constitutional provisions of religious freedom.

RPK says further, “The word ‘Allah’ existed before the word ‘Muslim’ or ‘Islam’.--- Muhammad the son of Abdullah –(or) ‘Muhammad the son of the Servant of Allah’ long before the Revelation when he ‘became’ a Muslim.” How do the Muslims (meaning Malays) explain this if they say that Allah belongs to the Muslims?” Thus RPK deduces that the term Allah would have been used by Pagan Arabs before the time of Prophet Mohammed, Praise be to His Name.

Those aligned to the Federal Opposition, Pakatan Rakyat, generally believe that the gazetted ban on non-Muslim use of “Allah” is a concoction of the UMNO-led Federal Government to project its Islamic image to Malay Muslims, and politically out-manoeuvre the Islamist PAS in the opposition Pakatan (Alliance). It is perceived that in face of the ban and the following controversy, the Malay Muslim base of PAS and possibly Parti KeAdilan Rakyat, would be eroded to the advantage of UMNO.

Pakatan Rakyat parties have come out in consistent support of the High Court ruling, based on fundamental Islamic teachings.

The Leader of the Federal Opposition, Datuk Seri Anwar Ibrahim, had also quoted an influential world Islamic cleric, Sheihk Dr.Yusof Al Qaradawi, as saying that there is no problem with Christians referring to God as Allah.
Tok Guru Nik Aziz, the PAS Menteri Besar of Kelantan had before the court ruling said that he did not oppose the Catholic Herald using the word ALLAH.

PAS issued a statement in prompt agreement with the High court: “it is consistent with the federal Constitution and Islamic principles”and that “based on Islamic principles, the use of the word Allah by the people of the Abrahamic faiths such as Christianity and Judaism, is acceptable” .--“PAS strongly objects to any aggressive and provocative approach that can lead to tension in society,” it is quoted.
In a measured response a day after the PAS statement, an official spokesman of Parti Keadilan Rakyat says "the wish of the non-Muslims to call their God Allah is a positive turn of events and should respectably be recognized. -- There is no necessity for any faction in society to take advantage of the current circumstances and turn the dispute into a narrow political propaganda.”
But far-reaching political ramifications are unavoidable. “-- the political and economic costs for Prime Minister Datuk Seri Najib Razak's administration will linger for much longer--- a significant setback to the central theme of his new administration — the “1 Malaysia” policy which is designed to bring the country's multiracial and multi-religious communities together, “ a Straits Times article quite accurately describes the political fall out.

It is clear that 1Malaysia mantra is also taking direct hits, in Sabah and Sarawak as much, or even more than in KL. Over 40% of the people of Sarawak are Christians, and a roughly similar proportion in Sabah, the majority being indigenous peoples.

1Malaysia will face a severe predicament as the Appeal Court is widely expected to reverse the High Court decision. In appeasing an arguably large Muslim constituency in Peninsular Malaysia, such a court reversal would adversely affect the Christians in Sabah and Sarawak. Both sides of the political divide will undoubtedly interpret the electoral significance of the issue on both sides of the South China Sea.

A senior Sabah Christian member of the Cabinet, Tan Sri Bernard Dompok, made an oblique comment favouring the continued use of the term “Allah”, suggesting that the use of “Allah” follows from the widespread use of the Malaysian national language. “The Sabah communities have always used Bahasa Melayu as it is the regional lingua franca and Christianity has been in Sabah since 1881,” the Plantations Industry and Commodities minister is quoted as saying.

In Sarawak, the sole KeAdilan State legislator, Dominique Ng (Padungan), has called on government to respect the ruling. Ng, a Buddhist himself, asks the government to explain why it may not now release all of the confiscated religious articles to the churches and individuals concerned. He refers to the reported confiscation in Kuching on September 15th 2009 ---of 15,000 imported copies of Bibles bearing the word ALLAH, and quoted other instances of confiscation of Christian articles. (Writer: In view of the stay of execution of the High Court ruling, the ban obviously remains in force.)

Ng said, “--that leading Muslim clerics and so many Malaysian Muslims are so religiously principled in their stand in sharing the use of the term ALLAH, is indeed a defining moment in Malaysian communal relations. -- the Barisan National would be well advised to embrace rather than resist through another court challenge and thus seeming to encourage other acts stoking social tension.”

“ This is indeed a litmus test of 1Malaysia. The Prime Minister should let Malaysians be ONE in the belief of God and Allah, a ONENESS which will be promoted using a shared term ALLAH, blessed be His Name ! ”

“ Sarawak Government should ---reassure all Sarawak Christians of their rights under the Malaysia Constitution and the Spirit of the Malaysia Agreement,” says Ng. Under the Malaysia Agreement in 1963, Sarawak and Sabah people have greater space for religious freedom in spite of Islam being constitutionally defined as national religion.
Sarawak KeAdilan chairman, Baru Bian, declared that there “is no place for religious extremists and religious bigots in this country, as we are a nation of varied religious beliefs and practices. --Cobbold Commission Report clearly recorded that ‘freedom to profess, practice and propagate any religion’ should be guaranteed-- that ‘Sarawak should be a secular state. This is the reason I believe that today Sarawak remains as such without any official state religion.”
Dr. John Anthony Brian of Sarawak, wrote on his blog, “For Sabah and Sarawak we are watching UMNO reaction carefully. We fully understood PAS and PKR stance on the issue now. UMNO should be able to manage their response in the most sensitive manner to the feeling of non- Muslim too.” “As natives of Sabah and Sarawak, as “pribumi” of Malaysia with Christianity as our religion we can also exercise our rights to organize protest over ABIM / PKPIM protest. But where will this road lead us to?” he retorted, referring to planned protest demonstrations in KL against the High Court ruling.
This writer had written in his blog in April 2009, a related article “Sugguh Besar Allahku” based on an Indonesian hymn bearing that title translated as “Glory be to God.”
I wrote further, “--an Iban (Dayak) showed me the the first lines of the Genesis in the Iban bible where clearly the word Allah was used from the very beginning that the Iban Bible was published (add: about a century ago). -- the implications of such a legal ban on the word Allah, for Christians in Malaysia using the local language Bible. Enormous distress, to say the least.” Thus the majority of the indigenous Christians, not knowledgeable in English or Chinese, would not have any Bible which they can use, this an intolerable infringement on their constitutional rights on freedom of worship.
I further pointed out that an Indonesian Christian would be banned from bringing the Indonesian language Bible into Malaysia for personal use or as gift to a Malaysian Christian friend, and for that matter any other Arab Christian carrying an Arabic Bible into Mallaysia.
The international relations repercussions from the ban should be anticipated. The battered image of Malaysia overseas will be dealt more blows in both the Western and the Islamic countries. Malaysia would be singularly out of step with the rest of the Muslim world, often described as Ummah, by banning non-Muslims from using the term Allah; this a highly arrogant move against learned and authoritative Muslim sources locally and overseas.
The Islamic Society of North America (ISNA) commends the landmark ruling by a Malaysian Court on December 31, 2009, that affirms the religious freedom of Malaysian Christians. –“We call on the Malaysian government to uphold the religious freedom of Christians and to let the court ruling stand. We also urge Muslim NGOs to respect Islamic teachings and long-held Islamic traditions, and to withdraw their opposition to the use of the word “Allah” by their Christian compatriots,” its statement reads.
Malaysian authorities have clearly ignored the scenario that the gazetted ban may have extended repercussions beyond its own Christian and Muslim citizenry.
News of the controversy is already widely reported by the media worldwide. “Prime Minister Najib Razak called the A-word controversy a “sensitive issue” -- What a disappointment for a man who ran for office promising to create “One Malaysia,” writes the Wall Street Journal.
Significant damage may also result from the controversy in relations with the Indonesian people; Indonesia is the largest Muslim nation, with growing clout on the regional stage given historical, cultural and geo-political realities. Imported Malay language Bibles are from Indonesia; banning implies that what is acceptable to Islam in Indonesia is not to the government of Malaysia. What this arrogance would do to the recently bruised relations with the major ASEAN partner remains to be seen. Other ASEAN neighbours would surely not welcome any unnecessary strain on inter-state relations by a quirk issue.
There has to be a way out of this serious impasse threatening harmony, beyond the decisions of civil courts.
The people in Sabah and Sarawak may arguably be exempted from the ban on the basis of the Malaysia Agreement, but this would be a 2Malaysia solution, surely welcome by Sabah and Sarawak Christians but perhaps unacceptable nationally.
Writer believes it is the duty of responsible government to work on a couple of fronts:
1. Political. The crises is widely believed to have political partisan origin. The partners, other than UMNO, in the 13 party BN (national front) coalition should have their voices heard on the issue, however feeble, especially the BN partners in Sabah and Sarawak. Federal BN rules by virtue of support of BN partners in Sabah and Sarawak, so the leverage by the latter may not be that weak! The folly of the ban should be admitted.
There should be an all- party (including Pakatan) round-table to desist from further using the issue to partisan political advantage, but this contingent on the following.
2. Community. Rather than holding mass demonstrations, community confidence-building forums should by held, organized by government and civil society.

3. Inter-Religious Dialogue. This is perhaps the most crucial in influencing positive or negative development in other areas. Top religious leaders of Muslim, Christian churches, perhaps other religions, should sit and agree to a joint position which will guide community, political parties, government and perhaps courts.
Lawyer Azril Mohd Amin, writing at Malaysia Insider, called for mediation as an instrument of conflict resolution, this synonymous with the above dialogue proposal.
” The Catholic Church --has expressed its willingness to engage in dialogue with the Muslim clergy and find an amicable solution to the Allah row currently threatening—“ reports MKini news-portal. This is a reassuring development which writer hope and believe the Islamic clergy will respond favourably to, in genuine and respected Islamic traditions .

Concluding this review, and lest it be forgotten, may I share with readers :

“The great faiths, and would one dare to say scientific non-theist faith, are Divine gifts to humanity, different in form to suit different cultures, at different times of history. They are however very similar in substance, in the shared core values of love and humanity, and they should be universally shared in the globalised confluence of digital age civilisation.

That apparent differences in faiths may not lead god-created communities, and indeed the entire world, to self-destruction in nuclear-age conflicts, but that the shared universal values be the driving force bonding humankind, divinity and divine-created Planet Earth.” (Being Easter reflections April 2009 on my blog.)

May God Allah be praised!

PROJECT NEW MALAYSIA

“The Policies of Pakatan Rakyat.” THIS IS PROJECT NEW MALAYSIA !

Dr. Francis Ngu, member Parti Keadilan Rakyat, Sarawak. Dec.21^st, 2009

As the most serious nation-building document that has emerged for some time, the document now deserves responsible critique from the Malaysian community, partisan allegiance aside. This critique hopes to spur constructive public debate on the policies in the new found spirit of democratic participation ushered by the birth of Pakatan Rakyat.

This is an attempt to bring about far reaching reforms which the people are now anticipating. A fresh new national consensus is sought by Pakatan Rakyat which will be worthy of a progressive nation facing the challenges of the globalised scene of the 21^st Century.

It is wide-ranging in scope, covering major political, governance and social-economic areas, and is thus necessarily in an outline or summary form. Based on the “People’s Rights” values underpinning, it is now the role of civil and political society to fill in the details over time. Wide indeed are the spaces open up, in a new spirit of freedom, equitable rights and social compassion, to advance efficient and effective administration, infrastructure development, green economic progress, service delivery, etc. The agricultural sector however, deserves direct attention by itself.

Civil and political rights built upon an freely informed citizenry, will be guided by the Constitution and backed up by an independent judiciary and other effective criminal- justice institutions.

Beginning with a fresh Peoples’ Consensus, the Policy Paper not only calls for all to abandon ethnically and religiously divisive orientations, but to marshal all the strengths available from the fine values found in all religions and cultures to overcome the ills of society and nation. A humane market-based economy with more equitable wealth distribution will sustain a united people living in social harmony.

Under the part on Constitutional Democracy, the youth above 18 will be automatically given franchise. Malaysians will implicitly have to mature earlier, and the education, must among others, emphasize critical thinking and abandon rote-learning. The energies and creative imagination of Youth will be tapped earlier, as is the case in developed countries. The one- man one-vote principle will be enhanced, but part proportional representation is not as yet considered.

The spirit of Federalism (not just the letter of) is not only promised but guaranteed for Sabah and Sarawak by the Policy Paper. This, read together with the policy of administrative decentralization and Federal devolvement, holds hope for the 2 component States to explore a much higher level of State Autonomy as more and more strongly desired by Malaysians of the 2 States. Compelling political and historic considerations aside, greater devolvement of governance to the 2 states separated from the Peninsular by the South China Sea is technically and logistically more efficient.

Notwithstanding, wide devolvement of Federal functions and state funding realignment are by themselves giant steps forward for a united and progressive Federation. Guaranteed representation in Parliament by the smallest ethnic minorities of the nation in Parliament should be an added desired feature.

Attention is paid to regional disparity, and regional resource realignment is featured. Sabah and Sarawak can become the new engines of growth and progress for the nation, if the just guarantees of Federalism capture a new found sense of national commitment from Sabahans and Sarawakians at home and abroad.

Pakatan must remove a pervasive sense of despair and hopelessness of Sabah and Sarawak people facing decades of political and economic marginalization in the Federation. Pakatan “promises to make a fair and open assessment of the principal issues---”, but has not decided on whether the assessment is to be an administrative or academic research exercise, or of a more authoritative form, that of a Royal Commission on Sabah and Sarawak.

Thus Pakatan will be expected by Malaysians to make the first really serious national thrust in addressing regional imbalance and truly unite all Malaysians of Sabah, Sarawak and Peninsular Malaysia.

Based on the principle of People’s Economy, there is to be a beginning for Economy By the People, Of the People and For the People. This addresses a needs-based affirmative action policy, a social safety net for marginal groups, labour rights, minimal wage, housing for the poor, assistance to small private entrepreneurs.

Pakatan will thus put Malaysia on the road of social democracy, as practiced in advanced countries. The funds for social welfare will come from massive savings from prudent government spending and high financial integrity in government. Social welfare will itself boost domestic consumption and the retail and services economy.

Not mentioned, but needs-based affirmative action, and welfare benefits would require quite a large initial outlay in a sound means-testing mechanism to award eligibility, and periodic reviews of such eligibility. Introduced step-wise, cash welfare measures need not spark too much inflation, but be a small stimulus to an economy in 3 quarters of negative growth.

It is only possible to consider GST and withdrawal of fuel subsidies many years down the line, contingent upon broadly increased personal incomes and backed by a sound social welfare system.

On Infrastructure, broad-band internet must rank on par with other infrastructure, for both economic competiveness as well as environmental considerations. It is even said that before major highways are planned, the digital infrastructure must be assessed first. For one, work and other economic activities may be carried out from the home, reducing traffic on highways of large cities significant enough to slow highway development as well as reducing carbon footprint.

There will be belated but strong investment in public transport which is integrated and efficient; the public transport investment should cover smaller townships other than major cities to cover the day when fuel subsidies have to be wound down, and carbon auditing is enforced by an international regime.

On Environment, Pakatan should do more and set a step-wise timetable towards a future date by which to stop logging in all native-growth forest (primary jungle), and log only secondary and planted forests. This could be built into the international carbon trading schemes, and future international assistance in reforestation. The remaining living Habitat must be preserved for the welfare of the indigenous peoples, other environmental and ecological considerations not forgotten.

Environment education and consumer behaviour, human rights should feature strongly in the civics subject in schools, but no cramming for examinations please!

On Education, the challenges of the global village, may require the national education system, to be defined not as a conformist monolith, but to embrace diverse streams of education, including mission schools, mother tongue schools and even private schools.

A high level of autonomy for mission and mother tongue schools, even if government funded, should be assured to best bring out their time-tested dynamism, in healthy competition with fully national schools.

The growth of the services economy will derive essential strength from multi-culturalism;

opportunities should be widely available to learn several other foreign languages.

Critical to the nation, education must move away from rote learning for examination, to critical thinking, mental creativity, formation and articulation of ideas, communication of ideas, personal development, lifetime learning, appreciation of the arts and heightened social consciousness. Upon these are to be built, science, technology and material progress.

Malaysian people have a repertoire of artistic talents in their blood, but locked away under the stress of a materialistic and authoritarian society. How will their artistic and cultural talents be fully unleashed to add to both the spiritual and material wealth of society?

Greater attention needs be given to education in culture, and training in visual and performing arts from nursery to university. Music is acknowledged to promote neuro-linguistic development, benefit mental, even physical health. Social experiments among the poor enclaves in a Latin American country is said to have reduced crime among juveniles. Would music and arts be a relatively cheap instrument in addressing social problems in Malaysian youth?

Clearly, Pakatan is holding up public health sector as the mainstay of health policy, with implicit increase of both infrastructural provision and service funding. The Malaysian Health Services Commission will arrive, only a few decades later than advocated by the medical profession!

Conceivably with its inauguration, there will promptly emerge a National Health Plan with a national health financing mechanism to back it up long term. Health care is an extremely complex field; Pakatan should consider stepping up Health Services Management and Planning training to prepare management personnel conversant with issues facing modern health care delivery.

The excellent policy paper has not however mentioned Science and Technology Development so essential for Malaysia to free itself from the “middle income trap” or “the resource curse”, as so eminently addressed by an UMNO veteran Tengku Razaleigh Hamzah. There needs to be a further policy statement on Research and Development.

The Barisan federal government is now challenged with a serious and quite comprehensive policy paper from Pakatan Rakyat, to which now it would do well to give a meaningful response; such would be expected by people living under a two-party system.

No document is perfect, this included. For now, Pakatan joint policies put forward are certainly adequate to pull Malaysia out if its deep doldrums, even its terminal crisis. Fullest credit must be given to its brain-child, Datuk Zaid Ibrahim.

For the future, the document will surely be continually refined and improved with the participation of all Malaysians, partisanship notwithstanding. This must stand as a central and historic document, a living document whose narrative will steadily grow to meet the continually progressing aspirations of a nation whose citizens are seeking liberation from tyranny and authoritarianism.

This is Project New Malaysia, belonging as much to the people of Sabah and Sarawak as to people in Peninsular states. This is the tough project which all Malaysians have to work on for the next several generations. Until then, Malaysians will not be able to stand tall and equal. God-willing, and Insyallah, it shall succeed!

Upon Project New Malaysia, the health of the nation will be restored, its place in ASEAN and the international community enhanced. A New Malaysia in a New Dawn deserving of the commitment of every Malaysian!

My alma mater

St. Joseph’s School Rally
Sons of St. Joseph a voice is resounding,
Promptly respond to your duty’s sweet call;
Answer you all for the trumpet is sounding,
Your mater’s proclaiming her watchwords to all.
Forward her children dear,
Ever with hearts sincere,
Render with joy to your mater her due;
All that is vile reject,
Heaven will e’er protect,
Sons of St. Joseph’s valiant and true.
Prayer and labour your motto still bearing,
Forward with courage in ways that are just;
True to your standard be doing and daring,
As faithful Josephians in Heaven will trust.
“Once a Josephian, Always a Josephian!”

MALAYSIANS, LOOK EAST THIS AUGUST 31ST. !

Francis H. H. Ngu , Kuching, 31st August, 2009.

It has been some two decades since Malaysia under Mahathir adopted a Look East Policy, using Japan as the model for the development of Malaysia. On a historic day of political change in Japan, the Look East Policy is revisited for its broader ramifications to Malaysia.

The diligence of Japanese workers, work ethics and the team spirit are indeed worth emulating, but then these are the product of hundreds of years of culture. The backdrop of that culture includes hardships resulting from natural calamities, and sparse natural resources, against which Malaya and Borneo were and still are in sharp advantage as compared to Japan. The Japanese is also a culture where the prominent influence of Chinese civilization stares in your eyes. From tea-drinking and Buddhism, to chinaware and painting, and to lexicon and calligraphy, the creative Japanese have brought the Chinese influences into their unique own.

On to their own rich culture too, were grafted the science and technology of the Western industrial revolution through the process of the Meiji Renewal, and western concepts of democracy and Human Rights, particularly after WW II.

From the start, Malaysia looks a vastly different substrate from Japan. It has a culture on which Indian, Arabic, Chinese and later Western colonial cultures were preeminently grafted on to the indigenous cultures of the Malay archipelago. The foreign input into Malaysian culture may thus be said to be more sustained, direct and diverse than is the case of Japan. The strong infusion of the English language through colonial government and the growth of Chinese language education through sheer commitment of the sizable Chinese ethnic minority are also distinguishing features. The legacy of the British judicial system and the structured civil service, also puts Malaya and former British Borneo in comparative advantage. The Constitution and Westminister styled parliamentary were to be the basis of the healthy growth of a young nation.

Why then did Japan rise as Pheonix from the atomic holocaust of WWII to become the second largest economy in the World, and Malaysia rose to the Second World, but is now under threat to slip towards the Third World again ?

At first glance, Malaysia appeared open to positive foreign influences, from including its once aggressor, Japan; and Malaysia even promised to take a lead in the ICT age through the Multi-Media Supercorridor. But did it even ever Looked East to Japan ?

Japan was and is not shy of foreign influences, East or West, while Malaysia in great but unintelligent nationalist zest, jettisoned the English language from the education system, thus shut itself from an invaluable comparative advantage asset of learning and communication. The Chinese language education was softly suppressed, thus depriving Malaysia leverage of what is emerging as an increasingly important international language.

Japan kept corruption and crony-capitalism at bay through a robust criminal justice system; from the 1989 Judicial Crises, the Malaysian executive branch has controlled the Judicial branch, subverting the separation of Powers so essential to the healthy functioning of democracy. What is a great strength of Japan was not taken on board, but what functioning judicial infrastructure Malaysia had was slaughtered.

Japanese enjoy civil and political rights little different from any liberal western country; Malaysians are to be cowered by repressive legislation governing behaviour of academics and higher education students, the print media and rights of assembly and expression. Is it so difficult to understand that the free intellect and the free individual is the basis of a creative community and nation?

Malaysians are not allowed to learn the art of accountable local government from Japan or anywhere else. Grass-roots democracy or participatory democracy are remote concepts in Malaysian lexicon. Why deprive the Malaysians a vital instrument of social commitment and engagement? Are these latter not the accompaniments of the Japanese work culture about which Malaysians were exhorted to emulate ?

Look East or even look anywhere, has thus been mere rhetoric mired in the broader Malaysian ruling National Front agenda of the political and economic supremacy of a monoculture; as incitefully coined Ketuanan Melayu, this a mere pretence for the political survival of an unpopular ruling elite class.

The rejection of English may have had the effect of shutting out western ideas of civil and political rights, egalitarianism, feminist ideas and possibly religions deemed Western. Thus English language was temporarily brought back for Science and Mathematics education, but not for the liberal Arts subjects, if there is anything Liberal in Malaysian education. The refusal to promote the Chinese language education is to be understood from the ruling perspective and priority about monocultural hegemony over broader national competitiveness issues.

The Malaysian crony-capitalism, corruption, and political hegemony founded on race rhetorics meant that the worst aspects of the free market far supercede the its better strengths in its impacts on Malaysian economy. Distortion to labour, prices and incomes becomes further bugbear to progress and social stability. Investors leave Malaysian shores.

The political change of the largest world economy, USA, and now the second largest, Japan, puts Malaysia and the world on notice. On the heels of China, the new Democratic Party government of Japan will be using social welfare spending as one of the tools of stimulating its long ailing economy. Will both China and Japan be building a social security system to match those of western social democratic systems?

One can look East, South, North and West, the message is unmistakenly clear every where; CHANGE WE MUST ! Look to Japan for a smooth transition of power in a mature democratic Land of the Rising Sun. Looking East this season for Malaysians is as good as looking anywhere else, and look East really hard this time round.

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.’