Saturday, May 24, 2008

Malaise in our Public Health Services

Malaysiakini carried a 2-part opinion piece, by Dr Ahmad Sobri on the sad state of affairs of our public health services, particularly on paediatric cardiovascular services which seem to be going nowhere. See Malaise in our Public Hospitals

We had recently heard from the press that we would be sending some of our congenital heart disorders to a well-known hospital (The Narayana Hrudayalaya) in Bangalore, India at taxpayer's expense. Interestingly we were told that these surgeries would be performed at a surprisingly economical RM 10,000 per case, excluding transfer costs. Another critique (Bangalore heart trip self-inflicted malady of Malaysian healthcare) has detailed the state of malaise in our public health services, especially that related to cardiothoracic surgical services.

What was of course surprising was the haste with which the new Health Minister announced this, and I am sure many of us, doctors and cardiologists in particular, were shocked and dismayed that once again our health care services have been found wanting, and that we have to resort to sending our citizens away to foreign lands for so-called expert surgeries.

It harks back to the days in the 1960s and 1970s when we had to send our cardiac patients to Australia, New Zealand, UK and even the Philippines long before our own cardiac services were developed... Then, I am aware of two preeminent cardiac surgeons who provided great support to accepting our patients on a charitable basis: the late Sir Brian Barratt-Boyes (Greenlane Hospital, NZ) and Dr Avenillo Aventura (Philippine Heart Centre). [Interestingly and sadly, Barratt-Boyes passed away 2 weeks following double-valve replacement surgery at the Cleveland Clinic, in 2006 at the age of 82 years.]

Now some 30-40 years later, we appear to be sliding back in time, when we appear to need assistance once again to tackle the backlog for our own hapless citizens. How is it that we cannot develop a programme strong or farsighted enough to cater to our changing needs? How can our health care planning be so piecemeal that there appears to be no sustained or long-range vision for continuity?

Why has our institutions and public hospitals failed to harness a failsafe system of continuously and systematically training and apprenticing a steady crop of well-trained and dedicated specialists and support staff?

Why are we always losing so many experienced staff to the private sector (where some do become underemployed and underworked) or worse to other countries, where their skills are lost forever to the nation?

Why do we make many doctors feel that no one is indispensable, and that every one can go whenever they want or wish to do so, ("we can do without them")? Why do so many petty-minded individual egos of ambitious heads of departments, seem to derail the prospects of bright and enterprising doctors from staying and contributing?

Perhaps, we have too much of a civil-service mindset, which dictates that someone has to leave, so that they can be replaced. Perhaps, we have been promoting too many unqualified or under-qualified people, based on dubious merits and hence contributing to the Peter principle of mediocrity breeding mediocrity, with nary an outstanding person to replace the less able but self-interested head.

Why are we not allowing greater diversity of talented doctors/specialists/experts to remain in public institutions and jealously guard their rights and livelihood? Why do we let petty Napoleans (administrative tyrants) create their inner circles of cronyistic yes-men, who can then only perform at levels so low that no major advancement or improvement can ever be permitted to emerge? Hence we have been having fluctuating fortunes of various departments and specialist units which thrive or deteriorate according to staffing or expertise strength.

I think the Ministry of Health (MOH) and our medical institutions (including the universities) must look at itself honestly and objectively, and see where they have gone astray. We must ask how we can now come together to develop a health care system which guarantees a steady stream of skilled personnel and experienced specialists to cater to our ever more demanding populace.

Building hugely expensive monuments of health care facilities without the needed ancillary staff support and the expertise, are all exercises in futility and smacks of sinful profligacy of hard-earned and finite public funds!

It is good to reflect on some of the unique suggestions made by Dr Sobri. Perhaps, from afar, it is easier to say what needs to be said without the fear or nicety of being too close or too personal.

Let's resolve to do better. The MOH must see the entire health sector as one, and not as a dichotomy of public versus private interests. The MOH must not be always seen as being too interested in correcting the perceived wrongs and misdeeds of the private sector, to control through more and more bureaucratic regulations and dictates; while ignoring its own backyard.

These breed wider chasms of viewpoints, discontent and noncooperation, although in the shorter term, these paint a deceptive papermache veneer of having done something for the public...

But the reality is that we don't necessarily need more laws and regulations. We do need however, better and more concerted planning and execution of farsighted and far-reaching policies.

We must realise that we haven't progressed as much as we should have, (when we compare objectively with our neighbouring countries) notwithstanding all the excuses, the blame-shifting, the beautiful structures...

As I have said so before, our health care delivery system is simply too patchy and inconsistent, and for the poor public out there, it might be too much of a lottery to obtain the best possible access to treatment; especially when they have very limited choices, or none at all.

A shorter version of this appears in malaysiakini as State of our health

1 comment:

Dr D Quek said...

Dato Ron McCoy emailed me the following comments:

"Dear David,

It is a sorry tale of the state of health care in the country, which has suffered for decades because of a fractured national health policy and incoherent MOH officials, including both civil servants and politicians. Health care has always been a low priority issue with successive governments.

The MMA must accept some of the blame because we have not pursued health reforms with the commiment and passion that it deserves.

Civil society has been suppressed and stunted by an authoritarian government for 50 years, which thrives in a feudal society that has to learn to challenge authority with courage.

The people who can make a difference are largely unaffected and therefore unconcerned with that mediocre standard of public health services, because they are politically connected and therefore able to access public health on a semi-private basis or economically able to use the private sector.

Health tourism is going to exacerbate the public-private divide further.

I think the MMA should... bring the concerns expressed in the email to the DG's attention and get his response to some of the claims made in the email, which may or may not be accurate.