Doctor consult at MOH hospitals to remain at RM1 and RM5...

(See also Malaysiakini State of our Health)

In a climate of rising costs across the board, it is heartening to hear the Minister of Health proclaim that the cost of consulting with an MOH doctor is to remain the same, i.e. RM 1 for medical officer, and RM 5 for a specialist (The Star, June 11, 2008). And this includes medications to whit!

The MOH spends a disproportionate amount of money providing heavily subsidised health care services (RM12.9 billion)--from primary to tertiary levels--to our Malaysian citizens, and some complain also to a large number of illegal immigrant workers and their families.

Yet despite this, we are not a recognised country with any consistent form of universal health coverage. Universal health coverage is noted for example in Canada, Australia, the United Kingdom, and most of Europe. Other nations attempting some form of universal coverage include India and recently Thailand.

Nevertheless, our public health sector does play an important part in providing very affordable health care to some 70 per cent of the population. Fortunately too, this public sector has not yet fallen under the economic juggernaut of free-market dictates of getting every citizen to pay for services at market value and prices!

Although our health care budget has remained relatively low (3.8%: with the public sector spending 2.2% of the nation's GDP, 1.6% by the private sector, UNDP Human Development Report 2006) we have always been touted as having one of the best and more accessible health care services in the developing world. Our rural health service where there is an accessible health facility, within 5 km in any direction, is commendable and has been emulated by other developing nations. Yet, although modeled some 30-40 years ago, not much has changed.

Simple uncomplicated health matters, such as childhood vaccination programmes and maternal antenatal-perinatal care are one of the best aspects of our rural health services. Thus, previous scourges such as polio, tetanus, diphtheria and whooping cough are now rarely encountered and are almost totally eradicated from our Malaysian shores. Our childhood mortality data shows that we have now an enviable rate close to most developed nations.

(Tertiary and catastrophic medical care, on the other hand, are another matter, for which our citizens' access is still spotty and where we still lack direction, continuity or consistency of care.)

But there are deep pockets of very erratic and unapproachable sectors especially in the jungles of Sabah and Sarawak where, the indigenous peoples are somewhat left outside of the loop, and are seriously underserved.

Flying services into these remote sites (frequently the only access mode available) are subject to the caprice of the weather as well as to the mechanical uptime of the helicopters/small planes, and the grudging willingness of rostered medical personnel.

To top it all, some grandiose mis-planning of a few new health centres certainly take the cake for stupidity. Some facilities have been built without considering the lack of continuous piped water or regular electricity supply, or even accessible roads, becoming the proverbial white elephants, so emblematic of political and bureaucratic profligacy and waste! I learned of some of these missteps when I had the privilege of participating in SUHAKAM's health accessibility forums in Kuching (November 2007) and Kota Kinabalu (January 2008). See Equitable Access to Health Care for All.

Many interested citizen groups are aghast and indignant as to these pointless exercises in futility, but for me, they serve as eye-openers which should help future planning as well as to forestall and guard against such gross miscalculations from ever occurring again. However, as many are wont to point out, bureaucrats with political motives and expediencies have pretty short memories, but very thick skins and over-expressed egos and self-interests!

I also remembered that the previous Health Minister talked about the development of mobile clinics to be deployed to suburban areas in the hopeful belief that these would cater to the suburban poor and neglected (these would naturally costs some hundreds of millions of ringgit!). Some hundred-odd clinics were to be newly equipped and manned to help disperse the normal crush at our outpatient polyclinics at larger district hospitals in the country, or so it seems.

However, this idea seems to run counter to the fact that many of these areas are already served by many private clinics which competitively vie for a piece of the diminishing pie! That these public mobile clinics should now compete unfairly with our private brethren doctors appears inefficient and callous. After the election of March 2008, we have not heard of the rehashing of such plans--so perhaps it is good that they should not be resurrected!

Then lately, the new Health Minister once again suggested that perhaps it is timely to tap into the private sector to help complement the outpatient services of the MOH hospitals, which initially generated a great deal of interest among some GPs (The Star, June 13, 2008). He lamented the fact that so very few doctors are willing to serve in MOH facilities to ease the manpower shortage--is it possible that RM80 per hour is considered not sufficiently attractive?!

Perhaps dispersing the outpatient load out to local neighbourhood GPs with adequate compensation and contracted pay-for-performance standards can be a reality in the near future--thereby enhancing the much-talked about but poorly realised public-private integration goal for the health sector.

In another development, the respected Sultan of Perak Sultan Azlan Shah suggested that perhaps the private sector through donations, can help out to contribute more towards public health care facilities (The Star, June 13, 2008). However, private donations and endowments can at best be sporadic and piecemeal, and would not be a viable or sustainable long term affair or effort. Moreover, selfless philanthropy toward public good isn't exactly Malaysians' forte or natural inkling; although there have been notable exceptions.

While philanthropy is a good gesture of corporate social responsibility (CSR), it should not be any private citizen's (corporate or individual) responsibility to upgrade and/or maintain such public health care facilities. Our tax dollars through careful and appropriate allocations should bear such budgetary and fiduciary responsibilities.

I wonder how much longer our government can sustain such a mechanism of subsidising so heavily the public health care sector; notwithstanding its role in maintaining its social compact, and providing the very essential safety net for the bulk of modest-earning Malaysians, including the chronically-ill, the unfortunate, the stricken and the needy.

What is interesting is that even with the much discussed (yet to be finalised/implemented) National Health Care Financing Scheme, for civil servants and their dependents, it has been reassuringly confirmed that they will still be under the direct purview of the government coffers. This qualified exception is something quite uniquely bothersome, which could derail the meaning of what is to be 'one' uniform system of National Health Service for the country, i.e. universal access to health care for every citizen.

Perhaps, to remove this entrenched civil service benefit is too great a political dice to throw, and the anticipated backlash and fall-out too nasty to fathom! What's troublesome is that this effectively excludes more than 1.2 million public servants and perhaps another 4 to 5 times the number of their dependents, or more from this proposed scheme (that by whichever reckoning appears to resemble the British National Health Service).

For the private citizen, that is another matter, this scheme is theirs to contribute and finance, but is it theirs alone?

One wonders if this is workable, especially when we are planning for this so-called 'single payer' system. Aren't we jeopardising the law of maximum numbers when we hope to tap into the largest community-rated scheme ever, so that individual premiums can be most affordably capped and therefore be most cost-efficient?

We all need to have a good re-think on this. We need more dialogue and inputs from all the stake-holders, but especially from the public who will be directly affected, and the health care providers who will need to adjust their roles and responsibilities. Will free-market health care see its demise any time soon?

More importantly, will a hurriedly pieced together scheme suffer the real but ignominious possibility of insolvency and failure to deliver, that has wrecked so many other national health systems the world over? Perhaps, the devil we know (even, if quite imperfect) is better than one that we don't...