Sunday, March 15, 2009

Whither Medical Excellence for Malaysia, vis-a-vis Singapore?

Time magazine's 23 March, 2009 issue carried 4 striking pages of frontispiece advertorial from Singapore Medicine. In short, it captures the essence of what Singapore usually touts itself, i.e. that Singapore is "the ultimate healthcare destination—one destination that's done them all."

4 simple steps are articulated:
1. First, collect really good doctors,
2. Then, put them into slick healthcare facilities,
3. Third, connect the above two to a wonderful healthcare system, and
4. After that, put them all into an accessible, convenient and safe country.

It goes on to say that "putting them all together takes some skill but even trickier is making it sustainable and not just on paper. Prices must not escalate, the public sector must continue to serve the local population, the quality of healthcare must not fall, and the commitment of putting patients first must not waver. Keeping all things in balance is where many stumble. There... 4 easy steps to create a world class medical destination. Not many actually get there, but some do..."

There is much that can be admired with such a simplistic take on marketing and self-assurance. But we in Malaysia already know that Singapore and its proud citizens appear to have buckets of such self-belief and its carefully-nurtured culture of excellence and meritocracy.

Its government of PAP-leadership and dominance for 44 years, has never pretended otherwise, and has always exhorted its citizens to be world-beaters, the best in the world that they can ever be, and has striven relentlessly toward this goal.

Founding patriarch and much admired (and criticised) Minister Mentor Lee Kuan Yew brooks no nonsense when he plainly tells his wards that unless Singapore invests in its people and services par excellence, Singapore will not survive.

Especially so when seen in the context of it being surrounded by a sea of potentially hostile neighbours. It's probably not too blunt to say that not too many are enamoured with or are in fulsome praise of Singapore's stupendous progress. Notwithstanding its much acclaimed if disgruntled "pulling-up-its-own-bootstraps" performance and efforts, there is more begrudged resentment than genuine approbation. More than one piqued regional leader had even labelled Singapore, an inconsequential "tiny red dot" in Asia. Another exasperated Taiwanese legislator even decried and denigrated Singapore as an cocky "booger".

But let's be brutally honest. It is one bright spot, one that is nigh impossible to ignore! One that has put many lesser or even greater nations to shame! Why? Because its dogged pursuit of nearly incorruptible and flawless administrative and socially-directed economic policies, has made this tiny island city-state into one of the wealthiest nations in the world.

Economically and administratively, Singapore has excelled. It has become one of the richest nations (albeit for a small population of around 6 million). It has also been recognised as one of the least corrupt, most efficient, most business-friendly, unabashedly meritocratic, 'squeakily' cleanest countries in the world.

Yes, it has done so with uncompromising suppression of its still fledgling if dismembered hapless opposition. Anyone who dares to challenge its superlative vision, who dares breathe and preach too much unfettered democratization, who dares criticise the government or its methods, without the full facts and arguments of any semblance of brilliance and superlative moral scruples, would be vigorously challenged to the point of utter defeat, even destruction.

Thus for a long time, the people of Singapore has had to stifle their creative juices or indulge in any piddling aspirations for greater freedom of expression—why rock the boat, why derail the gravy train that has provided so much, so well, and for so long...? What's the beef about having your individual say when you can't provide a better alternative?

Singapore still believes in a unique form of rigidly-guided democracy, one where a paternalistic neo-Confucianist mindset oversees its top-down system of highly-virtuous mandarin-like governance, where state interests supersede individual freedoms—which, to be fair have been loosening recently...

Still, it is also one of the most autocratic, which has relentlessly bankrupted many an opposition politician because of their less than stellar pursuit of the truth, or even the most 'innocent' moral taint. The leaders rigorously prosecute civil defamation suits as its checks and balances against any perceived slight on the Singaporean government's honour and its jealously guarded 'morality'. Foreign news media are also not exempt from the overarching reach of its prosecutorial tentacles—a Wall Street Journal editor has just been fined S$10,000 for contempt.

But it has delivered its promises of an enviable, comfortable, high quality of life, if not socially, at least materially, within the constraints of its tiny footprint in terms of land area, natural resources and influence.

Thus, it is not surprising that it has always had aspirations to grow to its self-realised larger-than-life potential of being an economic giant which can teach the world a thing or two, about what constitutes good governance and administration.

This is a neo-Confucianist-Asian model of philosophy-king benevolence, where the majority of its citizens thrive and are taken care of, to the point of placid contentment, and indeed docile acceptance of its pampered lot, and timorous awe and deference of its puissant godlike leaders.

It probably is unfair to label its citizens as subservient, but many of my emigrated friends are quite content and happy with the status quo, which has bred a less critical mindset, but who remain seriously competitive and very intolerant of inefficiency and corruption.

It has developed into a world-class services centre, which vies with and competes unyieldingly with the best in the world. In this context, are we surprised that Singapore would have tried to do their stuff any differently? No, that is why in many ways and on many an occasion, that is their modus operandi. It has not been afraid of attracting foreigners to beef up its intellectual genetic pool.

It so happens that healthcare is just one of its core centres of excellence—and Singapore has undoubtedly projected its strength and its capability by showcasing more than a few of its superlative talents and expertise.

Thus, our neighbouring city state has been constantly and consistently selling its excellence, and not unashamedly touting its own super duper facilities and expertise. This, Singapore and its supremely confident physicians and surgeons, have always positioned and marketed its declared supremacy, its capacity for the best experience and delivery that modern healthcare can offer and then some more.

Sometimes, these promotional exercises can be very overbearing and over the top. Although mostly uninvited in neighbouring ASEAN countries, Singaporean healthcare companies have brazenly advertised in naked marketing activities which appear to infringe upon the codes of conduct of local or regional medical practice. (Advertising, while frowned upon, has been removed as a punishable professional misconduct in the city-state, in line with free trade expectations.) Such excesses, even if pursued with ignorance, smacks of arrogance, which rightly peeve many local physicians—they are viewed as being too brash, too boorish, too deprecating of local/regional standards, or lack thereof.

Many Malaysian doctors feel piqued and somewhat angered that they have been unfairly compared with, even slighted. Our egos become deflated, when comparisons of our lesser performances are highlighted. On more than enough occasions, our shortcomings become glaring and we get irritated that for some reason of other, we appear second-rated and not nearly as good as we should or could be.

Deep down perhaps, there is that little bit of green-eyed envy that for some inexplicable reason, in some instances at least, Malaysian healthcare cannot really be considered at par with many aspects of that of Singapore.

What piques us is that many of our own locally-trained doctors are now practising in Singapore, our own colleagues of yesteryears who have found the climate of challenge and excellence to their liking and choice. At least half a dozen of my own class of 1979 University of Malaya's medical school are now deeply ensconced in the Singapore health care system—and thriving well! Many more of my school friends from the 1970s are also excelling and serving in the Singapore Medicine system.

But I suppose this is true of any community—we are now so globalised, so mobile, that we can be wherever or whoever we wish to be. It is sad but not altogether surprising that so many of our talents have found the Singaporean experience to their taste. For a myriad of reasons, there have also been others in other countries, who have chosen not to return to serve in our Malaysian shores...

Because, Singapore has always touted its unapologetic culture of excellence and meritocracy, many talented people especially those from nearby Malaysia, are attracted to and would naturally gravitate towards such a city state. The attraction is due to possibly sociocultural similarities and even ethnically-proximate comfort zones. Malaysia's loss, as they say, is Singapore's gain...

More seriously, we have to ask ourselves, Malaysian doctors, where we are in the scheme of things? Are we truly comfortable with where and who we are?

Are we necessarily inferior in delivering healthcare? Are our standards below par, when compared with Singapore and the rest of the world? If this is so, is this perception unfair and unrealistic, or is it the unvarnished truth?

Why is there this divergence (or at least that notion) in health care delivery and standards when not too long ago we were so close as to be one single country and people in the 1960s? Perhaps, because any if not every doctor in Malaysia can possibly work in Singapore, (we are suitably qualified and registrable) there should not be any reason, why we should be looked upon differently.

Still there's that general perception (among some discerning Malaysians) that delivery of services is sufficiently contrasting: that superb consistent competent care can more often than not be obtained from Singapore rather than in Malaysia.

Why this possibly preferred pilgrimage across the Causeway for many a second or third opinion or tertiary specialised medical care, remains an ultimate choice for many a patient who can afford to choose... The reasons are thus, not too hard to fathom...

Until and unless Malaysia get beyond its own parochial and ethnically-sensitive constraints, it will be hard for us to compete for such true excellence. We can gripe and show all our angst and outrage, but we will have to do more to show that we can be truly world-beaters.

It is no shame to look over our nearby shoulder across to Singapore, and see how they have done so well, so fast and so consistently. I believe we do have the human capital, which we have shared from a common stock for so long.

It is just the will and the determination to want to be the best, to maintain that excellence of service, that is lacking or missing...

A slightly abridged version appears in the opinion section of malaysiakini "Whither Medical Excellence for Malaysia" (published March 20, 2009)

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