Thursday, November 26, 2009

1 Malaysia Clinics: More for the Haves?

1 Malaysia Clinics: More for the Haves?
Dato’ Dr Sarjeet Singh Sidhu
Hon. Dep Secretary, MMA

No sooner had the PM announced the 1 Malaysia Clinics to be set up in urban areas the idea was being lauded by one and (almost) all. 
On the surface it does seem to be a good idea. I mean who can quarrel with the idea that now more (Govt) clinics will be within striking distance for the urban folk in our over-extended, sprawling cities? 
No more long distance travels and no more long waits and the poorer sections of the rakyat can get the same treatment as their better-off counterparts who will be visiting the private clinics to avoid long waits at the Govt hospitals. That in essence, I think, is how most people will understand the concept. But no, some people have a different, if flawed understanding.
With the concept of 1Malaysia still quite nebulous in most citizens’ minds it is inevitable there be some confusion. The 1Malaysia concept is understood by some to be a vision wherein we (Malaysians) will think along non-ethnic lines, and by some to mean there will be a cross-section of ethnicities represented in every (Govt) department and in every phase of the nations development, that all Malaysians will have equal access to Govt funds (scholarships for example).
In general (hopefully) most Malaysians think it means or must mean 1 Malaysia policy should serve all and equitably[1] or as some voices on one forum [2] said:1Malaysia to me is Malaysia for Malaysians... 1 Country regardless of race” or “1Malaysia... A country of equal opportunities...  And ethnocentrism is a thing of the past.
Whatever each individual’s perception of the concept the PM says that “the 1Malaysia concept’s ultimate objective is to achieve national unity among its people. He said "In other words, 1Malaysia is a concept to foster unity in Malaysians of all races based on several important values which should become the practice of every Malaysian””. [3]
Here is one more Malaysian who does not quite know what it all means; he asks: Can someone enlighten me why there are plans to have "1Malaysia Clinic"? Do you mean that the clinic have Malay, Chinese, Indian and other doctors operating in? Do you mean that other clinics are not par with 1Malaysia theme? where clinics are not open for all? Do you think this "1Malaysia" tagline is over-used? [4]
So now that we are sure that many Malaysians are unsure as to what 1Malaysia means perhaps we can take a look at the shortcomings in relation to the 1Malaysia clinics.
The World Medical Association (WMA) and the United Nations encourage “Task-Shifting” (TS) in specific situations. The WMA Resolution on TS [5], adopted by the WMA General Assembly, New Delhi, India, October 2009 describes it TS as a situation where a task normally performed by a physician is transferred to a health professional with a different or lower level of education and training, or to a person specifically trained to perform a limited task only, without having a formal health education (my emphasis). It further states A major factor leading to task shifting is the shortage of qualified workers... The rationale behind the transferring of these tasks is that the alternative would be no service to those in need (again emphasis added). The WMA does, however, caution that This may be appropriate in countries where the alternative to task shifting is no care at all but should not be extended to countries with different circumstances; in other words TS is not for places where there is already available quality healthcare provided by doctors.
Clearly, in our situation where the stated reason for opening these 1M clinics is to ease the burden of government hospitals as there would be more patients seeking treatments for minor illnesses in these clinics [6] the care will be provided by less skilled personnel (“manned by medical assistants or paramedics”). It would be difficult to oppose the plan if the 1M clinics were actually manned by doctors, but that is not the case here.
To my mind the obvious flaws in the IM clinics plan are:
  1. These will provide service by less qualified personnel to that segment of Malaysians.
  2. Not withstanding the above, these clinics will provide additional services to those who already possess such services by qualified personnel.
  3. What is the standard of care that the courts will expect from these 1M clinics? If a lower standard is expected (i.e. commensurate with the training and expertise of the MAs) then this is clearly a case of providing lower standard of care in areas (urban) where a better standard of care is already established via the plethora of GP clinics in urban areas.
  4. What will be the legal liabilities arising out of medical mishaps consequent upon the use of “medical assistants or paramedics”? And mishaps will arise sooner or later.
As Dr Mary Cardoza pointed out in an email correspondence “the concept of "bringing the service to the people" is good but there are already many GP clinics in the towns (to) provide this service to people.  The obvious areas where these IM clinics will be of better use are areas where NO service at all is available for now. Examples that spring to mind are the Orang Asli settlements (especially if far from towns), and the deep interiors of Sabah and Sarawak.
Every year Malaysia is set to get 3000 new doctors entering service (half from local universities and half from overseas universities). Already we have insufficient places for their housemanship training; many will be quickly released and enter private practice. How are all the current GPs and the new ones expected to come in going to make ends meet?
According to a Bernama report Penang is already looking at sites for these clinics [7] and this despite the knowledge that Penang already has so many GPs and Private hospitals in such a small area. This is again a case of providing even more benefits (IF there is any benefit to be derived from treatment by less qualified personnel) to those who already have more than ample access to healthcare whilst leaving out those who have NO access to healthcare.
It’s been reported that For a start… an allocation of RM10 million will be provided to set up 50 clinics in selected areas” [6]. That works out to RM 200,000 per clinic per year. Now if the REAL aim of the 1M Clinics is to ease the burden of government hospitals as there would be more patients seeking treatments for minor illnesses in these clinics” [6] then it will be far more prudent and convenient to spend that money by roping in the GPs who already dot the entire landscape of most cities and towns. Again as Dr Mary Cardoza points out in her mail “MMA has offered the services of its members for this purpose many years ago and was told that this was accepted in principle; however, nothing concrete has materialised”.
I, for one, cannot fathom how 10 clinics, strategically located in overpopulated areas of our cities, with ample quality care available can be a move forward because they will now have even more clinics, run by less qualified personnel, to make life easier for them, whilst large areas with no or inadequate healthcare will remain so for some time more? 
Is it because these areas are under-populated? 
Am I missing something: more for the ‘haves’ and less for the ‘have-nots’?


  1. NST 23 Oct 2009
15 November 2009
After I wrote of the above it was brought to my notice by a politically well-connected individual that there is more to the 1M clinics than meets the eye. It seems that the push for such clinics came from the Medical Assistants (MA), once called Hospital assistants (HA), and recently “promoted” to Assistant Medical Officers (AMO). Evidently the suggestion for such clinics, to be run by the MAs/HAs/ AMOs, came from the MAs themselves. It’s been said that this is one way for some of them to remain in the urban areas (mainly the cities and larger townships) and not get posted out to remote areas. The designation as AMOs gives them better status and, together with the running of the 1M clinics, will add weight to their requests for a jump to a higher level on the pay scale. But why would anyone pay attention to such requests? Well, it’s been said that are many of these MAs, and a great number of them are active (influential?) party members. Makes sense? It does if the story is true.

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