Thursday, November 26, 2009

1Malaysia Clinics: It’s time to get angry, agitated, involved!

Dr David KL Quek,

“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions  and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.”
~ Sir William Osler

Once again the internet and the alternative media are abuzz with recriminations and angry bloggings on why such an obviously regressive move has been foisted upon us, the hapless doctors, especially the GPs in urban locales!

Yet, a few public-minded readers of main stream media had only high praises for the government for proposing these new free clinics for urban dwellers, as evidenced by the letters of support in their interactive columns.

This is not altogether too surprising because, many of these people obviously feel that health care costs have become too costly for them to afford, but which is quite unsupported by the facts on the ground. Our private health care costs are quite reasonable and of high standards when compared with our neighbouring countries, in terms of purchasing parity or inflationary terms.

Perhaps, for too long the government has been offering practically free health care services to nearly everyone, so much so that not many people bother to plan or budget for any such ‘extra’ expenses. Perhaps, we now believe that health care should be an expected right of the citizen.

Like it or not, however, ours is not a single-payer National Health Service. Our tax base is actually very small (1.2 million taxpayers, and probably 6 million provident fund contributors), and there have really been no preferential or special social/health taxes to cater for this in our budget.

The latest national budget 2010 has indeed shrunk the health care allocation from the public purse, down some 4.8% to just over 13 billion ringgit. The government expects the private sector to take up the slack and push the overall health expenditure to a respectable 7% of our GDP, instead of the current 4.9%. Clearly the public service expenditure is not enough to cater for this.

So where is the money coming from, if the public sector puts in piecemeal local projects such as 1Malaysia clinics to compete with urban GP practices? In terms of quantum, the 10 million ringgit for 50 urban 1Malaysia clinics does not make much sense, except perhaps to assuage some misguided ego-boosting government agency or two!

Most importantly, do we really need these clinics?! Isn’t the shortage more in remote and rural areas, especially in the interiors of Sabah and Sarawak, where the doctor-population ratio is so wretchedly large, and the health care facilities so sparse and sporadic?

This is especially ironic because in towns and cities, there are enough doctors to cater to the health needs of most, if not all urban dwellers. In the Klang Valley itself the doctor-population ratio is around 1 in 380, more than enough for even the most developed nations. This is also true of most cities in the country (around 1 in 600). There is therefore, really no shortage of health services or personnel in such urban areas.

In fact, due to some skewed sense of urban penchant, doctors especially GPs, continue to vie with each other, ever so competitively by locating in inner-city sprawls, with many now just eking out paltry livelihoods.

So why, it begs the question, would the government see fit to jostle for such overcrowded spaces, if not to spite the medical profession?!

Perhaps, there is that misguided thought that by offering urbanites some goodies, no matter how inane, citizens might be persuaded to look upon the federal government more favourably, considering that almost all metropolitan parliamentary political representatives are from the opposition parties!

Nevertheless, notwithstanding the possibly noble intentions of the authorities, we seriously question the rationale and the sudden move, which we feel are at best misguided and not too well-thought of.

We understand that because for a very long time, we have had tax dollars paying for our nearly free public health care services, a large number of our citizens have come to expect that this should continue indefinitely. However, one to five ringgit for seeing a doctor in the public health care sector, hugely subsidized or free investigations and therapies, and months of free medications, (totalling only 2% copayment for public health care expenditure), cannot be a sustainable option!

Yet the reality is that this type of system is highly unlikely to be sustainable in the longer term—most countries in the world are finding out that they cannot afford this without enforced rationing, prolonged waiting times, diagnostic and therapeutic delays and even deliberate choice reductions, to exclude new, cutting-edge or really expensive therapies. In other words, something’s got to give!

But, we too are aware that some 35% of our populace (the less endowed) actually depend and benefit from such a much needed service, that we feel this cannot be done without.

But we have to reconsider a different mechanism to respond to such needs—I believe the medical profession will wholeheartedly support a revamp of a properly considered alternative mechanism(s), but these should be undertaken with in-depth input from all stakeholders and which would require great political will and planning!

Should we then be embarking on such a drastic paradigm shift? Perhaps, as some health economists might suggest. Yet, we continue to push private healthcare initiatives and insurances; new hospitals and medical centres are mushrooming; and we are targeting and enlarging our medical tourism incentives, which leads to a schizophrenic scenario as to what we truly want!

Instead of boosting and improving healthcare services and access, we appear to be taking the cheaper but possibly inferior approach; worse, at taxpayers’ expense on the one hand, and paradoxically encouraging super-duper specialist private sector growth on the other! We inadvertently but invariably encourage and push public to private sector expertise migration, thereby undermining the public services even more…

Perhaps, this exercise is just another political posturing which had been hurriedly pieced together to extract some cheap brownie points on a perceivably weak government, whose popularity needed some wagging-the-dog boosts!

To add salt to the wound, these so-called 1Malaysia clinics would compete with the already overly cutthroat urban clinics; but to be manned by medical assistants. That notion of not too subtly shifting the task downward by possibly non-health personnel bureaucrats is what takes the cake of adding insult to injury!

In one fell swoop, it would appear that the MOH had “ambushed” (as voiced by one angry doctor) the medical professionals once again, by proposing newfangled schemes which are arbitrary and even at first glance ‘illegal’, especially when viewed vis-à-vis the Private Healthcare Facilities and Services Act/Regulations and the Medical Act.

It is pointedly clear that any and every clinic should be manned by a registered medical practitioner. To do so otherwise would be to go against the law no matter the fact that there may be supervision from a medical practitioner from afar. Whatever mechanism of oversight now employed would appear to be an afterthought justification, which is convenient but probably still illegitimate.

In fact, the MOH and the law has prosecuted and indeed fined and jailed medical practitioners for employing under-qualified or unqualified people just for such unprofessional practices! Now it appears that one law is to be applied differentially for the private sector clinics, and another for those operated by the Ministry of Health!

Now it appears that many medical practitioners are up in arms, at least vocally, that such a move by the Ministry of Health once again undermines the bittersweet equanimity of our already beleaguered medical practices, just recently reeling from the imposition of the private health care facilities and services Regulations in 2006.

It appears to some doctors, that no medical society seems to care for them and their piled-on plight, and some have expressed their intentions to start another “grouping” to vent just such an opposition to these dastardly moves of the uncaring MOH, and yes, even the MMA! Isn’t this just like trying to re-create the “wheel”?

Still, perhaps it is good for more of us medical professionals to feel the need and the want to do something and at last, to resort to some form of collective action.

That is what and why most societies are formed for—to come together so that as a group representing a common purpose, we can be more effective in pursuing a cause, or to exert pressure against another, which is inimical to the group.

That is what the MMA is all about too, except that many choose to think that the MMA has been too ineffectual, and therefore some have chosen to denigrate and denounce its so-called inaction and ‘useless’ purpose!

They cry “what has the MMA done for me?” while at the same time shamelessly refusing to acknowledge that they have poorly supported the MMA, most by not even becoming members!

How many doctors turn up for rallies when called upon by the MMA leadership? Perhaps a few hundred, whom I fully salute! How many bother to turn up for our Annual General Assembly meetings, year in year out, to debate policies and issues, and yes even to engage in politicking mindlessness and arguments? A dismal two to three hundred!

As of this year, the MMA has just 8100 members in benefit, out of a total registered 26,000 medical practitioners, a paltry 30%! Yet, we are the largest representative body of the medical profession, but we could definitely show a greater strength of purpose and unity. We need more members to join our cause and increase our profile.

We, you have to show greater participation and engagement in our, your association, despite its inherent discordance and splintering interest groups! That is the essence of democracy and participatory membership. That is the essence of being involved, being engaged, wanting to contribute to perhaps influence a change no matter how small, but perhaps also in helping to shape a major policy which will affect our professional lives and livelihood!

But a fair and close scrutiny would immediately expose the truth: our MMA’s public sector arm, SCHOMOS, has been exemplary in catering to the benefits and interests of our public health care doctors. Perhaps our private practitioners section (PPSMMA) can do better, but we have actually been busy working hard on many issues to try and resolve with as many stakeholders as possible, by being as inclusive as we can.

When push comes to shove, at least some have been moved to take action, to have become agitated, angry and perhaps finally, willing to take some action, belatedly as the case may be. Sadly, such reactive knee-jerk reflexes are only triggered whenever our purse strings appear to be at risks, our livelihood’s at stake. In such a light we often come across as venal and mercenary. We should be more professionally-minded while we work hard and unapologetically for our professional interests and practices!

Yet, when it comes to unity of purpose and real positive contribution, these are often met with walls of silence and inaction, even apathy. It is time to come aboard and engage us to make us better, stronger, more meaningful! Come and join us and help us make better changes!

So what have the MMA done these past few weeks?

  1. We have set up committees to look into the affairs of GP issues: met with and dialogue with the DG of Health and his MOH directors to share our concerns;
  2. The recent National PPS NWC met with Director of Medical Services Dr Nooraini Baba to straighten out some difficulties, i.e. amendments/modification of the PHCFSA/R; private specialist hospitals setting up of feeder clinics, errant dispensing without prescription pharmacies, even the setting up of 1Malaysia clinics in urban areas;
  3. We have formed a protem group to address the possible threat and extension of statutory requirements and MSQH accreditation moves for GPs,
  4. We are working with the Academy of Family Physicians of Malaysia (AFPM) on developing a QIP programme which will enhance the quality and CPD of GPs/family physicians,
  5. We are opposed to any splintering move of GPs into FPs and others,
  6. We are opposed to the 1Malaysia Clinics being manned by non-doctors, or even their locations in competition with our urban GPs, and have expressed our concerns directly to the Minister and the MOH;
  7. We have been discussing mechanisms on how to integrate our GP services into the overall Primary Care practice to alleviate the overcrowded public health care clinics—the Minister is very interested, but logistics and administrative barriers remain, recent announcement shows some progress;
  8. We have worked out more favourable terms with FOMEMA, enlarging to 750 foreign worker examinations quota per annum, and streamlined radiological training for clinics with x-ray facilities
  9. We are working with EPU to understand more of how the privatization plans would favour the medical industry;
  10. We have worked with the MOH and EPU on understanding and moderating the implications of the ASEAN free trade zone, i.e. MRA and AFAS, when these come on board from next year, with full operational capacity by 2015;
  11. We are working with various mass media which will work with us to enhance our profession-public interaction and communication, Astro’s Tamil service will showcase a collaboration with MMA on a series of expert talk shows from late this year or early next year 2010;
  12. We are convening and engaging specialists to rethink our national health policy directions; discussing with various groups on case-mix/DRGs mechanisms;
  13. We are actively engaging with WHO, Transparency International, ASLI, Human Rights Coalitions, on issues of better governance, better accountability, best practices, and human rights concerns, etc.
  14. We are working on how to enhance the image of the medical profession in our run-up to our Golden Jubilee (50th Anniversary) next year!
  15. I have set-up a Facebook group blog strictly for medical professionals to engage more concretely issues, where everyone once registered can input, contribute, share and debate health care concerns (MyHealth Matters-MMA 2009-2011)

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