1Malaysia Clinics: An Exercise in Futility

My recent article in Malaysiakini Commentary (04 Dec 2009):

Budget 2010 while seemingly benign and nearly forgettable, did not quite please many a doctor or those in the health care system.

The sudden and sneaky introduction of the so-called '1Malaysia clinics' to be manned by medical assistants, instead of doctors, and to be located in urban locales have piqued nearly all private medical practitioners in the country.

The internet and the alternative media are abuzz with recriminations and angry bloggings by doctors and doctor groups, who question why such an obviously retrogressive move has been foisted upon the Malaysian rakyat.

Yet surprisingly, not a few public-minded readers of main stream media had only open praises for the government for proposing these new supposedly 'free' clinics for urban dwellers, as evidenced by the letters of support in their interactive columns.

Clearly, many such supporters feel that recent health care costs have become too much for them to afford, although, this is quite unsupported by the facts on the ground.

Our private health care costs are quite reasonable and of acceptably high standards when compared with our neighbouring countries, in terms of purchasing parity or inflationary terms.

Most city clinics charge a reasonable sum of between 25 to 40 ringgit for physician consultation including medications. This works out to be less than a usual meal for 2 or 3 people.

Yet we understand that for some people, this may prove to be too expensive. These urban poor would usually be those who utilise the public sector clinics in government establishments.

It is likely that for too long the government has been offering practically free health care services to nearly everyone on demand, that not too many people bother to plan or budget for any such 'extra' expenses. Perhaps, many now believe that health care should be an expected right of every citizen.

Whichever is the case preferred, our rakyat must make their stance clear to the government. Which system do they want? A command state-controlled public-driven national health system, or the current dual-tier system of a market-driven free choice private system, working in tandem with a 'safety net' mechanism funded by the public purse?

However, like it or not, ours is not a single-payer National Health Service as yet. Our tax base is actually very small (1.2 million taxpayers, and probably 6-7 million current provident fund contributors), and there have really been no preferential or special social/health taxes to cater specially for this in our national health plan.

The latest national budget 2010 has indeed shrunk the health care allocation from the public purse, down some 4.8 percent 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 percent of our GDP, instead of the current 4.9 percent.

The reduced public service expenditure is not enough to cater for this. So it appears that the government wants to move toward improved efficiencies and reduced expenditure, rather than simply continuing with more of the same, unsustainable model.

So what's the logic of the public sector putting in such piecemeal local projects such as 1Malaysia clinics? In terms of quantum and social impact, 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.

More importantly, do we really need these clinics?! Do we want such questionable lower standard of care just because it is superficially cheaper to maintain?

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?

It 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 towns and cities in the country (around 1 in 600). There is therefore, really no shortage of health services or personnel in such urban areas.

Health care can never be a free lunch

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 subsidised or free investigations and therapies, and months of free medications, (totalling only 2 percent copayment for public health care expenditure), cannot be a sustainable option.

The current realisation is that most countries in the world cannot sustainably afford socialised medical system, unless there are accompanying high statutory contributions or taxes.

Yet despite such high social taxes, some upwards of 40 percent, there are unavoidable glitches with enforced rationing, prolonged waiting times, diagnostic and therapeutic delays and even deliberate choice reductions, and even to systematically exclude new, cutting-edge or really expensive therapies.

In other words, something's got to give. Health care can never be a free lunch! Infinite health care needs always outstrip finite resources.

But, we are aware that some the less endowed of our populace actually depend and benefit from such a much needed service. Thus, we feel this service cannot be done without, no matter the pressing need to revamp the system.

It is estimated that one-third or so of the rakyat are looked after by some 10-12 percent of pimary care physicians now left in the public sector service, which explains the overcrowding, long queues and waiting times.

But we have to consider a different mechanism to respond to such needs. I believe the medical profession will wholeheartedly support a reform 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 with such haste? Perhaps sooner rather than later as some health economists might suggest. Yet, different agencies of the government appear haphazard in their approaches to the health care 'industry'.

They have promoted and 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!

Sadly this has excluded sufficient public discourse and debate - these opinions might be quite different from what the government imagines it knows. Instead of boosting and improving healthcare services and access, we appear to be taking the cheaper but possibly mediocre approach; worse, at taxpayers' expense on the one hand, and paradoxically encouraging super-duper specialist private sector growth on the other!

It cannot be denied that by having economists dictate some of these market driven policies, we inadvertently but invariably encourage and push even greater public-to-private sector expertise migration, thereby undermining the public services even more...

Adding insult to injury

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 authorities had "ambushed" (as voiced by one angry doctor) the medical professionals once again, by proposing newfangled schemes which are arbitrary, uncalled-for and possibly 'illegal', especially when viewed vis-a-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 Ministry of Health 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!

So it is not surprising that many medical practitioners are up in arms, that such a move by the government 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.

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. 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 doctors' purse strings appear to be at risks, their livelihoods at stake. In such a light doctors often come across as venal and mercenary. Yet the reality is more complex than that.

As physicians we have been advocating for greater professionalism and higher standards of clinical care. As doctors we believe that our patients expect a higher better standard of care, too. As we move up the quality ladder, we should not be resorting to possibly lower standards just for quirky convenience or political purposes.

The current concept of '1Malaysia' clinics just do not gel, and are uncalled for. What the authorities can do instead, is to tap into the hugely available GP clinics which are already crying out for more patients and greater public-private partnership. Let's work together rather than waste public funds for questionable standards of care, and shortchanging our less discerning rakyat.

Dr David KL Quek was the editor-in-chief of 'MMA News' (bulletin of the Malaysian Medical Association) for 11 years. He is currently president of the MMA.