Tuesday, December 29, 2009

Oriental Daily Interview: Current Healthcare Concerns in Malaysia

Current Healthcare Concerns in Malaysia
Interview with Ms Piong Tsuey Yin, Senior Reporter, Oriental Daily (29 Dec 2009)

1. The Government is considering paying a portion of the bill for treatment at private clinics under a proposed healthcare reform plan which is expected to be ready next year. “The plan is to pay a portion of the bill but there is a cap to the amount, the public will pay the remaining amount.”said Health Minister Dato' Sri Liow Tiong Lai.
What’s your opinion on this?

The MMA welcomes any forward looking mechanism to improve the delivery of primary health care (i.e. GP or family clinics) to the rakyat. There is actually a glut of GP clinics in urban areas, many of which are under-utilised, some GPs are seeing only a handful of patients a day. Many of these clinics are suffering economic hardship; many are manned by locum doctors only, who in turn are paid poorly.

So, if the MOH can offer a mechanism to distribute some patients who are using the overcrowded government clinics, then this would be most welcome. Perhaps a quantum of payment per patient can be agreed upon, but this cannot be so little as to be meaningless.

Medications can of course be obtained at government pharmacies, which will help to reduce costs, but unfortunately this may inconvenience the patients. If the public can help co-pay a little, then this will also be very good.

2. Dato' Sri Liow said the ministry was studying several models implemented in other countries such as paying medical bills through deduction from the Employees Provident Fund or a tri-parte payment scheme were medical cost would be borne by the patient, his employer and the government. Which way do you think Government prefer? (EPF,medical coupons or compulsory insurance?)

At present it is very difficult to withdraw money from the EPF, therefore this is not a very practical approach for outpatient doctor visits. Using medical coupons or insurance may be better.

However, the paper work involved in either coupons or insurance should not be so much that it cripples the system. Also insurance companies tend to deny treatment and screen without seeing the patient's needs, and this will be very hard in simpler illnesses. Medical coupons may be difficult to keep a tab on, and have a potential to be abused.

It appears premature that any form of mechanism can just be rolled out anytime soon. The MOH must engage the medical profession and work out a win-win partnership to ensure the best benefits and convenience for the rakyat.

3. Is “unified government and private hospital charges”policy a prelude to implementation of national health insurance? 

This may be the best way forward. A genuine partnership or some form of integration of the public-private sector especially for primary health care services, should be considered.

We need a portable system of reimbursement mechanism or payment scheme where the rakyat in need of primary medical services can access any clinic whether in the government or private sector, where each Malaysian is guaranteed access to this service. This is called universal access to healthcare where many countries believe is a human right, and this is also endorsed by the WHO and UN.

The National Health Insurance or Financing Scheme is still being worked out. So far, there are many hurdles, because exactly how much each one worker or self-employer contribute is still being debated.

There are too few income tax payers or employee provident fund contributors in Malasysia, which would make this group community-rated insurance affordable to all.

What about those with family members, how do we calculate the quantum of contribution?

How would the government choose or afford to pay for its own civil servants and families, and would this dilute the community pooling of risks for the insurance to work optimally?

There is talk that this compulsory contribution should be around 5 to 6% of the basic salary, with the employee paying half, and the employer the other half; there is also a possibility of a cap on ceiling of total contribution per year, but nothing has been finalised yet.

4. Had the government announced the implementation details of national health insurance? What is the main key to make judgement toward the implementation details by public? Is it the transparency and detail of the implementation?
If the government does not announce the details and open for public discussions, do you think the results of the implementation of national health insurance will be good?

I have discussed some of these unresolved issues above. It is true that the government needs to engage with more stakeholders to work out a better mechanism which is agreeable to most parties. Greater transparency in the details would be welcomed and with greater input by more people, this could be a more robust system, which ultimately affects all Malaysians.

Therefore, the MMA fully supports greater discussions and public input. I suspect not everyone will agree to this scheme, but in any major policy change, it is to be expected.

Look at how the huge health reform bill in the USA had turned out with great partisan debate and recriminations, but at least nearly everyone has a say--this is how a democracy functions, with the majority gaining the final say with modifying input from the dissenting minority, and not just bulldozing a policy down the throats of the citizens!.

5.If our government practise national health insurance by unified the charges, do you agree with this? Why?

Common charges will have to be agreed upon, but this does not mean that the charges are identical in the public or private sector.

Some basic charges will be acceptable and reimbursed on both systems, but at the private sector hospitals, some form of 'luxury' or better facility co-payments may be necessary, unless the government wants to nationalise the entire health care system and make it a state concern.

But the MMA does not see the second option happening because we believe that the government still practices a free market economy. A group of common diseases and emergency care will be provided for all, including catastrophic illness such as cancers, chronic illness, but more than that, other agreed upon mechanisms of extra payment will be dependent on public or private options.

6. Most people think that health care reform is good. What is your opinion toward Malaysia's privatization policy in the past?

It is difficult to gauge what had actually happened in the past. It is true that since the 1980s there had been a flurry of new private sector clinics and hospitals being developed. But this is consistent with the economic trends of the era.

There have been some unfortunate misplacement of privatisation of some state-owned health care concerns (e.g. cleaning maintenance services, government pharmacy, etc.) into the hands of politically-connected cronies--these patronage practices are unproductive and lead to wastage of public funds.

However, privatisation helps to modernise and upgrade some of the services and provide a form of competition for the public health services sector too. It allows good doctors to expand their expertise locally albeit in the private sector, without  being lost to overseas countries, e.g. Singapore or Australia; although of late we are experiencing some out-migration of professionals again.

But of course privatisation always leads to loss of expertise and specialists away from the public sector, which in a way undermines the capacity of the government hospitals and clinics. Better incentives are needed to keep our government doctors and personnel happy in service.

7. Liow said the proposed healthcare reform would also see the Government introducing the national health financing scheme.
Some people worry that national health insurance may create a way of embezzle. How do you think about this?

The National health financing scheme is unlikely to be made policy by the next 1 to 2 years. There are many other problems which have not been resolved.

The MMA is not actually concerned that the national health insurance would lead to embezzlement. We are more concerned that the national authority overseeing this fund (which may run into billions of ringgit) be properly applied and used--this must be a government or parliament empowered authority and not a privatised concern.

Also, the administrative costs should be kept to a minimal as is practised in the USA's Medicare or MediAid, These quasi-governmental agencies only use 5-6% on clerical, administrative work, and the rest for actual health care needs--i.e. they are very efficient and cost-effective.

Private insurances tend to be very wasteful, with as much as one third (33%) going to administrative matters, which means that only 65 sen to the ringgit is actually left for real health care use! The government or parliament must have a very tight control over the use or expenditure of this fund.

8. Do you think national health insurance is able to solve the problems which are created by privatization?   Will it create new problems, such as the government can control the private health sector easier than before?

The MMA does not think that privatisation is the root cause of problems in the health care system.

Globally, health care costs have gone up exponentially because of greater medical advances and also increased patient knowledge, empowerment and increased demands for the best, the fastest and the most cutting edge medicine. People are living much longer, and thus are having more diseases which are linked to lifestyle, and older age.

No country in the world except perhaps communist Cuba has a state controlled health system. Even Britain's NHS is more and more privatised, although basic to secondary care are still guaranteed as a universal right. But most people (at least in the past) have been quite willing to wait their turn for some therapies or surgeries, which is part and parcel of a national health care system.

Australia, Canada, Taiwan and even northern European countries also have wait times, but huge social-health-education compulsory contributions/taxes, some upwards of 20 to 35%  of their wages.

If Malaysians are willing to pay such taxes, then our health care system will almost surely run better, but not when everyone expects free or very cheap health care costs. There is no free lunch in health care. But in Malaysia, the government has been subsidising health care for so long that everyone expects this. For simple primary care, may be this is possible, but for more advanced and up-to-date care, this will no longer be affordable for any government.

Malaysians have to wise up to the fact that as much as 10 to 15% of their savings have to be allocated for healthcare, at some stage of their lives. By having a mechanism to cater to some basic healthcare needs, this will help streamline a more efficient and perhaps cost-saving method of health care.

But Malaysians must expect some form of rationing and waiting, even co-payment. Health service on demand or immediately, will never be possible for any state funded system of national health insurance. For that extra 'luxury' service, then some co-payment for these privileges will still be needed.

But in a nationally guaranteed health care system, all health or medical emergencies will always be provided for, without unnecessary delay.

9. I heard that private hospital group intends to open clinics, how do you think about this?

 In principle, the MMA is against the setting up of primary care clinics by private hospitals because they have an unfair advantage over GPs. There has been a moratorium on this in the Private healthcare services and facilities regulations which prohibit the setting up of such clinics in the private hospital vicinities.

However, many are now setting up such clinics as feeder clinics to channel such patients to their own private hospitals which would limit choice and may encourage over-utilisation of amenities such as x-rays or CT scans etc. The MMA is opposed to such practices.

10. What direction should Malaysia's healthcare reform move towards? Specifically, what should our government do?
How can we solve the shortage of doctors in government hospitals?

 Our current 'shortage' of doctors in the country is due to poor and lopsided distribution of doctors around the country. For most towns and cities, we do have enough doctors, most urban locations in Malaysia already have a doctor-population ratio of 1:400 to 1:600, a WHO mark/standard of adequacy of health care.

If there is better allocation planning and career-path plans/hardship allowances for younger doctors, these problems may be solved, with most doctors being willing to go to more remote and inaccessible areas in the country, such as in the interiors of Sarawak and Sabah.

There will soon be sufficient doctors in the country, if not a very serious glut and oversupply. We have to date, 23 medical schools in the country producing some 1500 doctors with another 1000 to 2000 graduates returning from overseas! We understand that another 6 medical schools have been approved but not yet functioning.

At this rate of medical graduate production, we will reach 35,000 to 45,000 doctors by 2015, when there will be too many for our system to absorb, and many doctors will be unemployed, even by the government's MOH! We must not become a diploma mill producing nation with dubious quality medical graduates!! We need to knock some sense into our authorities, quickest possible!

There are simply too many private medical schools in the country, with too little oversight as to the final quality of the medical graduates produced. There will be a need to check the quality and the quantity of the medical graduates, otherwise many may soon not be having a job to go to, as already is happening in countries such as the Philippines, Indonesia or even India.

We do need an urgent health care reform agenda, but we must all participate in formulating one that is best for the country, starting with the need for guaranteeing universal access to health for all.

But the mechanism for payment and reimbursing health care costs has to be streamlined and improved upon to contain the escalating cost and wastage.

Basic and catastrophic or emergency care should be affordable or insurable for all, with some form of leeway for quicker access and more luxury care for those who purchase a premium service, because like it or not, we are a free-market consumer driven society, and cannot shy away from these demands. But we must be careful about too much wastage from either excessive demand, administrative or patronage-connected (crony or rentier economic) leakages.

Dr David KL Quek

President MMA

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