Private or public wings are but a fallacy... by JT

Private or public wings are but a fallacy

Letter by JT, in Lim Kit Siang's blog

It appears that yet again, CAP’s SM Idris has decided to go on a frolic of his own. This time by stating that Private Wings in Government Hospitals are the wrong things to do. Sometimes one really have to suspect if this guy truly knows what he is talking about or goes about criticizing everything and anything sundry just to occupy his time. There are only three components to a hospital bill: 1) Doctor’s fees 2) Hospital charges (Bed, Nursing, Utilities, Investigations, etc) and 3) Consumables (Medicines, gloves, catheters, stents, etc).

This government has been benevolent enough in providing and perhaps in the case of Sabah trying to provide, items 2 and 3 but cannot match up to 1. Idris wants equitable healthcare for everyone. When he says equitable what does he mean? If he means placing a few GTN tablets under the tongue for a heart attack, or placing a plaster of Paris cast for a broken tibia, or delivering the 3rd child in a mother with no co-morbidities, or putting up a drip for a dehydrated patient or placing a few stitches on a wound caused by the neighbor’s dog, that’s fine. This government would have no problems accommodating them.

But if he is talking about plating/nailing every fracture of a victim of a high speed polytraumatized patient, reconstructing all the facial bones in an accident victim, or doing a bypass for a coronary patient with recurrent pain or ballooning and placing an emergency stent in a patient with a heart attack or doing a liver transplant in a patient with liver cirrhosis, then Idris must surely know that even all of Malaysia’s GDP and PETRONAS’s reserves will not be able to cure this country’s health woes. The US belatedly learned that medical technology and its ensuing advanced care can indeed bankrupt the nation causing Obama to desperately apply the brakes on its run away healthcare program that is highly sophisticated but yet cannot provide for almost 40 million Americans.

The reason why the government cannot match up to No. 1 is simple. To train specialists and retain experienced ones is not a simple issue. There are only so many who can operate on the brain or heart safely, a few who can carry out liver transplants with little mortality and even fewer who are interested in doing and following up bone-marrow transplants or manage and handle complex equipment to save critically ill neonates. Yes, these specialists can choose to go to the private sector or emigrate to the Western world but many would prefer to serve. But the service conditions and pay, really, for lack of a better term “suck” – especially the service terms.

Attending umpteen mindless meetings with no endings, going for compulsory ceramahs and believe it or not, even assembling in the sun to witness flag raising ceremonies just after clocking in and putting up with lunatic, disinterested head of departments interested only in conferencing and resorting wears your patience – precious time that could be well spent managing and treating patients. Idris and CAP should look closely into the poor management styles of our government hospitals wherein all our healthcare problems actually lie.

Our Government hospitals are akin to state hospitals in the UK that Aneurin Bevan, Britain’s NHS architect, once had to put up with after World War 2 before Margaret Thatcher straightened out their managements in the 1980s by converting them to Trusts. Even though Bevan had famously won over doctors “by stuffing their mouths with gold”, rampant mismanagement and poor accountability in hospitals continued till the time Thatcher stepped in. The fault of mismanaging our health resources lies not with the Prime Minister. It does not lie with Parliament, the Cabinet, the Public Services Department nor the Public Services Commission, but entirely with the Ministry of Health or elements within it. Failure to correct these faults is causing healthcare delivery in Malaysia dear.

Tell me Idris, why do we need a “Director-General” of Health. Are we still in wartime? Hospitals must be professionally managed by CEO’s with a strong founding in hospital administration, law and human resource. Ask any hospital group worth its salt out in the private sector, be it Pantai, KPJ, Parkway or Fortis what they look for in a capable Hospital CEO. You can also take it from me that none of these fellas will employ an ex-Kementerian Kesihatan Pengarah to run their hospitals simply because you must be well-versed with customer requirements, billing, accounts, auditing, purchasing, cash-flows, budgets, maintenance, training and dealing with specialists and staff. Can you name even one Government Hospital here in Malaysia that is run by such a CEO? If you don’t manage an outfit professionally, this healthcare nightmare you and your organization keep harping about is never going to end.

The Institute Jantung Negara (IJN) is run by a pro and they do function efficiently. However there is no one in accounting at the Ministry of Finance (MOF) to whom the hospital belongs to, who have the ability to check the IJN’s double and sometimes quadruple billing. The MOF has learnt the hard way what a health monopoly can do to your budget. Irate MOF officials suggested that IJN’s management be hived off to Sime Darby’’s health arm who are tough on accounting so that the leakages can be plugged and the savings be used to help even more patients. But an ignorant public only saw IJN as a government hospital and Sime Darby as an evil money machine.

Similarly, do you really think all these massive hospital infrastructure and expensive medical equipment are properly researched before being requisitioned? The answer is of course an emphatic NO! Due to both political and corrupt leakages, precious money meant for treatment is hived off. The Public vs Private divide is but a fallacy. There never was nor is there such a divide. The only distinction one has to make is the level and quality of healthcare delivery and who has to pay for it. Make the service efficient and get the government to pay for it. It works pretty well in the UK. There is no Einstein involved in this at all.

And how do we do that? The best way to avoid a Full Paying Patients’ program (FPP) is to make certain our hospitals are professionally run. There are only three hospitals in this country that are not run by the MOH (excluding the Armed Forces Hospitals and the Orang Asli Hospital). They are the University Malaya Medical Center (UMMC), HUKM (Hospital University Kebangsaan Malaysia) and HUSM (Hospital University Sains Malaysia). All of them have private wings. The private wings at both UMMC and HUKM are doing much better then HUSM. But private wings only form a portion of the income these hospitals survive on. Other sources of income include rentals to food and sundry outlets, income from parking fees, from pharmaceuticals, research grants and from the various courses and conferences conducted by the lecturers.

It’s true that there is subtle soliciting by some specialists; it’s true that some of these specialists are posting their cases even earlier then they should and it is also true that they delegate some of the work at the public wing to their Registrars. It’s further true that even top doctors applying to be lecturers are sometimes blatantly prevented from joining the University for fear their capabilities would “cut” into their private income, to the detriment of patient care as a whole for the University. But a sharp CEO can put a stop to all this easily. Private hospital CEO’s manage these sought of problems on a daily basis. But the system has undoubtedly worked for these universities. You see, unlike the bottomless pit of unaccounted money that government hospitals are usually lavished with, all these hospitals under the Ministry of Education now have to look for additional sources of income to keep their operations afloat. And this process is teaching them to be efficient.

Key to their goals are the retention of their top doctors by incentivising them so that they still remain to provide at least the input and expertise in teaching both undergraduates and postgraduates in addition to providing good patient care. The nursing standards in the UMMC in particular are excellent and with all the paramedical support available at this hospital, patients who make it to this hospital are indeed a privileged lot. The care provided in this particular hospital has got a lot to do with the design of the hospital itself and the training programs laid down by its pioneering founders.

But the specialists are a different matter altogether. Their numbers are limited and their expertise even more scarce, which means an astute CEO, must know how to utilize their abilities to the maximum for the benefit of as many patients as possible. Contrast this with the specialists at the MOH who keep getting transferred every now and then. How in heavens is this going to benefit long term patient care and follow-up? Further, private wings were built at these University hospitals to not only retain the current specialists but in the hope that even private, experienced specialists will bring in their expertise to collectively benefit patients in exchange for help in teaching. But this remains largely an unfulfilled pipe dream.

Everyone forgets that almost half the country’s most senior and experienced specialists available in the private sector take on only not so ill patients because they cannot match the infrastructure required and available in Government Hospitals for such patients. At the same time, these same experienced specialists are not available to the very ill patients being managed by less experienced specialists in government hospitals. How do we tap their expertise and amalgamate them into the government healthcare system so that all Malaysians benefit?

Private wings in University Hospitals have remained largely the personal domain of University Specialists, defeating one of the key aims of the hospital’s investment effectively reducing both income and the incorporation of external expertise into the University. A tough CEO would have put this right. Similarly if Private Wings in government hospitals are going to be for the exclusive use of only government doctors, then expect another hijacking of the facility by government doctors with no external doctors using the facility. Again it will be a monopoly and with monopoly will come all the other unsavory practices associated with it.

Thus far the MOH has been hoodwinking this government and public by throwing this Public vs Private divide. All invitations to “help out” are insincere or come with strings attached such as “You must be MMC registered…. and 10 other conditions in fine print”. The challenge in fact is to not only get these specialists to lend their expertise for instance through private wings but also to open the door to even foreign specialists in the areas of expertise this country lacks in. This way Malaysians get the best care as both infrastructure and the expertise becomes available. Our Sultans need not go to Singapore for treatment nor our kids to India for surgery.

The reality of the manpower situation is, this country is extremely short of qualified, experienced technical staff. It’s high time the government takes the role of computing costs diligently including the various fees for doctors and other medical professionals now widely published in various government and insurance schedules.

Every Malaysian patient must have the availability of the best medical care this country can offer. And every Malaysian patient need not pay a cent. You only need to properly manage the system. Surely we don’t need to call in Margaret Thatcher to help us do that. For intelligent accountants, like PETRONAS ex-CEO, Hassan Merican, matching the infrastructure to manpower would be a cinch. Surely there are many more accountants of Hassan Merican’s caliber that can lead the Health Ministry in providing efficient services.

The Academy of Medicine and the various colleges incorporated in it including the MMA and its subcommittees have tried in vain to match and incorporate the entry of this country’s experienced and senior consultants in the private sector to the sometimes excellent medical infrastructure the government has invested in but invariably failed.

Perhaps the CAP or other similar organizations can do what thus far the Academy of Medicine and MMA have failed to accomplish. Keeping the public and private divide wide apart is detrimental to the healthcare delivery in this country. Equitable access to quality healthcare care paid for by the government is what CAP and other NGOs should target for. And this can only be achieved by aggressive integration of both the public and private sectors with the government footing the budget.

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My Comments (DQ):

The above perspective while arguably passionate about what has gone wrong with our health care system, does not really provide concrete answers or models with which to offer our Malaysian public. 

The arguments put forth contain many errors as well as misconceptions about our health care system. It appears that the author's perspective is full of biases with sketchy patchy understanding of what's really happening out there. It is easy to skim on the surface of health care issues and slant it one way or the other to back up one's viewpoints. 

However, the overall slant is towards greater extension of the private sector to keep highly qualified expert doctors happy, but which should be open to competition, and not limited to public service doctors. This is a flawed and simplistic take on how to retain  doctors in service, as well as trying to rationalise greater market-driven system of heatlhcare.

Yet there is little perspective about the rising costs of unfettered health care and how we can rein this in. It appears that the author feels and assumes that the bulk of our health care cost must be borne by the government, yet earlier in the debate, he or she acknowledges that no one nation can afford all these modern therapies. How should we find the money, if our public is so disdained at contributing or paying more. We still do not have a dedicated social contribution fund or tax to cater exclusively for health care.

So other than some possibly genuine concerns and brickbats about why some of the models we have adopted so far, may be wrongly applied, I truly cannot find any worthwhile or pragmatic solution(s) in this article, which can meaningfully help reform our health care system... At best this is a distorted cry for a better system, but unfortunately the polemic is superficial, fractured and incoherent.