MMA News August 2010: Health Reform in Malaysia: What should MMA’s Response be?

Health Reform in Malaysia: What should MMA’s Response be?

Dr David KL Quek, drquek@gmail.com

“Physicians know from experience how people’s health is placed at risk when they lack insurance and access to basic, timely care. A profession that has sworn to put the patient’s interest first — to conduct itself as a profession and not merely as a business — cannot justifiably stand idly by and allow legislation that would extend basic access to care to go down to defeat while refusing to contemplate any meaningful measures it might take to reduce health care costs.” ~ Howard Brody. Medicine’s Ethical Responsibility for Health Care Reform — The Top Five List. N Eng J Med 2010; 362(4):283-4.

The recent few months have seen heightened media interests and wider coverage of impending health reform in Malaysia, particularly with the roll out of the 10^th Malaysia Plan and the New Economic Model, and most contentious of all, the possible introduction of a national health insurance/financing scheme.

The rebranded ‘1Care for 1Malaysia Healthcare restructuring’ has now been systematically announced by the Ministry of Health. Its broad concepts have been briefed to some stakeholders, including the EPU, the Cabinet, Bank Negara and even some medical groups, including the MMA. In short, instead of the previously much touted public-private ‘partnership’ concept, this revamped plan marks a leap of faith into public-private ‘integration’ of services, starting with primary health care.

The trouble is that despite some of these briefings the technical details remain fuzzy, and the implementation routes are even more nebulous, being very short on details. Importantly, there appears to be lack of coherence of a well-constructed and consensual national policy which would have embraced more feedback from all if not most stakeholders and players—after all, health care affects every one of us, without exception.

It is true that 11 years ago in 1999, the MMA joined the Citizen’s Health Initiative and proposed a Health Manifesto for Malaysia[1] (endorsed as a resolution at MMA AGM 2000), which argued that primary care should be better integrated for more rational utilisation of healthcare, that would “be comprehensive, well-coordinated and address community health needs as well as those of individuals.” This Manifesto also addresses concerns about an improved form of healthcare financing, preferably by not overburdening the more indigent. It also urges the government to commit more public resources to healthcare, uplift the public healthcare sector, and to uphold the principles of community solidarity but unequivocally opposes privatization or corporatization of public amenities.

Since then there have been other voices of concern expressed about taxing the Malaysian public more, particularly when there have been sporadic attempts at greater privatization, with the view to recoup some of the increased costs of improved healthcare for those who can afford, i.e. full-paying patients, private wings or wards at government hospitals. Grave misgivings have also been made about the economics of the then proposed National Health Insurance Scheme (SIKK, Skim Insurans Kesihatan Kebangsaan).[2]

In May 1999, As MMA News editor, I had stated that “the MMA has fought against such a hurried implementation… For years, the MMA has requested the government to be more transparent in its formulation of policies regarding the direction and execution of our national health plans. For years, we have argued that a National Health Plan be publicly debated and formulated. We have pleaded that our public health facilities be maintained as they have been proven to be exemplary to the rest of the developing world as a beacon model of primary health care. Near universal and easy access to medical and health care has always been touted as a rightful pride for Malaysians.”[3]

Thus this time round, the MMA continues to believe that this bold step is too huge to be unilaterally planned and executed by one Ministry alone, despite its undoubted experience, expertise and its extraordinary inputs from high-powered consultations and training from several commissions, workshops and surveys. We do acknowledge that these plans have been gestating for years now, and have been studied, revised and revised again. But just arguing and contending that the Ministry of Health had spent millions of ringgit and tens of years modifying, honing and perfecting such a concept, is not enough.

One of the most contentious aspects is the seemingly reckless push to raise the number of doctors in the country to more than 83,000 by 2020, i.e. to attain a so-called ‘developed’ economy status with a 1:400 doctor-population ratio,[4] without addressing the actual dynamics and mechanics of quality and/or opportunity for training and job opportunities. Whereas countries such as UK and USA achieved such status over many decades, we are trying to do so in one. Worse, there are grave concerns that even by 2020, our country’s 35-million population then, might not achieve that projected high-income earning capacity of USD 15,000! So we could be producing substandard medical graduates whose future prospects might possibly be with no guaranteed employability or jobs!

While we are all supportive of improving the number of doctors in our nation, this should be planned and orderly, not blunderbuss and rash to simply inundate the country with medical graduates regardless of quality, standards and training opportunities. We cannot afford such a rapid mass production rate of medical graduates or healthcare workers and not expect, issues of mismatch of supply-demand when thousands of doctors could possibly be unemployed, underemployed, or even unemployable!

30 medical colleges with 40 medical programmes and counting, with hundreds of nursing colleges are feats of unthinking and simplistic planning. Setting impossible targets of say 1000 family medicine specialists by 2020, implies scrambling without proper planning, any which way, to produce and to ‘train’ just to get these numbers! Thus, can quality be assured? Do our bureaucrats or our MOH care? Or, are our officials so bent on key result indicators that quality and safety issues matter not at all?

It is pure nonsense to use the excuse that with so many new graduates, we can then have a larger pool of more talented doctors, surgeons, scientists and researchers who can then be up to the mark to compete globally, as touted by some officials! (“We need some good 20-30% who will form the talent pool, in the national interest; the rest, they can fend for themselves!”) ‘Larger number of doctors also means better quality healthcare’ is again another seriously flawed sophistry.  Such specious arguments are irresponsible and inane. This strategy is simply economically unsound and wasteful of the huge educational expense both to the country and to parents, with totally misplaced opportunity costs!

The tens of thousands of college graduates who are unemployed and unemployable now in the country underscore the terrible failing standards of our local universities. These colleges are becoming diploma mills simply for the sake of producing graduates whose dubious quality and non-acceptance has been decided by the market place! The MMA categorically opposes such moves to undermine the sanctity and standards of the medical profession. We already lament the questionable standards and quality of many of our other graduates or allied health workers.

We recognise that healthcare and health systems have been evolving relentlessly over the recent decades, more so in the free market capitalistic mould after 1989, with the demise of socialism-communism. There is that dynamic tension between social justice and equitable care for all, versus free market growth of consumerist profit-motivated private establishments. Malaysia is caught within just such a split-minded approach. We are caught between the dichotomous throes of advocating lower-cost socialized healthcare on the one hand vs. expensive on-demand value-added private healthcare, with the view to even growing and selling medical or health tourism to foreigners!

Since the 1980s with the rise of Reagan-Thatcherist market-driven economic success, Malaysia had tacitly encouraged the explosive growth of private hospitals and private practice. This has led to the current two-tier healthcare system, which although fraught with inequities and differential benefit for some select portion of the population, had also raised the standards and quality of tertiary health care. But it has also inevitably stoked growing demands for better individualised care, with lower tolerance for delays, queues, waiting for turns in a system not equipped to cater for instant responses to every demand.

Unfortunately as with most countries worldwide, healthcare costs have escalated so much that just keeping up with medical advances and technological improvements and its attendant greater expertise training and services, have created big sucking holes in most governmental budget allocations.

Services disparity and forced rationing of such finite resources have led some to rethink that perhaps some better way forward needs to be designed—that our healthcare system has to be restructured. It is not the sole or unique experience of Malaysia, but true for all countries trying to grapple with this relentless exponential trajectory of healthcare costs and demands!

So we do understand why the government appears pressured to revamp our healthcare system. However, how this is to be executed has caused more than a few ripples in the usual composure of the Malaysian public. Most of the decisions and proposals made appear to have been developed without adequate participation from enough stakeholders, thus creating a rather discordant reception from many parties, including many doctors and the MMA.

Simply touting national interest and the larger ‘good’ is not enough to persuade any systematic ‘buy in’ from the public or for that matter from professionals and NGOs, which must necessarily be included in a more intimate dialogue of proper exchanges and true sharing. We have seen too many governmental projects reeking of bad faith and huge waste of public taxpayers’ funds, in the recent past, to believe blindly that the government knows best!

Dialogue and feedback must be a two-way process to reach reasonable consensus and sensible modifications, even contradictory opinions and conflicting viewpoints may be potentially better alternatives in the long run. Thoughtful consensus building should be the better way forward rather than dogged insistence on the primacy of one’s staunchest belief that one is absolutely right—no one can truly own that exclusive right to be infallible.

Just briefing and talking down at stakeholders would not be the approach that breeds confidence nor would it encourage support of possible unpopular policies, which impact lives and livelihoods, no matter the noblest of intentions!

The GST proposition is one such policy which has met with widespread rejection by most Malaysians, because it is perceived rightly or wrongly, to unfairly penalize the poorer segment of our society. The same goes for rapid and blanket removals of subsidies, no matter how noble the fiduciary need of our government to try to rein in our widening national budget deficit. Inflicting ‘pain’ on the public is usually not tolerated well at all, or the ballot box will be used to assert some form of a protesting voice—the rakyat is saying quite loudly “listen to us for goodness’ sake, or else”?!

Yet, because the MMA and I as president, have been articulating some of these concerns, some senior MOH officials have accused us of being too confrontational, too parochial, and obsessed with vested interests. By declaring and threatening even, that the MMA can easily be made irrelevant and therefore be excluded from further MOH discussions, these officials fall prey to their own perceived self-importance that they should not be disagreed with.

The MMA regrets such a condescending attitude, as it does not do justice to inviting genuine dialogue. It is unbecoming of a responsible authority to flex its muscles, in its necessary if bittersweet encounter with arguably the largest representation of medical professionals in the country i.e. the MMA. We may not have all the political clout that we wish to have, but wield it we must and would, if we are sidelined or muzzled![5]

Interestingly 11 years ago I had said that “we appear to have become only one of the ‘trade unions’ that they nominally and perfunctorily have to dialogue with—they need not accept or listen when they choose otherwise. More disconcerting is the fact that policies are increasingly decided without thorough feedback from the medical profession. Our views were often summarily dismissed, as being too partisan and biased of self-interest. This is sad because, the leaders of our medical profession have consistently been the strongest advocates for our patients’ interest. Our patients’ interest is paramount, and we have always stated and espoused such, particularly for the less-well-to-do, and the poor. As doctors we have been wary of rising health costs and have been striving to contain them.”[6] Therefore, I have not really changed my position from way back when I was as blunt; at least, I have been consistent!

So, such arrogating of paternalistic ‘power’ is not new and seems to represent the usual ‘template’ of response from the MOH. I believe that this is no longer acceptable in this day and age of demanded greater openness, nor will it be left unchallenged. The MMA genuinely hopes for a true dialogue of equals, and not simply be treated as sounding boards, which have no echoes…

Top-down “I’m telling you so” approach is a definite switch-off, which only entrenches belief that such authorities have too much bureaucratic conceit to listen to anybody else, but their own usually agreeable voices and like-minded pliant officers. Therein lies the danger—no one within the system will be bold enough to contradict or challenge the higher authority, period—thereby breeding complacency, and allowing less than perfect or even flawed models to be accepted without critical appraisal or modification.

I believe the MMA must take on the unenviable task of being that outspoken body that dares to be truthful so that better outcomes could evolve from genuine sharing and communication—believe us when we say we are not purposely obstructionist and we are not wet blankets out to douse all embers of innovation and reform. We can help the MOH shape better policies and plans if we are allowed greater input and exchanges. Other NGOs too can contribute to make our system reform even better and more robust.

Shutting out the legitimate voice and concerns of the MMA or any other social interest groups, would thus, not be the judicious approach. We are not saying that we have all the right answers, but we do get perhaps sufficient feedback and definitely more incisive questions that impact on real life, real people, real doctors! No government or bureaucrat has that exclusive right to all the information and expertise for any public policy! No one indeed has that puissant authority to decide on the fate of so many, unless we wish to devolve into a command-economy of an autocratic state!

This attitude would certainly not go down well with public expectations of greater democratic space in this current era of proclaimed government transformation programmes, which are supposedly to be more people-centred, more transparent and more accountable.

This planned policy shift from an entrenched 3-decade old private-public dichotomous healthcare delivery system (which has served us reasonably well), to an integrated unified system has humongous implications, not just for private medical practitioners, but also for employers, insurers, third party payers and the public.

With the touted national health insurance scheme, where every private Malaysian citizen is mandated to contribute, the shift is even greater, into an unknown entity which may not function as seamlessly as this has been simplistically suggested. It is almost as if the private health care system as we know it will be nationalized, albeit paid for by another form of mandatory citizen or poll tax!

Although purportedly to be rolled out in 4 stages, this health restructuring scheme should not be a crude social experiment, just because it is about time someone decides to do something about it—we are all concerned as to rising healthcare costs and are trying to ensure that every Malaysian has timely, affordable and equitable access to healthcare. But the 1Care plan needs more than just an idea. It has to encompass the myriad details and minutiae which define the complexity of healthcare today.

Yes, change and reform is always worrisome and not always welcomed. True, some change can be painful but necessary. But change must be reasonable and palpably better for the people to buy in. With the gross excesses, wastages and leakages now so repeatedly exposed, the government can no longer expect the rakyat to accept wholesale whatever it wishes to dish out at will.

More and more of us, the vocal public, will demand to know more, and ask why. We also expect greater debate so that the best alternatives can be arrived at, which benefit the greatest number of our citizens, at the best costs and savings. Most of us are ready for painful exercises if these can be achieved at the best possible price-benefit ratios. But we wish to see corrupt and layered patronage wastages become things of the past—we need to show commitment that we are plugging these corrosive leakages.

Why health reform now? It is like a two-edged sword, which can cut both ways—the imperfect if acceptable one we now know (affordably cheap, nearly freely accessible, inconsistent and occasionally delayed services, etc.), versus the even greater unknown (possibly paying more, restricted doctor registration/access, co-payment of medicines, uncertain access to secondary care, possible reduction in doctors’ income, etc.)… Because this restructuring paradigm specifies public-private integration, this novel approach carries with it so many imponderables, so many implications, which could potentially and adversely affect the Malaysian public and all its players including healthcare professionals and caregivers.

It has been likened to a Bevan-like revolution[7] to transform the Malaysian health system into a National Health Service, with one command authority, that breeds so much uncertainty. The trouble is that social circumstances and economic realities were so different then from now. This is particularly ironic because in the UK, the new conservative Cameroon-Clegg government has just set about trying to dismantle the NHS as it now stands![8]

So it really might be better to pause a while, and reconsider our options. To be sure there is no one best template for healthcare that fits all, and we will have to find one that works best for us Malaysians.

In Australia and previously in the UK there have been all inclusive National Health Planning Commissions, which continue to work together to come up with regularly updated comprehensive, cohesive, coherent policies, plans and directions. Every notable stakeholder including healthcare and medical professionals have always been included in this ongoing exercise to find the best way forward.

The WHO has acknowledged that health care workers including appropriate NGOs be consulted intimately to come up with the best plans agreeable. In the 2006 World Health Report, it is stated that “When looking for ways to improve performance, we have found that nothing works as well as talking to health workers themselves. Their ideas are just amazing. They will tell you what to do.” [9]  Perhaps it is time to consider and convene a proper National Health Planning Commission now for Malaysians.

Enlightened Australia recently carried out a national health systems review where: “the Government undertook an extensive consultation process to test the report’s recommendations with patients, health professionals and the Australian people. In 2009 and 2010, the Prime Minister, the Health Minister, other Ministers and senior officials conducted more than 100 consultations with patients, health professionals and the public. The Government has listened carefully to the expert advice and views put forward by the Australian community. Key feedback from consultations indicated a community desire for:

·      a stronger Government leadership role, coupled with higher standards and increased funding for public hospitals;

·      reduced health sector bureaucracy, simplified governance and accountability, and greater

autonomy and flexibility at the local level;

·      better access to multidisciplinary primary health care;

·      better public hospital services and shorter waiting times;

·      better access to health care in rural Australia and disadvantaged areas; and

·      improved integration of information technology across our health system.”[10]

However for Malaysia, debate on so many important public issues and policies are often muffled or not aired at all. But healthcare reform must not be one of these closeted issues, which have a sneaky way of becoming law or policy. We must ask pertinent questions now and get more appropriate responses before we are ready to accept these proposed profound changes. Among the more pressing questions and concerns are the following:

• National healthcare financial scheme or community-rated insurance? Separate tax or provident fund collection? What about the poor, the self-employed? How about dependents—extra premiums?
• How much must employers contribute? Would this extra burden be passed on to the citizen, or would this be subtracted from the current EPF designated allocation?
• How much is the government contributing from tax revenue allocations? What about social safety nets?
• Who manages this fund? Would civil servants and their dependents be tapping into this fund as well? If so, are the government agencies also contributing toward this fund by paying into this community-rated fund?
• Otherwise, would the private sector employee be doubling up to pay for something which they have already contributed as taxpayers?!
• Is there a ceiling as to how much one needs to contribute? Would purchase of private health insurance top-up be allowed? If not, what’s the role of health insurance in the new scheme?
• Integration of GPs into Public Sector Primary care, or vice-versa?—how soon, who for, when?
• Role of GPs in the 1Care for 1Malaysia Health restructuring;
• What are the roles of Family Medicine Specialists, Members of Academy of Family Physician diploma? 
• Are they to be de facto in charge, controlling other GPs?
• If this is selective and not inclusive, why should the public and the doctor accept or contribute to an untried system, which reduces choice, and may not ensure fairness and equity?
• How would the proposed integration of primary care services be implemented?
• Would the government’s public sector amenities be corporatised or privatised to an outside agency with the MOH reducing its role to that of regulatory function?
• Would public sector amenities be given priority in the distribution of patients, at the expense of GPs?
• Would GPs be marginalized?
• Who pays who? GP’s fees—minimum fee for service, or capitation? Incentives? Grants and tax relief?
• Would all GPs be required to become a FMS? Do we have the capacity for retraining?
• Isn’t this potentially increasing healthcare costs?
• If so why should doctors buy into such a system?
• What goals and objectives have not yet been achieved, since GPs now look about >60% of all primary care patients in the country?
• Are there indicators, which have shown inferiority of our current system compared with other countries’?
• Credentialing—another layer of bureaucracy? MSQH? Who pays who? How much? Is it worth it?
• Co-payment for prescriptions, for ‘special care’, chronic disease management?
• Separation of prescribing from dispensing, how soon? How much co-payment by the public?
• How would the GP gate-keeping function work?
• Would private sector hospitals be marginalised, sidelined?
• How would the free-trade agreements on healthcare be impacting on our system, what roles would foreign investors play? What about the still expanding establishments of more and more private hospitals? What are their roles in the new scheme?
• Whither indeed health or medical tourism?

Theoretical constructs remain just that, until pragmatic ground-level exercises showcase their shortcomings or test their true robustness. But a premature implementation of any restructuring which results in a systematic failure of delivery would be catastrophic. It could be very costly in terms of public confidence and even more disastrous, when delays and hiccups cause untoward bad outcomes for ill patients seeking help.

We therefore need to get the authorities to clearly define the role of MOH, the private sector (if there is any left standing!), the employers, the third party payers and insurers, in the new system, apart from the planning charts.

We also need to send a very clear and strong message to the government concerning the problems that could potentially arise and impact on both the public and the medical profession. Let’s all rally together and unite for a common good! We must encourage and get greater public and stakeholder input and feedback. Perhaps only then we can work something out which will meet the expectations of most if not all of our citizens.

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[1] Citizen’s Health Manifesto for Malaysia. (http://www.prn.usm.my/old_website/chi.html) Accessed 4 August 2010.

[2] Subramaniam Pillay. Health Care: Can we afford to fall sick? (http://www.aliran.com/oldsite/monthly/2005a/4e.html) Accessed 4 August 2010.

[3] David KL Quek. Imminent corporatization of public health services—causes for concern. MMA News, May 1999. (http://www.vadscorner.com/editorial05 99.html) Accessed 4 August 2010.

[4] Medical Development Division. Doctors: Country’s requirement by the year 2020. Ministry of Health, July 2010.

[5] The American Medical Association has also seen an erosion of membership, down from 69% in the 1962 to about half that today; almost exactly as to where MMA stands now. Yet although weakened in representation, the AMA speaks robustly for the medical profession, and maintains a healthy running dialogue with various health authorities in the USA, such that they still impact critically on reimbursements and revisions of the state-funded Medicare and Medicaid. (Harold Sox. The Ethical Foundations of Professionalism—A Sociologic History. Chest 2007; 131:1532-1540)

[6] David KL Quek. Imminent corporatization of public health services—causes for concern. MMA News, May 1999. (http://www.vadscorner.com/editorial05 99.html) Accessed 4 August 2010.

[7] Aneurin Bevan, was post-World War 2 British Labour party Health Minister who pushed through UK’s National Health Service on 5 July, 1948. Bevin famously stated that “The collective principle asserts that... no society can legitimately call itself civilised if a sick person is denied medical aid because of lack of means…  The National Health service and the Welfare State have come to be used as interchangeable terms, and in the mouths of some people as terms of reproach. Why this is so it is not difficult to understand, if you view everything from the angle of a strictly individualistic competitive society. A free health service is pure Socialism and as such it is opposed to the hedonism of capitalist society.” (Aneurin Bevan, In Place of Fear, p100, 106)

[8] Seumas Milne. We cannot allow the end of the NHS in all but name. The Guardian, 14 July 2010.

 (http://www.guardian.co.uk/commentisfree/2010/jul/14/the-end-of-the-nhs-in-all-but-name/) Accessed 4 August 2010.

[9] World Health Organization. Working together for health. World Health Report 2006

[10] Australian Government. A National Health And Hospitals Network For Australia’s Future. March 2010. Commonwealth of Australia.