With 1 Care, the choice will not be there
The 1 Care health system transformation plan for Malaysia is now in the process of being sold to the public.
To our knowledge, the development of the blueprint is being fast-tracked and that the detailed plan to implement 1 Care will be ready as early as 2012.
Technical working groups are already hard at work on this. As the term technical working group implies, it is the technical details are being worked out - not the decision for plan for a new health system. Thus, we are way past the “still in planning process” (The Star, May 13, 2011).
We must address certain issues that are raised before implementation.
We are told that the new health system will be in the substance and form of the NHS of the UK. We strongly urge for a critical rethinking of this for the following reasons:
1. Existing Primary Care Provides Better Accessibility and Choice
The primary care model of the NHS has many failings. The picture from the NHS shows that it is not the proven mechanism to facilitate appropriate access to higher level of care. In the UK, this system requires patients to make appointments with the GP, even for acute conditions. As a result, the A&E Departments of hospitals are jammed with patients and waiting lists for cold cases to see the doctor or undergo surgery is long.
On the other hand, Malaysia has a better healthcare system. We had good KPIs reported in the latest National Health Accounts Report. Our health system has been praised in many international reviews and articles published in journals.
In Malaysia, government health facilities have a good system of referral and provide the safety net for the poor. Those who can afford to pay out-of-pocket consult private doctors. This is a good balance of those seeking private and public healthcare.
What the government really needs to do is protect those using private care from exorbitant charges and being over serviced. This can be handled by strict enforcement of the relevant provisions in the existing Private Healthcare Facilities and Services Act1998/Regulations 2006.
There is choice with the present system. With 1-Care this choice will not be there. The patient and public pay upfront in the form of insurance or taxes. If they do not want the doctors or the service that is allocated, they will have to pay again for what they choose.
2. 1 Care will cost more
Worldwide it is recognised that a system based on general taxation is the most efficient and equitable.
Experiences from many countries have shown that the rise of healthcare cost is higher when other forms of healthcare financing are introduced.
Instead of finding another method of financing, including social health insurance, to improve efficiency through provision of greater choice and better control on cost of health care delivery, the MOH should look internally on wastage and efficiency and improve the government system to be better than the private sector as shown by experiences in Singapore and Hong Kong where the public prefers the public system.
The 2002 Report of the Study on “ Healthcare Reform Initiatives in Malaysia” by three Health Ministry-appointed consultants led by Donald S Shepard have clearly diagnosed the important issues of healthcare delivery in Malaysia and proposed solutions.
Cost-wise, the consultants “calculated that in the year 2000, the average ambulatory consultation (public facility) outside of a specialised hospital (including average prescriptions and laboratory services associated with that visit) costs RM91, while the average inpatients stay cost RM1,091 (or RM286 per day).
In contrast, the fee for an amublatory visit, RM1, has not increased in years and covers only one percent of the economic cost of an average visit”. This does not include the economic cost of long waiting time and time off work.
We know that the average cost for a GP outpatient consultation including prescriptions would only be between RM30 to RM50. Waiting time is shorter. Thus it is clearly cheaper and more efficent to just outsource this ambulatory outpatients to the existing robust GP system thereby releasing the public system to concentrate on secondary and tertiary care. The recovery economic cost of a shorter waiting time will also benefit the patient and the community.
3. Transformation versus Evolution
The overall recommendation of this extensive study based on the diagnosis of our healthcare system was for the country to proceed with “limited reform”.
This reform “should improve the management of the public healthcare services so that they can provide better working conditions for their staff,fill critical vacancies,enhance responsiveness to population’s needs and wants, and maintain an equitable basis for financing healthcare services”.
4. Improving stakeholders' feedback for 1-Care Consultation
The cost and implications of 1-Care affects all. Judging from the concerns expressed by many doctors and the public in the media, it is clear that those so called stakeholders that are invited for discussion are:
1. Either not real representative of the profession
2. Or the stakeholders are not providing feedback
3. Or the stakeholders are some favoured few
It will be good governance to inform the public who the stakeholders are (in name and organisation) to ensure that they are truly representative and to include more public representation like patient groups, consumers, employer representatives and more NGOs.
5. Corporatisation of Public Hospitals.
The 1 Care systems requires corporatisation of public hospitals - the establishment of administratively autonomous hospitals through devolution of authority from federal control, a variant of corporatisation ala IJN. This will be in line with the seamless integration of private and public healthcare facilities.
This is clearly not possible as private facilities are profit-driven as compare to public facilities which is socially-driven. Furthermore this is contradictory to that reassurance given by the health minister in 1998 that the government will not corporatise public hospitals.
At the end of the day one would create a huge profit-driven monster that will be impossible to control as the regulator (i.e. the government) will also be an operator of the industry via its GLCs.
To our knowledge, the development of the blueprint is being fast-tracked and that the detailed plan to implement 1 Care will be ready as early as 2012.
Technical working groups are already hard at work on this. As the term technical working group implies, it is the technical details are being worked out - not the decision for plan for a new health system. Thus, we are way past the “still in planning process” (The Star, May 13, 2011).
We must address certain issues that are raised before implementation.
We are told that the new health system will be in the substance and form of the NHS of the UK. We strongly urge for a critical rethinking of this for the following reasons:
1. Existing Primary Care Provides Better Accessibility and Choice
The primary care model of the NHS has many failings. The picture from the NHS shows that it is not the proven mechanism to facilitate appropriate access to higher level of care. In the UK, this system requires patients to make appointments with the GP, even for acute conditions. As a result, the A&E Departments of hospitals are jammed with patients and waiting lists for cold cases to see the doctor or undergo surgery is long.
On the other hand, Malaysia has a better healthcare system. We had good KPIs reported in the latest National Health Accounts Report. Our health system has been praised in many international reviews and articles published in journals.
In Malaysia, government health facilities have a good system of referral and provide the safety net for the poor. Those who can afford to pay out-of-pocket consult private doctors. This is a good balance of those seeking private and public healthcare.
What the government really needs to do is protect those using private care from exorbitant charges and being over serviced. This can be handled by strict enforcement of the relevant provisions in the existing Private Healthcare Facilities and Services Act1998/Regulations 2006.
There is choice with the present system. With 1-Care this choice will not be there. The patient and public pay upfront in the form of insurance or taxes. If they do not want the doctors or the service that is allocated, they will have to pay again for what they choose.
2. 1 Care will cost more
Worldwide it is recognised that a system based on general taxation is the most efficient and equitable.
Experiences from many countries have shown that the rise of healthcare cost is higher when other forms of healthcare financing are introduced.
Instead of finding another method of financing, including social health insurance, to improve efficiency through provision of greater choice and better control on cost of health care delivery, the MOH should look internally on wastage and efficiency and improve the government system to be better than the private sector as shown by experiences in Singapore and Hong Kong where the public prefers the public system.
The 2002 Report of the Study on “ Healthcare Reform Initiatives in Malaysia” by three Health Ministry-appointed consultants led by Donald S Shepard have clearly diagnosed the important issues of healthcare delivery in Malaysia and proposed solutions.
Cost-wise, the consultants “calculated that in the year 2000, the average ambulatory consultation (public facility) outside of a specialised hospital (including average prescriptions and laboratory services associated with that visit) costs RM91, while the average inpatients stay cost RM1,091 (or RM286 per day).
In contrast, the fee for an amublatory visit, RM1, has not increased in years and covers only one percent of the economic cost of an average visit”. This does not include the economic cost of long waiting time and time off work.
We know that the average cost for a GP outpatient consultation including prescriptions would only be between RM30 to RM50. Waiting time is shorter. Thus it is clearly cheaper and more efficent to just outsource this ambulatory outpatients to the existing robust GP system thereby releasing the public system to concentrate on secondary and tertiary care. The recovery economic cost of a shorter waiting time will also benefit the patient and the community.
3. Transformation versus Evolution
The overall recommendation of this extensive study based on the diagnosis of our healthcare system was for the country to proceed with “limited reform”.
This reform “should improve the management of the public healthcare services so that they can provide better working conditions for their staff,fill critical vacancies,enhance responsiveness to population’s needs and wants, and maintain an equitable basis for financing healthcare services”.
4. Improving stakeholders' feedback for 1-Care Consultation
The cost and implications of 1-Care affects all. Judging from the concerns expressed by many doctors and the public in the media, it is clear that those so called stakeholders that are invited for discussion are:
1. Either not real representative of the profession
2. Or the stakeholders are not providing feedback
3. Or the stakeholders are some favoured few
It will be good governance to inform the public who the stakeholders are (in name and organisation) to ensure that they are truly representative and to include more public representation like patient groups, consumers, employer representatives and more NGOs.
5. Corporatisation of Public Hospitals.
The 1 Care systems requires corporatisation of public hospitals - the establishment of administratively autonomous hospitals through devolution of authority from federal control, a variant of corporatisation ala IJN. This will be in line with the seamless integration of private and public healthcare facilities.
This is clearly not possible as private facilities are profit-driven as compare to public facilities which is socially-driven. Furthermore this is contradictory to that reassurance given by the health minister in 1998 that the government will not corporatise public hospitals.
At the end of the day one would create a huge profit-driven monster that will be impossible to control as the regulator (i.e. the government) will also be an operator of the industry via its GLCs.
DR STEVEN KW CHOW is president of the Federation of Private Medical Practitioners’ Associations Malaysia.
1 comment:
Disagree with Point #5.
Government can still own the public hospitals but be paid by DRG based pricing instead of the prepaid model now. This will get the efficiencies desired in public hospitals as administrators cut out waste.
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