Tuesday, February 7, 2012

Malaysian Health Reform Socio-Economics I ... by Dr David KL Quek

Malaysian Health Reform Socio-Economics I
Dr David KL Quek

(Published in The Malaysian Insider, 7 Feb 2012)

Is the Malaysian health system really in trouble that it requires such a drastic revolutionary change? Is 1Care for 1Malaysia Health Reform the answer? Will this proposed radical change make our health system more efficient and effective as touted by the officials?[1]
Or, is this proposed Reform too ambitious and sweeping, that it could possibly lead to severe disruptions to our current health system that we are so used to?
More importantly, would this health reform plan become another government-linked corporate entity, which instead of benefiting the public only enriches a few favoured cronies or insiders?[2] The difference now, is that, this will be a humongous multibillion-ringgit exercise and the fattest cow to milk to date!
Sadly, at this juncture in time—in the name of social development, modernization, and economic necessity even—there have been so many government-linked projects being scandalized and mired in corruption accusations and profligate leakages.
Thus, it would be foolhardy to implicitly trust in the government to do the right thing, despite the economic rationale or correctness, indeed despite even the most honourable, intentions! We are dealing with the health choices and rights of the public, which could become severely disrupted and endangered if or when hurried reforms turn out to be another debacle of catastrophic proportions! We cannot afford a failed social experiment of this magnitude!

Economics and Health Care Rights
Let’s examine the proposed 1Care Health Reform. What indeed is this new concept that we are dealing with? The Ministry of Health has stated and defined the objectives of this 1Care transformation as follows:
“1Care is the restructured national health system that is responsive and provides choice of quality health care, ensuring universal coverage for the health care needs of the population based on the spirit of solidarity and equity.”[3]
Theoretically, the above concept is a fully acceptable ideal. But it should not become just a neat slogan. Everyone should have equitable access to health. No one can or should deny this universal premise. No one should be disadvantaged or discriminated against when compared to another just because of his or her ability to pay more, or who can afford more. Most importantly, no one should ever be denied life-saving or symptom- or pain-relieving medical care just because of cost considerations. In reality however, this is not so simple.
Those who can afford to pay more would almost surely be able to purchase health and medical care at will, just because this is the way the free market works. Those who have more disposable or discretionary income and means, almost always have a greater purchasing power to a wider variety and urgency of goods and services. This applies to every economic sphere and not just for health care. That is the way of world these days. Most people except perhaps those living in command socialist economies accept some degree of ease or disparity in their capacity to access healthcare, according to their individual means. This is socially unfair but also universal in its reach.
But again this is an undeniable truism, despite its distasteful and off-putting implications: the less endowed or less informed are almost always less demanding and have lesser recourse to demand or to expect more for any services or goods. If you earn more and have more money, you are able to afford more goods and services (sometimes known as ‘utilities’). If not, you would have to sacrifice not just the more luxurious aspects of the accompanying extras, but sometimes, even forego some basic necessities!
Thus, those who wish for more goods and services would have to work doubly hard and to strive harder when given a chance to gain, earn or excel. In competitive society, everyone is expected to achieve productivity for themselves to the best of his or her abilities. However, the playing field is often uneven and is never equal. Therefore the inherent inequalities of income and lifestyle must be considered, when we wish to examine how fairly society provides goods and services for its citizens. This is particularly relevant when we consider healthcare services for society at large.
It is now well accepted that modern free-market society expects every individual to strive to provide for him/herself in the spirit of self-interest and self-betterment. Free competition would arguably allow the best and the most able to achieve more and thus provide the impetus for self-achievement and wealth accumulation. Free market economics imply that society as a whole will be able to lift itself up by its own bootstraps, to ever higher levels of development, both socioeconomically as well as in terms of human development, so it is believed.
Increased wealth, unequal as this may be concentrated in the hands of some or a few, will somehow trickle downwards so that most of society at the various strata would benefit or reap some rewards, for themselves and their families. This creates ‘healthy’ competition as well as competitive behaviour, which some argue contributes toward faster societal progress, because self-interests and individual desire for goods/services, almost always trump communal or other interests, outside the self or family.
But clearly there is a down side to this laissez faire market economic model. Increasingly we know that the rich and the powerful have grown ever richer and more powerful, and poverty appears to entrench and deprive the poor even more tenaciously than before in the poverty cycle—so much so that the wealth gap widens inexorably. The poor and the have-nots continue their inescapable slide down the poverty trap—the spiral of marginalization, impoverishment and deprivation, whilst the rich grow ever richer.
Difficult as it is to consider, that is what the globalised world has now become—more and more market- and consumer-driven and more individual-focused. The wealth gap or income disparity between the rich and the poor (or GINI index[4]) continues to widen and serve as a serious challenge for governments worldwide.
Although with rising GDP growth, some benefits do trickle down to reach the lower strata of society, disgruntlement and discontent among society’s underbelly of the aggrieved and dispossessed, often strains society’s stability and fester public dissatisfaction. Worse, if the poorer segment of the population continues to grow and widen—this socially unjust disparity between the haves and the have-nots could be destabilising and could cause serious class conflicts.
Thus, there have been growing research and studies into the economics of income inequality, with many different models and indices being developed to try and describe these as close to reality as possible.[5] It is hoped that these indices can help focus efforts to reduce these gaping inequalities as well as perceived inequities and perhaps develop better socioeconomic strategies and paradigms toward achieving greater social justice and cohesion.
Therefore social reform, which can eliminate or reduce such disparities, is always welcome in the name of social equity and fairness. Clearly this applies to healthcare discrepancy as well. So some reform is in order, at least nominally to reduce the gap of accessibility and perhaps too, to staunch the falling standards of health care. Just how this is to be realised is somewhat contentious, and the details of the government’s proposed reform remain unclear, and need to be better fleshed out. Here are where many outside the ambit of the Health Ministry and the policy makers, find grave disquiet, disagreements and contentions.[6],[7]

Universal Coverage—the ideal health care goal[8]
Health financing options for any particular country, are determined largely by the stage of its economic development—the poorer or less developed the country, the more likely it is for healthcare financing to be dominated by out-of-pocket payment options—healthcare is considered to be a luxury, instead of being a right or a privilege of being a citizen, a resident or a taxpayer.

For the poorer nation, there is normally no social protection against ill health, because out-of-pocket payments create financial barriers that prevent the poor from seeking and receiving needed health services.[9] Which is why, our own pro-poor almost fully-subsidised public health system has been acclaimed and acknowledged as one of the best around the world, and not just for the developing world! Many underdeveloped nations have sent many cycles of delegates to learn from our much emulated public health system. So the premise that we are doing poorly in terms of healthcare is a myth, we are not. Of course, this is not to say that our health system is beyond reproach or improvement. There is much that can be made better.
Universal coverage as a guarantee for most if not all citizens is usually only provided by more developed or socially enlightened economies. But the mixes of payment options vary tremendously, with the more mature and socially equitable nations offering more tax-based or strictly demarcated or allocated social insurance for health. But such overall taxes tend to be very high and approach close to 50 percent or more of earned incomes. Their tax bases are also broader, usually more than 70% of the working populations are taxpayers, which enable such governments to implement collection mechanisms such as dedicated health insurance on a more inclusive and more comprehensive risk pooling (community-rated) manner. Examples include the Scandinavian countries of Norway, Sweden and Norway, and Canada and Australia.
Countries such as the United Kingdom are ‘blessed’ in that a National Health Service was implemented decades ago, just after the Second World War, before free-market capitalistic practices have become entrenched. Other European countries have health systems, which are largely dominated by centrally controlled single-payer healthcare services with a sprinkle of private offerings for the wealthy. But most of these centrally controlled systems evolved over decades, often taking even longer than 50 years.[10],[11] For the more recent experiences of Taiwan, Thailand and South Korea, this evolved over the past 30 years, also through fits and starts. Despite this, health and medical care are often purchased services from private entities by the central authorities based on negotiated reimbursement plans, and varying copayment options to decrease overutilization of services, and ameliorate moral hazards.
The USA is somewhat of an anomaly among developed economies in that it follows a free-market system of free choice and self- or employer-purchased insurances or managed care (MCOs) or health maintenance organisation (HMOs) options (to provide what is popularly known as managed competition). Unfortunately, this has failed to stem the tide of healthcare cost escalations, which has now exploded to a hefty 17% of its GDP (some 2.8 trillion USD!) and its famously lack of universal coverage for its teeming uninsured—this number has now reached 47 million of its 300 million population (some 16 % of the population!).
This is also why the World Health Organisation (W.H.O.) has been pushing every nation towards achieving this goal of universal coverage for all.[12] But this implies that governments, policy makers and the public are enlightened enough to agree to and allocate sufficient tax revenues toward health care, as well as to agree to some form of cost-sharing and risk-pooling. They must thus, also agree to the imposition of mutually-acceptable or negotiated social health insurance schemes to cover all the residents within their borders.
Universal coverage implies secure access for all to appropriate promotive, preventive, curative and rehabilitative health services at affordable costs. Besides financial risk protection, the extent of the population covered (e.g. who is covered) and the extent of health service coverage (e.g. what is covered) must also be properly defined, although this must clearly fit within the framework and context of affordability and means.
It therefore implies that governments provide sufficiently robust systems of emergency, catastrophic care and safety net services, so that the indigent and those impoverished can still partake of the health services without unnecessarily having to delay, to choose, or to sacrifice basic essentials for health, or vice versa. In other words, such barriers to healthcare access must be eradicated for as many people as possible, if not for everyone.
It further infers and probably necessitates that the country’s tax collection practices are mature, socially redistributive and reasonably equitable, so that the majority of the population can be adequately covered. Perhaps one of the most important considerations from the point of accountability is that administrative and service costs should be kept as low as possible, and not be allowed to bite into the already limited funds for whatever healthcare programmes!

[1] http://www.lepak.tv/watch/323b07e591c9ff3/1Care-for-1Malaysia-health-systemTrust
[2] Chan Chee-Khoon. Privatisation, the State and Healthcare Reforms: Global influences and local contingencies in Malaysia. 4th GASPP Seminar on Global Social Policies and Social Rights? New Delhi, India Nov 8-10, 2000. http://gaspp.stakes.fi/NR/rdonlyres/9543986B-3E29-42CD-8088-F3992A2B48F2/0/chan.pdf (accessed 3 Feb 2012)
[3] Ministry of Health. Health Systems Transformation: 1Care for 1Malaysia. Jan 2011
[4] Gini Index or coefficient, measures the degree of income inequality in a country. Gini index is calculated from the Lorenz curve, where cumulative household income is plotted against the number of families arranged from the poorest to the richest. Malaysia has a Gini Index of 46.2, similar to USA of 46.9 in 2009. http://www.indexmundi.com/malaysia/distribution_of_family_income_gini_index.html
[5] Fernando G De Maio. Income inequality measures. J Epidemiol Community Health 2007;61:849–852. doi: 10.1136/jech.2006.052969
[6] Steven KW Chow, Ng Swee Choon, Federation of Private Medical Practitioners Associations of Malaysia (FPMFAM). 1Malaysia Healthcare – Transforming For The Better Or Worse. 3 May 2010. http://fpmpam.org/content/presidents02.html (accessed 8 Jan 2012)
[7] Silent move to push 1Care will burden the rakyat, says activist. http://thethirdeye.posterous.com/press-statement-silent-move-to-push-1care-wil (Accessed 25 Jan 2012)
[8] Guy Carrin, Inke Mathauer, Ke Xu, David B Evans. Universal coverage of health services: tailoring its implementation. Bulletin of the World Health Organization. 2008; Volume 86, Number 11, November, 817-908. http://www.who.int/bulletin/volumes/86/11/07-049387/en/#  (accessed 25 Jan 2011)
[9] Preker A, Langenbrunner J, Jakab M. Rich-poor differences in health care financing. In: Dror D, Preker A, eds. Social re-insurance - a new approach to sustainable community health care financing. Washington, DC: The World Bank; 2002.
[10] Barnighausen T, Sauerborn R. One hundred and eighteen years of the German health insurance system: are there any lessons for middle- and low-income countries? Soc Sci Med 2002; 54: 1559-87 doi: 10.1016/S0277-9536(01)00137-X pmid: 12061488.
[11] Carrin G, James C. Social health insurance: key factors affecting the transition towards universal coverage. Int Soc Secur Rev 2005; 58: 45-64 doi: 10.1111/j.1468-246X.2005.00209.x.
[12] Sustainable health financing, universal coverage and social health insurance [A58/33]. Geneva: WHO; 2005.

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