Health Reform: Private Sector & GP Role Confusion

Health Reform: Private Sector & GP Role Confusion

Dr David KL Quek

drquek@gmail.com

(President's Page, MMA News October 2010)

“Physicians must become a constructive voice in deciding how health care costs can more appropriately reflect society’s values and needs. Planning for that eventuality should begin now, but cannot be led by a single specialty organization, cannot aggravate the town/gown split in medicine… and cannot be performed in a way that violates the Hippocratic oath. However, it must be done. At the very least, a set of detailed options needs to be developed to contain costs, and physicians should lead the debate about how such options might be implemented. There is no group more trusted in society than physicians. If anyone can lead development of such a plan, it should be physicians.” ~ Robert H. Brook, Rand Corporation[1]

Health Reform Vs. Changing Social Demands & Needs

It has been said that change must be transformational, even radical, if it is to have its most paradigmatic footprint on society that the reformist or revolutionary wishes to leave behind.

Most leaders appear to love these types of change, of wanting to be seen to be bold, novel and innovative, yet impactful and perhaps most importantly, best remembered historically.

Aneurin Bevan has been immortalized as that one socially-driven politician, who had established the National Health Service (NHS) for Britain in 1948, during the socioeconomic turmoil following World War II. Half a century on, its iconic legacy has been contentiously recognised as arguably the most enduring model of health system for the modern world. Even if at times, the NHS appears archaic, and unable to meet the growing demands of contemporary society and its knowledge-savvy citizens.

But even as we continue to debate the NHS’ longevity, the new British government is bent on reforming and liberalizing its lead-shorn laggardness.[2] Command single-payer systems may work but can also become unruly and top heavy. So much so, that demands for individual choice crescendo to become a deafening clamour for better, more efficient delivery of safe and timely healthcare.

Not many ill patients are now willing to resignedly wait their turn, to queue as per economically-dictated rationing. Even if this individualistic preference is achieved at some higher premium costs! Essentially, more and more people are expecting and demanding more personalised rather than uniform factory-style care—impersonal cogs on the grinding wheels of soulless clockwork but cost-constrained efficiency is not enough.

But grappling with societal demands versus economic reality is not always easy, nor entirely logical. There is always that irrational component of wanting more individually, than what is best for the larger good of the many. This applies to healthcare more so than to other social demands or needs. We demand this as of our human right, but also wish upon that seemingly nonnegotiable luxury of timely, proficient, safe and compassionate care.

Paradoxically, no one wants to pay more than he or she needs to, and yet hankers for unfettered access to more and more medical advances. We all want new and up-to-date therapies and indulge in ephemeral dreams of erstwhile longevity or prolonged physical beauty, while at the same time we begrudge rising if unpalatable costs! Governments and policy makers are thus caught in this quagmire of finite resources, limited supply and endless demands.

Private vs. Public sector restructuring

For Malaysia, authorities have once again resurrected plans to restructure our health care system, perhaps this time far more comprehensively, drastically even, than ever before. Thus, in tandem with the slogan-heavy pronouncements of the government of Dato’ Sri Najib Razak, we are now introduced to the concept of ‘1Care for 1Malaysia’ health restructuring.[3]

We have the 1Malaysia, the GTP, the NEM, the recently heralded ETP: Economic Transformation Programmes, hence the current acronym of “1Care for 1Malaysia” for healthcare reform.

To be sure, these plans are now much grander, more re-engineered to fit the model of a marked policy shift both in terms of funding as well as structure. But, coming in the prolonged wake of our widely expanded private sector over the past 25 years, such plans to integrate public-private sectors, cause much confusion and understandably some resistance as to the final direction and form of where our health care system is heading.

Having said this, we are not Luddites who irrationally oppose change for the mere sake of it. We strongly believe there are genuine concerns that many if not most practical aspects of such a huge undertaking have not been worked out satisfactorily. That perhaps, some of these ideas might not be the best that have been articulated, and which might need exhaustive scrutiny and public feedback.

Herein lie some of the unspoken nitty-gritty ‘devils in the detail’—there’s been minimal consideration for practical particulars, but much theoretical and high-sounding huh-hahs and noises. We however, accept the contention by some officials that this is very much “work in progress”.

“Health reform is not only about health insurance companies, physicians, and pharmaceutical and device companies.

It is not only mandating health insurance for everyone… Health reform is about people. And people must become full participants and assume much greater responsibility for their actions if health benefits are to be maintained at an affordable cost.” ~ Richard H. Brook, Rand Corporation[4]

MMA believes that change should not be based on misplaced or erroneous premises. While the privatization approach is contributory and possibly instrumental in the world’s experience of skyrocketing healthcare costs, this is but one dynamic of free-market economic forces, not the one all and be all.

However, the lurking suspicion that private healthcare is the root evil of all healthcare woes is a cynical approach to the dilemma of strategic healthcare planning in the midst of escalating and apparently uncontainable costs.

The MMA wonders if the authorities and the government continue to believe in the free-market and private sector of health care in this country, or is this the start of a determined effort to gradually dismantle the private sector altogether?

This is not to say that we believe in the unbridled rise in healthcare costs to untenable levels, leading to gross inequity in access to the poorer segment of society, or to those haplessly afflicted by catastrophic illness. MMA continues to staunchly believe in and advocate for a sustainable model of universal access to healthcare for all.

It is the ‘how’ and ‘what’ of achieving this, which causes much discomfiture. What’s the final product like? How would this ultimately affect the medical profession and the public?

Thus, the transformation plans must clearly position the roles of the private vs. the public sectors despite the possible move toward a single payer system, where contract purchases of private services could still serve to improve efficiency in the delivery of health services.

1Care for 1Malaysia Health Reform

What is 1Care? “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,” says the MOH.

Theoretically, such a definition is fully acceptable. It is a neat slogan and concept, but just how this is to be realised is somewhat contentious, with the details being quite unclear, as of now.

More importantly, the question that needs to be asked is, why change, why now, and if so, how?

The government and the MOH has considered reform for some time now, perhaps as long as 15 years according to MOH officials, with inputs from several sources including many experts and consultants the world over as to how we can transform our health system into something even better.

One theme keeps recurring, “Is our current system of an entrenched dichotomous private-public approach sustainable?”

According to our government, this appears not. Healthcare cost is rising and shows no signs of abating as elsewhere in the world. Health care spending has been increasing and out-of-pocket (OOP) payment for health care services especially in the private sector has been mounting.

The proportion of OOP is now around 40%, which mimics the profile of a third world ‘underdeveloped’ economy. Most developed nations have only 20 to 25% OOP in their health expenditure profiles, with the government and the Social Health Insurance (SHI) partaking of around half to two-thirds of the Total Health Expenditure (THE). Unfortunately the Malaysian government contributes just 44% of the country’s total health spending, with the private sector playing catch-up to fill in the void created.

In MMA’s view, the government spends too little on our health care: the government contributes just 2.1% of the GDP to healthcare (from government tax revenue allocations) with the private sector taking up the slack of another 2.7%. Our healthcare expenditure is around 7% of all total government spending, but still accounts for only a paltry 4.8% of the total GDP.[5] WHO recommends at least 8%. Most developed economies spend some 8 to 15% of their GDP on healthcare.

We can do this better. We need greater government commitment to healthcare budgetary contribution, perhaps 4% of the GDP, in order to take leadership and encourage the private sector to emulate these more committed efforts. Together perhaps we can consider expending some 8 to 10% of our GDP for health care.

We agree that we are facing many challenges: we need to a) ensure that our services meet our patients’ needs, b) to enhance our performance to ensure higher quality of care and c) ensure that our healthcare delivery is less sporadic and more equitable, i.e. we need to overcome our limited and mismatched health care resources. However, many are asking: “If it ain’t broke, why fix it?”

A WHO consultant has actually expressed caution when discussing the need for drastic change. According to internal sources, he has recommended the following:

·       More evidence to assess if the benefits of the reform justify the costs

·       More analysis on service delivery aspects of the reform

·       Exploration of ‘partial’ reform options

·       Piloting of different components of the 1Care proposal

Interestingly, in a World Health Report 2006[6] (Working Together for Health), the WHO has found that most Malaysians surveyed had a favourable impression of our healthcare delivery i.e. 88% of patients perceived of having been treated with respect in their last encounter at a healthcare facility.

Importantly for a nation which spends just under USD500 per capita on healthcare per annum, our health statistics are quite impressive: our under-5 mortality is remarkably low, our life expectancy has also progressed remarkably well, i.e. we are above the curve of cost-efficient healthcare ourcomes, although clearly we can do much more to improve our lot!

The GP Misconception & Private-Public Integration Plans

One of the pillars of the touted transformation is the public-private integration plans of the new system, now suggested to take place over a longer spread of time, perhaps through the 10^th to 11^th Malaysia Plans i.e. 10-15 years even.

Here, the overall plan is to move towards a primary care provider-led system, with the thrust towards more promotive-preventive care and early intervention. Family medicine specialists would serve as hands-on first provider as well as gatekeeper function in a totally revamped primary care-led referral system. Payments for services would be via capitation methods and case-mix models, clearly a huge shift to the unknown.

According to our MOH officials, our current crop of GPs would have to be retrained, re-credentialed and ‘upgraded’ to be able to fit into the system, which is one particular area where MMA strongly feels is unfair and onerous. The unwilling or the ‘untrained’ GP would be relegated to a lower level of a minion worker.

For some reason, there has always been that cynical belief by the health authorities that our GPs out there have been short-shrifting our patients thus far, that they have failed to deliver an appropriate level of care to our patients all these years. This, we believe, is unjustified and unlikely to be the general truth.

This has come across starkly in some of our dialogues with the Ministry of Health (MOH). Such is the mindset and perception of our health authorities! There is that prevalent feeling that GPs are not good enough and have done too little to improve the standards of their practice, although this has not been borne out by whatever little data that we have.

This is especially ironic when you consider that all our GPs have ‘graduated’ from the public system through at least 3 and now 4 years of compulsory service.

What does this imply for the apprenticeship role of the MOH, when the housemanship years are now extended into 2 years with mandatory rotations through various disciplines, and another 2 years of medical officership? Perhaps this speaks volumes for the disordered or ‘failed’ approach in ‘training’ or utilizing our MOs that they should still be considered inadequate after 5-6 years of medical school, 3-4 years of supervised housemanship and even mandatory medical officership!

I think this is grossly unfair to our doctors, that they should be perceived this way, unless there are inherent weaknesses in the system of training and supervision… Then the fault lies elsewhere, which must be corrected! I believe no other profession undergoes such a prolonged rigorous phase of supervision and still suffers the ignominy of being considered inept!

Even the lawyers have just one year of pupillage, post-CLP! We are not talking about rocket science here (even then the astrophysicist or engineer undergoes not more than 3-4 BSc, plus 4-5 years of PhD!), but basic general and yes, even family medicine practice!

But, it may be time for MOH to institute a more systematic training module for GP-wannabes; a more structured and perhaps senior GP-attachment for hands-on approach… This may be the preferred system than simply using the newly-minted medical officers as fresh pairs of hands to cover unwanted and unpopular disciplines, e.g. emergency departments, pathology, outpatients, administration, etc.

It is true that we have a dearth of information or research data pertaining to the performance or outcomes of our GPs. The MOH decries the fact that too few GPs participate in any surveys and studies to evaluate their services, their worth and outcomes. But this does not mean that our GPs are second-rated, as believed by the MOH.

Underperformance occurs in both public and private sectors

On the other hand, we have had at least 2 reports from the MOH describing just how poorly some of our public clinics have performed especially with respect to clinical and medication errors, etc. in particular those pertaining to non-doctor based services, i.e. those carried out by medical assistants or nurses.[7]

According to a Penang study, in 2009, “medical assistants at government health clinics and government hospitals were found to be responsible for many medication errors. Of the 1,612 prescriptions generated by medical assistants in a single week, 1169 errors were noted and some were critical errors, involving the use of at least one medication categorised as Group B medicine, which only medical officers are authorised to prescribe.” [8]

To claim that several global health officials have expressed favourable opinions on our public health system, thereby implying that our government-run clinics are therefore excellent, is misleading and perhaps too self-congratulatory!

We readily accept that our infrastructure and system of primary healthcare access to most of our rural population within 5 kilometers is laudable, and has been adopted by other developing nations. But we beg to differ that these services provide the ‘best’ care that can be offered.

Consider the following mundane scenario of nearly every ‘public’ outpatient clinic, countrywide.

When it comes to chronic disease management, delivery of care is to say the least, sparse, sporadic and generally basic. There is very little continuity of care, with almost every clinic consultation (stretched to once in 4 to 6 months or longer!) being attended to by a different doctor nearly every time. Some 2 to 5 minutes seen in an overcrowded 2 to 3 patients in a shared space, cannot be the best approach—overworked medical officers furiously scribbling in self-kept medical cards, whatever little history, examination or tests, and in most instances, a rehash of the previous prescription (with little or no change), cannot truly imply good care or outcome!

Contrast this with the usual GP, who more often than not looks after families and perhaps even generations of families. The personal touch is all the more apparent in many cases, where chronic disease ailment such as hypertension, diabetes, arthritis and even some stable CVD are often looked after as best can be, with cost constraints being the usual bugbear. But GPs are adept at balancing costs with acceptable outcomes, and obviously do provide sufficient counseling to matter for the returning patient.

True, they also look after acute ailments such as fevers, cuts, falls, bruises, etc. Some even dabble in occupational health after undergoing some relevant courses. True too, that many a GP would prefer not to see the very ill or gravely injured patient due to lack of facility or support services. But such is the sagacity of good clinical practice to know one’s limits and refer judiciously.

The contention that many patients in the private sector doctor-hop and shop around is not the usual phenomenon, and probably occurs in a minority. But we do need more data to confirm or refute this and we urge our GP colleagues to participate in more studies to really address such possible misconceptions.

We also need to find out why many patients utilizing the public sector clinics revert to the GPs for either follow-up care, second opinions or reassuring care once in a while; or vice-versa—we need to document how well or how poorly some of these public-private shift of patients are doing and why.

We personally know of so ‘many’ instances of poor control of BP or blood glucose or HbA1c from government clinics that we must document the extent rather than just dwell in smirking hearsay. We urge GPs to document these carefully so that we can provide feedback of such suboptimal care to the authorities.

Similarly, the public clinics can and should also cross-document the mistakes or poor performances of the GPs or private sector out there. In the interests of patient safety, this should be the ongoing concern of every practicing physician, not to find fault but to monitor safety, so weaknesses can be identified and rectified. Until then, we believe that many of these are unfounded and based on inherent prejudices which apply both ways!

Market Forces & Private Sector Vibrancy

But perhaps the reality is simpler. MMA contends that the staggering 62% of the total Malaysian outpatient population, who rely on our GP services, cannot be an anomaly or a quirk of fate or circumstance!

Market forces, ease of care access, cost-effectiveness and reasonable outcomes, mean that most GPs must be doing something right. Of course there is information asymmetry, and that many patients may not know better, but we believe they are not stupid.

Of course, some patients do doctor-hop to find the best, most effective and most accommodating! After all, would anyone pay good money to have his/her illness badly treated, month on month? Would companies pay their panel doctors so that their employees’ health profiles deteriorate with time?

While insurance companies and third party payers complain bitterly about rising costs, would they continue to service such inept doctors if they are as bad as perceived?

Thus, we believe that the authorities have got their perceptions wrong, but we stand ready to be corrected.

The MOH must shift from their moral high ground and engage with the private sector, which play their critical part in alleviating the crush of needed services that the public sector cannot provide satisfactorily to the more discerning population. That despite their suspicion that market-driven health care is fraught with mercenary conflicts, this does not necessarily mean that the paying patients receive poor or sloppy care!

In most instances, the MMA believes that most patients (whether private or public) in Malaysia do receive a decent modicum of health care services, which are appropriate and cost-effective. But access can be improved particularly for the urban poor and the remote/rural needy.

Chronic disease management of course can be improved too, and our health indices must show better outcomes—the steady rise in non-communicable disease profiles is worrisome and may be reflective of public health malfunction due to faulty lifestyle excesses rather than therapeutic failures.

Catastrophic outcomes on the other hand can be better managed by both better promotive-preventive population-based measures, and yes, better concerted approaches to holistic chronic disease management. Of course, this implies that every doctor should actively engage in continuing professional development—we believe this is crucial for modern practice and professionalism.

We must find a middle path towards realising a more acceptable approach to reform our healthcare system, but we all need more data, research as well as greater stakeholder feedback and buy-in.

Misidentifying the private sector as a healthcare cost adversary would be off-target, and would only serve to deviate from the genuine problems associated with modern healthcare!

Also, by adhering to persistent and mistaken precepts, we may embark on a restructuring programme, which may meet with stout resistance and uncertain outcomes from both the medical profession and ultimately the more knowledgeable and empowered public.

---

[1] Robert H. Brook, MD PhD, Rand Corporation. What If Physicians Actually Had to Control Medical Costs? JAMA 2010: 304(13):1489-90

[2] Department of Health, UK. Equity and Excellence: Liberalising the NHS. London, DH, July 2010

[3] Dato’ Dr Maimunah bt A Hamid, Deputy Director General of Health (Research and Technical Support). 1Care for 1Malaysia:
Restructuring The Malaysian Health System. Presented at the 10^th Malaysia Health Plan Conference on 2^nd  February 2010

[4] Richard H. Brook, MD, PhD, Rand Corporation. Rights and Responsibilities in Health Care – Striking a Balance. JAMA 2010;303(22): 2289-90

[5] Ministry of Finance, Government of Malaysia. National Budget 2010

[6] World Health Report 2006 (Working Together for Health), Geneva, 2006

[7] Khoo EM, et al. Medical Errors in MOH Primary Care clinics. Research Highlight IPSK/H0/602/003/002(26)/2 of 2008/e2. Letter of intent for improving Patient Safety: Primary Care. MOH/S/IPSK/05.08(RR)

[8] Dr Jayabalan T and others, The Star, 07 January 2010, pg N45

malaysiakini-Dr Cynthia Lee: '1Malaysia' clinics: Rubbish them or improve them?

'1Malaysia' clinics: Rubbish them or improve them?

Dr Cynthia Lee
Mar 25, 10
7:39pm

 

My goodness, are we on the wrong track here! Malaysiakini has carried several stories lashing out at the '1Malaysia' clinics, but, as ever, most of the voices come from bean bag know-it-alls.

I am pleased MMA president Dr David Quek – who would be one of the few in the trenches – has spoken favourably and fairly about the clinics and their establishment.

But I nearly fell off my chair when I read the story about malpractice at the clinics. Has Dr T Jayabalan just woken up? Malpractice is everywhere, in this country and all over the world.

So firstly, let's not act like there was never any margin for human error. Much better that we act on narrowing it.

Secondly, the clinics were launched in January. Why did it take Jayabalan three months to bring this issue up? Is it because he was conducting his study? If so, then it would seem that this 'malpractice' was foreseeable. In which case, shouldn't he have publicised the theme of his study for the sake of public awareness?

Better yet, he could have written an open letter to the health minister voicing his concerns or sent him an e-mail or even a Facebook message. These days, he could have even Tweeted him. No shortage of channels there.

Thirdly, the transparency issue is a pathetic waste of time. Was Jayabalan's study transparent? Did he announce it before it was conducted? If so, can we please have his methodology, sample size, questions and tabulated results with anecdotes from interviews?

We could go point for point, but let's not bother anymore. The clinics are there. Is the intent to rubbish them or improve them? So far it has been the latter. Unless you have been in the healthcare system, both public and private as I have, it is hard to penetrate these ridiculous arguments.

This is sad, desperate politicking. It's a fight about who's right, not about doing what's right.

So this is what I suggest. Stop talking. Help the people who really need these services by offering to assist in upgrading the facilities.

You could hold talks in vernacular languages, explaining what kinds of cases the '1Malaysia' clinics are suited to handle. You could gather donations to print posters saying the same. Through the MMA, get the Health Ministry's permission to put them up in the clinics.

You could gather doctors to volunteer their services (The arguments used about doctors have portrayed them very unfairly as money-grabbing. Several doctors and dentists I know would be only more than willing to offer their services. So many already are).

Many of the doctors I refer to are in the public healthcare system so to say they will be 'pinched' and public hospitals will become understaffed is alarmist. This comes from the 'brain drain' occurrence. There has no doubt been one, but the Health Ministry has already taken remedial steps. Doctors in public hospitals have had their pay upgraded, and are now allowed to do private practising hours.

A GP in the private sector told me that any doctor in a government hospital far out-earns her.

You could have the MAs and SNs watch the doctors while they work, so that they polish their skills.

You could even have an 'adopt-a-clinic' drive – health practitioners living near the clinics could form groups, and decide what they could volunteer. The clinics are there, like it or not. And there are hundreds of people desperate for care.

To the critics of this programme: You have the skills. You have the insight. You have influence. You have an approachable health minister. Just make it work.

1Malaysia clinic: is the Health Ministry above the law?

Letter
By RS
From Lim Kit Siang's Blog 

It is distressing to learn from Dr. T. Jayabalan, the health adviser to the Consumers Association of Penang that medical assistants are giving out prescriptions for the wrong medicines or prescribing medicines which they are not allowed to prescribe and they have also been found to have wrongfully diagnosed patients at a study conducted at Kampar, Perak.

And feedback thus far, from the MOH regarding the validity of MCs (Medical Certificates) issued by 1Malaysia Clinics have been unsatisfactory. The explanation issued by the Health Ministry’s Medical Practice Division officer, Dr Noraini Baba, stating that according to an internal MOH circular, MAs are allowed to issue MCs seems to suggest that she either doesn’t know the law or thinks she can actually circumvent a law through a department circular.

But perhaps CAP too should share of the blame for this vague situation. The last time they made so much noise, it resulted in ignorant officers at the Health Ministry rushing to pass an reckless legislation called the Private Healthcare, Facilities and Services Act (PHFSA) which was conjured up in the dark corners of the Health Ministry and stamped with the Official Secrets Act (OSA) effectively excluding the stake holders from taking part in the discussions. The Act is surely unconstitutional.

A doctor today with an Annual Practicing Certificate (APC) is legal under the Medical Act 1971 but becomes illegal if his premise is unregistered under the PHFSA 2006. But a Hospital Assistant (HA) working in a presumably legal PHFSA premise, 1Malaysia Clinic, becomes immediately illegal as he has committed a felony under the Medical Act 1971 since under this Act only registered medical practitioners are allowed to work in medical clinics.

This is the end result of people like SM Idris who give half-baked ideas to our poorly trained civil servants who then create silly laws in a knee-jerk unthinking fashion, which ultimately not only endanger people’s lives but place the government eventually in a legal quandary. Worrying statistics of wrong prescriptions and misdiagnoses seeping out of 1Malaysia Clinics maybe just the tip of a disaster waiting to happen.

If we keep making up unending rules and regulations for the delivery of healthcare in this country, the whole of Sabah and Sarawak will soon be paralyzed as HAs there run many of our rural clinics and even provide anesthesia for many of the rural hospitals there. And anesthesia is no child’s play as even propofol; supposedly a very safe anesthetic can kill as it did the late Michael Jackson. In a country with limited trained medical human resources we have to initially stratify the levels of care that we can offer and much depends on both the quantity and today, the quality of medical professionals we have at hand.

Our rural health clinics are still run by midwives termed “Jururawat Desa“ while our health clinics are run by a combination of staff nurses, medical assistants and doctors. Our hospitals are run by all of these people and specialists. But specialists alone are not good enough if we want to deliver quality care as we need the help of physiotherapists, lab technologists, radiographers, biomedical personnel, critical care nurses, operating room technicians, anesthetic technicians and a whole gamut of other health personnel.

Some of the monster hospitals that this government has built like Sungai Buloh, Ampang and Serdang are today nothing more then glorified nursing homes. Patients rush in thinking they are in for high-tech care, but a quick glimpse of the ICU will show 20 beds with 5 junior nurses trying desperately to man the 20 beds with no respiratory therapists, technicians, doctors or even the critical care specialists or anesthetists around.

A great many of the Malaysian population, especially in urban areas are very dependant on the General Practitioner who are the lynchpins in healthcare both in the UK and Australia . In the UK , GPs are today credited in reducing smoking in the general population, monitoring and preventing strokes and heart attacks from modern day epidemics such as diabetes mellitus and hypertension.

In Mexico , Singapore , the US and in Europe , GPs were in the forefront in stopping the spread of the deadly influenza virus H1N1. GPs there were provided training, test kits and eventually Tamiflu to check the disease. Amazingly, in direct contrast, the MOH in Malaysia decided to bypass the resourceful neighborhood GP and instruct likely infected patients to rush to the Sungai Buloh Hospital with disastrous results where hundreds of patients mulled around at its lobby with staff stretched to their limits. Only after a huge public outcry in the face of mounting unacceptable mortalities did the MOH rescind and supply the generic version of Tamiflu to GPs.

For chaps like Idris, GPs in Malaysia are there only to make money and must therefore be shackled with draconian laws and treated as common criminals if they cross the line. They should be jailed or fined if their premises are unlicensed. In fact one doctor, Basmullah Khan, was needlessly jailed for three months just because his premise license was technically “not approved”. Only a malicious government would close down any health facility where hundreds of patients have been depending upon the expertise of the doctor for treatment and follow-up simply based on a bureaucratic edict.

No country in this world treats its doctors this way except for Malaysia , another Malaysian first I guess.

But what are the repercussions of this sought of enactments on medical practitioners? A GP in Sungai Pelek, who once used to put up a drip for a dehydrated patient suffering from diarrhea due to food poisoning, refers the patient because he doesn’t want to take a risk under the PHFSA. He has even been told to remove the two beds he always keeps for such emergencies at this remote town. A GP in Triang seeing a dengue patient, lethargic, nauseated with a platelet count of 80,000 decides to refer when previously he would have asked the patient to come for a daily course of IV fluids and monitored his clinical features and platelet counts. And a GP out in Gemas refuses to deliver a full-term patient in labour with an almost full cervical opening for fear the baby may be born ‘flat’ and he would have to face the draconian PHFSA. So he decides to be safe and call for the ambulance to Segamat, 20 miles away. The baby is of course born in the ambulance.

And right here in Penang, a GP sees a diabetic patient suffering a coronary, lies him flat and places a couple of GTN tablets under his tongue when previously he himself would have administered crushed aspirin to the patient and given him a bolus of heparin which he always keeps for emergencies of this nature and perhaps some morphine. Of course he could have administered all of this and nothing would have happened if everything went well. But if the patient developed a complication, lo and behold he would be criminally charged and the MOH would tell him to speak to the judge if he wanted a lesser sentence.

The GP doesn’t need this. It’s better to play safe. Is there any wonder why our government hospitals and their outpatient departments are overflowing. This is the type of defensive medicine that placed America into trouble.

The Prime Minister may have meant well in wanting to provide free outpatient care for poor urbanites. And the MOH could have advised him of a multitude of options including opening their own current urban health care clinics, even for 24 hours using their own doctors or outsource the service to GPs for an appropriate price.

Why did the MOH choose to break the law by allowing unregistered medical practitioners to treat patients when surely they know that this is wrong? Were they politically pressured or were they plain ignorant. How would the Ministry defend itself in the event a patient sues for malpractice?

It is an irony in itself that the MOH goes around closing clinics run by registered medical practitioners while they themselves use unregistered medical practitioners to run clinics in urban areas where there are an abundance of doctors. Is the Ministry of Health above the law?

malaysiakini-Susan Loone: Malpractices alleged at 1Malaysia clinics

Malpractices alleged at 1Malaysia clinics

Susan Loone
Mar 22, 10
2:43pm

 

A medical practitioner has criticised newly formed 1Malaysia clinics set up by the Ministry of Health for providing poor quality of medical services to patients, which include wrong prescription of medicines and wrong diagnoses.

Dr T Jayabalan, who represents workers and the Malaysian Trade Union Council, claimed that a recent study he conducted in Kampar, Perak revealed that medical assistants in government clinics have been issuing wrong prescriptions to patients.

He cautioned that the clinics, brainchild of Prime Minister Najib Abdul Razak (right) which aimed to provide access to healthcare for all Malaysians nationwide, may also be affected by these malpractices as all of them are manned by medical assistants and nurses.

"This seems to be common practice among medical assistants. They are giving out prescriptions for the wrong medicines, or prescribing medicines which they are not allowed to prescribe. They have also been found to have wrongfully diagnosed patients," said Jayabalan, who is also health adviser to the Consumers Association of Penang.

Though he called setting up the clinics "laudable", he said that the public now want quality instead of just 'good' access to healthcare.

Jayabalan made these claims at a talk titled 'What is wrong with our health care system?' on Saturday at the Caring Society Complex in Penang.

The event was organised by Sembang-Sembang Forum, a group of Penangites concerned with social and civil issues affecting their daily lives. Former Gerakan assemblyman for Machang Bubok Toh Kin Woon moderated the event.

Jayabalan also said he was appalled that the 44 clinics, launched in January, targeting the urban poor, and charging merely RM1 for its facilities, were not set up in a transparent manner as doctors were caught unawares by the project.

Currently, there are 10 1Malaysia clinics in the Klang Valley, five each in Penang and Johor, four each in Perak, Sabah and Sarawak, two in Kedah, one in Perlis and three each in the rest of the states.

Questionable staffing of clinics
His statement is supported by Malaysian Medical Association president (2009-2011) Dr David KL Quek in January who said that "while the MMA supports better, affordable and more accessible healthcare facilities to the public, the manner in which this has been announced, where they are to be sited, as well as the fact that these clinics were to be manned by medical assistants and nurses, took many doctors by surprise".

Meanwhile, Dr Jeyakumar Devaraj (right), Parti Sosialis Malaysia Sungai Siput parliamentarian, lamented the acute shortage of medical staff, especially specialists, to attend to the needs of rising number of patients.

He said that in April last year, the Ministry of Health has approved licenses to establish 45 new private hospitals in the country.

Health Minister Liow Tiong Lai has disclosed that since the implementation of the Private Healthcare Facilities and Services Act 1998 and its regulations in 2006, the ministry has received 55 applications for the establishment of new private hospitals, of which 45 have been approved.

Jeyakumar brought up concerns that for each private hospital set up, about 10 senior medical experts would be 'pinched' from public hospitals.

"This will severely affect the standard of service provided at the government hospitals especially at a time when there is already a severe shortage of doctors to serve in the public sector," he added.

NST: DG Health: Clinics with no patience

Clinics with no patience

NST, 2010/02/08
Annie Freeda Cruez

KUALA LUMPUR: A total of 457 medical establishments nationwide failed to comply with the Private Healthcare Facilities and Services Act 1998 and remained unregistered with the Health Ministry.
There were also doctors who operated clinics before getting approval from the state Health Department or the Health Ministry.

And there were those who provided complimentary care and allopathic medical care without authorisation, Health director-general Tan Sri Dr Ismail Merican said.

“Organisations, big or small, must exercise accountability in continually improving the quality of their services and safeguarding the standard of care,” he told the New Straits Times.

He cautioned that doctors performing medical procedures and operations must do so at registered facilities.


While some establishments are in the process of registration, others are renewing their licences.

Dr Ismail also raised concerns over the number of unlicensed private haemodialysis centres.

A total of 82 out of 452 centres are unlicensed.

Action will be taken to ensure that only licensed haemodialysis centres are allowed to provide treatment.

Some, he said, simply refused to comply because of the ministry giving “leeway ” in providing infrastructure, such as the dimension and size of certain areas or rooms, which were esigned for patients’ comfort and safety.

He also said there was an acute shortage of qualified and experienced professionals (affiliated nephrologists and persons in charge) and paraprofessional staff (registered nurses and medical assistants) overseeing haemodialysis treatments at private haemodialysis centres and hospitals.

Dr Ismail was also alarmed that only 20 per cent of the private dental clinics registered last year had an autoclave with a certificate of fitness from the Department of Safety.

A total of 1,442 clinics were registered in 2008 and of the number, 1,303 were inspected and only 20 per cent had an autoclave with CF.

Worse was the fact that a few clinics were still using boilers to sterilise their instruments.

“Private dental clinics need to improve on their safety and health aspects, especially in terms of infection control. We know that almost 20 per cent do not comply with current guidelines,” Dr Ismail said.

Last year, there were 1,547 private dental clinics registered with the Malaysian Medical Council.

Following inspections in 2008, clinics found lacking on infection control were advised to equip themselves.

The Malaysian Dental Association has also planned a series of talks for practitioners.

Dr Ismail said in dentistry, patient safety concerns were mainly in the areas of infection control and radiation safety.

Infection control and radiation safety are among the areas inspected under the regulations of the act.

Dr Ismail said the Dental Act 1971 was also being amended.

“Various changes have been made to this act, including conducting a qualifying examination for those without recognised qualifications to register as practising dentists in Malaysia.”

In addition, specialist registration will be made mandatory.

malaysiakini-DG Health: 1Malaysia clinics boon to urban poor

1Malaysia clinics boon to urban poor

Aidila Razak & S Pathmawathy
Jan 28, 10
1:09pm

'1Malaysia' clinics have been set up with the urban poor in mind to provide a form of financed healthcare and to reduce the burden on overcrowded government clinics," said the Health Ministry's director general Ismail Merican.

"Healthcare is becoming increasingly expensive and if the government does not act, there will come a time will come when the public can no longer afford it," he said.

"There are a special group of people with special needs - the urban poor. So far we have been concentrating on the rural poor. We have rural clinics run by assistant medical officers and nurses.

"They have been running for decades. And because of the strength of the rural healthcare system, Malaysia is often said to have among the best healthcare systems in the world.

"The recently established '1Malaysia' clinics fill this need and they are equivalent to normal government clinics, which are manned by medical assistants."

Ismail (above) said the living conditions of the urban poor were quite disturbing and the 50 clinics introduced all over the country were to cater simply to their basic needs.

"A lot of them who are sick are not going to bother to go to a clinic because they do not the transport or the means. Often, if they had medical treatment early, more serious problems could have been prevented."

He added that the '1Malaysia' clinics are situated within walking distance in these poorer areas.

Patients had only to pay RM1 for treatment. Once a week, a doctor is appointed to check on the clinics, audit the prescriptions and monitor the work of the medical assistants.

"I must tell you that the community is very happy about this. I met a pak cik who was walking with a cane and he said he would never go seek medical treatment ordinarily, 'but since your clinic is here, I come'," said Ismail.

Changing catheters

He made it clear the MAs are not taking over the role of doctors, but there were many tasks they could on their own.

"For instance, if a patient's catheter needs to be changed, do you want the old man to queue for two hours to see a doctor? This task could be easily done by a MA or the nurse. Children fall down the stairs and you want to wait for hours just to get a dressing?

"The MA cannot start treatment. There is no medicine to be prescribed there other than for simple illnesses like coughs, colds, and stomach aches," stressed Ismail.

"Say somebody comes and the blood pressure is high the MA is not going start treatment.

"The first thing he will ask is whether the patient knows he has hypertension. If the answer is yes, the MA will want to know if he is taking his medication. If he says no, the MA will order him to continue with the medication or tell him to go see a doctor and start treatment."

He added that RM10million had been allotted to monitor the effectiveness of the clinics for about three months.

He mused that that a healthcare financing mechanism might be one solution to cope with the growing cost of healthcare but felt the time was not right for its implementation.

"The public is very demanding and they are insistent on high-quality care but they do not want to pay too much for it.

"But if we don't have a healthcare financing system, there is a big possibility that the public will not have the healthcare infrastructure they want. The cost of drugs and technology are going up all the time. At some point we might have to introduce that."

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Comments from mk readers:

by drvk 

The scenario described by the DG as to how the MA is going to handle cases will remain as a description only. In reality there are a lot of things that can go wrong and they often do in the practice of medicine. Even an ex clinician should know that. I wonder how much of the 10 million will be allocated for malpractice suits? And for your information,catheters ARE being changed by MA and staff nurses in ALL Government clinics and hospitals already!.

by lim chong leong 

The real issue is all along we did not cater for the health of the rural poor and now giving them peanuts is actually no big deal. In this modern time and age, we should have already one sizable clinic in every kampung and mobile ones for more remote areas. Instead we have hospitals worth millions that grow fungus or are structurally unsound. The truth is much public money has been spent with little progress. Satu lagi projek Barisan Nasional. So don't be conned by this Ismail Merican with his little crumb hand-outs.

NST-MSQH: 1MALAYSIA CLINICS: Have qualified indicators to improve service

1MALAYSIA CLINICS: Have qualified indicators to improve service

2010/01/26
DR M.A. KADAR MARIKAR, Chief executive officer, Malaysian Society for Quality in Health 

PREVENTION and promotion of health is the cornerstone of primary healthcare and the best and most affordable way to save lives and improve overall health.
The setting up of the 1Malaysia clinics should be lauded because access to affordable healthcare is an important dimension of quality healthcare.

The issue of 1Malaysia clinics being managed by senior paramedics (assistant medical officers and registered nurses) should be an acceptable measure in times of shortage of doctors, and the Health Ministry has given the assurance that proper standard operating procedures are in place to govern the roles, responsibilities and limitations of paramedics to make sure that safe and quality healthcare services are provided to the deserving.

Continuous education for paramedics is of equal importance in maintaining their skills and knowledge.

The 1Malaysia clinics should be regarded as a "triage centre" to lessen the burden faced by the Health Ministry's community clinics (Klinik Kesihatan) and the emergency departments of government hospitals. It is well known that the majority of cases seen in the emergency departments are minor cases. With the setting up of 1Malaysia clinics, the authorities should be able to manage such cases there.

The 1Malaysia clinics should also be able to play an important role in the wellness paradigm being expounded by the Health Ministry by providing more needed preventive and promotive healthcare services.

The majority of cases seen in emergency departments are minor cases that can be treated in 1Malaysia clinics.

As one of the main advocates of safe and quality healthcare in the country, we hope that quality indicators will be set up to monitor the provision of services by 1Malaysia clinics.

Quality indicators such as the number of patients who return to a 1Malaysia clinic with the same complaint or illness after 48 hours of receiving treatment and the number of appropriate referrals to doctors may be used to assess and improve the safety and quality of services.

They may provide important feedback on whether 1Malaysia clinics should be manned by paramedics or upgraded to clinics managed by doctors.

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My Comments (DQ):

While it is good to urge for quality indicators to check on the performance of clinics, this should not be another exercise at maximising earnings for related industry players. 

The MSQH is a separate independent body which was initially set up together with MMA and APHM through the auspices and encouragement of the MOH, through an MOU signed in 1998. 

However, the MMA is undergoing a serious re-examination of its involvement due to somewhat 'opaque' processes and most importantly the procedural and ultimate goals and possible vested interests involved. 

Funding and spending processes must also be made more transparent, because this must not evolve into a personal-to-holder behemoth which is unanswerable to no one, least of all the medical profession and/or the authorities.

1Malaysia Clinics: Comments in Malaysian Medical Resources:

Dr Alan Teh's Comments in Malaysian Medical Resources:

1Malaysia Clinics

The recent introduction of the 1Malaysia clinics has more political connotations than a genuine attempt at providing quality healthcare to the poor. Clinics run by medical assistants with the minimal of equipment is to me a waste of public funds.

As a person who has worked for many years with medical assistants, I can attest to the fact that the government is toying with the health of the public in order to earn some political points.

The quality of medical assistants is suspect, from the selection of candidates to their training methods. Many of these medical assistants lack basic aptitude to practice medicine. Some are even poorly qualified. Training of medical assistants are different and hardly involves the rigours of medical schools. Their diagnostic ability is questionable.

Their role in the rural community is understandable but to allow this responsibility of managing clinics in the urban areas where doctors suffice, is tantamount to dereliction of duty by the policy makers.

Would any of our VIPs visit a medical assistant for even a simple ailment? Many would flock to ’specialists’ for the best available care. Why then are we toying with the health of the general public?

The reason of providing accessible healthcare to the urban poor is a misdirection. There are many clinics in the urban area, way too many actually. It might have been more prudent to implement schemes for the poor where their visits to the general practitioner is subsidised.

There are actually existing programmes in place via the Welfare Department to cater to these group of individuals where their healthcare is fully borne by the government. So what is the role of 1Malaysia clinics?

The name speaks for itself. Promoting a political agenda using tax payers money with total neglect of their wellbeing.

President's Page Berita MMA Jan 2010: MMA’s Concerns & Reservations regarding the 1Malaysia Clinics

MMA’s Concerns & Reservations regarding the 1Malaysia Clinics

Dr David KL Quek, President, MMA

MMA's ‘Unpopular’ Viewpoints

There has been a raft of adverse public opinions raised by some writers, including MOH officials, in effect questioning why doctors are so venal and self-serving that they oppose government’s efforts to reach out to the poor, especially the urban poor, with the recent opening of the ‘popular’ 1Malaysia clinics.

The MMA and I personally, have also been vilified as agents provocateur in opposing what is generally viewed as a beneficial move of helping the poor gain ready access to such facilities at such remarkably affordable rates. 

Unfortunately, such views are sadly off the mark and miss the points why many among the medical profession are unhappy. I will try and explain the scenario better, so that more people can understand the realities behind our angst.

As MMA President, MMA’s Roles for Public and Private Doctors

First, I am very mindful that I have been elected to represent all doctors of Malaysia, whose views and professional matters must necessarily fall on my shoulders. Sometimes weighing personal viewpoints against the counter demands of various dissenting doctors can be convoluted. However, when doctors’ concerns and interests appear to be ignored, it must be MMA’s responsibility to highlight, especially when these are perceived to threaten their livelihood or practices.

In fact, GPs form around 40% of our MMA’s membership, 40% from the public healthcare service doctors, and another 20% from the specialist groups.

We too have been fighting for the betterment of work conditions, perks and remuneration for our public servant doctors, lest this is forgotten. Indeed the recent hike in special allowances, tax perks and promotion exercises have been the long-standing joint efforts of the MMA and the enlightened Director-General and Secretary-General of health, and the Nation’s Chief Secretary (KSN), who saw it fitting that we have to reward these doctors better to encourage them to stay within the civil service.

Just these last few months alone, more than 6000 junior doctors in the public health sector got promoted from U41 to U44 grade, and some senior specialists have been promoted to JUSA C grade, which we extol as timely and certainly encouraging.

Thus, it is a disservice to say the MMA is only looking after the private concerns of doctors. We are empowered to pursue proactive actions as part of our role in maintaining and strengthening our professional interests for all doctors.

To further imply that the MMA had made rash judgements is inaccurate. This polemic possibly serves to justify the policy decisions that the authorities had elected to enact. Our earlier press statements have all been made after due diligence and care while double-checking with more than a few unimpeachable sources.

Surely, it is understandable that every profession or work group in the country could occasionally come into cross-purposes with the authorities, the regulators and the government. Such is the dynamic of society and its people.

MMA’s Responsibilities & Robust Response

Which profession or professional body can abdicate from such a position or task? But this should not be misconstrued as selfish and greedy objectives or policies. It is grossly unfair to assume so, when the reality is so different.

I dare say that most if not all doctors whether the GP or the medical officer in the government clinic, have the patient’s interests first and foremost. We unabashedly promote this approach all the time and have urged our doctors to remain faithful to their Hippocratic oath of empathetic service and caring public duty.

Doctors are an integral part of our professional workforce, perhaps a little more privileged than others. Many students and parents also aspire for themselves or their children to pursue such a noble profession, usually at huge family expense, sacrifices, very hard work and dedication. Most of our public here and abroad still views the doctor as arguably the most trusted and respected, as shown by many public opinion polls.

Indeed, it is with profound consideration that the MMA through me as spokesperson, have to articulate some unrecognized but uncomfortable concerns. But we are not actively or purposely working against the public interests. If anything, we have always been our patients’ strongest advocates.

Neither are we picking a fight with the MOH officials with whom we have always been working well together. But sometimes, there will be issues and implementation of policies or practices which we would have to disagree with, and which we would need more robust interaction to resolve in the best possible way. Perhaps then, we can be heard more closely, and our viewpoints recognized as legitimate and fair.

Clearly, some policy decision making from the authorities may sometimes clash with the perceived wisdom of our doctors and perhaps the very acts of medical professionalism itself. We have to reserve the right to disagree, but hopefully without too much rancour or recrimination, so that our professional and practice issues can be better highlighted and perhaps protected.

MMA Supports Universal Healthcare for All, especially ready and affordable access for the poor

At the very outset, let me as President of the MMA, reassure the public, the government and the MOH that the MMA has never opposed whatever measures which may bring better access of healthcare to the rakyat, especially the poor, the marginalized, and the underserved, whether in the urban or rural locations.

We fully support every effort to ensure that the poorest among us, as also of every resident of Malaysia, must have easy, affordable and high quality healthcare, as a human right for all.

We fully appreciate that for many decades now, many world authorities, have praised Malaysia’s primary healthcare structure as being among the best among developing countries, the world over. We are proud that nearly every citizen of Malaysia has relatively easy access to a healthcare facility under a radius of less than 5 km.

Therefore, we recognize that this new endeavour by the government to provide 50 re-branded klinik kesihatan as easy-to-access “1Malaysia clinics” to the urban poor, is laudable and is in line with its caring concept.

However, while the MMA supports better, affordable and more accessible healthcare facilities to the public, the manner in which this has been announced, where they are to be sited, as well as the fact that these clinics were to be manned by medical assistants and nurses, took many doctors by surprise.

1Malaysia Clinics: Many Doctors Confused and Angered

Initially, my personal opinion is that just 50 clinics around the country would have very little impact on any doctor’s rice-bowl, although the MMA has reservations that opening these in urban areas appears redundant, because we already have so many GP clinics in almost every town and suburb in the country. 

Datuk Dr Mah Hang Soon of Perak while visiting the soft opening of these clinics, alluded to the fact that there were already some 319 GPs in the four towns where these 1Malaysia clinics have been sited!

What we did not realize is that, many GPs are much angered by this move, which at first glance appear trivial and inconsequential to some of us. There has been much anxiety and confusion among many GPs from all over the country.

I have received literally, hundreds of angry and condemning sms’s, faxes and emails demanding that the MMA address this issue, which GPs felt has been set up to unfairly impact on their services once again. Such was the general impression that they are once again bearing the brunt of perceived one-sided governmental action, following so closely on the heels of the unpopular Private Healthcare Facilities and Services Act and Regulations (PHCFSA).

The major peeve is the manning of these clinics by non-medically registered personnel, i.e. medical assistants and nurses rather than doctors. This approach appears to many GPs and doctors as taking many steps backward, despite reassurances that there will be oversight and supervision by some doctors, periodically.

We thank YAB Prime Minister for trying to reassure us that our doctors will not be impacted, and that these clinics are simply basic ones to cater for monitoring diabetes, hypertension and some simple ailments. YAB PM left the question of expansion of these clinics opened, depending on the success of its popularity… Hence, our concerns remain. Many GPs continue to feel strongly that these clinics should not have been opened and manned in this manner.

No Real Doctor Shortage, Better Deployment the Answer

MMA believes there is no real shortage of medical doctors, but a misdistribution of resources. The MMA feels strongly that doctors should be deployed to man these clinics. We understand the logistical problems, which have arisen time and again due to doctor reluctance to be relocated to more rural or remote locations. Yes, despite all the improved perks, retaining doctors in the public service remains a challenge.

Proper and fair deployment with guaranteed career paths for further training or preferred posting after such rostered ‘hardship’ postings will allow greater participation by ambitious younger doctors.

Also if these 1Malaysia clinics are now to be part of the expanded public healthcare system, then the MMA believes that even more public sector doctors would be willing to be deployed in rotation, or as part of a training initiative for an enhanced family practice/general practice vocation.

Upgrade all Health Clinics, even for the remote and rural areas

Even rural or suburban ‘klinik kesihatan’s can and should be upgraded to doctor-manned clinics which would enhance the overall standard and quality of care for everyone, urban and rural. What we are saying is that these services even for the poor, can be made even better with clinics, which are doctor-covered 100% of the time.

We do not and have never any intention to antagonize or belittle any other related professional group, but the reality still cannot be denied. We are sorry if MAs or nurses felt that they have been belittled. That is furthest from our minds, as we have always recognized their contributions and roles.

However, these personnel whom we all deeply respect and are dependent on, are specifically-trained and have defined scopes of practices, which are as stated quite explicitly, to ‘assist’ doctors to carry out healthcare services, and never intended to replace doctors.

Thus, the specific roles of allied health personnel will not be eroded, but instead should complement those of doctors. It is a norm that doctors should remain in this day and age, as the minimum standard of care, where indeed possible.

We cannot always look backwards in time and compare the 1960s and 70s, where because of our fledgling healthcare service then, we had to utilize these medical assistants, assistant nurses and midwives to provide very critical services, especially in rural and remote areas around the country. Then, quite obviously some kind of healthcare service is better than none at all, and these have served us very well, indeed.

Our maternal and childhood mortality and morbidity data underscores the success of such a much-lauded program, which are being emulated by many other developing nations. We are rightfully proud of this.

But, despite such strides, our health vital statistics still lag behind more advanced countries, which suggest that more improvement can still be achieved. We need not look far, but a check with our Asian neighbours, would show that many have all greatly improved health statistics, certainly better than ours.

It is acknowledged that some nurses have now degrees, Masters and even PhDs, but the reality on the ground remains that these are few and far between. Furthermore it is well-known that these well-trained personnel are usually administrative and not deployed to service health clinics. However, it remains incontestable that their training does not equal that of a doctor’s.

Nevertheless, we fully support the Malaysian Nurses’ Association’s call to further upgrade the calibre, responsibilities and training of nurses in the country. This will undoubtedly enhance the standard of care for all Malaysians.

However, there are also rising concerns that the mushrooming nursing colleges around the country has also cast a growing cloud of ambiguity as to the average quality and standards of our nurses trained recently. This is also true of our many medical schools!

This is the hard truth, which our health system must learn to address before they become unmanageable. But do we dare ask these difficult questions? Is any one authority seriously looking into this, or are we just too comfortably complacent at simply getting out the numbers?

Thus, the MMA maintains that all of these clinic services are best fully supervised directly by a doctor in proximity, in every healthcare establishment. This practice of having surrogate allied health personnel should always be a stopgap measure, which should be discontinued once sufficient efforts were made to enhance our services.

Using such alternate substitute personnel to replace doctors would never be allowed in any of the private hospitals or private medical facilities. So, clearly because of real life shortages and economic factors, we resort to such practices. But in an ideal world, these would not be the preferred choice.

So should we be stuck in the past, or have we to move forwards? Although the Ministry of Health and many other people feel differently, the MMA believes that we can have sufficient doctors to be deployed to service clinics around the country, notwithstanding logistical problems such as doctor reluctance to be deployed to more remote locations, and the continued attrition of public doctors to private sector ventures.

We are convinced that we are now producing sufficient number of doctors (at very expensive rates!), and they can now hopefully function in their true capacity and training to oversee and run these clinics. That is the premise of the MMA and most doctors—we should not compromise on this, simply for economic or other purposes.

Surely if all else are equal, if payment for service is not the concern, who would any one sick person prefer to see, a doctor or another healthcare professional?

This is not to say that there cannot be a complementary assistive role for allied health professionals. Nurses, nurse practitioners, medical assistants, special technicians, physiotherapists, all or some of these, are indispensable and would enhance the overall healthcare experience.

Our premise is that to each professional, its own tasks and duties based on its specific capacity and training. However, this does not mean we are disparaging or looking down on these very important personnel, whom we work with on a daily basis! We must not allow blurry accusations of the MMA from distracting us on the real issue at hand.

Question of Double Standards of Legal Implications of Clinics

Almost every doctor who had complained, believes that this approach of using clinics to be run by MAs and nurses alone, is wrong in law. Our Medical Act dictates that registered doctors should run any health/medical clinic only. Yet, while this is so for the private medical practitioners, there appears to be another law for government-backed facilities where this requirement can be ignored! (It is true that under the Medical Act, the Health Minister can waive or exempt certain regulations.)

That there appears to be one law for private doctors and another for the government or MOH has provoked a sense of injustice and deep anger, especially because quite a number of doctors who had fallen foul of this law had been severely punished recently. Some doctors have openly asked why they too cannot also employ MAs in their clinics, to look after simple basic health issues too, while each doctor can oversee a few clinics without being physically present!

Of course, the MMA does not and will not condone or encourage any doctor to break the law. Therein lies our dilemma of such a perceived differential application of the rule of law, which is increasingly questioned by more and more of our more vocal citizens. Blatant double standards are badly frowned upon by well-reasoning people, including doctors!

If all these 1Malaysia clinics can be manned by doctors, even house or medical officers (registered medical practitioners) then this degree of unhappiness would be much dissipated. The MMA urges an overall upgrading of these clinics to that manned by at least registered doctors. We believe this will help defuse the situation, and more importantly will enhance the quality of care for patients.

It should not be that if one is poor, then one has no option but would be serviced by whatever is offered at the cheapest mode. Such inequity exacerbates social injustice and is an affront to modern human rights concerns.

Safety & Quality of Care Concerns are real, likely to be better with Doctors

With such a move, there will not only be improving access to the poor but also ensuring safety, higher quality of care, possibly fewer errors, lessen medico-legal mishaps, despite the payment of only RM1! Of course, we can harness the special capabilities of the MAs and nurses to offer quicker access, but one that is supervised by a doctor. With such a move, the question of legality, more appropriate therapies, timely referral and even medical chits can be resolved.

A recent report by a group of doctors in Penang (Dr Jayabalan T and others, The Star, 07 January 2010, pg N45) stated that “A study in 2009 revealed that medical assistants at government health clinics and government hospitals were found to be responsible for many medication errors. Of the 1,612 prescriptions generated by medical assistants in a single week, 1169 errors were noted and some were critical errors, involving the use of at least one medication categorised as Group B medicine, which only medical officers are authorised to prescribe.”

They concluded that “It must be noted that medical assistants are trained to assist medical officers and not to provide treatment in the same manner as medical officers.”

Another study published in 2008 by the Institute of Health Systems Research (comprising researchers from both University Malaya and MOH doctors), on “Medical Error in MOH Primary Care Clinics”, had also found many more errors hitherto unexposed to the public. Of 1753 clinical records reviewed by a team of family medicine specialists, a very high percentage of medical errors were discovered: 57.2% occur in primary healthcare sites, and 93% of medical errors were deemed preventable. The majority of medical errors are related to medication. Medical assistants saw 81% of the total of records assessed, and thus were responsible for the majority of these medical errors.

A lack of knowledge and skills of MOH staff has been shown to contribute to medical errors. They concluded that there is a need to improve the quality of healthcare services provided by MOH health clinics.

Therefore, safety issues must always be considered. This is not to say that doctors cannot make such similar mistakes, but with far more comprehensive training and education, doctors are expected to make fewer of these errors. Medical protection insurance, when taken up by doctors, also helps to ensure greater patient protection.

MMA shares World Medical Association (WMA) Concerns about Uncontrolled Task-Shifting

For many of us in the MMA, the delegation of duties in the 1Malaysia clinics to non-doctors despite its noble intentions of trying to reach out to more of the urban poor, is a form of task-shifting from the medical doctor, which is much feared and roundly cautioned by medical professionals around the world.

While some poorer nations with very short supply of doctors have resorted to task-shifting some of health care to nurse practitioners or health assistants (even encouraged by WHO), this is not the usual exercise for countries aspiring toward a higher standard of care.

This move also contrasts starkly with our vaunted new approach to encourage greater Medical Tourism initiatives, and could lead to questions of uneven healthcare standards, and possibly safety issues. This could unfavourably impact our efforts to promote health tourism from safety conscious foreigners.

Lest doctors be lambasted as ‘elitist’ once again, we declare that we are not. But we respect standards and clear task demarcations, which define one profession from another. Task separations have been mankind’s refining benchmarks for better and more specialized work designations, and we believe this approach is particularly appropriate for the medical and health profession.

Importantly, MAs and nurses do not replace the need for doctors, they assist them to help free up more time for more consultative, diagnostic or more special therapeutic roles. This exercise should never be an exercise for economic or other purposes. Safety and Quality of healthcare must always be our prime concern.

Utilise our Extensive GP Network

Our GP clinic network is extensive in the urban setting. All towns small and big have perhaps too many GP clinics. In major cities these are now highly competitive, even excessive and oversupplied. Many clinics have concerns of viability and under-utilisation. Perhaps, some of these are not sufficiently popular because of poor preparation or other reasons, but most can be improved upon with proper distribution or dispersal of patients.

Therefore, many GPs have asked why they have not been roped in to help out in these clinics for the poor, if only the MOH or government can help reimburse these clinics to help out. We understand the differences in expectations, amenities and perhaps problems with reimbursement protocols, but these can be worked out for the benefit of all.

Our GPs stand ready to be incorporated into a partnership, even an integrated system for better primary care for all our citizens.

But MOH concerns that some or most GPs are of unsure/unsound standards are unfounded and biased. Otherwise how is it that some 62.1% of Malaysians who need medical treatment, seek private primary care consultations in the first instance (2006 National Health and Morbidity Survey)?

The MMA is leading a primary healthcare workgroup to further coordinate measures to raise the standards and quality of patient care among all our GPs and/or family physicians. This will enhance the quality of care even higher for our citizens. We are also working with the MOH to see how we partner or integrate the primary health care system in the country. Again differing standards of expectations, logistics and reimbursement mechanisms need to be sorted out.

GP Woes are Real and Mounting

Many other problems remain to be resolved, which cannot be achieved by any party alone. Our private sector doctors and GPs are also concerned with many other competing issues such as feeder clinics, wellness health screening centres, pathology laboratories posing as clinics; Managed Care Organisations, third party payer or insurance discounting, capping and selection, etc.

There are also rising complaints and perceived sporadic ‘harassments’ from MOH officers implementing the PHCFSA, although these are supposedly for guidance for existing clinics, as was the understanding with previous Ministers of Health. Such pressures make the beleaguered GPs very sensitive to these threats on their practice, they seem to have been assaulted from all angles, with more coming on-stream, even before the other has gone away.

MMA Expects Greater Consultation & Shared Purpose for the Way Forward

Perhaps, less appreciated by government and MOH authorities is the fact that health matters and policy changes affect many sectors, including healthcare providers led by doctors, who should be the natural partners for consultation and engagement for the greater good of the public, the rakyat.

The MMA is ever ready to be a steady partner for working closely and supportively with the MOH, but we must not be taken for granted to agree with the MOH’s every decision.

The MMA is not arrogant. Conversely at various times, our increasingly demanding members have accused us of being too placid and accommodating with the MOH. We have been trying very hard to work with the MOH over many matters of shared interests—during the increased outbreaks of dengue fever, and the H1N1 influenza, we have been tireless supporters of many MOH initiatives which are not universally shared by some sectors and the public.

Together, we believe the end results have been much better than we had feared despite initial uncertainties. Our rakyat’s overall confidence without panic seems to be the final result, which benefits all Malaysians. The pandemic flu second wave appears so far to have been kept in check.

Sometimes our differing methods of implementation may appear to have crossed purposes, but this is mostly due to misunderstanding and lack of communication. The MMA still remains the largest representative body for doctors, with the longest and arguably the most dependable history of doctors’ interests and public health concerns.

Although not always evident, most doctors do depend on MMA’s leadership to articulate some physician concerns, which are not so easily conveyed to the authorities.

As civil and government servants, public sector doctors are bound by government orders and hierarchical levels of authority, which implicitly ‘gags’ many from raising legitimate concerns and criticisms. MMA thus fills in this unenviable void to voice concerns and doctors’ interests, without fear or favour, because that is our remit, although this may sometimes be seen to be irritating and perhaps too ‘garang’.

We recognize that the government and MOH policy makers need a degree of autonomy to enact certain regulations and laws, but without adequate and proper feedback from the doctors or stakeholders on the ground, the implications might be unforeseeably difficult to implement. Indeed many regulations are now seen to be fraught with real-life difficulties and incongruities, which have to be modified and streamlined, as an after sight.

The MMA believes that no authority or government can produce perfect policies, laws and legislations; we can help shape and modify these regulatory frameworks, which ultimately work best for all concerned, in a win-win approach—we and other physician groups, should be engaged and consulted with, for the best cooperative approach to enhancing our healthcare system.

Greater Challenges ahead, Let’s work together

We are all for better medical services for the public and we are certainly very sympathetic to the poor and those who have been marginalized.

We urge the MOH to work with the MMA to recognize and address the many legitimate concerns of the medical practitioners in the country that are mounting. We have to develop a much more refined and planned system of health care and all its encompassing concerns and provider needs.

Let doctors and society have greater and more meaningful input to help resolve some of these issues to help bring about the best health care system for our country.