Dialogue with Health Minister: MMA’s Concerns & Reservations regarding the 1Malaysia Clinics

MMA’s Concerns & Reservations regarding the 1Malaysia Clinics

YB Dato’ Sri Liow Tiong Lai, Minister of Health,

Thank you very much for agreeing to have a timely dialogue with doctors and the MMA. I also wish to thank Mr Lim Eng Leong for facilitating this dialogue, which many of our MMA members have called for.

As is now quite well-known to you YB Dato’ Sri, there has been a lot of confusion, anger and fear among many private sector doctors, especially GPs (General Practitioners) throughout the nation when the issue of 1Malaysia Clinic was first broached by the Prime Minister during his Budget 2010 speech in October 2009.

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 and the marginalized, whether in the urban or rural locations.

We fully support every effort to ensure that the poorest among us, as of every citizen 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 Manned by Non-doctors Cause Concern of Quality, Safety for Patients

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 appear redundant, because we already have so many GP clinics in almost every town 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 small and inconsequential to some of us. There has been much anxiety and confusion among many GPs from Johor Bahru to Penang, Kota Bharu, Kota Kinabalu and Kuching.

Many Doctors Confused and Angered

I have received literally, no less than hundreds of angry and condemning sms’s and emails demanding that the MMA address this issue, which they 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 Private Healthcare Facilities and Services Act and Regulations.

The major peeve/concern 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 from afar.

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.

No Real Doctor Shortage, Better Deployment the Answer

MMA believes there is no real shortage of medical doctors. 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 situations.

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. Even rural or suburban ‘klinik kesihatan’s can be upgraded to doctor-manned clinics which would enhance the overall standard and quality of care for everyone, urban and rural.

Question of Legal Implications of Clinics to be run by Non-Doctors

Almost every one doctor who had complained, believes that this is wrong in law. Our Medical Act dictates that any health/medical clinic should be run by registered doctors 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 waived!

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 have openly asked why they 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. There 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.

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 a registered doctor. We believe this will help defuse the situation.

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.” Therefore, safety issues must always be considered. This is not to say that doctors cannot make mistakes, but with far more comprehensive training and education, these errors are expected to be fewer. Medical defence 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 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.

It is true that in Australia, UK, USA and some northern European countries, some of these paramedical practitioners have been tasked to look after screening and continued care of some chronic ailments such as diabetic or hypertension control, these are very closely controlled with very clear lines of responsibilities. There are also very different career paths for these health professionals who are usually degree holders with higher educational capacity and they also undergo further clinical practice diploma training.

Importantly, these 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. I enclose here, the two recently passed resolutions and statements by the WMA for your perusal.

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 even excessive and oversupplied. Many clinics are having 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.

The MMA is leading a primary healthcare workgroup to 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.

In this context, the MMA welcomes the statement by the Prime Minister in his opening of the Kampung Kerinchi 1Malaysia Clinic yesterday, that ....”cases from here (1Malaysia clinics) will be referred to them (private doctors) for further examination or treatment...” and we hope that this will be implemented as quickly as the 1Malaysia clinics have been set up.

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 steady partner for working closely and supportively with the MOH, but we must not be taken for granted.

The MMA is not arrogant, although at various times, we have been accused of being too placid by our increasingly demanding members. 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. Although because of the rising doctor population, our percentage representation has declined to around 32%, the MMA still represents sufficient doctors in the country, in fact it remains the largest representative body for doctors with the longest and arguably the most dependable history of doctors’ interests and 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. Indeed many regulations are now seen to be fraught with real-life difficulties and incongruities, which have to be modified and streamlined.

The MMA believes that no authority or government can produce perfect policies, laws and legislations; we can help 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.

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; MCO, third party payer or insurance discounting 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.

Glut of Medical Graduates Coming Sooner than Later

With the rising number of medical graduates, there is genuine fear too that very soon even the MOH cannot sustainably employ all these doctors. There would simply not be sufficient posts for the coming glut of doctors.

By 2015, there is a real possibility that there would be some 40 to 45,000 doctors. Some 1200 to 1500 medical graduates are graduating from our 23 local medical schools. Another 1000 or more foreign trained doctors are returning yearly, and these seem to be rising with each passing year.

Where will these doctors go to practice? Will the public sector be able to absorb all these doctors? We are already experiencing oversupply of house officers in all our major hospitals this year with some of these young doctors having to share a patient, and some departments allowing them to do shift work, quite unheard of before in the past!

Will the GP sector too be saturated in due time? Will there be any moratorium to stay the production of so many doctors, at least within the country? Will we become a diploma mill for medical graduates who would no longer have any career certainty of employability? Would we be following the path of the Philippines, Indonesia or India where surplus doctors have retrained to become more sort-after nurses to work in first world countries, This would be a great waste of our resources and severe drain of our citizens hard-earned savings.

Greater Challenges ahead, Let’s work together

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.

Otherwise a potential crisis of unimaginable proportion could arise, which could unleash even greater problems both for disgruntled healthcare providers including very expensively trained doctors, who may have too little to do or even unemployed!

Let doctors 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.

PM: 1Malaysia clinics no threat to private clinics

1Malaysia clinics no threat to private clinics: PM

KUALA LUMPUR: Prime Minister Datuk Seri Najib Tun Razak said private doctors need not worry that their earnings would be affected by 1Malaysia clinics.

He said this was because the 50 1Malaysia clinics set up nationwide would concentrate on giving patients normal medical examinations like checking blood pressure level for hypertension, and sugar level....

“Actually, they (private doctors) will not be affected because the cases from here (1Malaysia clinics) will be referred to them for further examination or treatment, or the patients will then go to the government hospitals.

“So, I do not regard this as a win-lose situation but actually a win-win situation ... it’s easy for the people while the private clinics will receive patients as usual,” he told reporters after launching the Kerinchi 1Malaysia Clinic in Lembah Pantai here Thursday.

The prime minister was replying to a question on the concern voiced by the Malaysian Medical Association (MAA) over the existence of 1Malaysia clinics as they felt it could affect their income.

He said Health Minister Datuk Seri Liow Tiong Lai would hold a dialogue session with MMA members to assure them on the matter.

However, he stressed that 1Malaysia clinics were established solely for the benefit of the people.

“It is all for the interest of the rakyat (people) who are our No 1 concern ... this is what the Government stands for,” he said, adding that there were already 44 1Malaysia clinics in operation nationwide.

Najib said establishing the 44 clinics within two months was a record for the Health Ministry under the 2010 Budget, as the target of setting up 50 such clinics was almost met within such a short time.

On the proposal to increase the number of 1Malaysia clinics, he said the Government would evaluate the need based on the public response and the effects of the new approach in expanding public healthcare.

“If the response and effects are good, the clinics will possibly be increased ... but let us evaluate first as 50 (clinics) is a big number. And we also need to determine the effectiveness of these clinics and this new approach. From there, we can decide,” he said.

Najib said most of the 1Malaysia clinics were located in town areas as outside urban areas were 2,000 rural clinics which had existed since the country’s independence.

He said the Government had allocated RM10mil for the 50 1Malaysia clinics this year, but the amount was not for the buildings but for the internal fittings and medicines only.

Earlier, Najib who is also Finance Minister, said the setting up of the clinics was truly in line with the 1Malaysia concept mooted by him, as they were open to all races, especially from the low-income group.

He said the effort was introduced and implemented by the Government to ensure that quality health services in this country could be justly, equitably and wholly accessed by the people.

“That’s the Government’s aspiration,” he added.

“And access to the service (from 1Malaysia clinics) definitely involves a minimum cost, that is, RM1 ... the cheapest in the world or can be regarded as almost free.

“Besides that, patients don’t have to wait long as the 1Malaysia clinics will provide fast service. In this situation, the Health Ministry also benefits as the government hospitals will be less crowded with patients needing just basic treatment.”

Najib said the 1Malaysia clinics would operate daily, seven days a week, from 10am to 10pm, and manned by paramedics comprising medical assistants and trained nurses. -- Bernama

1M Clinic: Advice and Comments from Senior Doctors

Further Advice and Comments from Senior Doctors

Dr Steven Chow, President, FPMPAM (MMA member):

I can empathise with you the difficulties navigating through the challenges leading our medical fraternity in today's scenario.

Clearly,Klinik 1Malaysia is just another nut and bolt of a bigger political agenda. It is a political response to the issue of medical provision disparity in the urban poor. Legally and morally, the government of the day has the mandate to do so. The current public perception is that it is wrong for the private medical profession to challenge this.

When the Klinik 1Malaysia program was first revealed on Budget Day 2009 it was a body blow to the private practitioners. On the one hand, the PHFSAct and Regulations clearly requires private clinics to be manned at all material time by a registered medical practitioner. On the other hand, these 1Malaysia clinics need only to be manned by HAs and MAs. We fully agree with you and our doctors on this point and have already written earlier to express our concern regarding this irregularity.

After the launch of the PHFSAct Regulations 2006, we met the then Minister of Health on 16.8.2006 with our set of proposed amendments to the Regulations. He was absolutely supportive and the following points were categorically stated:

1.    The said Regulations simply prescribes the basic minimum standards that private healthcare facilities must adhere to by law and that these standards were applicable to BOTH private and public healthcare facilities. This was the explicit comment of the Minister in the presence of his entire senior MOH officials.

2.    The objective of the Law was not to criminalise the private doctors or to jail anyone of them.

However, the Minister did add a caveat, ie: "as long as he was the Minister" etc etc. Well, time and history has told a different story. I am afraid, history may repeat itself again with your forthcoming meeting.

The unfortunate thing is that GPs have previously been prosecuted and clinics closed when they were found to have HAs or MAs covering for them. The basic principle is that there cannot be a different set of laws for the private and the public sectors.The way forward is to push for specific amendments in the  PHFSA Regulations to specifically state that likewise  private clinics can also engage HAs and MAs.

The notice is already out for a meeting to discuss the draft amendments to the PHFSA Regulations on 12.1.2010. We need to focus our efforts on this meeting.The promised amendments are already 3 years late.

The rice-bowl of the GPs is unlikely to be significantly affected by these 50 clinics. The patients they cater for are likely to be those who are going to the government hospitals OPDs anyway. The PR line of the MOH is politically correct ie.  the scope of their function and capability will be different to that of a private medical clinic and they are there to serve a unmet social need. We can see that as a strategy, these clinics are likely to be situated in areas where the urban poor have limited access and also affordability to private care.

In a bigger picture, the livelihood of the GPs will be severely affected by the following:

1.    Private hospitals opening chains of feeder clinics under the guise of wellness screening centre etc etc 

Surprisingly, the MOH have approved the registration of such feeder clinics. This is already happening and will escalate with the developing scenario where the major private hospitals are already under GLCs. .The present laws and regulations are silent with regards to the business dealings of these hospitals.Their justification is that some university hospitals are also providing such services.

2.    Foreign enterprises opening private healthcare facilities in Malaysia and or buying up  GP/ primary care clinics with the inception of AFTA and the MRA with effect from 1.1.2010.If Malaysian doctors are too expensive to employ they may jolly well import them from lower-cost neighbouring countries.

3.    Loss of the dispensing facility of private clinics - this is being actively pursued by the pharmacist lobby and it does appear that it has the MOH sanction.To our knowledge, there is stated policy in the MOH and a roadmap is already in existence for its implementation in less than 5 years time..

4.    Incursion into the traditional medical practice by industry like private laboratories, health screening enterprises etc. including operating and running of clinics.

5.    Discounts, administrative charges,management fees etc etc extracted by MCOs. TTPs, insurance companies and all sorts of medical middlemen.

6.    Profession Fee schedule not in synchrony with rising operational cost 

What is extremely worrisome is the future implications and evolution of the 1MClinic model. The way things are going, there is nothing to prevent some enterprising private healthcare companies with the backing of GLCs to capitalise on the 1MClinic model and develop this into a full blown industry. It makes good business sense.

The stage is now set for a perfect storm when all these players get their act together.

Sadly, soon we will see the demise of the existing independent private GP system of this country that has faithfully provided for 60% of the outpatient care at an affordable cost. We are already hearing of comments by some in the MOH clamouring for the "nationalisation" of the independent private GP system.. Aren't we all "One Malaysian doctors",we have asked  "What is there to nationalise further? Why are we not treasuring a system that has worked wonderfully well for our rakyat? Why do we allow commercial entities to suck away the money that the people have diligently put aside for their healthcare?

The bottom-line is that healthcare cost will sky-rocket, the public will complain, the doctors will be blamed and the government will enact more regulations and there will yet be another cycle of self-perpetuating change.

Best wishes for your meeting.

Datuk Dr DM Thuraiappah (Chairman, AFPM):

We think we should address a fundamental question.

1. The MOH should stop creating reactions from the profession on knee-jerk proposals from politicians.
2. I have heard from a MOH official that the MOH does have a blue-print of the national health reforms. However, if there is a blue print, then MMA should be consulted.
3. MMA should push for reform of the health care system by MOH divesting itself and bringing about the following:
1. MOH to be a policy maker and monitor of regulations.
2. Healthcare to be delivered by Primary, Secondary and Tertiary Care Trusts.
3. The National Health Fund to be the payor for the delivery of health care.

MMA can then deal with the three institutions as and when necessary for different needs. Good uniform healthcare delivery in the nation should be a common goal and we should not be competing with each other.

I think we should put this forward as our contribution to the nation.

Dato' Dr Joseph Eravelly (Past President Academy Medicine, Malaysia): 

I have been following the many comments from leading office bearers of the MMA past and present. I am glad that the general tone is one of common sense, moderation, and not a rush to rash action.

Dr. Mohan Das’ comments are rational and needs to be studied carefully.  So also is the paper sent by Dr. Steven Chow.  

I am afraid the President should not wait to be guided by the views of the majority. The majority view may sometimes become emotional and almost mob-like. Instead as a leader he must lead.  Any crisis is an opportunity to think strategically and come up with solutions that earn the respect of your members.

After reading the many comments I thought I will add my two cents worth to everything that has been expressed. 

I believe there are two issues to be addressed here. The first is not just an incident which has generated all this heat. That incident is but a part of the larger and emerging risks of private medicine especially for GPs. Steven Chow has described these risks in some detail but does not offer solutions. 

The second issue is what the MMA can do for its members.  It requires thinking rationally and planning ahead instead of reacting to every crisis as it occurs.

Let me take the first issue. It is a fact that every doctor that goes into private practice (specialist or GP) has one primary overriding objective. That is to earn a better income for himself and his family.  He moves into the free market. He must but usually does not, understand the principle of SWOT. His limitations are imposed by the way he practices as well as by competition and the price elasticity of supply and demand.  His patients are really customers who must perceive value in paying his charges. Nowadays that customer is getting smarter and realizes that there are choices.

Businesses plan according to perceived behavior of customers.  They also use marketing tools to influence customer behavior.  Sure costs go up but clever marketing can persuade people to bear higher costs.

The business environment that the doctor works in will, and does, change. The pace of this change will quicken. Now freely available are BP sets, glucometers, and self-requested complete lab tests. Soon abdominal ultrasounds, brain scans, and even CT angiograms on-demand may become available. Consumers will also increasingly buy medicines directly from pharmacies without prescriptions or get a prescription for a small fee without consulting a doctor.  There are other dangers that have been lucidly pointed out by Steven Chow.  

Why consumers have changed is because of economics – price, convenience and speed. There is also an increasing belief that there is little value in consulting GPs. This is perhaps also reinforced by the GP himself behaving like he is selling medicines.   This is why I think it is better to give up dispensing and charge for prescriptions. 

But change in business models associated with altered consumer behavior is also affecting other businesses.  Mobile phone companies, PC makers, automobile companies, airlines, and even retailers suffer in the face of this change. They spend millions trying to anticipate and adapt not only to new technology but changing regulations by the regulator. Some die and fade from the scene.   Why then should a medical business playing in the same market complain and ask for protection. 

All these businesses play by the rules of the free market. That market is remorseless and unforgiving but generally fair and favors efficiency.   In the case of medicine especially governments will intervene if there is a sense of market failure by which I mean a failure to allocate resources efficiently according to needs.  Think Obama and his healthcare plan in the USA. 

The trigger event for today’s discourse is the implementation of 1Malaysia Clinics. As Tan Sri Ismail has said, that should not affect GPs and I agree. What is being planned in Malaysia is also occurring in different ways in the world. Let me explain.

In the US for example, for many years now nurses have been trained as anesthesiologists, and give G.A. even for brain and heart surgery operations.  At the Mayo Clinic they are using nurse practitioners to stand in for doctors on night calls with the power to prescribe and to call for tests. Technicians do bone marrow biopsies almost as if on an assembly line. Nurses and technicians insert and manage ventricular assist balloon pumps and pass pressure lines and Swan-Ganz catheters when required. These providers are trained and certified. The point to note is that it is possible to use non-doctors to do relatively sophisticated medical procedures.   It is a fact of life we must anticipate and accept. 

Compared to all these things that paramedics are being better trained to do, the work of the GP in his clinic looks like a walk in the park. To oppose the 1Malaysia proposal by the government will be tantamount to saying that better educated, better trained doctors cannot compete with nurses and medical assistants in the free market.  This argument sounds absurd.  Hence opposition to this activity should stop.

I come to my next point.  What can the MMA do for its members?  I fear that the MMA has become gridlocked in a huge bureaucracy. Most of this mess is created by doctors themselves, not the leaders.  There is nothing that the MMA seems to do for the betterment of its members.  No wonder your membership declines. 

Yet MMA is a very important organization that must be protected and enhanced.  It calls for a paradigm shift in thinking.  I have raised a few points on this line of thinking in a letter to you in August 2009. There is no point repeating everything else that I said before. The most important point worth repeating is that the MMA has Market Power.   We must understand this and learn how to use it in the free market.  

My Comments (DQ):

Thanks for all the feedback and comments. As I have said so earlier, approaches to leadership differs from one to another. 

One can opt to be autocratic, consultative, or leading by consensual direction, based on personal conviction and majoritarianism. The latter is what I practise. I do not believe I have the sole right to simply push ahead with my own opinions alone, although I may have a broader perspective than most.


Most of the points raised have actually ben raised by me in my President's pages and past editorials. But they are certainly worth repeating for those not in the know.

Regarding Steven's points of GP challenges, most if not all were enumerated in my September MMA News President's page, where I addressed the many issues which we are helping to resolve. Yes we will be fully committed to be present at the Amendment exercise for the Private Health Care Facilities and Services Act which will be held next Tuesday, where I will lead our MMA team.

I agree with Joe Eravelly that the 1M clinics will make only a very small dent, if at all, on the urban GP's financial concern, which is what I had stated at the earliest statements. 

However, this nonconsultative manner in which such policy change of task-shifting had been announced and implemented, is disturbing, and may become a very critical slippery slope from which all other government-MOH-doctor relations might in future be defined. 

If projects or policies are deemed for the so-called 'public good' or worse, for political mileage, then any authority can and will go ahead, regardless. 

I believe doctors as a group should not stand by as toothless tigers. We have to make a stand to be counted, that is my position as defined in my election manifesto, and I will pursue this if supported by my members, without fear or favour. 

Just because something is a done deal and/or foregone conclusion, if it is wrong or unacceptable, does not make it an irreparable right. It should still be opposed and hopefully rectified or modified to an acceptable compromise. This way, we move forwards with our cross-purposes being assuaged in some small ways, evolving into what we call a win-win situation. 

We must not allow our status to be continually eroded so that we can be dismissively bypassed without being consulted. Indeed we must learn to imagine the bigger picture; imagine a master plan when the entire National Health structure becomes revamped overnight, then what? 

It is a frightening scenario. But thankfully, thus far we the MMA, have been consulted on the preliminary aspects of the possible revamp embedded in the 10th Malaysia Plan.

In this day and age and especially after March 8, 2008, the Malaysian people have found a new and exciting liberated voice of empowerment--to question, to dialogue, to be counted and to help input their concerns and voices, so that a burgeoning sense of people power can be instilled into a laggard behemoth of more-of-the-same government. 

But be rest assured, we will not simply scream and shout, we will work earnestly but energetically together as best we can, but we must be counted as partners, not as mere puppets...

Although, many physicians especially specialists appear to see the 'bigger picture's and are somewhat  dismissive of the 'molehill' plight of the GPs;  my grapevine from the ground has been thunderingly loud, agitated and disturbed! I hear you all, and that is why I feel compelled to empathise with the GPs more. 

Personally, I am not in the least impacted by this issue, as of now. But I foresee a possible erosion of our strength and professional interests, if politicians and bureaucrats continue to simply enact policy changes and laws or even administrative dictates at will, without proper consultation with as many stakeholders as possible. 

A letter to the editor in The Star today, addresses a similar concern, while pointing out the shortcomings of our MA/nurses-led clinics even at our klinik kesihatans, already  so entrenched and in existence in the country. 

I believe we do have legitimate concerns, which must be resolved to the best possible compromise, with promises for greater consultation in the future. I think we are not asking too much, after all we are in this together, strange bed-fellows and all...

Malaysiakini Letter: PHFS: No 'ambulance' to rescue harassed doctors

PHFS: No 'ambulance' to rescue harassed doctors
Malaysiakini Letter: RS, Dec 21, 09, 4:46pm

I refer to the Malaysiakini article 1Malaysia Clinics: An exercise in futility and the continuing nationwide harassment of general practitioners especially in the state of Penang by elements at the health ministry led by its controversial director-general, Ismail Merican.. The current fault where private practitioners are now being treated as quasi-criminals by the health authorities and continue to do so must decidedly lie with these doctors themselves.

Unlike the majority of post-2008 Malaysians, they have chosen to remain silent and must now, like all unregistered voters, pay that proverbial high price for remaining cloistered in their shells.

Their grouse, the Private Health Facilities and Services Act (PHFSA) is the demonic brainchild of consumer groups. Doctors at the health ministry put together a disparate chunk of ambiguous edicts from various different countries and called it the PHFSA.

These doctors who tried to do a hard sell on the then health minister, Chua Jui Meng, throughout his tenure failed when, Jui Meng, being a trained lawyer, refused to buy it. For starters, he knew both of them had obstructed discussion of the proposed legislation by blocking inputs from the very doctors it was going to be applied upon by lumping all discussions pertaining to the act under the Official Secrets Act.

Secondly, Jui Meng, now a stalwart with Pakatan Rakyat, discovered their motives for wanting to force doctors to purchase equipment peddled or attend courses driven by health ministry cronies as the main reason behind the application of the OSA on a medical law. However, these doctors realised their opportunity when an ignorant Chua Soi Lek walked into the picture. This time their sales pitch worked.

Appalled doctors who realised the gravity of their connivance and implications of the proposed law threatened to march to Parliament but were let down when their own representatives sold them out lock, stock and barrel to Chua. The PHFSA became a reality and soon enough despite all of Chua's pronouncements (who himself was proven to be untrustworthy by subsequent video revelations at a Batu Pahat hotel) engulfed a bona fide, unsuspecting doctor from USM, Dr Basmullah Khan who did not even have the financial means to engage counsel.

Despite ambiguity virtually popping out of every line of the Act, a judge decided to throw Basmullah into the slammer instead of reading the PHFSA together with that of the duties of a medical practitioner as outlined in the Medical Act 1971.

Malaysia Medical Association (MMA) doctors who were stung by his jailing, tried to sign-up for an EGM to discuss this issue but yet again were foiled by their own brethren at the MMA who instead of focusing on the gravity of such a law on the profession, instead chose to split hairs regarding the inadequate number of members who had asked for the EGM (apparently, some had not paid their subscriptions on time and therefore not eligible to call for an EGM, let alone vote).

The MMA, from whom much was expected for something to be done about this law, remains quiescent and ineffective to say the least. The MMA has failed in two very important tasks. One is its role in the Malaysian Medical Council (MMC). It has been part and parcel of MMC hearings involving the suspensions or reprimanding of six leading specialists and 10 senior GPs, one of whom was suspended for employing a 'Medical Assistant' (now glamorously called 'Assistant Medical Officer' – the types that don't do housemanship and take only three years to graduate after Form 5 and appear today as possible stand-ins for the urban run '1Malaysia' clinics proposed by the government).What irony.

A significant number of these doctors lost their clinical rights based on an archaic misdemeanor called infamous conduct. What's that? The MMA, by being an active member in prosecuting and doling out 'punishments' by taking away doctor's livelihoods in hearings led by a hopelessly biased government establishment unschooled or poorly advised on medical litigation matters has no business representing private doctors anymore.

Of great disappointment is that almost all the doctors suspended, reprimanded or struck off are from the private sector, the very doctors whom the MMA purportedly represent. Despite the health ministry being the ministry with one of the highest number of complaints this government has ever had to face, why isn't there even one single doctor from the government sector struck off, reprimanded or suspended?

Legal advisors to the Malaysian Medical Counsel (MMC) have complained about the blatant abuse of PIC heads and the health ministry DG himself in not following legal procedures but who choose to become judge, jury and executioner against all legal advice despite evidence to the contrary. Some of these advisors have even walked out in protest.

But the MMA remains silent. Shouldn't the MMA, like the British Medical Association, be wearing the other shoe and taking the MMC to task or even to court instead of being part of this shameful charade?

But more ominous is the complete lack of action regarding the PHFSA. Clearly the harassment continues unabated. Doctors in Penang are up in arms, some even considering leaving the profession as the ministry's 'enforcement officers' who clearly have nothing better to do continue to prey on their practice. Meanwhile, the road side pile jabbers and 'sin seh' peddling leaves and acupuncture continue to do roaring business, no thanks to the ministry's endorsement of traditional medicine. Further, the '1Malaysia' clinics run by 'Assistant Medical Doctors'- a lobby far more powerful then the impotent MMA, are now threatening to come on aboard.

By now, the MMA should have written to every private practitioner if they want an EGM to discuss the PHFSA. By now, they should have consulted a team of lawyers to seek leave to look into a judicial review and stay all further actions of this acrimonious act. By now, they should have gone to the ground and provided legal assistance to doctors severely harassed by enforcement authorities.

By now, they should have pooled funds from all GPs affected and sued any authority who acted or trespassed clinics illegally or have contravened in the legal restitution of medical care to the infirm by qualified doctors.

By now, they should have decided whether they are up to the mark in delivering and discharging their duties to the very doctors who (and to those who didn't) put them in-charge. All future MMA presidential hopefuls should perhaps note that if they want to be 'yes men' like many of our Court of Appeal judges, then they should just perhaps focus on their practice instead of assuming an office from which they very well know they cannot discharge their duties effectively.

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COMMENTS (DQ):

Obviously, here is a doctor who has some ideas as to what has been happening but also confused as to the exact roles of MMA and MMC. Furthermore, his suggestion that private doctors are erroneously charged and victimised by the MMC, using archaic rules of professional misconduct, is probably ill-advised and quite inaccurate. 

His blanket acceptance that all those charged by the MMC are innocent victims is also disturbing and not based on facts. Most if not all these complaints arise from disgruntled patients, with some where the MMA simply act as a conduit for the complaint towards the MMC because of inability to resolve the issues to the satisfaction of both parties. And no, not all MMC members are yes-men. MMA leaders likewise are not to be tarred with the same brush. 

But this letter provides some food for thought.

MMA’s Grave Concern about 1Malaysia Clinics being manned by Medical Assistants

MMA’s Grave Concern about 1Malaysia Clinics being manned by Medical Assistants/Nurses

When Prime Minister Najib Razak announced in the Budget 2010, the setting up of 50 1Malaysia clinics in urban areas, the MMA was dumbfounded and perplexed.

That these clinics be set up at all, is perhaps a good exercise in public relations for our Prime Minister, who must have genuinely felt the need to offer some much needed goodwill to the urban folks, especially the poor and the marginalised.

However, what is more disturbing is the plan to have these clinics run by medical assistants and/or nurses, which in effect places the standard of these clinics at the level of third world countries, where there is a real scarcity of fully-registered physicians. It is certainly a major step backwards for a progressive nation such as Malaysia, which aspires to be fully developed by 2020, just 10 years away.

The Malaysian Medical Association (MMA) is gravely concerned that such a major shift in policy with regards public sector healthcare should be so implemented without sufficient input and discourse with stakeholders, such as the medical practitioners and perhaps even with officials of the Ministry of Health. It has been suggested that some health officials were also taken aback by this announcement, but they have been made to implement this as a directive, come January 2010. (I stand to be corrected on this fact.) It appears that this plan was brought about by fiat, rather than by persuasive rationale or long-term planning.

Firstly, let us reassure the public that the MMA is not simply protecting its turf. Of course, we are keenly interested in the welfare and wellbeing of medical practitioners, but we are also always concerned about our patients, i.e. the rakyat out there, who are our reason to exist, our raison d’être.

We welcome the government’s concern about our rakyat’s health needs. We also recognize that for many urban poor, their only recourse to health care is that offered by the overcrowded and understaffed MOH outpatient clinics. That there have been much queuing and long waiting times is notorious and wasteful in terms of productivity. Certainly we should do better.

We also know that new health ministry directives have been employed to try to shorten waiting times to less than 30 minutes; this has been included as part of the KPI/KRA so proudly announced by the government. Perhaps because of this huge problem, the need to lessen the burden of fixed outpatient clinics and the logistics of manpower distribution has prompted this new approach.

But we also urge the government to recognize that throughout the country, in urban areas, there are already in place many GP clinics, some only a few doors away from each other in almost every urban block of shop-houses or complexes.

There is a severe glut of GPs in urban areas, where in the Klang Valley, Penang, Johor Bahru, Melaka, Ipoh and other major towns. In all these townships and cities, the ratio of doctor to population is around 1 in 400, more than the WHO recommendation of 1 in 600.

While some GPs have been very successful, the great majority is simply ekeing out a meagre and mediocre living, many GPs are seeing less than 20 patients per day and so are under-utilised. This is grossly unproductive and wasteful when seen in the context of the long arduous training and huge expense required for producing any one doctor, whether locally or abroad.

Our problem is learning how to manage the distribution of the doctor-patient function better and more efficiently. It is with this in mind that for several years now, the MMA and the Ministry of Health have been seeking a better public-private partnership in shaping a better health care system for the country.

Unfortunately because of the differential system of fee and/or payment mechanisms, this is proving rather tricky to bring about a cohesive transferable system. Thus, there has even been growing talks about integrating the public-private sector for primary care medical services. This will hopefully seamlessly integrate the use of almost all GPs into a primary care network where the public can register and seek treatment at either public or GP clinics, interchangeably or by choice, with a common reimbursement mechanism. This will undoubtedly be the way forward.

Of course quite a few discrepancies need to be addressed, e.g. differing expectations, possibly standards of every aspect of care, variable amenities available, level of support staff, etc. But these can be worked out, and we are establishing common areas of standardisation, which will then ensure that the public can be assured of and experience as high a standard of health care as possible.

So, in this context, the hurried establishment of the new 1Malaysia Clinics appear irrational and un-called for. If the government feels genuinely that these have to be carried out regardless of the medical profession protestations, then the minimum that it should do, is to ensure that these clinics are duly manned by registered medical doctors, fully in charge of all aspects of the clinics. This standard of medical care should not be compromised.

Why is this such a prerogative? Because in this day and age, it is quite unbecoming to offer a lesser level of care to those citizens just because they cannot afford to pay to see a doctor. Employing medical assistants and nurses to do a doctor’s job is called task-shifting, which is employed mainly in third world countries where there is severe shortage of doctors. To do so in this country would be a major step backwards and in our MMA’s view, shameful and unnecessary.

Do we have enough doctors? Of course we do. It is just the mal-distribution and poor logistics, which need to be addressed. Recently, more than 2,500 new doctors joined the public service as house officers. It is understood that many of these are under-deployed in the various departments of the government hospitals.

Due to the mushrooming of so many medical schools (23 as of this year) in the country, and medical graduates returning from abroad, we will continue to have some 2,000 to 3,000 new doctors returning to our shores annually!

We can certainly tap into this growing number of doctors to help make our public service clinics more efficient. At the very least the public will be better served by some recognized registered medical doctor, although they may just have probationary medical licence—the fact remains that they have had sufficient training and learning. Medical officers, registrars and specialist, (who can also be deployed to enrich the public sector healthcare service, if need be), can supervise these younger doctors.

Why is the MMA so concerned about clinics being manned by medical assistants or other unregistered medical practitioner? Because under the Medical Act, this is illegal.

Because as of now and in the past, doctors who employ such unregistered persons have been charged and penalized for unprofessional conduct, with some severely sanctioned, even suspended or deregistered!

Because medical assistants cannot prescribe any more than some very simple medicines, cannot sign any medical leave chits or write any report, and would become subject to medico-legal challenges, with no precedents.

Because we are concerned that ‘bogus doctors’ should not be allowed to harm our rakyat! In the past there have been some bogus personnel who have continued to defraud many patients because many of them do not know the limits of their level of competence and training—who feel that they are not bound by any laws.

There should not be one law for some and another for others, even if approved by the government or the MOH.

Two wrongs do not make a right.

The MMA believes that setting up 1Malaysia Clinics in urban locales is wasteful, redundant and shortchanging the rakyat. Utilising the already many GP clinics would be the better way forward. 

Furthermore, manning these clinics by other than registered medical doctors is also wrong and undermines the health care service, which leads to a possibly poorer standard of care, which can lead to many uncharted medico-legal problems.

We urge a rethink about this project, and for the MOH to seriously look into the implications of this poorly advised move.

The MMA will strive to work together earnestly with the MOH to help raise the level of healthcare for Malaysians, but not by compromising on the standard of care, or of shortchanging the uninformed rakyat.

Dr David KL Quek, President MMA

1Malaysia Clinics: It’s time to get angry, agitated, involved!

1Malaysia Clinics: It’s time to get angry, agitated, involved!

Dr David KL Quek,

drquek@gmail.com

“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions  and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.”
~ Sir William Osler

Once again the internet and the alternative media are abuzz with recriminations and angry bloggings on why such an obviously regressive move has been foisted upon us, the hapless doctors, especially the GPs in urban locales!

Yet, a few public-minded readers of main stream media had only high praises for the government for proposing these new free clinics for urban dwellers, as evidenced by the letters of support in their interactive columns.

This is not altogether too surprising because, many of these people obviously feel that health care costs have become too costly for them to afford, but which is quite unsupported by the facts on the ground. Our private health care costs are quite reasonable and of high standards when compared with our neighbouring countries, in terms of purchasing parity or inflationary terms.

Perhaps, for too long the government has been offering practically free health care services to nearly everyone, so much so that not many people bother to plan or budget for any such ‘extra’ expenses. Perhaps, we now believe that health care should be an expected right of the citizen.

Like it or not, however, ours is not a single-payer National Health Service. Our tax base is actually very small (1.2 million taxpayers, and probably 6 million provident fund contributors), and there have really been no preferential or special social/health taxes to cater for this in our budget.

The latest national budget 2010 has indeed shrunk the health care allocation from the public purse, down some 4.8% to just over 13 billion ringgit. The government expects the private sector to take up the slack and push the overall health expenditure to a respectable 7% of our GDP, instead of the current 4.9%. Clearly the public service expenditure is not enough to cater for this.

So where is the money coming from, if the public sector puts in piecemeal local projects such as 1Malaysia clinics to compete with urban GP practices? In terms of quantum, the 10 million ringgit for 50 urban 1Malaysia clinics does not make much sense, except perhaps to assuage some misguided ego-boosting government agency or two!

Most importantly, do we really need these clinics?! Isn’t the shortage more in remote and rural areas, especially in the interiors of Sabah and Sarawak, where the doctor-population ratio is so wretchedly large, and the health care facilities so sparse and sporadic?

This is especially ironic because in towns and cities, there are enough doctors to cater to the health needs of most, if not all urban dwellers. In the Klang Valley itself the doctor-population ratio is around 1 in 380, more than enough for even the most developed nations. This is also true of most cities in the country (around 1 in 600). There is therefore, really no shortage of health services or personnel in such urban areas.

In fact, due to some skewed sense of urban penchant, doctors especially GPs, continue to vie with each other, ever so competitively by locating in inner-city sprawls, with many now just eking out paltry livelihoods.

So why, it begs the question, would the government see fit to jostle for such overcrowded spaces, if not to spite the medical profession?!

Perhaps, there is that misguided thought that by offering urbanites some goodies, no matter how inane, citizens might be persuaded to look upon the federal government more favourably, considering that almost all metropolitan parliamentary political representatives are from the opposition parties!

Nevertheless, notwithstanding the possibly noble intentions of the authorities, we seriously question the rationale and the sudden move, which we feel are at best misguided and not too well-thought of.

We understand that because for a very long time, we have had tax dollars paying for our nearly free public health care services, a large number of our citizens have come to expect that this should continue indefinitely. However, one to five ringgit for seeing a doctor in the public health care sector, hugely subsidized or free investigations and therapies, and months of free medications, (totalling only 2% copayment for public health care expenditure), cannot be a sustainable option!

Yet the reality is that this type of system is highly unlikely to be sustainable in the longer term—most countries in the world are finding out that they cannot afford this without enforced rationing, prolonged waiting times, diagnostic and therapeutic delays and even deliberate choice reductions, to exclude new, cutting-edge or really expensive therapies. In other words, something’s got to give!

But, we too are aware that some 35% of our populace (the less endowed) actually depend and benefit from such a much needed service, that we feel this cannot be done without.

But we have to reconsider a different mechanism to respond to such needs—I believe the medical profession will wholeheartedly support a revamp of a properly considered alternative mechanism(s), but these should be undertaken with in-depth input from all stakeholders and which would require great political will and planning!

Should we then be embarking on such a drastic paradigm shift? Perhaps, as some health economists might suggest. Yet, we continue to push private healthcare initiatives and insurances; new hospitals and medical centres are mushrooming; and we are targeting and enlarging our medical tourism incentives, which leads to a schizophrenic scenario as to what we truly want!

Instead of boosting and improving healthcare services and access, we appear to be taking the cheaper but possibly inferior approach; worse, at taxpayers’ expense on the one hand, and paradoxically encouraging super-duper specialist private sector growth on the other! We inadvertently but invariably encourage and push public to private sector expertise migration, thereby undermining the public services even more…

Perhaps, this exercise is just another political posturing which had been hurriedly pieced together to extract some cheap brownie points on a perceivably weak government, whose popularity needed some wagging-the-dog boosts!

To add salt to the wound, these so-called 1Malaysia clinics would compete with the already overly cutthroat urban clinics; but to be manned by medical assistants. That notion of not too subtly shifting the task downward by possibly non-health personnel bureaucrats is what takes the cake of adding insult to injury!

In one fell swoop, it would appear that the MOH had “ambushed” (as voiced by one angry doctor) the medical professionals once again, by proposing newfangled schemes which are arbitrary and even at first glance ‘illegal’, especially when viewed vis-à-vis the Private Healthcare Facilities and Services Act/Regulations and the Medical Act.

It is pointedly clear that any and every clinic should be manned by a registered medical practitioner. To do so otherwise would be to go against the law no matter the fact that there may be supervision from a medical practitioner from afar. Whatever mechanism of oversight now employed would appear to be an afterthought justification, which is convenient but probably still illegitimate.

In fact, the MOH and the law has prosecuted and indeed fined and jailed medical practitioners for employing under-qualified or unqualified people just for such unprofessional practices! Now it appears that one law is to be applied differentially for the private sector clinics, and another for those operated by the Ministry of Health!

Now it appears that many medical practitioners are up in arms, at least vocally, that such a move by the Ministry of Health once again undermines the bittersweet equanimity of our already beleaguered medical practices, just recently reeling from the imposition of the private health care facilities and services Regulations in 2006.

It appears to some doctors, that no medical society seems to care for them and their piled-on plight, and some have expressed their intentions to start another “grouping” to vent just such an opposition to these dastardly moves of the uncaring MOH, and yes, even the MMA! Isn’t this just like trying to re-create the “wheel”?

Still, perhaps it is good for more of us medical professionals to feel the need and the want to do something and at last, to resort to some form of collective action.

That is what and why most societies are formed for—to come together so that as a group representing a common purpose, we can be more effective in pursuing a cause, or to exert pressure against another, which is inimical to the group.

That is what the MMA is all about too, except that many choose to think that the MMA has been too ineffectual, and therefore some have chosen to denigrate and denounce its so-called inaction and ‘useless’ purpose!

They cry “what has the MMA done for me?” while at the same time shamelessly refusing to acknowledge that they have poorly supported the MMA, most by not even becoming members!

How many doctors turn up for rallies when called upon by the MMA leadership? Perhaps a few hundred, whom I fully salute! How many bother to turn up for our Annual General Assembly meetings, year in year out, to debate policies and issues, and yes even to engage in politicking mindlessness and arguments? A dismal two to three hundred!

As of this year, the MMA has just 8100 members in benefit, out of a total registered 26,000 medical practitioners, a paltry 30%! Yet, we are the largest representative body of the medical profession, but we could definitely show a greater strength of purpose and unity. We need more members to join our cause and increase our profile.

We, you have to show greater participation and engagement in our, your association, despite its inherent discordance and splintering interest groups! That is the essence of democracy and participatory membership. That is the essence of being involved, being engaged, wanting to contribute to perhaps influence a change no matter how small, but perhaps also in helping to shape a major policy which will affect our professional lives and livelihood!

But a fair and close scrutiny would immediately expose the truth: our MMA’s public sector arm, SCHOMOS, has been exemplary in catering to the benefits and interests of our public health care doctors. Perhaps our private practitioners section (PPSMMA) can do better, but we have actually been busy working hard on many issues to try and resolve with as many stakeholders as possible, by being as inclusive as we can.

When push comes to shove, at least some have been moved to take action, to have become agitated, angry and perhaps finally, willing to take some action, belatedly as the case may be. Sadly, such reactive knee-jerk reflexes are only triggered whenever our purse strings appear to be at risks, our livelihood’s at stake. In such a light we often come across as venal and mercenary. We should be more professionally-minded while we work hard and unapologetically for our professional interests and practices!

Yet, when it comes to unity of purpose and real positive contribution, these are often met with walls of silence and inaction, even apathy. It is time to come aboard and engage us to make us better, stronger, more meaningful! Come and join us and help us make better changes!

So what have the MMA done these past few weeks?

1. We have set up committees to look into the affairs of GP issues: met with and dialogue with the DG of Health and his MOH directors to share our concerns;
2. The recent National PPS NWC met with Director of Medical Services Dr Nooraini Baba to straighten out some difficulties, i.e. amendments/modification of the PHCFSA/R; private specialist hospitals setting up of feeder clinics, errant dispensing without prescription pharmacies, even the setting up of 1Malaysia clinics in urban areas;
3. We have formed a protem group to address the possible threat and extension of statutory requirements and MSQH accreditation moves for GPs,
4. We are working with the Academy of Family Physicians of Malaysia (AFPM) on developing a QIP programme which will enhance the quality and CPD of GPs/family physicians,
5. We are opposed to any splintering move of GPs into FPs and others,
6. We are opposed to the 1Malaysia Clinics being manned by non-doctors, or even their locations in competition with our urban GPs, and have expressed our concerns directly to the Minister and the MOH;
7. We have been discussing mechanisms on how to integrate our GP services into the overall Primary Care practice to alleviate the overcrowded public health care clinics—the Minister is very interested, but logistics and administrative barriers remain, recent announcement shows some progress;
8. We have worked out more favourable terms with FOMEMA, enlarging to 750 foreign worker examinations quota per annum, and streamlined radiological training for clinics with x-ray facilities
9. We are working with EPU to understand more of how the privatization plans would favour the medical industry;
10. We have worked with the MOH and EPU on understanding and moderating the implications of the ASEAN free trade zone, i.e. MRA and AFAS, when these come on board from next year, with full operational capacity by 2015;
11. We are working with various mass media which will work with us to enhance our profession-public interaction and communication, Astro’s Tamil service will showcase a collaboration with MMA on a series of expert talk shows from late this year or early next year 2010;
12. We are convening and engaging specialists to rethink our national health policy directions; discussing with various groups on case-mix/DRGs mechanisms;
13. We are actively engaging with WHO, Transparency International, ASLI, Human Rights Coalitions, on issues of better governance, better accountability, best practices, and human rights concerns, etc.
14. We are working on how to enhance the image of the medical profession in our run-up to our Golden Jubilee (50^th Anniversary) next year!
15. I have set-up a Facebook group blog strictly for medical professionals to engage more concretely issues, where everyone once registered can input, contribute, share and debate health care concerns (MyHealth Matters-MMA 2009-2011)  http://www.facebook.com/group.php?gid=181442416810