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

Private or public wings are but a fallacy... by JT

Private or public wings are but a fallacy

Letter by JT, in Lim Kit Siang's blog

It appears that yet again, CAP’s SM Idris has decided to go on a frolic of his own. This time by stating that Private Wings in Government Hospitals are the wrong things to do. Sometimes one really have to suspect if this guy truly knows what he is talking about or goes about criticizing everything and anything sundry just to occupy his time. There are only three components to a hospital bill: 1) Doctor’s fees 2) Hospital charges (Bed, Nursing, Utilities, Investigations, etc) and 3) Consumables (Medicines, gloves, catheters, stents, etc).

This government has been benevolent enough in providing and perhaps in the case of Sabah trying to provide, items 2 and 3 but cannot match up to 1. Idris wants equitable healthcare for everyone. When he says equitable what does he mean? If he means placing a few GTN tablets under the tongue for a heart attack, or placing a plaster of Paris cast for a broken tibia, or delivering the 3rd child in a mother with no co-morbidities, or putting up a drip for a dehydrated patient or placing a few stitches on a wound caused by the neighbor’s dog, that’s fine. This government would have no problems accommodating them.

But if he is talking about plating/nailing every fracture of a victim of a high speed polytraumatized patient, reconstructing all the facial bones in an accident victim, or doing a bypass for a coronary patient with recurrent pain or ballooning and placing an emergency stent in a patient with a heart attack or doing a liver transplant in a patient with liver cirrhosis, then Idris must surely know that even all of Malaysia’s GDP and PETRONAS’s reserves will not be able to cure this country’s health woes. The US belatedly learned that medical technology and its ensuing advanced care can indeed bankrupt the nation causing Obama to desperately apply the brakes on its run away healthcare program that is highly sophisticated but yet cannot provide for almost 40 million Americans.

The reason why the government cannot match up to No. 1 is simple. To train specialists and retain experienced ones is not a simple issue. There are only so many who can operate on the brain or heart safely, a few who can carry out liver transplants with little mortality and even fewer who are interested in doing and following up bone-marrow transplants or manage and handle complex equipment to save critically ill neonates. Yes, these specialists can choose to go to the private sector or emigrate to the Western world but many would prefer to serve. But the service conditions and pay, really, for lack of a better term “suck” – especially the service terms.

Attending umpteen mindless meetings with no endings, going for compulsory ceramahs and believe it or not, even assembling in the sun to witness flag raising ceremonies just after clocking in and putting up with lunatic, disinterested head of departments interested only in conferencing and resorting wears your patience – precious time that could be well spent managing and treating patients. Idris and CAP should look closely into the poor management styles of our government hospitals wherein all our healthcare problems actually lie.

Our Government hospitals are akin to state hospitals in the UK that Aneurin Bevan, Britain’s NHS architect, once had to put up with after World War 2 before Margaret Thatcher straightened out their managements in the 1980s by converting them to Trusts. Even though Bevan had famously won over doctors “by stuffing their mouths with gold”, rampant mismanagement and poor accountability in hospitals continued till the time Thatcher stepped in. The fault of mismanaging our health resources lies not with the Prime Minister. It does not lie with Parliament, the Cabinet, the Public Services Department nor the Public Services Commission, but entirely with the Ministry of Health or elements within it. Failure to correct these faults is causing healthcare delivery in Malaysia dear.

Tell me Idris, why do we need a “Director-General” of Health. Are we still in wartime? Hospitals must be professionally managed by CEO’s with a strong founding in hospital administration, law and human resource. Ask any hospital group worth its salt out in the private sector, be it Pantai, KPJ, Parkway or Fortis what they look for in a capable Hospital CEO. You can also take it from me that none of these fellas will employ an ex-Kementerian Kesihatan Pengarah to run their hospitals simply because you must be well-versed with customer requirements, billing, accounts, auditing, purchasing, cash-flows, budgets, maintenance, training and dealing with specialists and staff. Can you name even one Government Hospital here in Malaysia that is run by such a CEO? If you don’t manage an outfit professionally, this healthcare nightmare you and your organization keep harping about is never going to end.

The Institute Jantung Negara (IJN) is run by a pro and they do function efficiently. However there is no one in accounting at the Ministry of Finance (MOF) to whom the hospital belongs to, who have the ability to check the IJN’s double and sometimes quadruple billing. The MOF has learnt the hard way what a health monopoly can do to your budget. Irate MOF officials suggested that IJN’s management be hived off to Sime Darby’’s health arm who are tough on accounting so that the leakages can be plugged and the savings be used to help even more patients. But an ignorant public only saw IJN as a government hospital and Sime Darby as an evil money machine.

Similarly, do you really think all these massive hospital infrastructure and expensive medical equipment are properly researched before being requisitioned? The answer is of course an emphatic NO! Due to both political and corrupt leakages, precious money meant for treatment is hived off. The Public vs Private divide is but a fallacy. There never was nor is there such a divide. The only distinction one has to make is the level and quality of healthcare delivery and who has to pay for it. Make the service efficient and get the government to pay for it. It works pretty well in the UK. There is no Einstein involved in this at all.

And how do we do that? The best way to avoid a Full Paying Patients’ program (FPP) is to make certain our hospitals are professionally run. There are only three hospitals in this country that are not run by the MOH (excluding the Armed Forces Hospitals and the Orang Asli Hospital). They are the University Malaya Medical Center (UMMC), HUKM (Hospital University Kebangsaan Malaysia) and HUSM (Hospital University Sains Malaysia). All of them have private wings. The private wings at both UMMC and HUKM are doing much better then HUSM. But private wings only form a portion of the income these hospitals survive on. Other sources of income include rentals to food and sundry outlets, income from parking fees, from pharmaceuticals, research grants and from the various courses and conferences conducted by the lecturers.

It’s true that there is subtle soliciting by some specialists; it’s true that some of these specialists are posting their cases even earlier then they should and it is also true that they delegate some of the work at the public wing to their Registrars. It’s further true that even top doctors applying to be lecturers are sometimes blatantly prevented from joining the University for fear their capabilities would “cut” into their private income, to the detriment of patient care as a whole for the University. But a sharp CEO can put a stop to all this easily. Private hospital CEO’s manage these sought of problems on a daily basis. But the system has undoubtedly worked for these universities. You see, unlike the bottomless pit of unaccounted money that government hospitals are usually lavished with, all these hospitals under the Ministry of Education now have to look for additional sources of income to keep their operations afloat. And this process is teaching them to be efficient.

Key to their goals are the retention of their top doctors by incentivising them so that they still remain to provide at least the input and expertise in teaching both undergraduates and postgraduates in addition to providing good patient care. The nursing standards in the UMMC in particular are excellent and with all the paramedical support available at this hospital, patients who make it to this hospital are indeed a privileged lot. The care provided in this particular hospital has got a lot to do with the design of the hospital itself and the training programs laid down by its pioneering founders.

But the specialists are a different matter altogether. Their numbers are limited and their expertise even more scarce, which means an astute CEO, must know how to utilize their abilities to the maximum for the benefit of as many patients as possible. Contrast this with the specialists at the MOH who keep getting transferred every now and then. How in heavens is this going to benefit long term patient care and follow-up? Further, private wings were built at these University hospitals to not only retain the current specialists but in the hope that even private, experienced specialists will bring in their expertise to collectively benefit patients in exchange for help in teaching. But this remains largely an unfulfilled pipe dream.

Everyone forgets that almost half the country’s most senior and experienced specialists available in the private sector take on only not so ill patients because they cannot match the infrastructure required and available in Government Hospitals for such patients. At the same time, these same experienced specialists are not available to the very ill patients being managed by less experienced specialists in government hospitals. How do we tap their expertise and amalgamate them into the government healthcare system so that all Malaysians benefit?

Private wings in University Hospitals have remained largely the personal domain of University Specialists, defeating one of the key aims of the hospital’s investment effectively reducing both income and the incorporation of external expertise into the University. A tough CEO would have put this right. Similarly if Private Wings in government hospitals are going to be for the exclusive use of only government doctors, then expect another hijacking of the facility by government doctors with no external doctors using the facility. Again it will be a monopoly and with monopoly will come all the other unsavory practices associated with it.

Thus far the MOH has been hoodwinking this government and public by throwing this Public vs Private divide. All invitations to “help out” are insincere or come with strings attached such as “You must be MMC registered…. and 10 other conditions in fine print”. The challenge in fact is to not only get these specialists to lend their expertise for instance through private wings but also to open the door to even foreign specialists in the areas of expertise this country lacks in. This way Malaysians get the best care as both infrastructure and the expertise becomes available. Our Sultans need not go to Singapore for treatment nor our kids to India for surgery.

The reality of the manpower situation is, this country is extremely short of qualified, experienced technical staff. It’s high time the government takes the role of computing costs diligently including the various fees for doctors and other medical professionals now widely published in various government and insurance schedules.

Every Malaysian patient must have the availability of the best medical care this country can offer. And every Malaysian patient need not pay a cent. You only need to properly manage the system. Surely we don’t need to call in Margaret Thatcher to help us do that. For intelligent accountants, like PETRONAS ex-CEO, Hassan Merican, matching the infrastructure to manpower would be a cinch. Surely there are many more accountants of Hassan Merican’s caliber that can lead the Health Ministry in providing efficient services.

The Academy of Medicine and the various colleges incorporated in it including the MMA and its subcommittees have tried in vain to match and incorporate the entry of this country’s experienced and senior consultants in the private sector to the sometimes excellent medical infrastructure the government has invested in but invariably failed.

Perhaps the CAP or other similar organizations can do what thus far the Academy of Medicine and MMA have failed to accomplish. Keeping the public and private divide wide apart is detrimental to the healthcare delivery in this country. Equitable access to quality healthcare care paid for by the government is what CAP and other NGOs should target for. And this can only be achieved by aggressive integration of both the public and private sectors with the government footing the budget.

----------------ooooo00000ooooo------------------

My Comments (DQ):

The above perspective while arguably passionate about what has gone wrong with our health care system, does not really provide concrete answers or models with which to offer our Malaysian public. 

The arguments put forth contain many errors as well as misconceptions about our health care system. It appears that the author's perspective is full of biases with sketchy patchy understanding of what's really happening out there. It is easy to skim on the surface of health care issues and slant it one way or the other to back up one's viewpoints. 

However, the overall slant is towards greater extension of the private sector to keep highly qualified expert doctors happy, but which should be open to competition, and not limited to public service doctors. This is a flawed and simplistic take on how to retain  doctors in service, as well as trying to rationalise greater market-driven system of heatlhcare.

Yet there is little perspective about the rising costs of unfettered health care and how we can rein this in. It appears that the author feels and assumes that the bulk of our health care cost must be borne by the government, yet earlier in the debate, he or she acknowledges that no one nation can afford all these modern therapies. How should we find the money, if our public is so disdained at contributing or paying more. We still do not have a dedicated social contribution fund or tax to cater exclusively for health care.

So other than some possibly genuine concerns and brickbats about why some of the models we have adopted so far, may be wrongly applied, I truly cannot find any worthwhile or pragmatic solution(s) in this article, which can meaningfully help reform our health care system... At best this is a distorted cry for a better system, but unfortunately the polemic is superficial, fractured and incoherent.

Malaysiakini-CAP: Private wings will cripple public healthcare

Private wings will cripple public healthcare

SM Mohamed Idris
Mar 9, 10
6:06pm

The Consumer's Association of Penang (CAP) views with deep concern the government's proposal to implement its full-paying patient (FPP) scheme via commercial private wings (CPWs), which in its pilot project at the Hospital Selayang has failed to benefit both doctors and patients. Such a scheme is fundamentally flawed and will only serve to deprive the low income and poor rakyat of their right to specialist care as is their basic human right as citizens.

By right, there should be a very clear separation between the public and private sector when it comes to healthcare. This is because the government is responsible for regulating the private healthcare sector and carrying out enforcement duties.

In fact, private healthcare is, in principle, is supposed to complement public healthcare and not assume the role of the public healthcare sector as the principle guardian of the rakyat's health. This abrogation of duty by the government towards the rakyat is now being manifested by its various exercises in corporatisation and the outright albeit gradual and systematic privatisation.

As far back as 2004, CAP had objected to this proposed scheme. Now the government seems insistent on reintroducing this unjust programme despite the public outcry. If the proposal is implemented, it will mean that public hospitals will have a private wing purely for commercial purposes; the idea being to increase remuneration for government doctors and other medical staff.

At the outset, the idea seems novel and attractive to those working in the public sector. However, there are serious implications for consumers especially the poorer ones. There is also the possibility of discrimination which might pit one set of professionals against the other.

A look at our private health sector and how it operates profitably should be able to give us an insight into the repercussions of a move to encourage privatisation in parts of the public healthcare sector.

For example, the general practitioner operates in a way that he profits from his consultation charges and for the procedures that he does outside of the routine ones like urine tests, blood tests, etc. He also makes money from dispensing medications, where prices are marked up.

The private hospital makes its money from a whole list of services that it provides. The list is exhaustive and includes the charges for the following: medicines, board and lodging, procedures (surgical), nursing, use of equipment and also administrative costs – all of which can be exorbitant and beyond the means of many. The above is likely to be duplicated if public hospitals set up private wings.

As it is, some public hospital settings in the country already have a public-private mix. The University Malaya Medical Centre (UH) is one such setting while the other is the Institut Jantung Negara (IJN). 

What have been the consequences of such changes?

So far, they can be said to be discouraging, to say the least. The costs of medicines, procedures, and laboratory charges at UH have shot up many times. The IJN is probably the costliest place for heart surgery. Also, the waiting time for heart patients who are unable to afford surgery could be up to two years or more.

There are other implications if the ill-planned scheme goes through. Among them are:

Manpower shortage - there has been a perennial shortage of medical manpower in the country. In the year 2000, there were 6,429 medical vacancies in the public sector. In 2004, there were at least 3,000 critical vacancies. In 2008, the doctor to patient ratio in the country was 1 to 1,105 patients.

As a result of this shortage, medical officers are very much overworked in the public sector. For instance, a medical officer in the Outpatient Department in the major government hospitals could see up to 150 patients a day or more (the ideal number recommended by the health ministry is a maximum of 50).

How is this shortage to be addressed with the commencement of CPWs? If there is an overall manpower shortage, why is there a need to deploy staff to the CPW and while facing ever increasing number of patients?

Inadequate infrastructure - there is a shortage of better-class wards even in the general hospitals so how do we accommodate the influx of CPW patients into the general hospitals? This could lead to depriving the poorer patient and the converting of beds for the use in the privatised wings.

In addition, there are already some big hospitals with insufficient medical equipment, for example, MRI machines. The patients who come in will have to be sent to another hospital to obtain these services, thus inconveniencing these patients.

Discrimination - upgrading of some hospitals to CPW status and not others will create discrimination in terms of remuneration for staff and this might cause an exodus of staff to greener pastures.

The lure of the ringgit can also be a temptation for corrupt practices - there could be corrupt doctors who would see patients in the CPW and admit them to the public side for procedures. He could then pocket fees illegally by offering a concession to the patient. This practice is rampant in places like India and Egypt where there is a public-private mix.

Equity and accessibility - to remain competitive, charges over the years will escalate. The net benefit for the poor will be less access and a further erosion of equity.

Sustainability - CPWs found not to be profitable might face a predicament unlike private hospitals. The latter can be closed down if seen to be unprofitable, but can the same thing be done for CPWs?

If the aim is to increase remunerations for medical staff, then there are some means whereby additional income for the government could be generated. Among these are:

Part payment by patients at government hospitals - Third-class patients should continue to be charged nominal rates for specialist and in-patient treatment. These charges can be raised slightly, where appropriate, to bring in more revenue. Those who cannot afford to pay full rates should be given discounts or, in the poorest cases, free treatment. Patients in the second-class and those in first-class should pay a greater percentage of the costs of treatment.

Increase the charges for outpatient treatment - the current charge of RM1 for outpatient treatment at 

government facilities could be raised. Based on the 1998 total outpatient attendances at government health facilities, raising the outpatient rate to RM5 could bring in at least another RM100 million which could go towards financing the healthcare system further. The figure would be much higher with the present day number of patients.

Extend Socso's services to include medical care in general - in other words, its services should not be restricted to only treatment for industrial accidents and occupational diseases. The annual 'profits' of Socso (which actually represents a significant subsidy to the state by workers) could thus be transferred to the Health Ministry through hospital payments.

Since Socso covers all employees earning below RM2,000 per month, the poor and lower-income wage-earners would be able to draw on their contributions to finance their medical bills in government clinics and hospitals, thus easing the financial strain on the Health Ministry.

If the existing Socso contributions are still insufficient, the rates for Socso contributions could be raised marginally. An increase of only RM1 a month by employees plus another RM1 by employers would yield a substantial overall increase in the government's healthcare spending capacity.

At the same time, the manpower shortage should be addressed. As a short-term solution, a fixed number of foreign doctors should be encouraged to take up permanent employment here. This measure could be halted once there is enough local staff to cater for our medical needs, especially in the rural areas.

CAP reiterates its objection to the government's proposal to create private wings in public hospitals for the purpose of increasing doctors' remuneration or for any other reason. The primary role of public hospitals is to ensure equitable and accessible healthcare especially for the middle and lower-income groups and the poor. There will be a conflict of interest if the already- overburdened public healthcare resources are further diluted to cater for private wings.

The initiation of a two-queue system within public sector hospitals will be disadvantageous to the very population they are aiming to serve, ie, the patients who need the service most. There is great potential for abuse of the system as was shown in previous attempts in the late 1960s.

If the intention of these private wings is to help retain public specialists, this has yet to be proven as there will inevitably be a tendency for specialists to use the private wing as a 'testing ground' before they leave completely for the private sector.

Introducing private practice in government hospitals is decidedly unacceptable as it will drastically change the face of the present healthcare system to the acute disadvantage of the rakyat. CAP calls on the health ministry to scrap the proposal for introducing the FPP scheme. The healthcare of the rakyat should not be compromised for monetary benefits.

The writer is president, Consumers Association of Penang.