A National Health Financing Fund will be set up, owned by and controlled by the government.

Are you sure? Are you quite certain these guys won't request for kickbacks, or that patients need to be referred to only certain specialists or hospitals for otherwise the second signature on that cheque will not be forthcoming?

An unfounded fear? It is already rampant between private hospitals and MCOs currently. Is Karol certain they have thought this through? Probably not. We just need to try this out, won't we? If everything works, well and good. If it doesn't, well a couple of patients will die in the ensuing chaos. A small price to pay to overcome the learning curve I guess. When the government holds these funds there is little accountability.

Our Auditor Generals can write volumes on this subject. But more importantly, the delay in releasing funds by our bureaucrats for health care can be exceptionally deadly.

This fund will receive income from a separate tax, possibly EPF and perhaps receive some input from general taxation especially in the initial period.

We are in fact back to square one, aren't we? Our national health budget is only 3 to 4%. Why can't we raise it to 6% and let professionals manage the show instead of all these Pengarahs, Deputy DGs, DGs, etc who have no clue about IT, marketing, finance, auditing and human resource. Malaysian Healthcare requires professional management as in every other organisation. You don't need to privatize it to be efficient.

The Chinese Army, Indian Railways and the United States Department of Defense employ millions of employees but runs very efficiently. Whichever way you turn this through; in the final analysis it is management of resources. And this is where the crux of the problem has always been with our healthcare system. We should have decentralized yesterday. It is the centralization that has virtually brought the entire system to its knees. Gone are the days when Medical Superintendents could tell the Minister of Health to go to hell. The prevalent submissiveness has blunted creativity and leadership. Everyone toes the line and marks time at the expense of innovativeness.

The National Health Fund will only pay for treatment of illnesses categorized in a previously accepted list. And patients must first go to a General Practitioner (GP) to whom they are designated. If specialist referral or hospital admission is required, it must be done by the patient's GP. The fund will not pay up if the patient by-passes the GP.

Except in emergencies I guess. And what of illnesses not covered in the list. Are patients expected to die at home? Understandably as a nation we need to ration ourselves. No system in the world can give you everything. It is preposterous that dengue, HIV, hepatitis, diabetes, cardiovascular disease, cancer and obesity are creating such great havoc in our society but our transplant coordinators and heart institute, with no doubt the tacit support of our mainstream media, appear to be championing heart transplants.

It is not that we cannot send someone up to space. But in our state of priorities, can we afford it? And what of areas where there are no GPs and the nearest facility is a klinik desa run by a midwife? Can the patient go direct to hospital then or would he/she be penalized?

Dangerous in Malaysia?

All GPs will be allocated a certain number of patients and become "fund managers". They will get the same income per patient whether the patient comes to their clinic 10 times in a year or not at all. This is to prevent over investigation and treatment by the specialists. If they stay within their budget, the GP will get a hefty bonus. If the GP exceeds this referral budget, he may face a financial penalty! This is to make GPs efficient gate-keepers.

In the Malaysian setting, this has to be dangerous. The MOH's unholy and rabid haste in implementing the PHFSA will now come to roost. If you expect a GP to "hold on" and "manage" the patient and refer when absolutely necessary, then the GP must be knowledgeably equipped.

In the NHS, a GP needs to have the MRCGP, followed by numerous other courses which include areas of your interest and the respective qualifications in obstetrics/gynaecology, paediatrics, surgery, urology, cardiology, geriatrics, dermatology, respiratory medicine or diabetes. No one GP can know everything. But short sighted officials at the MOH jumped the gun by excluding doctors from this decision making.

It is not registering and compartmentalizing them in a parliamentary edict that is important but equipping them with knowledge that is critical. In the UK, from whence our system evolved, GPs are constantly encouraged and funded to acquire more postgraduate qualifications including resuscitative techniques in ATLS, ATAACS and PHTLS. The current drive is to even include nurse practitioners to this arena and encourage nurses to acquire Masters degrees in areas of their interest.

In Malaysia, we are currently throwing nurses and MAs caught working in GP clinics in jail and by God, are encouraging sinsehs, bomohs, ayurveds and homeopaths to set up practice in our government hospitals. Now, what warped up mind would do such a thing? A mind that clearly has not seen enough.

Government hospitals will no longer get an annual budget. They will be paid by the amount of clinical service they provide according to a predetermined list of illnesses. Apparently if treatment for appendicitis is RM1,000, then this figure stays irrespective of whether there are any complications or the length of hospital stay. A private hospital that handles an appendix case will also get the same payment from the national health fund.

You really think private or even government hospital consultants will fall for this one? Their solution would be simple. Either the patient tops up or he will be told to go elsewhere including the traditional medicine specialist at Kepala Batas.

Private insurance will be allowed for illnesses that are not covered by the listed group of illnesses to cover specialist costs that are not incurred through the GP referral system. This is already the practice in the private sector

Teaching hospitals

And what of teaching hospitals? Are they included in this proposal? Or will they remain status quo with their working capital coming off the Ministry of Education. And what of training, teaching, etc. How do they find a place here in the general scheme of things? If teaching hospitals are also told to survive in this scheme of self sustenance and financial incentives, would students have their fees raised and will we have our lecturers disappearing to do their public patients in a private hospital to claim their fees as is currently happening now?

Health care in Malaysia cannot be managed as Karl Karol has recommended here. In fact it is a wonder that they are even here in the first place. Whose bird brained idea was this? There are enough Malaysians who are experienced and have worked in Australia, the US, Britain including both the public and private sectors in Malaysia who can provide far better and practical solutions.

But of course these doctors will not be able to provide their expertise to the Malaysian government becausethe MOH is not in talking terms with them. The MOH's current concern appears to be Traditional Medicine and illegal clinics if newspaper reports are to be believed.

The system we have here, put in place after independence and implemented by initial DGs, served this country well in the initial years but lost track sometime in the late 60's when the then DG abolished fee charging by consultants accelerating the exodus of doctors and specialists to the private sector.

Subsequent years failed to take into account the rapid advances of medicine, emerging illnesses especially those related to cardiovascular disease, cancer and an aging population. Our healthcare now is in dire straits and to wean it off its ventilator; you just cannot yank the tube off its throat and ask it to walk home tomorrow. The weaning has to be measured and whatever changes that have to be made must be kept simple and in this country transparent, for it to survive.

The problems facing our primary health care and hospital systems are not complex. We have to thank our original founders for this. But solutions to these problems should not be further complicated by incompetent handling by our health officials. Their bungling in building sometimes unnecessary hospitals located in the middle of nowhere, or of buying equipment that is scantily utilized and their witless attempts at IT and paperless hospitals costing tax payers billions of ringgit must now belong to the halls of legendary cock-ups in Malaysia.

Our government should look to the private sector where the majority of our doctors are based for solutions. To continue taking advice from our current lot of health administrators is to taunt fate and invite a far greater tragedy.

Put a better healthcare plan in place (Pt 1)

AHMAD SOBRI is a surgeon who has served in both the public and private sectors in Malaysia for 20 years. He is currently based in South England and his interests include resuscitative techniques including reanimation. His work also includes health policies, planning and finance.