State of our health

In a climate of rising costs across the board, it is heartening to hear the health minister proclaiming that the cost of consulting with an Ministry of Health (MOH) doctor is to remain the same, i.e. RM1 for medical officers, and RM5 for a specialist (The Star, June 11, 2008). And this includes medications to whit!

The MOH spends a disproportionate amount of money providing heavily subsidised health care services (RM12.9 billion) -from primary to tertiary levels- to our Malaysian citizens, and as many complain to a large number of illegal immigrant workers and their families.

Yet despite this, we are not a country with a consistent form of universal health coverage. Universal health coverage is prevalent in Canada, Australia, the United Kingdom, and most of Europe. Other nations attempting some form of universal coverage include India and recently Thailand.

Nevertheless, our public health service does play an important part in providing very affordable health care to some 70 per cent of the population. Fortunately too, this public sector has not yet fallen under the dictates of free-market economics of getting every citizen to pay for services at market value and prices!

The 3.8% from the GDP spent on healthcare is divided to 2.2% by government and 1.6% in the private sector, according to the UNDP Human Development Report 2006. Even though our healthcare expenditure has remained relatively low, we have always been touted as having one of the best and more accessible healthcare services in the developing world. Our rural health service where there is an accessible health facility within a 5 km radius, is commendable and has been emulated by other developing nations. Yet, although modeled some 30-40 years ago, not much has changed.

Simple uncomplicated health matters, such as childhood vaccination programmes and maternal antenatal-perinatal care are one of the best aspects of our rural health services. Thus, previous scourges such as polio, tetanus, diphtheria and whooping cough are now rarely encountered and are almost totally eradicated from our Malaysian shores. Our childhood mortality data shows that we have now an enviable rate close to most developed nations.

(Tertiary and catastrophic medical care, on the other hand, are another matter, for which our citizens' access are still spotty and where we still lack direction, continuity or consistency of care.)

Caprice of the weather

But there are deep pockets of very erratic and unapproachable zones especially in the jungles of Sabah and Sarawak where the indigenous peoples are somewhat left out of the loop, and are seriously under-served.

Flying services into these remote sites (frequently the only access mode available) are subject to the caprice of the weather as well as to the mechanical uptime of the helicopters/small planes, and the grudging willingness of medical personnel.

To top it all, some grandiose mis-planning of a few new health centres certainly take the cake for stupidity. Some facilities have been built without considering the lack of continuous piped water or regular electricity supply, or even accessible roads, becoming the proverbial white elephants, so emblematic of political and bureaucratic profligacy and waste. I learned of some of these missteps when I had the privilege of participating in SUHAKAM's health accessibility forums in Kuching (November 2007) and Kota Kinabalu (January 2008).

Many interested citizen groups are aghast and indignant with these pointless exercises in futility, but for me, they serve as eye-openers which should guide future planning as well as to forestall and guard against such gross miscalculations from ever occurring again. However, as many are wont to point out, bureaucrats with political motives and expediencies have pretty short memories, but very thick skins and over-expressed self-interests!

I also remember the previous health minister talking about the deployment of mobile clinics in suburban areas, to cater the poor and neglected (these would naturally costs some hundreds of millions of ringgit). These hundred-odd clinics were to be newly equipped and manned to alleviate the normal crush at our outpatient polyclinics at larger district hospitals, seemingly.

However, this idea runs counter to the fact that private clinics serve many of these areas, and therefore compete for the diminishing pie. That these public mobile clinics should compete unfairly with our private brethren doctors appears inefficient and callous. After the election of March 2008, we have not heard of the rehashing of such plans--so perhaps it is good that they should not be resurrected.

Lately, the new Health Minister Liow Tiong Lai suggested that perhaps it is timely to tap into the private sector to help complement the outpatient services of the MOH hospitals, which initially generated a great deal of interest among some GPs (The Star, June 13, 2008). He lamented the fact that so very few doctors are willing to serve in MOH facilities to ease the manpower shortage, is it possible that RM80 per hour is considered not sufficiently attractive?

Public-private integration

Perhaps dispersing the outpatient load out to local neighbourhood GPs with adequate compensation and contracted pay-for-performance standards can be a reality in the near future, thereby enhancing the much-talked about but poorly realised public-private integration goal for the health sector.

In another development, the respected Sultan of Perak Sultan Azlan Shah suggested that perhaps the private sector through donations, can help out to contribute more towards public healthcare facilities (The Star, June 13, 2008). However, private donations and endowments can at best be sporadic and piecemeal, and would not be a viable or sustainable long term affair or effort. Moreover, selfless philanthropy toward public good isn't exactly Malaysians' forte, even if there are notable exceptions.

While philantropy is a good gesture of corporate social responsibility (CSR), it should not be any private citizen's (corporate or individual) responsibility to upgrade and/or maintain such public health care facilities. Our tax dollars through careful and appropriate allocations should bear such budgetary and fiduciary responsibilities.

I wonder how much longer our government can pay for expensive healthcare subsidies, notwithstanding its role in maintaining its social compact, and providing the very essential safety net for the bulk of modest-earning Malaysians, including the chronically-ill, the unfortunate, the stricken and the needy.

What is interesting is that even with the much discussed (yet to be finalised/implemented) National Health Care Financing Scheme, for civil servants and their dependents, it has been reassuringly confirmed that they will still be under the direct purview of government. This qualified exception is something quite uniquely bothersome, which could derail the meaning of what is to be 'one' uniform system of National Health Service for the country, i.e. universal access to health care for every citizen.

Perhaps, to remove this entrenched civil service benefit is too great a political dice to throw, and the anticipated backlash and fall-out too nasty to fathom. What's troublesome is that this effectively excludes more than 1.2 million public servants and perhaps another 4 to 5 times the number of their dependents, or more from this proposed scheme (that by whichever reckoning appears to resemble the British National Health Service).

Law of maximum numbers

For the private citizen, that is another matter, this scheme is theirs to contribute and finance, but is it theirs alone?

One wonders if this is workable, especially when we are planning for this so-called 'single payer' system.

Aren't we jeopardising the law of maximum numbers when we hope to tap into the largest community-rated scheme ever, so that individual premiums can be most modestly capped and therefore be most cost-efficient?

We all need to have a good re-think on this. We need more dialogue and inputs from all the stakeholders, especially from the public who will be directly affected, and the healthcare providers who will need to adjust their roles and responsibilities. Will free-market healthcare see its own demise any time soon?

More importantly, will a hurriedly pieced together scheme suffer the real but ignominious possibility of insolvency and failure to deliver, that has wrecked so many other national health systems the world over? Perhaps, the devil we know (even, if quite imperfect) is better than one that we don't.

DR DAVID KL QUEK is interested sociopolitical affairs, social justice, health matters, professionalism and ethics. He is past editor-in-chief of the MMA (Malaysian Medical Association) News for 11 years and currently president-elect of the MMA.