Saturday, June 14, 2008

Equitable Access to Health Care for All

Equitable Access to Health Care for All: Is this still a Pipe Dream for Malaysians? A Medical Professional's Perspective

Dr David KL Quek, KMN, MBBS (Mal), MRCP (UK), FRCP (Lon), FAMM (Mal), FNHAM (Mal), FASCC (ASEAN), FCCP (USA), FACC (USA)
MMA representative to Suhakam's “Human Rights & Access to Equitable Healthcare” Dialogue, Kota Kinabalu, Sabah, 08 January 2008

“The availability of good medical care tends to vary inversely with the need for the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources.” ~ Julian Tudor Hart: ʻThe inverse care law.' The Lancet, 1971

“The reason we don’t know that we know things is that they conflict with more powerful ideas, and so we see them but fail to recognise them. The idea that inequality is a sign of economic health and social vigour is too compelling to permit serious engagement with the idea that inequality is anti-social and a cause of illness. We need to be told what we know, instinctively, about what makes a good society.” ~Marek Kohn, in Prospect magazine, September 2005.

Malaysians in general have had a sterling achievement in terms of advancement of human capital development, for the past 50 years since independence.

Our life expectancy at birth has risen from 55.8 years and 58.2 years for men and women respectively in 1957, to 71.8 years and 76.3 years, as of 2006. Infant and maternal mortality rates have markedly decreased to current levels, which equal those of developed nations.

Our primary health care service especially the rural health service has long been the envy and role model for other developing countries around the globe to emulate, deservedly endorsed by various agencies of the World Health Organization. I will not discuss this aspect further, but would concentrate more on the actual secondary and tertiary medical care access issues and their problems as these impinge upon the rights of the Malaysian patient.

In a recent high–level policy paper by SUHAKAM/UNDP [the Human Rights Perspective on Millennium Development Goals (MDGs)], one specific area of thrust to help move toward policy and practical goals is through improving the health status for Malaysians. These goals are articulated as follows:

Improving the health status

  • Policies and programmes that provide improved health care for the poor and vulnerable groups, as well as for the growing number of older persons, need to be formulated and implemented.
  • The poor must be excluded from user charges with increased privatization of health services.
  • Reproductive health targets, including those for adolescents, should be set, to further improve maternal health.
  • Sexual education in schools, as well as through civil society and religious organizations, should be intensified, to prevent health problems, such as the spread of the HIV/AIDS epidemic and pregnancy among youths.
  • Country-specific MDG plus targets relating to mental health, heart disease, and cancer should be set and monitored.

Yet, when one turns the pages of our daily newspapers, we are invariably accosted with pleas and requests for financial help to pay for some expensive, supposedly urgent life-saving medical services—particularly heart-rending stories when they involve babies and young children. This constant ʻbegging' for alms to help defray medical therapies and surgeries is unbecoming of a nation which aspires to be a fully developed one by 2020, i.e. a mere 13 years away.

A few years ago, when such pleas became too embarrassingly shameful to bear, the Ministry of Health initiated a Medical Assistance Fund (MAF). Unfortunately, despite occasional injection of funds from public pledges and the government, the distribution of such monies have been painfully slow, pedantically bureaucratic, and sporadic—so much so that the deprived still resorted to direct pleadings via the mass media to implore some sympathetic charitable souls to help out.

From a recent press statement by our DG of Health Tan Sri Datuk Ismail Merican, this MAF is now topped up to RM 25 million, but this will only be available to requests for treatment at government and public institutions only, which effectively excludes those seeking treatment from the private sector or overseas.

Another emergency fund launched by the Ministry of Health in collaboration with the National Welfare Foundation called “D’tik YKN” has been set up recently. It has received an initial allocation of RM 5 million. (“D’tik” is an acronym for Dana Talian Insan Kritikal Yayasan Kebajikan Negara.) This fund provides critically ill patients access to treatment within 24 to 72 hours, but is currently only available at Kuala Lumpur Hospital as its pilot medical facility to kick-start the programme.

Surely there must be a better mechanism to address these clangorous but pitiful entreaties for help from among the less well-to-do, the underprivileged, or simply the uninsured, or underinsured.

How is it that for so long we seemed to have weathered such demands in the past without these coming to the surface? Were there factually fewer cases requiring such special tertiary surgeries or therapies previously, say some 20-30 years ago? Or is it because we were less sophisticated then, more ignorant, and therefore less demanding of what medical treatment we are entitled to?

Perhaps over the past 2 or 3 decades we have become exposed to the stupendous advancement of medical progress, such that once desperately untreatable conditions are now given new hope of cure or palliation? Better education, improved literacy level and increasing human self-esteem and the huge explosion of information accessibility, especially via the Internet, have clearly contributed to this knowledge dissemination. Greater wealth distribution has of course also added to this new empowerment for more perceived rights and entitlement as citizens.

Health expenditure still low
However, Malaysia's health expenditure remains contentiously low. A total of 3.8% of the nation's GDP is spent on health care, with the public sector (i.e. government spending) accounting for 2.2% and private funding 1.6%. On average per capita, we spent only 374 PPP-USD for health in 2003, and we have 70 physicians per 100,000 population (i.e. one doctor for every 1428 citizens).

What is peculiar to Malaysia is that we have always had a rather mature dual system of health care service sectors—an incongruous dichotomy of private versus public health care sectors. There have been several papers presented to try and assimilate and integrate these two sectors so that they complement rather than duplicate each other, but so far, little has been achieved despite common thoughts on sharing patient information and talk of portable (IT-savvy electronic) personal health records.

The public healthcare sector is heavily subsidized by the government, and caters to the huge civil service employees, as well as to the less well-of (it is almost free from co-payments), such that some 70% (perhaps as high as 75%) of the population actually utilize these services almost exclusively; because for most, this is all what many perceive that they can afford to access any form of health care services, for themselves and their families.

One ringgit for consultation and medicines as an outpatient is clearly an economic anomaly, if any, to be considered as a co-payment for any health care service available anywhere in the world. Yet, our Malaysian public has been made so accustomed to this paltry sum (this cannot even pay for a bus fare or a canned drink) that it would appear politically inexpedient if any such fee adjustments were to be made or suggested.

So the government has to continue to appease the public and the electorate by staying this unsustainable course. Of course one can argue that for basic and emergency health care even the poorest can have access to treatment in most if not all of Malaysia's public health care sector.

It is true that there are sporadic attempts to offer affordable health services for the poor, but these are often fraught with uncertainties and limited scopes for the actual service rendered—it is not enough to simply offer advice and information—what is more important is that patients should also have access to what can be done—what treatment or surgery can be offered, without having to seek other alternative avenues of assistance.

However, Malaysians also expect modernization and better amenities of their health care services. Thus, huge amounts are allocated and have been spent on bringing up-to-date state-of-the-art equipment and facilities to nearly all of the major hospitals of every state or towns.

While such expenditure is laudable, there is a growing sense among the more discerning public, of possible wastage, less than spectacular structural excellence— from the outset many facilities are beset (some before being launched, even!) with ceiling leakages, mouldy infestations, structural defects, questionable fitness-to-operate certification, etc. These together with other dubious turn-key acquisition of costly equipment and beds, arguably make these hugely expensive facilities appear less than the best that they can be managed and/or run. We appear not to have achieved a bigger bang for the buck, so to speak.

State-of-the-Art Hospitals and Co-payments
When new modern state-of-the-art hospitals (built and equipped to the tune of hundreds of millions of ringgit, e.g. Selayang and PutraJaya Hospitals) are restructured so that full-paying patients can be charged for first class treatment—many protests were made, due to fears that the marginalized would once again be shortchanged and possibly neglected. It is not unreasonably feared that those who cannot pay may be made to wait unfairly long for therapies or surgeries which they need—that they might be preferentially sidelined by those who could afford to pay.

The Ministry of Health clearly views this option very differently, with the Minister Dato' Seri Dr Chua stating recently that patients are already enjoying the benefits, with some 103 patients paying some RM 116,000 as full-paying patients, with a small portion being disbursed to doctors.

Also another recent opinion piece commended the Ministry's move, stating that allowing this practice at these private wings might help retain some senior specialists from either resigning to join the private sector or even to practice as locum outside the public domain. In turn, these medical specialists can help remain in the MOH and still contribute to looking after the poorer patients in the respective hospitals.

However, some other critics are less sanguine about this practice. There have been examples bandied about that certain private wings of university medical centres are already practicing such preferential favoritism when dealing with fee-paying versus subsidized patients—that specialist medical treatments are offered fee-paying patients almost without any waiting time, whereas the poor have been made to queue, which can run into months, perhaps even years!

The uncomfortable truth is that, many of those in the queue have been told that they can always expedite their case when and once they have the requisite funds! Hence, the resorting to pleas for financial assistance from the public via the mass media, demeaning as this may be.

There is another problem—that of specialists and experienced staff leaving the public for the private sector. The usual cause for this ʻsenior staff hemorrhaging' is the financial ʻpull' factor.

Rightly or wrongly, the private sector is perceived of as being far more worthwhile, certainly more financially rewarding than the meagre public wages paid for slogging through the humdrum drudgery and thankless services for the masses.

Bureaucratic and office politics are other ʻpush' factors for this migration to so-called greener pastures of the private health care sector. This has led to the incongruity where some 60% of all the nation's physicians (in the private sector) are looking after some ʻprivileged' 30% of the population, and vice-versa! The depleted public sector doctors (some 40%) have to manage the greater 70% of population!

The perceived discrepancy between the public and private sector doctors' wages remain an unresolved bone of contention. Being part and parcel of the public services, only special allowances can be allocated to improve the final take-home pay for doctors. Of course this has been made more attractive lately with the abolishing of taxes on some of these allowances.

Still, some attrition to the private sector continues, and public sector shortages and congestion remain problems—which can affect timely and free access for poorer patients, using the system. The nearly-free treatment provided may sometimes be too much for the government to afford.

Yet, despite these misgivings, our Malaysian public has also been led to believe that health care costs in Malaysia are exorbitant, i.e. the private sector is charging too much; that doctors are profiting unfairly at the expense of the unfortunate public.

Surprisingly but not always obviously exposed, when we compare private medical practice fees and medical costs in Malaysia, we are actually modestly inexpensive—largely because our doctor's professional fees are consistently lower than those in neighbouring countries.

We are attracting foreign healthcare tourists because of our perceived modern facilities, greater technical and expert skills as well as affordability and cost-effectiveness. However, some people are unhappy as to this lopsided push for more tourist health dollars, which they feel may further disadvantage the poor.

But it is true that by and large, those who are uninsured and who are not civil servants, can find it expensive and in some cases unaffordable, when they seek private medical health care. Thus, their access to health care can be curtailed and they may resort to self-delays or seek alternative therapies, which in the long run may endanger their health even further. Others sometimes think that they can afford private health care initially, only to be burdened by high charges which accrue when complications set it unexpectedly or when unforeseen.

Unfortunately, there is no mechanism to assist such patients caught in such quandaries. However, most private medical facilities would offer discounts and even waive most of the extra charges, when they can after assessing the socioeconomic background of the patients and their families. But some also had legal demands dumped on them to reimburse these hospital charges, which can bankrupt the unwary.

What do modern patients want in health care?
In a recent report (A Clinical Vision of a reformed NHS, 2007) by the Joint Medical Consultative Council (JMCC) and the NHS, it was reported that the following are what patients want from their health care experience:
  • Fast access to reliable health advice
  • Effective treatment delivered by trusted professionals
  • Participation in decisions and respect for preferences
  • Clear, comprehensive information and support for self-care
  • Attention to physical and environmental needs
  • Emotional support, empathy and respect
  • Involvement of, and support for family and carers
  • Continuity of care and smooth transitions

The public as citizens may be concerned with abstract notions of good service such as affordability—free at the point of care; universality and equity; safety and quality; and health protection and disease prevention.

Although we do not have a similar survey conducted in Malaysia, I believe that many among the public would agree that the above-mentioned features are what they too aspire our health care service to be. Most importantly, everyone expects to have ʻreasonable' access to reliable effective and safe health care and advice. The problem is what is considered as ʻreasonable'?

Which model is sustainable?
This concept of universal access to health care is not easy to define or to delimit or more optimistically what it should embrace. Can it be a ʻbe all' and free for all comers? Clearly this is not a feasible nor reasonable option unless of course, we have command economy where every aspect of healthcare services is state-controlled and delivered via a system of one all-inclusive integrated services—there being no private sector or third party insurer or payer.

Unless we adopt such a radical or revolutionary change, as that practiced by communist Cuba, then we have to find an alternative approach—one that melds the two divergent arms of the private and public sector into a coherent complementary system.

Although many nations are increasingly looking toward the model of the NHS in UK, many are fully aware of its severe shortcomings and its rapidly evolving and chameleon-like shifts in practices and approaches.

The laissez faire free-for-all system as now practiced by the United States is clearly flawed and far too expensive (15% of the national GDP!) and leave too many disadvantaged groups fully neglected or uninsured (some 46 million people!) including many children and elderly (although the latter is assisted by Medicaid).

Other highly dependent state-insured nations such as the Netherlands, New Zealand are smaller populated but richer nations which spend an inordinately high portion of their social taxes on health, social and individual taxes can reach 50 percent or more—something that our country simply cannot match as of this juncture.

Germany for example, has a statutory health insurance system where 78% of the population contributes, the remainder being voluntary members or pay private insurance; in 2003 88% of the population has social health insurance.

However, it is estimated that only 30% (1.1 million tax-payers only!) of our adult population is paying any form of income tax or provident fund savings—how then can we raise sufficient community-rated premiums to help defray the enormous cost of health care for all?

Modified single insurer states such as Taiwan are facing serious financial crunches after grappling with an erstwhile successful model for the initial years—spiralling costs from more and more advanced treatment options are exhausting whatever reserves or spread of risks for its rapidly-ageing public. End-of-year credit squeezes and fund exhaustion (from DRG disbursements) are hampering high-cost surgical or medical procedures and therapies, thus elective procedural deferment and waiting times are increasing once again…

Co-payments are now being suggested as are rationing of certain forms of less than urgent or life-saving forms of therapies. In Germany, a physician fee of 10 euros is charged for a first visit to either GP or specialist, but free for other contacts within a quarter-year, if referred, to prevent doctor-hopping.

Our current model of private and public sector health care dichotomy is not without flaws, but is one that has provided reasonable access to health care for nearly everyone, with the public sector facilities serving as a fall-back safety net, whenever, higher costs therapies and surgeries preclude the patient from affording them.

This model may be sufficiently robust as to be tweaked and adapted so that we have a system which can work more efficiently with less wastage, despite our paltry expenditure as a whole. Although the health care budget is touted as some 5% of the GDP, actual government spending on health care and services amount to at most 2.6 to 3%, which is way below the number suggested by WHO and most health care advocates (which is around 8% of a nation's GDP).

Imagine if we can allocate another 5% into the healthcare budget, we can clearly achieve so much more and provide even better care and hopefully more access to cover more of the population, rather than the recurrent hiccups we encounter almost daily, these days.

A New National Health Care Financing Scheme and Authority
For a long time the MMA through its National Health Policy and Planning Committee headed previously by past president Dato RS McCoy have advocated a single-payer National Health Plan, which was presented to the government in a comprehensive monograph titled “Health for All”. We understand that large sections of our single-payer initiative proposal have been incorporated into the proposed scheme by the MOH in the National Health Care Financing Scheme (NHCFS).

Although in the beginning the MMA was enthusiastic about this development of the NHCFS, over the past few years, the very many alterations and distortions which have crept into the scheme, have created many concerns and doubts among those who had earlier favoured this approach.

This plan was earlier mooted as a single community-rated insurance scheme, which will provide mandatory and statutory cover for every Malaysian, through a central-collection and distribution system. Regional trust authorities were to be formed which act as gatekeepers as well as disbursers of funds and allocation of resources, so that healthcare costs can be contained; and excesses, wastage and duplication of services and testing are prevented or reduced.

A shared provident-insurance premium contribution is supposed to have been made by both employer and employee. What has not been agreed to, is the quantum of contribution, and whether this now dispenses with other health insurance incentives/benefits which employers now offer to many of their workers.

Furthermore, additional coverage premiums for family members remain uncertain, and factoring in this additional deduction based on the number of
dependents can clearly be difficult for a large segment of the public. What about the self-employed and the unemployed?

Then, there is the question of civil servants, the police and military personnel which the government has indicated that they would be provided for from the existing system, and that they would remain outside this new NHCFS. This has drawn huge criticism that a large proportion of the population (including their not unsizeable dependents) would therefore not be participating in this so-called ʻnational' health care financing scheme. Thus, this could unfairly burden the private sector with a disproportionate burden of the community-rated insurance scheme.

There is fear that there might be cross-subsidies to the public healthcare sector because the available public sector healthcare facilities would still be offering their services to privately-insured citizens, and hence be receiving reimbursement from this same financing authority. Separation of costs and services would become an unmanageable reality, and privately-insured citizens paying such additional insurance premiums could be paying far more than his or her fair share.

Therefore, although the NHCFS has been suggested as an all-embracing model, the manner of implementation appears fragmentary and less than convincing towards a health care system which offers universal access for all Malaysians. Interestingly after some review and counter-proposals from yet another Health Care Commission (Karol), the implementation of this NHCFS has been deferred to the next 10th Malaysia Plan.

I don't pretend to have all the answers, but clearly if we are to revamp our health care services so drastically as to have a “National Health Care Financing Scheme” then clearly this should be one that encompasses every citizen, and not piecemeal adaptation which only helps to complicate the practical issues on the ground. The very large segment of the population that comprises the civil services, must also fall under this category, otherwise the system would fail, as costs cross-coverage would surely be unavoidable and difficult to control.

Rather perhaps we could instill a newer mandated approach where each employed person be given incentives to insure himself and his family, and that a reasonable raft of healthcare services available should always be made accessible—either through some co-payment (Medicare model) or Medicaid when even the most indigent cannot afford. This must cover some regulated and specified diseases or ailments, and must include catastrophic illnesses which can often bankrupt even the most modestly middle-class of the citizens.

Which health care services should be readily accessible/available to everyone?
This sounds clichéd but becomes the lynch pin of any health care service in the world. Most would agree that all medical emergencies should fall under this category, where any ill person should have and must have access to life-saving or limb-salvaging care at the most urgent and timely manner as possible.

Still medical experts and regulators must identify specifically what should be the type and extent of health care which can be offered without due consideration as to costs and reimbursement. Clearly too, such often costly medical care must be insured upon (a central insurance mechanism or financing authority to reimburse claims to these cases) so that total coverage of an acceptable quantum can be disbursed to whichever sector is handling these emergencies—so that these would not bankrupt the system.

Would the DRG (Diagnosis-Related Groups) model work, and if so, have sufficient means testing been done to determine what the actual average costs are? Clearly in many countries where this is practiced, constant revision and meticulous attention to constantly shifting details and changes (socioeconomic, medical advances and newer techniques and technology costs and skills development, etc.), are a must. Still having said this, most DRG models utilize their allocated funds within shorter periods than have been projected, with unavoidable delays and deferments toward the end of each fiscal year.

Another very pressing issue of very great public concern, is that of catastrophic ailments such as major heart and brain affectations, critical infections (HIV/AIDS; SARS, Nipah, Enterovirus-Coxsackie, Meningitis, poliomyelitis, etc) and cancers. These must also be very clearly enunciated and itemized so that they are covered for the ordinary citizen.

How much coverage and to which extent would also have to be delineated. Then there is the question of prioritization and rationing—invariably there would be some degree of waiting and queuing and the question of how long, and triaging sicker patients who need treatment more urgently than others.

How can we make our public understand that these are necessary evils, which takes place in a finite system of services with finite limited resources, no matter the allocation?

If we allow a free-for-all access to all-comers whenever and wherever, then clearly costs will balloon and easily reach stratospheric levels of exorbitance and wastes. Perhaps the role of the National Health Care Financing Scheme would be able to encompass all such concerns and address these in models, which are not too bureaucratic or doctrinaire, where access can be stymied.

However, there must be some common ground for which to agree upon a system that works for Malaysia. We believe the government and the Ministry of Health must engage all interested parties to fully dialogue on this very pressing issue, so that everyone's interests can be represented.

A cut-and-paste approach behind several layers of closed doors and OSA dictates will only stifle rigorous and fair debate on this issue which involves and affects everyone. Ultimately there will have to be concessions and compromises. But, a user-friendly cost-effective and sustainable system beckons.

“First, let us embrace market economics - yes - but also recognize that free market economics are passé. We need an active role of the state, to help the poorest to break free of the poverty trap, and to help narrow the inequalities of a high-income market society… Let us understand that economic solidarity is insurance for all, the poor and the rich… Let us resolve to honor our commitments in the fight against poverty, hunger, and disease. Our commitments are small compared with our vast wealth, and the benefits will be vast.” —Jeffrey Sachs, Economics Professor, Columbia University, New York, in the BBC World Service Reith Lecture, 2007.

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