Saturday, June 21, 2008

Malaysian Healthcare Blues—We Need Newer Ideas, Better Personnel, not More Monuments…

“I regard the capacity of single-payer plans to ration effectively as a potential virtue. The need to ration care for the well insured is rapidly becoming inescapable in the face of an avalanche of new and costly technology. No system of rationing will be free of distortions, and a single-payer system may do the job well or poorly, depending on how it is organized and run. But creating politically sustainable institutions to ration health care sensibly and compassionately is one of the leading challenges that our nation cannot avoid and has yet to meet.” ~ Henry J. Aaron, Ph.D. Brookings Institute, Washington, DC 20036-2188 (NEJM 2003; 349:2461-2464)

Our National Health care system has been earmarked for change and modification for some time now.

There is some suggestion that it might even be considered for a more extensive revamp in the light of a planned move towards a Single Payer System, i.e. a National Healthcare Financing Authority and Scheme.

That this might be implemented soon is much anticipated, although the niceties and regulatory framework for such a potentially drastic exercise have yet to be fully revealed by the authorities that be.

Clearly the Health Ministry and the government of Malaysia will be finalizing the minutiae and will be rolling-out the scheme once the new Minister familiarize himself with the particulars of this long-awaited change.

In this regard we congratulate the new Minister of Health Datuk Dr Chua Soi Lek for his appointment into this hotbed of unending challenges, which has outlived many if not all of his predecessors. It will be good if the new Minster can approach this perennial quagmire with fresh eyes and ideas.

More important perhaps is the need for the Ministry of Health to re-appraise its priorities, as well as to formulate more consistently a definite Master Plan of where it wants the Malaysian Health Service to go in the coming decade or so.

Being a doctor himself, we hope the Minister can empathize with the healthcare providers especially physicians who have hitherto been emasculated from having too forceful a say, for fear of moral hazard and conflicts of interest.

Needless to say, we physicians believe that being an integral and inseparable part of the healthcare system, we should be the best qualified to understand the nitty-gritty problems and nuances of our profession and by that too the attendant problems of the healthcare and medical services.

The MMA of course stands ready to brief and assist in enlightening the Minister vis-à-vis these pressing problems.

The MMA has been instrumental in providing not merely lip service but also research and study plans concerning very many aspects of our healthcare services. Indeed we have been arguing for a higher standard of service for every Malaysian with the ultimate goal of global access of reasonable healthcare services for all without disparities caused by inability to pay or because of poor logistical or manpower support.

We have presented a comprehensive research document called “Health For All” (from the National Health Planning Committee of the MMA) to the government detailing these concepts of shared care and concerns. This committee is currently reviewing and updating another report to address newer more contemporary issues that we believe the government and the Ministry of Health can take due cognizance of.

We have argued for a shift towards a predominantly single payer system, because this is arguably the best mode of ensuring that every Malaysian be insured of getting every reasonable health care during acute illness, emergencies or catastrophic ailments, but at the same time respecting the constraints of a finite budget.

We have studied various other national systems of healthcare services and payment schemes, and have come to the conclusion that we must act soon before other forces of haphazard free-for-all managed care systems invade our tenuous state, and self-destruct whatever good the current system has allowed thus far.

We have also cautioned against an overloaded or third-party administrative structure which would in time consume too much of a chunk of the healthcare budget—ideally this should not account for more than 5 to 10%, so that more public monies from a mandatory contribution scheme, can be distributed more equitably to the people for their real health care needs.

While many envy the medical excellence and superlative care of the US model of healthcare, equally many consider this bloated behemoth to be untenable in the long run. The American model of managed competition or managed care-health maintenance systems have led to gross inefficiencies as well as to gross disparities of poor or no access (by some 43 million uninsured) to wanton wastage and spiraling runaway costs—upwards of 15% of the US gross domestic production.

In Malaysia we have been allocated just a paltry 3.8% (of the GDP: 2.2% public health allocation & 1.6% from private funding ) to play with—so it behooves us to be very cautious about adopting this very profligate model of excess and over-utilization of increasingly expensive services and medical technologies, and depriving an enlarging population of uninsured or uninsurable—i.e. the needy and indigent.

The Ministry of Health should seriously re-examine its expansion plans in its drive to convince the Malaysian public that it is doing everything possible to increase the quality of healthcare in the country.

We seem to have equated better healthcare services with building ever bigger and bigger facilities, at every town and urban centre. While this greater distribution is one way in which to expand our tertiary services—so that these can become more accessible to more of our citizens—we must also be equally concerned as to the quality of care of these services.

There is genuine concern that while we may have all these grandiose infrastructures in place (with more in the offing), we might still lack the requisite manpower, expertise or even simply the ancillary staff to support these services.

In the recent past decade or so, the Ministry of Health has been very aggressive at developing and constructing tertiary medical facilities at huge public costs, to cater to the needs and growing demands of our more discerning public.

That rapid phase of development has resulted in some very real access to expert but expensive healthcare services to many of the poorer segments of the population which would have been neglected by rationing just a decade or so ago.

To the government’s credit, many thousands of patients have benefited from such tertiary and sub-specialized care, so much so that Malaysians have prided themselves into believing that their health care system is now second to none and is at par with the very best in the world.

We therefore applaud the government for their foresight in pushing our Malaysian Healthcare services to the forefront of medical technology and expertise, so that some of our centres have now become singular referral sites even for some of our less developed neighbouring countries.

Medical tourism is now bandied about as a potential source of foreign exchange and income.
Conversely and ironically however, many of our own patients continue to be denied access to such services because of mechanisms which are beyond their control. Long delays or even cost-considerations have prevented unfettered access for some of these unfortunate people.

On the other hand previously untreatable and incurable diseases have become catchphrases for the newly-informed victims clamouring for some newfangled therapies which have yet to prove its ultimate benefits.

Clearly there are still areas where expert care is wanting or lacking and disparity between demand and supply exists. Better planning and greater training might provide an answer to this problem.

Because some of these catastrophic ailments can be extremely costly, there are presently insufficient mechanisms to allow everyone to equitably gain access to such care. Hopefully with a National Healthcare Financing Scheme this will become a thing of the past.

In the meantime, our Charity Health Fund has been assailed as being too niggardly and tardy at approving many requests for financial assistance to some of these costly but occasionally dubious medical therapies (which certain experts feel might simply be too prognostically dicey or not cost-effective to consider…) After all, we have only a very finite pool of resources and these public monies should be well-spent.

Nevertheless, our ever more demanding public now expects much more, perhaps more than we can adequately deliver or everyone and for every perceived ailment. They also expect faster more efficient delivery of services, as well as with better or even excellent results; and they are not too fearful to litigate or complain if less-than-expected outcomes occur.

Thus, although our healthcare services have expanded so rapidly, we have in many respects undermined our ability to sustain its continued excellence and productivity, and I believe its cost-efficiencies too. This is because we have let the development of our human resources and expertise to slide with inadequate planning and attention.

We have not in place a sufficiently well-structured training or apprenticeship scheme to continuously generate well-trained doctors, paramedics, nurse specialists, and properly accredited specialists, who can contribute with confidence and true expertise, for the sustained benefits of our people, and the public sector system.

In many respects, our training programmes have been haphazard and lack rigorous structure to ensure that our trainees once they graduate or pass out will be sufficiently well-versed with what are required of their operative skills and more importantly, of their so-called expert or ‘consultative’ decision-making and management proficiencies.

While we have been increasing our output of medical graduates in the past few years by encouraging the mushrooming of medical colleges (21, as of June 2008), we have failed to ensure that these graduates have been given the best quality medical education we can deliver.

We are adding some 1000-odd new doctors to the health service yearly, without too much concern as to the number or adequacy of their teachers or supervisors—indeed we stand accused of becoming another pariah state of medical graduate churners whose standards fall far short of international standards, if we continue along this murky path. The lack or withdrawal of reciprocity in recognition by foreign developed countries for our doctors is testimony to this sad fact…

We need a moratorium on the number of medical colleges as well as the number of medical undergraduates these colleges can undertake to teach or produce. Producing some 400 or so potential medical graduates from a single medical college demands more than a spirit of Can-Do-ism or a handful of teachers; there must be accountability that these doctors are well-taught too.

Every college must have adequate (rigorously specified) staff-to-student ratio—in every discipline so that the medical graduate it produces would not be of poor or suspect quality. More importantly this will ensure that the public will not be shortchanged or victimized in the longer term.

We must pay particular attention to this unruly development and nip this in the bud, before it is too late to intervene. Greed should not supersede the need for accountability when future lives of patients are at stake!

In this regard too, we urge the Ministry of Health (MOH) to encourage greater growth and development of its manpower and ancillary staff.

Doctors in the public services must be given more perks and given due recognition so as to attract them to stay longer and happier in service. One way is to provide proper and adequate training.

In order to do this, the Ministry needs to retain senior staff and experts so that these can be the much needed trainers and supervisors of the younger trainees. In this way the system will continually regenerate itself in terms of expert care and services.

The MOH has already allowed limited private practice for some specialists and other incentives for more allowances are now being given to service medical officers—these could be expanded further to make it not simply more work hours for more pay, but also more attractive and lucrative means, in other ways.

It is always a wonder to me how our neighbouring countries retain most of their experienced experts and specialists within the system, when we seem to fail here in Malaysia.

We have to seriously look at conditions of work and incentives to encourage more to stay in service as well as to provide some structured allowances for private practice, to these people in demand. Only then can we hope to stem their migration towards the seemingly greener pasture of the private sector.

Perhaps it is also time to allow those in the private sector to participate in the teaching of trainees or even to volunteer their services within the public sector. Such a radical step requires a paradigm shift but it is not impossible for the MOH to rethink this concept.

I believe that the MOH can do a lot more to develop the human resource strength of our public health sector, but this must be re-emphasized in a new model of understanding and planning at the very top.

The Health Ministry must continue to raise the momentum of growth of the healthcare sector, by demanding a higher piece of the GDP pie—even a rise from 3% to 5% might be sufficient to boost the morale of our healthcare services. The W.H.O. recommends an allocation of at least 8% of the GDP for comprehensive healthcare services. We need to train our nurses, our technicians, our radiographers and other ancillary staff much better, and we must pay them well too, in order to keep them happy in service.

However, although we must continue to modernize and upgrade our hospital and medical facilities, we must be prudent in ensuring that we do not go overboard in profligate expansion just for the sake of doing so. It is mind-boggling to note that most of our new hospital complexes currently being built are now costing hundreds of millions a piece!!

On top of that, the turn-key project model that is employed these days has to be reined in, and better audited. Why? Because these inevitably make the construction and development costs much more than what it should be—and all at public tax-payers’ expenses.

Medical equipment and amenities are also being purchased without due diligence as to its utilization potential or its real-life usefulness at all! For instance, should we continue to build huge unwieldy hospital complexes and superfluous medical facilities at every conceivable locale, or should it consider smaller but more accessible, better-managed but patient-friendly medical centres, clinics and amenities, which are not only more cost-efficient but also more productive and less wasteful in terms of resources (both human and material).

Other examples: do we need multiple robotic surgical facilities in remote areas of the country, expensive imaging technologies (e.g. PET machines, MRIs, etc) where their indications or utilization are suspect?

Worse, what about staffing these facilities with already-scarce experts remaining a perennial problem? Would not such expenses be better employed training and developing medical personnel and expertise?

These are some of the urgent areas for the Minister and the Ministry of Health to consider. Our Public Health Sector needs urgent and better human resource management, development and retention.

The Private Sector should also be ready to assist in a more cohesive seamless integration of services so that all our patients can benefit, by having more choices.

Smart partnerships as repeatedly advocated by the DG of Health should be made a reality by taking bold steps to address these real personnel issues, and not just creating ostentatious monoliths.

The MMA stands ready for a continuing dialogue with the MOH to ensure the realization of the best healthcare service money can buy for Malaysians.
“There are always a lot of people so afraid of rocking the boat that they stop rowing. We can never get ahead that way.” – Harry S. Truman (1884-1972) 33rd U.S. President

“Our lives begin to end the day we become silent about things that matter.” ~ Martin Luther King, Jr.

(MMA News Editorial, March 2004, updated June 2008)

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