Medicine—Reigniting our Passion…

Medicine—Reigniting our Passion…

Dr David KL Quek, drquek@gmail.com

“Where is the wisdom we have lost in knowledge?

Where is the knowledge we have lost in information?”

~ T.S. Eliot. The Rock, 1934

“Physicians combine two diverse tendencies in their daily functioning, a scientific mode of thinking and a clinical commitment to healing. The former requires us to be rigorous, dispassionate, objective, loath to reach conclusions until incontrovertible facts have been assembled. The clinical, or professional, component, on the other hand, compelled by the urgency to assuage suffering and to defend life, demands immediate action even in the absence of complete data." ~ Bernard Lown, M.D. in Prescription for Survival: A Doctor’s Journey to end Nuclear Madness. Berrett-Koehler Publishers, Inc., San Francisco, 2008, p.61.

Traditional roots of medicine demand some personal reflection…

Some thirty years of practising as a doctor can certainly embolden one to try and reflect upon a profession that so intimately inhabits one’s personal universe. Nevertheless, I do so with trepidation that I may have overstepped my expertise, my uncertain moral position in the august footsteps of so many unmatchable giants of our medical profession.

Yet, I have been impelled to do so, to try and set down my nebulous thoughts as to what and how the concept of the modern doctor is changing or taking shape, amidst the tremendous transformations and challenges that have swept the medical profession and health care scene.

Being a medical doctor is certainly one profession, which can become an all-consuming life and living itself—one learns to eat, drink, and breathe medicine.

Our thoughts and thought processes are submerged within the lingering echoes and ethos of a Hippocratic ancien regime: one of highly-structured codified dos and don’ts and exhortations of an intricately-crafted analytical process. Many are now lamenting the relevance of these methods and constraints, the seemingly outmoded sweeping codes, so enshrined within its antiquarian Aesculapian confines.

Nevertheless this singular system has continually defined and redefined itself, with modernizing inputs from our forefathers—all highly regarded stalwart champions of principled medical practices and professionalism. On the basis of the Hippocratic tradition, medical practice has been transformed increasingly into a more rigorous scientific system—one that is better evidence-based, with consistent veridical facts, and most importantly, one that is able to deliver reliable repeatable quality of care and cure outcomes.

No longer is the practice of medicine simply the handed down legacies of trusted wisdom and opinions of a few experienced if authoritative masters. Direct challenges to untested even if persistently accepted practices from long ago have helped democratize and expand the scientific reach of medicine into more solid bases of substantiation.

Science and art meld together in an intertwined universe of shifting and ratifying complexities, which ultimately give up its ghost in some form of a therapeutic modus operandi. At least, that is what appears to be the articulated goal of medicine—to comfort always, to heal sometimes, and hopefully never to cause harm: Primum non Nocere (First, do no harm).

Most importantly but often forgotten in the glitzy or fevered attempts at dealing with modern ailments and newly-medicalized disorders, we should remember that our patients are our raison d’étre. Medicine exists because there are patients out there who need or deserve our services, our care. The converse is not necessarily true, and may indeed not be to our patients’ benefit.

These days, it is possible to forget that oftentimes, tangential rather than exceptional discoveries create new demands for newer approaches which may have become too all-inclusive: our healthcare lattice is thrown far too wide and spread too thinly. So much so that lifestyle, ageing-related or other psychosocial aberrations have become incorporated within new designations as novel ailments.

Some have suggested that such ready ‘medicalisation’ may be too indiscriminate and inappropriate. Some have been promoted and perhaps may even have been invented by “Big Pharma”. Some of these disorders have become propagandized and marketed as “real” ailments, which need to be diagnosed, investigated, and yes, even treated aggressively.

Evolving evidence-based Medicine

From folkloric herbs, bone setting, stone cutting, etc. we have now entered into a new era of thrust for evidence-based medical practice, or at least that’s what has been loudly proclaimed of late.

Out of the ashes of historical anecdotes and passing down of learned experiences, accepted ‘truths’ have been systematically debunked when put to more rigorous testing and ratification. Many pearls of long-accepted wisdom have been crushed under the weight of new evidence, and in their places have arisen newer concepts of better-tested, better proven ideas. However, the reality is that medical practice is not all based on rigorous or dogmatic scientific facts. We still have so many incomplete answers or limited comprehension on countless ailments.

Complicating this is the fact that different ailments affect different patients differently: some more gently, while others more catastrophically and perhaps even fatally. Such is the inconsistency of occurrences which doctors have labelled as ‘idiosyncrasies’, i.e. chance events and effects, which affect individual patients in peculiar, unexpected and often inexplicable ways.

Unbeknownst to some of our frustrated patients out there (who wonder why we sometimes cannot be more definite or sure, or why some unexpected outcomes or complications continue to take place), doctors still don’t know quite enough, at least, not for each and every medical illness or variant. We still puzzle over why certain twists and turns occur despite the rigorous implementation of what’s considered proper treatment, which are guided by evidence and research. The human body still escapes total understanding and occasionally behaves erratically and outside the rigid boundaries of expectation.

Even the most brilliantly gifted or polymath amongst us, would shy away from presuming that they know everything. However, there are those who do perceive of themselves as ‘gods’, the know-all who can dispense largesse and treat without any qualms of uncertainty but with the dogmatic conviction of a cocksure pedant—the expert extraordinaire. But with the relentless onslaught of scientific evidence constantly permeating the information universe, it would certainly be foolhardy to be so presumptuous, leaving far too little for cautious error or acknowledgement of possible uncertainties.

Medicine’s self-correcting mechanisms may be slow, erratic and staggered…

By espousing a self-correcting mechanism based on scientific tenets, western-style allopathic medicine has been marching along relentlessly, almost always improving upon itself, whilst dumping wrong or inaccurate concepts, measures, or treatment modalities. Sometimes a long-discarded or long-forgotten concept is revitalized and rejuvenated as more discoveries prove its better consistency and veracity.

This flip-flopping of ideas and beliefs can be confusing to the layperson, who wonders why if medicine is a science, there is this shifting or changing of premises. How can some medical ‘facts’ suddenly be overthrown tomorrow by some newer discoveries, or newer ‘truths’? How can a drug, long prescribed for a certain indication, be suddenly hazardous for another condition, so that it has to be withdrawn?

This is especially so when news-breaking clinical studies show adverse outcomes much to the consternation and confusion of the research scientists who had predicted otherwise.

Just a few years ago, an arthritis pain-relieving drug Vioxx (refocoxib) was found to be associated with increased heart attack and stroke rates especially after prolonged use, and had to be withdrawn. But this later action was reluctantly foisted upon the company only after costly legal battles; Vioxx had earlier been approved for global use for several years. Thus, while Vioxx was very good at its narrowly-defined efficacy, it was unfortunately putting more people at risk of suffering and succumbing to seemingly unrelated cardiovascular disease. This covert but delayed safety issue was regrettably not uncovered soon enough, but was clearly not acceptable for treatment of non-life-threatening chronic disorders when there are safer alternatives available.

Another example relates to some changed surgical decision pathways. Why indeed have some long-established surgeries now been deemed unneeded, outdated and even passé? Yet at other times why have drastic, occasionally mutilating, surgeries to be emergently performed to save a tenuous life?

Gastric surgery comes to mind as a glaring example, when aggressive antibiotic-acid reduction medications have supplanted gastric resection for ulcer disease. A previously well-hidden bacterium (helicobacter pylori) is now established as the cause of most of stomach ulcers and even cancers. Yet, conversely some life-saving gastrectomies might still be necessary in severely bleeding and exsanguinating gastritis, when medical therapy fails.

Another controversial if more personally-decided surgery is that regarding the option for radical mastectomy or simple lumpectomy for breast cancer. Questions of staging and lymph gland involvement are not readily clear for many patients, who frequently opt for less mutilating if incomplete surgery. Then, there’s that question of whether every patient should have that expensive not-readily available PET-CT scan to determine if the cancer had spread beyond its usual boundaries…

The choice for complex angioplasties versus coronary bypass surgery for multi-vessel coronary artery disease is another point of contention, which sometimes border on personal patient-physician preference rather than hard scientific evidence. Such evidence bases unfortunately fluctuate in time-dependent verifiable specifics, which are sometimes dictated by contemporary changes or refinements in technique or device advances.

Thus, are there really any unfailing medical ‘truths’ out there? Perhaps there never will be. This is because modern medicine is often about evolving comprehension and continual scientific ratification of concepts and practices. Some of these may indeed be revolutionary and requiring paradigmatic change in mindset and orientation.

Best Fit Medicine ever changing, updating…

Modern medicine these days is constantly adopting what’s currently the best fit, the most appropriately cohesive model, to the best of our up-to-date understanding, as we dip our curious minds into the flowing river of advances and new knowledge. We can never really dip into the same river twice without its nourishing waters having moved along… but it is through this ever-changing experience that we can hope to harness the best that modern medical knowledge can offer.

Thus, we really cannot afford to simply sit back and be idly complacent while the inexorable advances of medical and scientific research and discoveries unravel with such accelerating paces—we have to update our knowledge base and skills all the time—hopefully on a lifelong journey of continuing professional development (previously known as continuing medical education), so clichéd, yet so much a desired mandate for today’s physicians.

The Internet, the World Wide Web and the explosive information expansion has not helped alleviate this dilemma of how to make practical sense of what’s good and what works. Because, for each of our individual patients—ultimately and in a very curiously uneconomic way—being a doctor usually means dealing with that one patient and his/her problem, piecemeal.

[Only in epidemics or potentially public health calamities e.g. avian influenza or SARS (severe acute respiratory syndrome) and the current A(H1N1) pandemic, do we engage our autocratic prerogative, which collectively and without exception, corral our resources and authorise therapeutic or prophylactic measures on a designated at risk or exposed population.]

Medicine can and does consume our souls if we let it, and it can and probably should dictate a mystical ethical code of conduct which should exhort us to rise way above all others, in our dealings with humanity and with our patients in particular.

“Deprofessionalization”

However, these days, in some areas, the practice of medicine appears to have been lost in translation. Many doctors are disenchanted with the so-called practice as usual—many are now feeling a greater and greater sense of loss of autonomy and a growing sense of ‘deprofessionalization’, where insurers, third party payers, and managed care organisations are dictating how they practice, who they can treat and when, and how much can be reimbursed or not at all.

In 2006, the roll-out of the private healthcare facilities and services regulations for Malaysian doctors, added more fuel to the firestorm of practice issues which seem to overwhelm the wretched medical practitioner!

So what do some doctors do? They have become angry and feel quite betrayed. Practising clinical medicine had become a grinding drudge for some: mounting paper-work, senseless work-flow charts and reports, with ‘ludicrous’ micromanaging oversights, which seem excessive and demoralizing. Many had described these harsh regulatory articles and especially the prescribed punishments as criminalizing and degrading.

Such laws seem to imply that doctors who had been practising autonomously all along with little intrusion or mishaps, have become potential felons (in one fell swoop of the enactment of the Regulations by the Minister of Health) and that if some of these practice issues are not modified or adhered to, they are to be regarded as criminals with stiff fines and even jail time! Some had indignantly expressed their intentions to quit practising medicine altogether, others are defiantly recalcitrant.

Some doctors have become so unhappy, angst-driven and frustrated that they have lost their zeal and passion for their medical practice—the former patient-doctor relationship have become sundered with suspicion and regulatory mess-up, which trespass into their sense of justice and professionalism.

Dabbling in Fringe Therapies…

Quite a number of the more enterprising have moved laterally to fringe margins of allied health disciplines. Dabbling or even full-time engagement with beauty or aesthetic health care appears simpler, i.e. away from the more demanding and challenging clinical practice of general or family practice.

Some also have moved into the even more lucrative anti-ageing or drug-dependency programmes, which once again seem to be more rewarding and satisfying, even if less taxing mentally or intellectually!

Others indulge in fringe, obscure if esoteric “techno-babble” pseudo-medical practices (e.g. electro-diagnostic analysis for general health promotion, live blood analysis as screening procedure for possible medical ailments, whole body aura analysis, colonic washout therapy, qi gong for all ailments, ozone therapy, chelation therapy, etc.) which creates a semblance of ‘scientism’ and rational modernity, but which are at best hocus-pocus quackery at its most sophisticated.

Some are embracing complementary alternative medicine, which appears to be increasingly popular and in sync with the more suggestible public out there, despite the fact that their scientific bases are so much less proved, or none at all.

Erosion of youthful dreams, reigniting compassion and vocation…

When as a young teenager I dreamt of becoming a doctor, my fledgling youthful hopes and ambitions now seem so wonderfully fervid and overpowering. Back then, the starry-eyed passion and awe seamlessly suffused through my senses and waking moments and enveloped my entire psyche and persona. Then too, my concept of altruistic high-mindedness appeared to overwhelm all other considerations.

How far-away these thoughts and feelings now sometimes appear, how nebulous, how child-like and oh, how evanescent… That naïveté, which I have so blurry-eyed conceptualised, now seems so distant a memory, sometimes… Hard-nosed reality these days shatters our childlike dreams of simplicity, equanimity.

It is against this backdrop, that we should address the issue of where our medical profession is heading. With the onslaught of rising commercialism, market-driven personal consumerism, and greater patient autonomy, it is becoming increasingly hard for the medical professional to practice as a doctor.

To be that quintessential compassionate, empathetic health care provider so to speak, can be extremely demanding and challenging, what with the inherent diagnostic/therapeutic uncertainties, the spectre of fees and costs, medico-legal and other pecuniary considerations impinging upon the doctor’s and the patient’s consciousness.

During the coming two years of my presidency I wish to address some of these issues through the prism of a physician who passionately believes that medical doctors can make a difference, that health care can and must be engaged to make it as human and humane as possible, while staving off the onslaughts of rising commercialism, medicalisation, political and/or third-party oversight and progressive loss of our physician autonomy.

I hope to inspire a new look into the possible art of healing which appears to have taken a backseat with the rising tide of challenges and the onslaught of de-motivating practice issues. We must learn to reclaim our sense of purpose, our vocational goal, and reassert our meaningful role in modern society.

Privatisation of Healthcare Services: Assessing the Accessibility, Cost and Social Dimensions of Private Healthcare

Dr David KL Quek,

President (2009-2011), Malaysian Medical Association

ASLI 3^rd Annual Series of Asia Healthcare 2009 Conference

“Charting a Blueprint for Your Healthcare Businesses and Services in Asia”,

Session 7, 17-18^th August, 2009

Maya Hotel, Kuala Lumpur

Abstract

Privatisation of healthcare services began in earnest following the opening up of the Malaysian economy in the Mahathir era in the 1980s. Prior to this, there were only a few private smaller scale community hospitals, maternity homes and scattered private clinics in urban areas. The growth became exponential (10-fold increase in hospital beds) in the 1980s, with the expansion of private wings of University hospitals and the corporatised entities of the Institut Jantung Negara (IJN) and National Eye Hospital. At the same time large state-controlled corporations such as Johor SEDC (Kumpulan Pelaburan Johor, KPJ) and Khazanah (the investment arm of the Ministry of Finance) began to make extended forays into the private healthcare business.

Until recently, private health care professionals comprise some 55% of the physician portion of the health care services of Malaysia. Since end of last month however, with greater numbers of young graduates returning in the droves, this proportion has reversed. Now some 10,070 doctors are in private sector, while there are more than 25,000 doctors in the public sector i.e. Ministry of Health, MOH.

Ironically, the public sector continues to cater to the bulk of the population, with the private sector seeing only around 30% of the patient population. This discrepancy meant that there is a luxury bias toward the private-paying patient, where there are more facilities and physician personnel looking after a select group of patients who are self-paying, or where there is a third party payer (insurance, managed care organisation or employer benefits).

There is disgruntlement among the citizens that for the poorer segment of the population, access and affordability healthcare issues are growing. Long delays, queue jumping or outright denial of certain expensive or very specialised but skilful therapies are points of contention, dissatisfaction and anger among the deprived or uninsured.

There is therefore considerable debate about the need or the future of private healthcare services, and a push toward a single national health service where access is guaranteed for every citizen based only on need and urgency. There is also rising concern at the push toward greater medical tourism by liberalization advocates of the government, when there is already this under-performance of our healthcare services at the ground level, where citizens’ health issues have yet to be optimized.

1. PRIVATE HEALTHCARE SECTOR

Private healthcare expansion began in earnest during the Mahathir premiership in the 1980s, where private hospital beds increased nearly 10-fold (from 1,171 to 10,405 between 1980 to 2003), and the private sector’s share of hospital beds increased from 3.9-5.8% to 23.4-26.7%.[1]^,[2]

The private sector has always attracted both general and family physicians who had opted out by opening individual clinics or by joining more established group practices; while specialists join the better-paying more personalised care practices in urban private medical centres. There has been a move to group more clinics together under single larger management entities; e.g. Qualitas Healthcare group which has been buying over clinics, with the purpose of consolidating, computerising, bulk purchasing, and bulk bargaining panel-negotiation goals. This group has been listed in the Singapore Stock Exchange at end 2008.

On average over the years depending on the economic circumstances, this private sector constitutes around 55% of all registered doctors, who look after some 25% of the population, most on a self-paying fee-for-service arrangement, and increasingly through some third party paying (e.g. health insurance) mechanisms.[3]

Since the end of last month however, with greater numbers of young graduates returning in the droves, this proportion has reversed. Now some 10,070 doctors are in private sector, while there are more than 25,862 doctors in the public sector i.e. Ministry of Health, MOH. There is concern that in the public sector, many of those in service tend to be younger, less skilled/experienced doctors, while many more experienced and senior doctors have left for the more lucrative private sector, usually looking after fewer and more select group of self-paying patients.

1.1 General Practitioner Clinics

Importantly nationwide, private clinics cater to most of the fee-for-service self-paying public, which include: private sector employees through panel doctor contract/insurance arrangement; thus relieving the already overloaded Ministry of Health’s public clinics.

In general, the citizens’ choice for such private clinic consultations and treatment is due to its easier access, simpler registration and appointment, and shorter waiting times. There is also possibly greater continuity of care with better personal attention from one’s own family physician or general practitioner—i.e. superior personal touches and closer encounters are the added values in private clinic visits, despite greater fees for consultation and medicines, which are frequently bundled together.

Some crossover of services however exists. Depending on patients’ demands or choices, these generally complement each other for the greater benefit of the patients concerned. Dissatisfaction or uncertainty with services from either sector has had on many occasions led to patients seeking second opinions and/or therapies from the opposite sector, and vice-versa.

Although there have been counter-accusations of poor and/or unprofessional care, or mismanagement issues, each sector does cater to the differing demands and expectations of the public. In economic terms there is some duplication of services, and possibly over-utilisation and wastage of resources, but patient choice is preserved as a right.

Thus, urban GP clinics provide easy care for common ailments and simple trauma/injury management, at very reasonable costs, especially for areas outside the main capital city—Kuala Lumpur-Klang Valley, and complement the public sector in helping alleviate the patient congestion on their severely overloaded outpatient clinics.

However, of late, with the mushrooming of many GP clinics in close proximity to one another, competition for patients has become keener, and many clinics are simply eking out a living, struggling to keep afloat, financially. Some have resorted to creative complementary alternative medicine or aesthetic/beauty health care models, to supplement or even revamp their practices. Still the MMA continues to receive complaints of there being too little work and income for a sizable number of clinics in larger urban locales.

This underutilisation of many urban clinics is wasteful. This problem of underutilisation could perhaps be explored as one mechanism to help out the overcrowded public sector outpatient clinics.

Redistributing public sector patients who sometimes have to wait several hours, to a panel of urban or suburban private clinics nearer their home, can be a real option for better patient care and attention. A payment mechanism can be worked out to address this purchasing of services, which will generate a win-win scenario for all concerned. However, logistics and bureaucratic red tape and registration exercises have made this approach of sharing of services impossible to carry out at the present moment. We understand that the Ministry of Health is looking into this potential public-private partnership to enhance the healthcare services to the public.

1.2 Private Medical Centres & Hospitals

For more serious illness and injuries, hospital care through well-equipped emergency departments (EDs) is now the expected practice. These medical emergencies are previously offered only at larger public sector general or district hospitals. These days however, most private medical centres boast of state-of-the-art emergency care at more luxurious settings and costs. Personal and more attentive specialist care are now demanded and offered at many of these private EDs, where many orthopaedic surgeons and neurosurgeons now practice privately.

However, private medical centres are not simply for emergency and/or trauma care. Most are now developed as competitive consumer-driven full-fledged healthcare facilities to cater for the more discerning public who would pay more to obtain perhaps better (perceptibly), more personalised, faster (less or no waiting time) and possibly more comfortable and/or luxurious medical care.

Health insurance or maintenance organisations have also bought into this system to offer more premium benefits to their clients, particularly those of the corporate world, where risk-averse and delay-averse market-driven results are expected. Executives and staff are offered contracted quicker and direct access to possibly more expert specialised care, with faster turnaround times and earlier return to work expectations.

Of late, the entry of different national and transnational capital flow into the private healthcare system has further developed the service capacities of this sector. Healthcare industry players such as the state-owned KPJ group (Johor State Development Board), Parkway Holdings (Singapore-based, American-invested), and latterly Khazanah National Berhad (a Ministry of Finance Malaysian GLC) have greatly influenced the direction and expansion of these private services, while at the same time inflating the cost of private health care services by offering more sophisticated amenities and newer technology-driven expert care.

Together with the Association of Private Hospitals (APHM), there has been a move to expand the services toward attracting foreign medical tourists, which is targeted to grow to 30% in 2008, and nearly 1 billion ringgit as of 2005.[4]

1.3 Purchasing Private/Corporate Sector Expertise

Migration of trained staff especially medical specialists to the private sector continues to bug the system. This then causes the expert service to stall, when the requisite expertise is lost. In critically short-staffed services such as neurosurgery, the public sector has to occasionally buy the services of private neurosurgeons to attend to their patients, especially during emergencies.

Currently, in Kota Kinabalu, Sabah, cardiology and cardiac surgical services are purchased with weekly rotations of specialists from the corporatized IJN, at hefty prices. Also being a corporatized medical centre, the IJN has been billing the government to take care of its public servants, pensioners and referrals from its MOH hospitals and clinics. This comes at a premium, with the government reimbursing some RM 31.3 to 144.5 million per year, from 1993 through 2004, respectively, for these services.[5] It is estimated that for 2008, the financial subsidy for IJN approached 250 million Ringgit.

However, because of higher wages and better work conditions/benefits, specialists at the IJN appear to have less rapid turnover (3% annually), and thus enjoy greater consistency and continuity of services.[6] This resource stability also makes continuing allied health care and specialist training possible, to enable it to maintain its reputation as a centre of excellence. But obviously this comes at a higher cost—perhaps this expenditure is more realistic in terms of healthcare economics. This successful model has now made it an object for takeover by a GLC, Sime Darby Bhd.²

So this model of public-private partnership appears to be successful and beneficial and attempts have been made to have it emulated. However, there have been serious misgivings about this concept of healthcare reform because of its wider socio-economic implications; the Coalition Against Health Care Privatisation has been most vocal against any development toward the passing of any extra cost to the public.[7]^,8,16

Poor planning and maintenance has led to infrastructure failures such as has been recently highlighted in KK’s Queen Elizabeth General Hospital, where an entire wing has been condemned, shutting down essential services such as intensive care and surgical operating units. This ad hoc approach has in the past few years, forced the urgent if expensive purchase of the former Sabah Medical Centre to be converted to the Likas’ Maternity Hospital. Now, there are plans to purchase the newer year-old 171-bed SMC at Luyang, to replace the condemned section of the main hospital in KK for the public![9]

1.4 Full Paying Patient

In 2005, another patient fee-paying system was introduced at certain premier public hospitals i.e. Full Paying Patient (FPP) scheme, where part of the fees were used for physicians’ reimbursement to supplement their income/allowance. Thus, this scheme provides those who are willing to pay more, quicker access and shorter waiting times for elective surgeries and other therapies. While this is one mechanism to recover some costs for the healthcare system, it is only a minor fraction of what the system truly costs. There has been great unhappiness that this will only encourage queue jumping from those who are well-to-do, and therefore penalise the poor and less-financially endowed, and consumer pressure groups have called for their abandonment.^15,16

Still, the sporadic but unending attrition of losing specialist to the private sector has long been the problem of the public healthcare sector, and staff and expertise retention is a perennial problem, which has yet to be resolved or tackled sensibly and judiciously. Some 300 doctors and 50 specialists leave the public sector annually.^7,[10],15

2. Private Healthcare Facilities and Services Act/Regulations

Currently, the Private Health Care Facilities and Services Act (PHCFSA)[11] and Regulations (PHCFSR)[12] have prodded the private sector to transform for the better, purportedly for safeguarding the safety of patients. But forced administrative micro-management, stiff fines and restrictions have angered many private medical practitioners.[13] Many are unhappy with the highhanded tone and manner of the regulations, inspections and implementation, which have been construed as trying to criminalise doctors.[14] At least one physician had been jailed for technical non-registration, and a few have been fined heavily because of technical breaches of these new regulations. Some clinics have been inspected with disdain and rudeness.[15]

3. HEALTHCARE SPENDING & ACCESS ISSUES²

Healthcare spending is still suboptimum in Malaysia, the government spending just 6.9% of its total expenditure on health care services (i.e. 2.2% of the GDP). However, the latest available data from the National Health Accounts have reflected a higher rate of spending for Malaysia as of 2007.

According to the National Health Accounts database (WHO website) Malaysia spends about 12.5 billion ringgit or 6.9% of its budgetary expenditure on healthcare as of 2007. For Malaysia, total health care expenditure in 2007 amounts to just around 4.4% of our GDP (with the public and private sector contributing 2.0% and 2.4% of the GDP respectively), but I foresee that this will have to grow to accommodate the rising demands from a more enlightened, more empowered population.[16]

In 2003, Malaysians spend just USD 374 in total (Purchasing Power Parity or international dollar rate) per person per year on healthcare expenditure, with the government contributing USD 218.⁵ In 2007, this has gone up to USD 591 per capita.^16,[17]

This compares with USD 1156 for Singapore, USD 260 for Thailand, USD 2244 for Japan, USD 1074 for South Korea, USD 2874 for Australia, USD 2389 for the United Kingdom and USD 5711 for the United States of America.⁵ As can be seen, although we pride ourselves as becoming more developed than many other nations around us, we have yet to emulate those with better and arguably more advanced healthcare services.

Out-of-pocket spending as a percentage of private expenditure on health takes up about 73-75% of the total costs, with some form of private prepaid plans (e.g. insurance) contributing 11.9 to 14.4% over the years from 1999 to 2007. Social security expenditure as a percentage of general government spending on health hovers around 0.8% only, mostly from requested withdrawals from the specific allowable account within the Employee Providence Fund savings (EPF).^5,16

3.1 Public Aversion to Paying More

Because of the ingrained norm of having to pay so little or not at all in public hospitals and clinics (which are almost totally subsidised), the Malaysian public does not feel that it has to budget for health or medical care, and this is reflected in many of our pensioners complaining of costly unplanned-for medical care. This is also reflected in our government’s paltry allocation of importance toward healthcare spending in our national budget.

There has been flip-flopping ambiguity from the MOH, as whether to allow market forces to dictate healthcare costs, but overall, there has been no public will to enact what could be unpopular.² Suggestions to end free treatment at public hospitals and highlighting that rising healthcare cost is too heavy a burden or political cost for the government, had not been too well-received by the citizens.[18]^,[19]

This strategy seemed to have disappeared following the recent electoral setbacks of the incumbent government. In a recent interview for internet media Malaysiakini, the new health minister Dato’ Sri Liow admitted that the public hospital services are heavily subsidised by the government: RM12.9 billion or 98% of the entire budget, while patients paid only 2%! But, Dato’ Sri Liow reiterated his views that government subsidies for patients utilising public healthcare facilities would continue (RM1 for outpatients clinic visits, RM5 for specialist clinic visits, and maximum RM50 for third-class ward hospitalisation costs), and pledged the populist view that such a quantum would continue, despite this being unchanged since the 1970s![20]

There is great expectation that the government of the day should not jeopardise this by instituting any mechanism, which can change this status quo—hence there is very little public or open debate on these issues.

3.2 Access Failure & Medical Assistance Fund

But concerns as to failures in access continue to pop up sporadically in the mass media.[21] Poorer patients have resorted to the mass media appealing for financial assistance to help defray medical costs, especially for some costly or tertiary specialist care—e.g. in one week alone in October 2007, there were at least 3 appeals for help.[22]^,[23],[24]

Thus, this has prompted some stopgap measures such as setting up a Medical Assistance Fund (MAF) of RM 25 million, by the Ministry of Health. However, this fund can only be utilised at public or quasi-governmental healthcare facilities, and appeals have to be vetted stringently to ensure need and priority, which had drawn sharp criticisms of this being too bureaucratic and slow, even unfair.[25] Yet another Emergency Fund (D’tik, an acronym for Dana Talian Insan Kritikal Yayasan Kebajikan Negara) has been set up. This fund of RM5 million, 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.^8,26

Clearly, such setbacks and failure of access implied that the public healthcare sector needed a revamp to enhance its capacities. Providing such services at huge or near-total subsidy appears untenable and unsustainable, and still left gaps, which had to be filled by creation of some extra mechanism to expedite access (predominantly by offering extraneous funds and/or donations). Thus, this explains in some way the government’s overt encouragement for the private sector to flourish and develop, in order to cater to the more willing, discerning, paying citizens, and leaving the public sector to look after the less endowed.

3.3 Corporatisation / Privatisation Controversy

Earlier hints that the public sector health services should be restructured into a government-owned non-profit entity, made economic sense in its first offering. This ‘corporatisation’ model implied converting most of the larger public hospitals into operating as quasi-private entities. This would avoid creating a two-tier system, and would facilitate disbursement of funds when a single payer health insurance scheme was introduced.[26] At least that is what had been planned.

However, many are still quite in the dark as to when or if these would be enacted, and serious doubts and anxiety have been raised. This ambivalence is now quite understandable because earlier attempts to corporatize these public hospitals and facilities were scuttled after news leaks prompted severe backlashes from some consumer and pressure groups and opposition politicians.^{15,16,17,[27]}

4. Skim Insurans Kesihatan Kebangsaan (SIKK)

This brings us to the question of having a single payer system, which has been earlier mooted as the preferred system for encouraging or implementing universal access to health for all.⁷

The much-awaited National Healthcare Financing Scheme, now rebranded as the National Health Insurance Scheme (Skim Insurans Kesihatan Kebangsaan, or SIKK), appears to be a political deadweight. Following the formation of the new government, this has once again been deferred for fears of public disavowal and protests. Perhaps, there are just too many variables inherent in the Malaysian system, which renders such a scheme too politically incorrect, too inexpedient to implement.[28]^,[29],[30]

Interestingly, when it was raised earlier, the MOH tried to allay public fears by announcing that civil servants (which number 1.2 million people, including military and police personnel) and their dependants, 200,000 disabled persons, 435,000 pensioners, 250,000 hardcore poor and an unknown number of unemployed individuals, would be exempt from the SIKK. What is not clear is whether the government would pay the premiums for these people or that they will continue under the present system of healthcare. The latter option would defeat the purpose, because this would undermine the community-rated concept of the SIKK.¹⁵

Also considering the fact that only 1.2 million Malaysians pay any taxes, collection of such a mandatory ‘health tax’ would be a struggle and challenge. It has been calculated that based on an estimated 4.63 million families in Malaysia (25 million population, average family size 5.4), this sharing of the burden (RM13 billion as of 2003) would encumber each family household around RM2,808 per year or RM235 per month.¹⁵ Clearly, many would not be able to pay, because more than 58% of Malaysians earn less than RM2000 per month, per family; and paying more than 10% of the salary on healthcare premiums would be too high! Besides, the government would still have to cough up possibly billions of ringgit to sustain the shortfalls and other preventive health care measures. This scheme has been criticised and rejected by the Coalition Against Healthcare Privatisation, as putting the onus of premium paying on the lower- and middle-income private sector employees and citizens.^{15, 16}

So, for the foreseeable future into the next 4-5 years at least, it is very unlikely that there will be any attempts to resurrect such a tendentious issue as a national health insurance mechanism. Our current system which has been described by Chee H. L.¹⁹ as segmented, polarising and eventually untenable, is therefore likely to be the status quo for the time being, and making this work better for our citizens should be the way forward, at least for the interim.

5. PARTNERSHIP: COLLABORATION VS. INTEGRATION OF SERVICES

The health minister Dato’ Liow has said that “Government and private sectors should work together. Because the doctors that we train are for the nation, irrespective of (whether they work for the) government or private. Doctors are serving the people. In Malaysia, 41 percent of our population go to private hospitals and clinics and 59 percent go to public health institutions. Therefore, the private sector is playing an important role to ease the burden and also the workload in government hospitals.”²⁶

It is heartening that the current health minister is enlightened and positive about this private sector contribution. Therefore, this is an opportune time to ensure that the mechanisms for better partnership between public and private healthcare sectors be forged to facilitate closer and more meaningful collaboration.

5.1 Is More Privatisation the Way Forward?

One way to further this is by privatising more of the public healthcare facilities, but this is fraught with uncertainties, although such exercises might make administrative and economic sense and offer greater balance sheet accountability. One inevitable problem will be the almost inescapable escalation of the cost of services to ‘real’ terms, with progressively less subsidies. The poor unfortunately, could be left out of the loop with uncertain safety nets to cushion their plight.

The recent suggestion by Sime Darby Healthcare to acquire a stake in IJN (now a corporatized entity 99.99% owned by the Ministry of Finance) has already brought a swift and negative dissident response from a newspaper editor.[xxxi] Gunasegaram P. has stated his dismay that “for large sections of the Malaysian public, the very idea of privatising IJN is shocking because charges will rise to astronomical levels.” He questioned whether there is any net benefit to the public or government, and that if there were any reasonable doubt, this privatisation should not be undertaken. He alluded to past experiences that previous privatisation exercise of other services had not brought down costs for the public or government. He concluded that “(t)here are some things that should not be up for sale at any price. Affordable health care for the general public is one of them.”[32]

In another article in The Edge Daily, it was reported that the health minister and his ministry is not too happy with this divestment, either.[33] However, the Prime Minster and his deputy appears to have already endorsed the plan, just cautioning the GLC against forgetting its social responsibility to the poor, and they seem to imply that this exercise would allow the private healthcare sector to grow even more.[34]

Latest reports suggest that this takeover bid by Sime Darby has been deferred indefinitely due to public outcry, and possible political fallout.[35]^,[36] The former Health Minister Datuk Seri Chua Soi Lek has also condemned this sell-off bid, which he said has put paid the good will of the government, despite it costing the government just a ‘paltry’ RM 200 million a year (about 2.5% of the national health budget) to run the IJN.[37] Thus, there is this incessant tussle for public need/good versus free-trade market-driven practices from administrative or financial/budgetary realities points of view.

5.2 ‘Rentier Capital’ Divestment Concerns

There are of course, also worries about ‘rentier capital’ economics where state assets are divested to politically well-connected private entities through a system of political patronage, perpetuating mutual dependence between the business elite and the political rulers, i.e. the ‘crony capitalist’ model that supervenes the true nature of this form of take-over. Most economists believe that this form of rentier capitalist model unfairly enriches these business elites at the expense of costlier services and goods to the public at large, and is therefore, wasteful and counterintuitive toward better productivity.[38]

5.3 Toward a More Efficient System

In his book on ‘Good and Bad Power’, Geoff Mulgan (a British political scientist) discusses that while most governments provide the structure, it is the more comprehensive, well thought-of infrastructure provisions that lead to transformative services—that “much of the recent thinking about service… has adopted models from the private sector… largely drawn on industrial… models favouring speed, standardization, flow and efficiency.” He went on to describe: “(t)hese services are human, immediate, personalized and rich in communication, anticipating need rather than just meeting it and ‘going the extra step.’ In the case of therapeutic services the servant’s job is to change the master, to make him healthier, fitter, and happier.”[39]

In a paper on the Singapore model of public-private partnership, Dr MK Lim identifies 3 key questions which should be answered: (a) how to raise revenues to pay for health care; (b) how to pool risks and resources; and (c) how to organise and deliver health care in the most efficient and cost-effective manner.

It is clear that there is no foolproof system anywhere on the globe. Some of the more successful models involve a mix of safety nets with monitored privatization/corporatization of services and allowing ‘coopetition’ (competition and cooperation) to thrive.[40] He further argues that “even in Europe, the sustainability of health care systems founded on egalitarian welfarism is increasingly being challenged as growth in demand outstrips supply. The debate is no longer about ‘who should pay?’ or ‘who should provide?’ but ‘who can do the job more efficiently?’”

5.4 Fine-Tuning Private-Public Partnership/Collaboration

Thus, as our two-tiered system is now so well entrenched, we should find ways and means to ensure that it works better and more efficiently, where we can synergise our efforts to provide good quality, safe, and cost-effective healthcare for our patients. However, this must not only be affordable but also be self-funding and self-sufficient.

Where too much bureaucracy bogs down the better productivity and efficiency, these should be dismantled and restructured in ways that encourage best practices, and which empowers and benefits the patient ultimately.

Practice issues such as difficulty in cross-referring patients between private and public sectors should be eliminated; data and medical information portability and sharing should be facilitated and unified. Where there is excess of amenities on either side, these should be shared with crossovers of public to private sector and vice-versa. Conversely, more cross-purchases of services should be facilitated where there are shortages. Arbitrary turf protectionist methods to deny either patient or physician access to information or services of either sector should be removed.

Information exchange can be made more efficient through the use of a unified system of health information portability mechanisms, e.g. MyKad or some other central access information systems, while safeguarding and ensuring patient confidentiality and privacy.

Full integration of private-public healthcare sectors appears unlikely, but better partnership and collaboration of services can be aspired to, where the best of each system can be harnessed for the healthcare betterment of our citizens. We should aim for a more cost-effective system, although not necessarily a lower cost one. A single or easily portable system of reimbursement should also be considered.

While corporatisation/privatisation is still much feared, as a model of divesting central control of unavoidable rising costs and developmental constraints, this might be the way to go, if the model for market-driven healthcare is adopted. This is the model practiced by Singapore, with its well-tried and tested schemes that can be tweaked to respond to the many diverse facets of healthcare peculiarities.⁴⁰ Or conversely, a single-payer (and/or single insurance) National Health Service mechanism could be introduced, learning from the examples of say, Taiwan, Canada or the UK.[41],[42]

Whatever the decision, the government must make greater efforts to engage and explain to the public the policy directions that it wants the country to advance with regards healthcare services. This is especially urgent because by 2010, when trade and services liberalisation is set to take place in ASEAN (Association of South East Asian Nations), with the roll-out of the AFTA/WTO (ASEAN Free Trade Area/World Trade Organisation) agreements, there will be other considerations of foreign participation and entry into this economically important sector.

References

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[1] Ministry of Health (MOH) (various years). Annual report.

[2] Ministry of Health (MOH) (2003, 2004). Indicators for monitoring and evaluation of strategy for health for all.

[3] Chee H. L. Ownership, control, and contention: Challenge for the future of healthcare in Malaysia. Social Science & Medicine (2008); 66: 2145-2156.

[4] APHM (Association of Private Hospitals Malaysia) website (2007), Available from: http://www.hospitals-malaysia.org/index.cfm (Accessed 13.12.08)

[5] Chua SL. Speech by YB Dato Dr. Chua Soi Lek, Minister of Health Malaysia, At The Annual Scientific Meeting 2005 of the National Heart Association, Hotel Hilton, Kuala Lumpur, 15 April 2005. Text obtained from <www.moh.gov.my/MohPortal/DownloadServlet?id=413&type=2> (Accessed 15.12.2008)

[6] IJN doctors: Don’t make us scapegoats. The Star online. 19 December 2008. (Accessed 19 December 2008) <http://thestar.com.my/news/story.asp?file=/2008/12/19/nation/20081219151718&sec=nation>

[7] Quek D.K.L. Imminent Corporatization of Public Health – Causes for Concern. Editorial. MMA News, 1999; Vol. 29 (May): pg7. Accessed on 15.12.2008 at

[8] Subramaniam Pillay. (for Coalition Against Health Care Privatisation) Can we afford to fall sick?

Aliran Monthly Vol. 25 (2005): Issue 4 <http://www.aliran.com/oldsite/monthly/2005a/4e.html> (Accessed 15.12.2008 )

[9] Joe Fernandez. Politicians ticked off over KK hospital woes. <http://www.malaysiakini.com/news/103275> (accessed 28.04.09)

[10] Citizens’ Health Manifesto for Malaysians. (Accessed 15.12.2008) <http://prn.usm.my/chi/main.html>

[11] Private Health Care Facilities and Services Act 1998 (Act 586). PCNB, Malaysia, 1998.

[xii] Private Health Care Facilities and Services Regulations 2006 (P.U. (A) 137/2006). PCNB, Malaysia, 2006.

[13] Quek D. K. L. Regulations now Enforceable—Cui Bono? (Who Benefits?). MMA News, 2006 (June), Vol. 36 (6):pg7.

[14] Quek D. K. L. Physicians under Siege: Sensing the Pulse of Doctors… MMA News, 2007 (Feb) Vol. 37 (2):pg7.

[15] Ong H. T. Private Healthcare Facilities and Services Act. (Letters to Editor). MMA News, 2008 (Oct) Vol. 38 (9):pg23.

[16] National Health Accounts, Malaysia, WHO Country information. http://www.who.int/nha/country/mys/en/ (accessed 4 June 2009)

[17] World Health Statistics 2008, World Health Organisation, France, 2008

[18] Paying more for healthcare: rising cost a heavy burden on government. The New Straits Times, 16 December 2004.

[19] Free treatment at public hospitals to end next year. The New Straits Times, 26 April 2005.

[20] Ong A. Private and public health can grow in tandem. Malaysiakini June 28, 2008. (Accessed 17 Dec 2008) <http://www.malaysiakini.com/news/85221>

[21] Mazlinda Mahmood. Affordable reproductive health services for the poor, The New Straits Times, Saturday, 27 October 2007, p N24.

[22] Little Kin Wai hopes to walk tall—He needs funds to help him grow, The Star, Saturday, 20 October, 2007, p N18.

[23] Single mum needs aid for kidney transplant in China, The Star, Friday 19 October 2007, p N26

[24] In need of aid to treat his burns, The New Straits Times, Monday, 22 October 2007, p N17

[25] Annie Freeda Cruez, Poor can apply to medical fund. The New Straits Times 17 Oct 2007.

[26] Ministry of Health (MOH) 2003. Malaysia’s health 2003: technical report of the director-general of health Malaysia 2003. Kuala Lumpur: Ministry of Health (pg 44-57)

[27] Jeyakumar Devaraj, Health Is Not A Commodity, Parti Sosialis Malaysia Press Statement: 8 June 2007.

[28] Authority for universal coverage could be set up this year—national health finance plan ready. The Sun, 4 March 2001.

[29] National healthcare not an insurance scheme: Chua. Sun2Surf, 15 April 2005.

[30] Skim insurans ganti penjagaan kesihatan: SIKK (Skim Insurans Kesihatan Kebangsaan) dua tahun lagi. Utusan Malaysia, 2 April 2005.

[31] Law K. C. Sime Darby seeks stake in IJN. The Star, Thursday, 18 December 2008; pgB1-B2.

[32] Gunasegaram P. Don’t privatise the National Heart Institute. The Star, Thursday, 18 December 2008; pgB2.

[33] Lim S-L. Sime Darby eyes IJN. The Edge Daily, 17 December 2008 (Accessed 18.12.2008) <http://www.theedgedaily.com/cms/content.jsp?id=com.tms.cms.article.Article_42e08286-cb73c03a-53897400-82ddada1>

[34] Teoh S. Najib: Sime Darby must commit to poor in takeover of IJN. The Malaysian Insider, 18 Dec 2008. <http://www.themalaysianinsider.com/index.php/business/14417-najib-sime-darby-must-commit-to-poor-in-takeover-of-ijn> (Accessed 18.12.2008)

[35] Cabinet hits pause button on IJN Sale. Malaysiakini, 19 December 2008. http://www.malaysiakini.com/news/95152 (Accessed 19 December 2008)

[36] Choo C.M. & Chong D. Cabinet all but kills Sime Darby’s bid for IJN. The Malaysian Insider, 19 December 2008. http://www.themalaysianinsider.com/index.php/malaysia/14503-cabinet-all-but-kills-sime-darbys-bid-for-ijn (Accessed 19 December 2008)

[37] Chua S. L. IJN Dollars and Cents.

<http://drchua9.blogspot.com/2008/12/ijn-dollars-and-cents.html> (Accessed 30 December 2008.)

[38] Jomo K.S. and Gomez E.T. (2000) The Malaysian development dilemma. In M.H. Khan, & K.S. Jomo (Eds.), Rents, rent-seeking and economic development: theory and evidence in Asia. Cambridge; Cambridge University Press.

[39] Geoff Mulgan. Civic Commitment (chapter 12). In Good and Bad Power: The ideals and betrayals of government. (2006), London, Penguin Books (pg 226-251).

[40] Lim MK. Transforming Singapore health care: public-private partnership. Ann Acad Med Singapore 2005; 34:461-7

[41] Susanne Grosse-Tebbe and Josep Figueras.(eds.)Snapshots of health systems in 16 countries. WHO, 2004. (Accessed 15 December 2008.)

[42] Physicians for a National Health Program. International Health systems. PNHP, 2008. <http://www.pnhp.org/facts/international_health_systems.php?> (Accessed 15 December 2008.)

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