CHUA: HAVE A HEART
by LKN
KUALA LUMPUR

Perhaps Lee Kuan Yew is right and we should indeed pay Ministers more if we are to expect a better dose of governance.

I read with bewilderment the MOH’s appeal to private hospitals to provide affordable heart surgery to the poor failing which it will invoke the Private Healthcare Facilities and Services Act 1998 (PHFSA) to direct these hospitals to carry out “their social responsibility.”

Chua appears to have been suddenly inspired with this brilliant idea following his visit to the Narayana Hrudayalaya Institute of Cardiac Sciences in Bangalore and speaking to its “world-renowned director” Dr Devi Shetty where 14 Malaysians have been treated.

He further reasoned that the MOH may “arrange for the poor to be treated in Bangalore at a minimum rate if presumably prices in Malaysian private hospitals are not “reasonable”.

The Health Minister appears to demonstrate either inconceivable fiduciary irresponsibility or complete economic ignorance as to why cardiac costs and its concomitant services are high in the private sector.

He further seems oblivious as to why the government’s own hospitals cannot be more efficient in treating these patients ignoring completely that costs in government hospitals are probably the same if not more save for the fact that the tax-payer instead actually pays the same bill for government patients.

More astonishing is the lame duck response of the Federation of Private Medical Practitioners’ Association of Malaysia president Dr Steven Chow who apparently says the federation supports the minister’s call. Doctors should perhaps review who they elect to run their organizations as statements of this nature are really counter-productive to the betterment of health services in this country.

The heart unit at the Christian Medical College headed by Stanley John in Vellore was at the forefront in the provision of cardiac services in India in the 1960s but modern heart services really came into being in India when the cardiac unit at the Railway Hospital in Perambur, Madras was established by T.J. Cherian to not only cater for the 4 million railwaymen and their dependants but also for the general public.

Following this, many heart units mushroomed throughout India and the majority of them are in the private sector.

The cost of an angiogram in India is about 10,000Rs (RM700) and an angioplasty for a two-vessel disease is usually less then RM10,000. Contrast this with a Malaysian private hospital including IJN, where an angiogram can cost anything between RM3000-4500. Angioplasty and stenting can cost between RM12,000 to RM25, 000 depending on number of arteries blocked and/or stented.

If you need a bypass, a patient in the general ward of a private Indian hospital pays about Rs100,000 (RM7000). If you are admitted to a deluxe ward the price is about RM10,000 or if you are in the super-deluxe ward the package price is around RM12,000.

These prices can be cheaper if surgery is done in smaller cities such as Coimbatore, Trivandrum, Madurai, Cochin, Vishakpatnam, Pune or Noida. They are pretty much standardized if they are done in Madras, Bangalore, Bombay, Hyderabad or Delhi.

Why are prices in India much cheaper? They have the same mortality and morbidity results and use the same equipment. The reasons are:

• The private heart units cater to a large middle class population estimated to be around 200 million and growing. Costs therefore are lower.
• India has constant and active cardiology and cardiac surgical programs that produces surgeons and cardiologists to cater for these illnesses.
• They have an even more active program that generate support staff such as cardiac cath lab technicians, echocardiographers, perfusionists, physiotherapists, critical care nurses, biomedical technicians and nutritionists.
• India’s medical technical base is so established that it manufactures even Siemens CT scan machines under licence at a much lower cost.
• Many private hospitals in India, to save costs, invest in equipment from the refurbished market rather then buy new as high tech medical equipment has the potential of becoming obsolete within months as a result of rapid medical advances.
• Pharmaceuticals and consumables are almost entirely generic and manufactured locally.
• Land and construction costs of hospitals are far cheaper and are not handicapped by anti-business regulations such as the PHFSA.

In Malaysia:

• The market is far smaller although it has the potential to grow bigger.
• We don’t have established programs to train surgeons, cardiologists or paramedics. Even the specialists that we bring in quit our government hospitals fairly quickly and politics in government heart units is so bad that administrators in the MOH have reportedly lost control over these units although they are of national importance. The Minister himself has admitted in the mainstream media that more heart units are required but manpower is a serious problem.
• Thanks to us signing patency laws we can’t even do parallel pharmaceutical imports forcing our hospitals to purchase medicine and consumables at euro or dollar prices.
• A private hospital in Malaysia is still deemed a commercial venture and land purchased is subject to commercial premiums. Approvals can take as long as 3 years and are now further restricted by the anti-business PHFSA. Even if approvals are given by local councils, they have the potential of being overturned by politicians or health officials as in the Telok Gadong hospital in Klang causing severe holding cost losses to the investor.
• Water and electricity at private hospitals are subject to commercial rates and bills are further subjected to service taxes.
• Private hospitals who borrow to set up hospitals are subjected to commercial 8% interest rates. Multimillion-dollar equipment hire-purchase loans are further subjected to shorter repayment periods of usually 5 years as a result of depreciation.
• Protectionist policies by the MOH and MMC have ensured that the void of specialists in the private sector cannot be filled leaving patients without specialists in both government and private sectors in many secondary towns. Even in newer hospitals such as Petronas’s Prince Hospital both Apollo Hospitals and Austria’s Vamed faced the brunt of this protectionism at the expense of escalating holding costs to our own Petronas.

But our incidence of heart disease is rising and we need to address these issues rather quickly and blackmailing the private sector with the PHFSA or threatening to send patients to Devi Shetty in Bangalore is not going to help neither patient nor country.

The Minister first needs to get his ship in order and this he can do by making certain that training programs for cardiologists, surgeons and paramedics are consistent and well established.

In this respect the Ministry should emulate the exemplary work of Datuk Abu Hassan of the Ministry’s Emergency services who instead of building a giant trauma center and monopolizing it has instead created more then 50 emergency physician posts throughout the country so that emergency services in all government hospitals are upgraded.

He has, in addition, established multiple training programs and conferences to further improve emergency services in this country.

The MOH must have similar programs for cardiac training.

The Minister in earlier media reports declared that finance was not a problem but manpower was in the provision of cardiac services in this country.

If such is the case, the MOH should open the unused unit at Serdang, possibly the new unit at Alor Star and should further upgrade ICUs and unused theaters in other general hospitals and contract out services to private specialists or hospitals.

In doing so the Minister should rein in the usual nonsense and obstructive policies that would generally be placed in his path by his own self-serving specialists to prevent private specialists in helping in the treatment of heart patients in this country.

Despite Chua’s rhetoric that private specialists don’t help out in government hospitals, the truth of the matter is his own government doctors are the ones who have placed endless barriers impeding private specialists from helping out.

But more importantly the Minister must bury his unconcealed animosity for the private sector and find ways and means to work with them for the betterment of this country’s healthcare. For a Malaysian minister, he appears to have no such inhibitions in working with the Indian private healthcare sector and Devi Shetty.