by YELVERTON

And what of Karl Karol, appointed by the EPU and MOH, to provide healthcare changes to a much vagaried population here in Malaysia not to mention health care staff. Well, they appeared to have zeroed in onto a few points and appear to be here to rubber stamp proposals by the same officials from the MOH who put us into our predicament in the first place. Government hospitals are today seen as giant, and on quite a few occasions, crumbling mortuaries with babies getting mixed up, dengue patients dying days later with no treatment, specialists who cannot string a proper sentence in English and of course now the home of the infamous petrolless ambulances.

KARL KAROL’S FINDINGS

1. Health care funding must come from the public’s purse and not taxes.

Meaning why in God’s name are we paying taxes for then? Our education system is in the gutter. Already our graduates have been made debtors for life and Mustapha has even taken it a step further by revoking their civil liberties by taking away their passports after, of course, humiliating them, their family, relatives and friends by splashing their names in our papers about their misdeeds of not paying up their PTPN loans although they may be unemployed. Our air force copters keep crashing. We pay tolls for our roads. And our soccer team doesn’t need our money because I am sure most Malaysians will now agree we ought not to have one. So why do you need our taxes. Oh OK. Inflation, etc, etc… .so whatever we are paying is just to “top-up” the short fall.

2. All government hospitals are to be corporatised for greater efficiency.

This sounds fair enough. Only problem is will the hospitals, just like MAS, Telekom and TNB supposed to continue employing deadwood or can we VSS them and will the government pay them off. And worse still as in MAS and PROTON, will the government continue with its lingering interference by placing retired Pengarahs to sit in as directors of these newly independent hospital boards complete with golf memberships, first class travel and holidays abroad? Will politicians walk in and scream “Saya tak mau bayar bill”.

3. There will be integration of the primary health care sector, the government hospitals and private hospitals.

Now this is where it gets tricky. We are not a developed nation… …yet. And in fact some areas of the country are very much third world. Our MOH has got this curious notion that clean water, clean air, clean food is not their headache. So what do we do when we get hit by cholera, typhoid, dengue, hand foot mouth disease, SARs, a resurgence of TB, not to mention the ever rising incidence of Hepatitis B and HIV? All to be managed by PFI (Private Finance Initiative)? Health Managers will scream not on your life because it doesn’t bring them money… .they will go the way of Britain’s Trusts, running a financial deficit, getting into debt, filing for bankruptcy and having themselves CTOSed and CCrised. For any nation and especially so a developing one, you privatize primary health care and emergency services at your own peril. This involves national security. You might just as well privatize the army and police force.

4. Financial incentives shall be the main driver of the system

Are health workers in Malaysia ultimately driven by money? Someone has got this equation wrong here. If you are a doctor having worked in Kapit or Manjung and get kicked about when you are trying very hard to pass your Membership examinations on your own and even when you pass, you are told to hang around a district hospital because you don’t have the cables, and after passing are continuously bypassed to be replaced by a local specialist much junior to you and further told your postgraduate qualifications are useless, do you seriously think these doctors leave because they want more money. The “steering committees” advising Karol are a simple case of the blind leading the blind and may be giving this consultant from the outback wrong input causing him to recommend wrong advice.

And what if moneys payable for services rendered by these hospitals are dragged if past standards of our notorious paymasters are anything to go by? Is payment by direct debit or is it going to be 60 to 180 days credit. All these hospitals will wind up if any squabbling regarding payment takes place. But perhaps government hospitals should taste what private hospitals have long since experienced — the uncertainty of payment. And what if consultants are unhappy with the fees offered and like the NHS, tell patients to get themselves admitted to private hospitals and cough up the difference. Driven by financial incentives? Where will the line be drawn and more importantly who in God’s name is going to monitor this especially since we lack specialists in almost every sector? Are these doctors going to be paid a basic with a cut in professional fees or are they wholly going to be independent contractors? Who will track them in a 1000 bedded hospital?

THEIR SOLUTIONS

1. A National Health Financing Fund will be set up, owned by and controlled by the government.

Are you sure? Are you quite certain these guys won’t request for kickbacks, or that patients need to be referred to only certain specialists or hospitals for otherwise the second signature on that cheque will not be forthcoming? An unfounded fear? It is already rampant between private hospitals and MCOs currently. Is Karol certain they have thought this through? Probably not. We just need to try this out wont we? If everything works, well and good. If it doesn’t, well a couple of patients will die in the ensuing chaos. A small price to pay to overcome the learning curve I guess. When the government holds these funds there is little accountability. Our Auditor Generals can write volumes on this subject. But more importantly, the delay in releasing funds by our bureaucrats for health care can be exceptionally deadly.

2. This fund will receive income from a separate tax and perhaps some from general taxation.

We are in fact back to square one aren’t we? Our national health budget is only 3 to 4%. Why can’t we raise it to 6% and let professionals manage the show instead of all these Pengarahs, Deputy DGs, DGs, etc who have no clue about IT, marketing, finance, auditing and human resource. Malaysian Healthcare requires professional management as in every other organization. You don’t need to privatize it to be efficient. The Chinese Army, Indian Railways and the United States Department of Defense employ millions of employees but runs very efficiently. Whichever way you turn this through; in the final analysis it is management of resources. And this is where the crux of the problem has always been with our healthcare system. We should have decentralized yesterday. It is the centralization that has virtually brought the entire system to its knees. Gone are the days when Medical Superintendents could tell the Minister of Health to go to hell. The prevalent submissiveness has blunted creativity and leadership. Everyone toes the line and marks time at the expense of innovativeness.

3. The Fund will only pay for illnesses categorized in a previously accepted list. And patients must first go to a General Practitioner (GP) to whom they are designated. If specialist referral or hospital admission is required, it must be done by the patient’s GP. The fund will not pay up if the patient by-passes the GP.

Except in emergencies I guess. And what of illnesses not covered in the list. Are patients expected to die at home? Understandably as a nation we need to ration ourselves. No system in the world can give you everything. It is preposterous that dengue, HIV, hepatitis, diabetes, cardiovascular disease, cancer and obesity are creating such great havoc in our society but our transplant coordinators and heart institute, with no doubt the tacit support of our mainstream media, appear to be championing heart transplants. It is not that we cannot send someone up to space. But in our state of priorities, can we afford it? And what of areas where there are no GPs and the nearest facility is a klinik desa run by a midwife? Can the patient go direct to hospital then or would he/she be penalized?

4. All GPs will be allocated a certain number of patients and become “fund managers”. They will get the same income per patient whether the patient comes to their clinic ten times in a year or not at all. This is to prevent over investigation and treatment by specialists. If they stay within their budget, the GP will get a hefty bonus. If the GP exceeds this referral budget, he may face a financial penalty! This is to make GPs efficient gate-keepers.

In the Malaysian setting, this has to be dangerous. The MOH’s unholy and rabid haste in implementing the PHFSA will now come to roost. If you expect a GP to “hold on” and “manage” the patient and refer when absolutely necessary, then the GP must be knowledgeably equipped. In the NHS a GP needs to have the MRCGP, followed by numerous other courses which include areas of your interest and the respective qualifications in obstetrics/gynaecology, paediatrics, surgery, urology, cardiology, geriatrics, dermatology, respiratory medicine or diabetes. No one GP can know everything. But short sighted officials at the MOH jumped the gun by excluding doctors from this decision making.

It is not registering and compartmentalizing them in a parliamentary edict that is important but equipping them with knowledge that is critical. In the UK, from whence our system evolved, GPs are constantly encouraged and funded to acquire more postgraduate qualifications including resuscitative techniques in ATLS, ATAACS and PHTLS. The current drive is to even include nurse practitioners to this arena and encourage nurses to acquire Masters degrees in areas of their interest. In Malaysia we are currently throwing nurses and MAs caught working in GP clinics in jail and by God, are encouraging sinsehs, bomohs, ayurveds and homeopaths to set up practice in our government hospitals. Now, what warped up mind would do such a thing? A mind that clearly has not seen enough.

5. Government hospitals will no longer get an annual budget. They will be paid by the amount of clinical service they provide according to a predetermined list of illnesses. Apparently if treatment for appendicitis is RM1,000, then this figure stays irrespective of whether there are any complications. A private hospital that handles an appendix case will also get the same payment from the fund.

You really think private or even government hospital consultants will fall for this one? Their solution would be simple. Either the patient tops up or he will be told to go elsewhere including the traditional medicine specialist at Kepala Batas.

6. Private insurance will be allowed for illnesses that are not covered by the listed group of illnesses to cover specialist costs that are not incurred through the GP referral system.

This is already the practice in the private sector

TEACHING HOSPITALS

And what of teaching hospitals? Are they included in this proposal? Or will they remain status quo with their working capital coming off the Ministry of Education. And what of training, teaching, etc. How do they find a place here in the general scheme of things? If teaching hospitals are also told to survive in this scheme of self sustenance and financial incentives, would students have their fees raised and will we have our lecturers disappearing to do their public patients in a private hospital to claim their fees as is currently happening now?

CONCLUSION

Health care in Malaysia cannot be managed as Karl Karol has recommended here. In fact it is a wonder that they are even here in the first place. Whose bird brained idea was this? There are enough Malaysians who are experienced and have worked in Australia, the US, Britain including both the public and private sectors in Malaysia who can provide far better and practical solutions. But of course these doctors will not be able to provide their expertise to the Malaysian government because… ..the MOH is not in talking terms with them. The MOH’s current concern appears to be Traditional Medicine and illegal clinics if newspaper reports are to be believed.

The system we have here, put in place after independence and implemented by initial DGs, served this country well in the initial years but lost track sometime in the late 60’s when the then DG abolished fee charging by consultants accelerating the exodus of doctors and specialists to the private sector. Subsequent years failed to take into account the rapid advances of medicine, emerging illnesses especially those related to cardiovascular disease, cancer and an aging population. Our healthcare now is in dire straits and to wean it off its ventilator; you just cannot yank the tube off its throat and ask it to walk home tomorrow. The weaning has to be measured and whatever changes that have to be made must be kept simple and in this country transparent, for it to survive. The problems facing our Primary health care and hospital systems are not complex. We have to thank our original founders for this. But solutions to these problems should not be further complicated by incompetent handling by our health officials. Their bungling in building sometimes unnecessary hospitals located in the middle of nowhere, or of buying equipment that is scantily utilized and their witless attempts at IT and paperless hospitals costing tax payers billions of ringgit must now belong to the halls of legendary cock-ups in Malaysia. Our government should look to the private sector where the majority of our doctors are based for solutions. To continue taking advice from our current lot of health administrators is to taunt fate and invite a far greater tragedy.