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From the President

29.2.2012

The news that 1Care was imminent saw a feverish flood of negative feedback from the professionals, consumers and public carried mainly in the alternative media.

Despite repeated denials by the Minister of Health it was clear that the implementation of 1CARE, health system transformation plan for Malaysia was already in motion with Phases 1 and 2 involving the public facilities already under way. The nuts and bolts for Phase 3 which involves the corralling in of the GP system were systematically being worked out by Technical Working Groups.

To our knowledge, the development of the blueprint is being fast-tracked and that the detailed plan to implement 1 CARE will be ready as early as 2012.

Technical Working Groups are already hard at work on this. As the term Technical Working Group implies, it is the technical details are being worked out - not the decision for plan for a new health system. Thus, we are way past the “still in planning process” (The Star May 13, 2011).

The Federation had felt the need to raise some fundamental issues.

1: Is the Concept of 1Care fundamentally flawed?

If one were to examine the stated current challenges of our healthcare system and the targets of 1Care as stated in the 1Care Concept Paper, it is clear that the targets do not address the current challenges. The contents of the two sides of the table just do not gel at all.

Most if not all the targets of 1Care are already achieved by our current system and this include universal coverage, effective safety net and responsive personalized care in the private sector.

Furthermore, many of the motherhood statements for 1Care have not been supported by data of comprehensive studies. Some are mere marketing and promotional terms for 1Care. Private spending for healthcare would be expected to overtake public spending as the government had made policy decision decades ago to have the private sector as the engine of growth. This cannot be a reason for changing the system.

2. Why chose the NHS-UK system? Our Existing Primary Care Provides Better Accessibility and Choice

The MOH had decided that the new health system will be in the substance and form of the NHS of the UK. We strongly urge for a critical rethinking of this.

The primary care model of the NHS has many failings. The picture from the NHS shows that it is not the proven mechanism to facilitate appropriate access to higher level of care. In UK, this system requires patients to make appointments with the GP, even for acute conditions. As a result, the A&E Departments of hospitals are jammed with patients and waiting list for cold cases to see doctor or undergo surgery is long.

On the other hand, Malaysia has a better healthcare system. We had good KPIs reported in the latest National Health Accounts Report Our health system has been praised in many international reviews and articles published in journals.

In Malaysia, government health facilities have a good system of referral and provide the safety net for the poor. Those who can afford to pay out-of-pocket consult private doctors. This is a good balance of those seeking private and public healthcare. What the government really needs to do is protect those using private care from exorbitant charges and being over serviced. This can be handled by strict enforcement of the relevant provisions in the existing Private Healthcare Facilities and Services Act1998/Regulations 2006.

There is choice with the present system. With 1-Care this choice will not be there. The patient and public pay upfront in the form of social health insurance, payroll deduction and taxes. If they do not want the doctors or the service that is allocated, they will have to pay again for what they choose.

3 1-Care will cost more

Worldwide it is recognized that a system based on general taxation is progressive and most efficient and equitable compared to Social Health Insurance which is characterized as regressive. Experiences from many countries have shown that the rise of healthcare cost is higher when other forms of healthcare financing are introduced.

The priority of the MOH should be to plug leakage, wastage and improve efficiency and responsiveness of the public system to be better than the private sector as shown by experiences in Singapore and Hong Kong where the public prefers the public system.

The 2002 Report of the Study on “Healthcare Reform Initiatives in Malaysia” by Ministry of Health appointed consultants led by Donald S. Shepard have clearly diagnosed the important issues of healthcare delivery in Malaysia and proposed solutions.

Cost-wise, the consultants “calculated that in the year 2000, the average ambulatory consultation (public facility) outside of a specialized hospital (including average prescriptions and laboratory services associated with that visit) costs RM91, while the average inpatients stay cost RM1091 (or RM 286 per day). In contrast, the fee for an ambulatory visit, RM1, has not increased in years and covers only 1% of the economic cost of an average visit”. This does not include the economic cost of long waiting time and time off work.

We know that the average cost for a GP outpatient consultation including prescriptions would only be between RM30 to RM50. Waiting time is shorter. Thus it is clearly cheaper and more efficent to just outsource this ambulatory outpatients to the existing robust GP system thereby releasing the public system to concentrate on secondary and tertiary care. The recovery economic cost of a shorter waiting time will also benefit the patient and the community.

4. Transformation versus Evolution

The overall recommendation of this extensive study based on the diagnosis of our healthcare system was for the country to proceed with“limited reform”.

This reform “should improve the management of the public healthcare services so that they can provide better working conditions for their staff,fill critical vacancies,enhance responsiveness to population’s needs and wants, and maintain an equitable basis for financing healthcare services”.

5. Stakeholders feedback for 1-Care Consultation

The cost and implications of 1-Care affects all. Judging from the concerns expressed by many doctors and the public in the media over the past six weeks, it is clear that those so called stakeholders that are invited for discussion are:

1. Either not real representative of the profession
2. Or the stakeholders are not providing feedback
3. Or the stakeholders are some favored few

It will be good governance to inform the public who the stakeholders are (in name and organization) to ensure that they are truly representative and to include more public representation like patient groups, consumers, employer representatives and more NGOs. All members of all TWGs must be required to declare any conflict of interest.

6. Corporatization of Public Hospitals.

1CARE requires corporatization of public hospitals - the establishment of administratively autonomous hospitals through devolution of authority from Federal control, a variant of corporatization ala IJN. This will be in-line with the seamless integration of private and public healthcare facilities. This is clearly not possible as private facilities are profit-driven as compare to public facilities which is socially- driven. Furthermore this is contradictory to that reassurance given by the Minister of Health in 1998 that the government will not corporatize public hospitals.

At the end of the date one would create a huge profit-driven monster that will be impossible to control as the regulator (i.e. the government) will also be an operator of the industry via its GLCs.

Conclusion

The Federation is of the view that 1Care does not answer the current challenges facing our healthcare system. It will increase the cost of healthcare tremendously. Compulsory SHI will burden the rakyat. For every rakyat the cost is expected to be 9.5% of total household income. The administrative cost alone is expected to take up to RM8 Billion or 17% of the cost of 1Care. This kind of money should be spent directly for healthcare delivery.

The choice of the NHS-UK model is also clearly not appropriate as it is a system that has fallen into deep trouble in UK itself. This system will decrease the responsiveness of our primary and secondary care delivery and will adversely affect access to healthcare.

Doctors and other healthcare providers alone cannot decide on 1Care.We are of the view that a public referendum is a must for any healthcare reform of this nature as it affects each and every citizen.

Dr. Steven KW Chow
President
FPMPAM

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