Governing is a task that requires making trade-offs and prioritising. One would put health as an important priority in national well-being and development, along with education. The government has showed indications for doing so - our health facilities have improved since the past to the point where we are one of the destinations for health tourism, rivaling Singapore, and significant numbers of students are paid to study medicine either in local varsities or overseas.

As the deputy health minister recently said: "We are trying to establish the best system for the Malaysian public health establishment as no other country has a system where the public gets excellent health care for as low as RM1."

However the recent reports of cutbacks in the Ministry of Health expenditures, along with the recent suggestion by the new health minister Dr Chua Soi Lek to create a private wing in government hospitals, are a cause for concern and public scrutiny.

Furthermore, the fact that the health expenditure might be saved if we cut other less important government expenditures, means that Malaysians must speak out regarding the matter.

At the moment, the percentage of government expenditure for health, compared to Malaysia's gross domestic product, is already lower than the recommendation by the World Health Organisation. Total expenditure, including both government and private, on health in 2001 is 3.8 percent of the GDP, whereas the proposed percentage by the WHO is at least five percent. However even this worrisome small proportion of expenditure dedicated to health is under threat.

Address weakness

A malaysiakini report revealed that the Ministry of Health is facing a deficit of RM210 million - a huge slice in the pie - and that it needs to find cost-cutting measures in order to pay personnel. This will include a radical slowdown in new appointment of personnel, cut on overhead costs and the use of "cheaper alternative drugs".

The cutback on allocation is due to the laudable intention by Prime Minister Abdullah Ahmad Badawi to cut our budget deficit this year; however one wonders why health, of all sectors, have to experience cutbacks when other less demanding expenditures can be reviewed. The national service which was just introduced and has been fraught with so many problems, cost RM500 million. Doesn't it make more sense for precious public resources to be channelled to existing vital sectors, such as health?

The public, as stakeholders in the public health services, both as consumers and taxpayers, deserve to know the details about the RM210 million slash in health expenditure. After all, wouldn't that be in line with the new prime minister's commitment to transparency?

A related issue is the suggestion to address the weaknesses in the public health system through the creation of what, in effect, will be a two-tier public hospital system. Consumers who are better off will be allowed to use private wings with better treatment and facilities.

One might be able to at least empathise with the suggestion had it come from countries without a significant private sector in health, such as the United Kingdom where government expenditure is 82.2% of the total expenditure on health in 2001.

In Malaysia, however, a vibrant private sector in health has been a regular feature (as exemplified by Dr Mahathir's own Maha Clinic or Dr. Tan Chee Khoon's Sentosa Medical Centre in the 1960s) that has grown more significant with our economic growth.

WHO statistics put the figure of government expenditure in Malaysia only just above half of total expenditure in health. Therefore the public (read: the well-off) already have the choice of resorting to private treatment.

It is commendable that the government wants to address the brain drain that is affecting the public hospitals in the country. As a result of relatively poor working conditions and low pay, many doctors choose to leave public hospitals after a few years to go into private practice.

Rightful pride

The problem, however, lies in the solution. Again, if indeed the government puts health as an important priority of nation-building, they can increase public health expenditure, putting a long term commitment to meeting WHO suggestions of five percent of GDP being spent on health.

The expenditure can be in the form of a better and more competitive pay structure for medical practitioners in government hospitals and an investment for better facilities. This will address

the 25 percent shortfall in doctor's posts in government hospitals, reduce waiting time, limit the privatisation of services in government hospitals and address the gap in the quality of services with private hospitals.

It will also create a sense of rightful pride and dignity for the doctors and nurses who work in government hospitals and play a pivotal role in national development. Recently the health ministry indicated that they want to study the salary package for doctors and specialists - but without considerable allocation of resources (and certainly unlikely in the face of significant budget cuts) - an effective change will not turn into reality.

In the short term, increased public health expenditure might even allow cuts in waiting time to be achieved similar to that in the National Health Service in Britain (for treatments such as hip-replacements or cataracts) or in Singapore (for liver transplants) - where certain crucial treatment can be done at private hospitals but subsidised by governments for consumers of public health services.

The creation of a private wing in government hospitals while trying to address the low pay issue for medical practitioners, only risks further hemorrhaging the gap between services for those who can afford private treatment, and those who will have to rely on (the public wing) of government hospitals.

While it might contain the drain of resources from government to private hospitals; it will create an internal equivalent which will affect those on the lower end of the socioeconomic ladder. The fact that Malaysia is emerging as a main destination for health tourism in the region is another cause for worry - if the health tourists flock to the private wings then it will cause a further drain in resources.

Private wings are the embodiment of a belief that by introducing the market to the public health sector, it will respond for efficiently and effectively. However the provision of adequate health services for the poor is a clear market failure and can best be achieved through a sustained long term plan to increase health expenditure.

NIK NAZMI NIK AHMAD is a current-affairs commentator studying in London. His blog can be read at http://www.niknazmi.com