With regards to the current state of the nation's healthcare system, I must say that I certainly disagree that the government should take back control of healthcare in our country, especially in its current management form.

Dr Abdul Khalid Sahan, who incidentally was instrumental in the corporatisation of IJN (the national heart institute) one of the most controversial and acrimonious incidences of opportunistic privatisation of a medical facility ever in the annals of Malaysian medical history - interestingly argues that the free market does not work for healthcare. His article makes fascinating reading but does not apply in today's context.

Perhaps the public would be more appreciative of the need for accountability if they really know what goes on in the government sector. It is 2006, not the patriotic, strictly socialist, welfare-ish 50s and 60s.

Former premier Dr Mahathir Mohamad, after his admission, subsequent heart surgery and recovery at the heart unit at the then General Hospital of Kuala Lumpur, allocated RM200 million for heart treatment to the unit in all probability to show his appreciation. However, the opportunists at that time quickly hashed up a privatisation proposal and IJN Sdn Bhd with a paid up capital of RM71million was born and locked to the Ministry of Finance (MOF), thus prising it away from presumably inefficient (Ministry of Health). Someone wanted to corner the cardiac business. To add insult to injury, the concession agreement spelled out that the MOH would not be allowed to open a heart unit in the central region.

The MOH had no choice but to open a heart unit at the Penang General Hospital two years later and subsequently in Johor Baru for the southern region and in Kucing for East Malaysia. Till this day, patients in the central region, Klang Valley included, are deprived of cardiac services at a government hospital and instead have to go to IJN for treatment and will have to pay for treatment unless they are government servants or have valid guarantee or referral letters. This may change if the government gets its act right at its new Serdang Hospital.

Outrageous monopoly

IJN's outrageous monopoly contributed to a prolonged waiting time for treatment of cardiac ailments as patients who cannot afford to pay or wait will have to run up to Penang or down to JB for treatment or leave their destiny to fate. But despite its unfair monopoly, IJN has proven why healthcare needs to be privatised or corporatised in some form. IJN has five operating theatres. Each operating theatre does 600 cases a year. In total, they do 3,000 cases a year. The MOH and the Ministry of Education (MOE) have a total of eight operating theatres for cardiac surgery alone and all operating theatres combined do less than 1,000 cases a year. It is because that someone else (the taxpayer) is paying the bill, the ministries' efficiency levels become questionable. IJN is run by the MOF and an army of accountants but not the MOH and MOE.

To make matters worse, constant infighting has caused many surgeons to resign from Penang while JB is constantly being bullied by someone who is intent on holding the MOH to ransom. There is a lone expatriate surgeon trying to hold the fort at Kuching. The public should visit the Penang Heart Unit to see things for themselves. The inefficiency and wastage despite all the money that has been poured in is truly astounding.

In 1996, the hospital support services of the MOH were privatised. Cleansing services, linen and laundry, clinical waste management, biomedical engineering maintenance, and the facilities engineering maintenance for the MOH's general, district and nucleus hospitals and other facilities (accounting for 14% of the ministry's budget) were contracted out in what was then described as the largest privatisation exercise ever for hospital support services.

This was a concession worth US$2.8 billion over 15 years, and it was awarded to three local consortia in joint ventures with their foreign partners, in an exercise with little transparency, accountability or competitive tendering. According to figures from the finance division of the MOH, expenditures on hospital support services went up from RM143 million in 1996 to RM468.5 million in 1997, a 3.2 fold increase with no commensurate expansion of services or improvement in quality. This steadily increased to RM507.9 million in1999.

This concession followed upon the privatisation of the Government Medical Stores (GMS) in 1994. A 15-year concession to procure, store, and distribute pharmaceuticals and medical supplies to government healthcare facilities (annual volume US$100 million, 8% of the MOH budget) was awarded to Remedi Pharmaceuticals (M) Sdn Bhd, a company closely linked to the ruling party. A study conducted in 1997 compared the price lists for GMS' and Remedi's overlapping items, and reported a 3.3 fold (weighted) increase in prices after privatisation, again with little evidence of improvement in quality of products or services provided. Again, in the 1980s right till the 90s, the MOH went on a hospital-building spree paying scant attention to manpower.

Benefit politicians

Construction was carried out mainly to benefit politicians and to help keep the construction industry alive. Billions of taxpayer's healthcare money was just squandered away by our so called health planners when any doctor slogging away trying to see 50 patients in two hours while covering for the operating theatre in a government hospital will tell you there was no discernible benefit to patients in general let alone to his own pay.

The 'vulturisation' of MOH's meager budget began as early as 1992 leaving patient care compromised due to lack of competitive tendering, cronyism and sweetheart contracts. This despite the fact that with expenditures of less than 2% of the GDP, public sector healthcare has been instrumental in delivering impressive value-for-money results: infant mortality rate of 8.1/1000 live births in 1998, life expectancies at birth approaching the mid-70s, 90% of the population living within 5km or one hour's traveling distance of a primary healthcare facility, immunisation rates which exceed 90% for most vaccine preventable childhood illnesses [Global Influences & Local Contingencies in Malaysia; Chan Chee Khoon. Citizens' Health Initiative].

The US, despite its technical superiority in medicine, has always been quoted as to why market driven healthcare is bad. Despite consuming 14% of GDP (double the Western European/ Japanese average), it leaves 45 million residents without health insurance cover, including 10 million uninsured children (one out of every seven). All very informative. But what is the solution for Malaysia? A country must evolve its own system depending on its people, resources, circumstances and in our case - cronies, shady deals, monopolisation etc. Can we trust the MOH in its current form with our meager healthcare budget? How sure are we that they won't squander it and sell the average patient out as they have before? How do we ensure that as many people as possible get the best care within our limited resources? How do we make certain corruption doesn't sink the system? It is only through transparency and accountability.

The inefficiency in our healthcare system is the direct result of a hierarchy set up during colonial times and brought forth to bear in these modern times. The system of having a director-general and multiple deputy DGs for everything sundry must be abolished and the system be allowed to move with the times. The MOH must go back to basics and focus on primary health care which is very critical to a nation and also perhaps emergency care. Acute care medicine read hospitals - should be decentralised and corporatised in one form or another. The government must work out a solution where the private sector is an integral part of our healthcare system. Letting matrons or doctors run a hospital in this day and age is an administrative disaster. Doctors make poor managers and should stick to what they are trained for doctoring.

A quick look at how efficient private hospitals are managed in Malaysia and especially Singapore would reveal that hospitals are managed by well trained CEOs who have an in-depth knowledge of not only human resources, but also of purchasing, industrial law, accountancy, marketing and IT. Each decentralised hospital, authority or region simply needs a firm, strict and efficient CEO. The MOH may claim that they are big. But so are MAS, TNB, Telekom, Walmart, Dell and Toyota. Inefficiency on the scale of MOH's, be it manpower or finance, at any one of the firms mentioned, will see it severely punished both by the market and ultimately by their respective shareholders. But in the case of MOH, favoritism, inefficiency, wastage, political interference, blatant corruption and sometimes downright pettiness rule the day instead of focusing on the job at hand.

Dr Abdul Khalid Sahan emphasises the importance of primary health care, accessibility to healthcare, containment of costs, maintenance of quality services and how important healthcare is to the economy of the nation. The paradigm shift where primary healthcare firmly remains in the hands of the government and acute care medicine be corporatised or privatised in some form with the involvement of the private sector is the way to move forward to achieve these goals.

Our government is in favour of improving the healthcare of every Malaysian. But the charlatans and the archaic system at MOH will make certain this will not happen. The MOH appears to have its own agenda. Otherwise, there is no reason whatsoever why almost 60% of all doctors are in the private sector and are continually kept out and even ostracised. I am certain, our MPs, cabinet and prime minister are quite unaware of what is actually going on. How can they be when the country's best and most experienced doctors are in the private sector and the cabinet instead takes advice from MOH officials ingrained in the antiquated system of yesteryears. This, more then anything else, is why we are on the wrong path to better healthcare in this country.

AHMAD SOBRI is the pseudonym for surgeon who has served in both the public and private sectors. He is currently preparing to migrate.