We read with great interest and agreement, the article by Dr HT Ong and others ' 1Care outpatient scheme - middlemen didahulukan? ', on the planned 1Malaysia Healthcare transformation reported in Star May, 24.
When this plan was revealed three years ago, the FPMPAM had cautioned that introducing a national health insurance, will not necessarily improve patient care and lower cost of delivery. In fact, our contention is that it may disrupt the continuity of present patient care in the country.
Our proposal is instead of a transformation is to allow the system to evolve, paying particular attention to areas of weaknesses, which cause the under-performance and poor delivery in the existing system.
Based on our knowledge, the proposed transformed system is supposed to be modelled from the NHS system of the United Kingdom. A brief view of the essential changes is as follows:
- There will no longer be separate public and private healthcare funding.
- All healthcare costs shall be met by way of a central fund that is in the process of being designated.
- All residents will be allocated to their GP in their locale, and given a number. They must see the GP in their locale should they require medical help. The GP will act as their primary doctor and if necessary, will refer them for a specialist opinion and care.
- All hospitals (no longer demarcated as private or public) will treat the patients referred and charge the national health insurance/fund who will reimbursed based on a "fees schedule "
- Patients can buy additional private insurance should they wish.
Among others, the reasons given to justify this healthcare transformation are:
- The inefficiencies in the present healthcare system, especially the long waiting list.
- The never-ending issue of rising healthcare cost and that the government can no longer afford to subsidise it.
- The new system solves the brain drain to the private sector.
Not a solution
What we, as practitioners fail to see (and we have discussed this extensively amongst ourselves), is how the government’s proposed transformation will solve what it is planned to solve for the following reasons:
1. Firstly, the proposed model will only increase waiting lists as clearly exemplified by NHS-UK which is the model for this transformation. Public complaints of unduly long elective surgery waiting list in terms of many months in many cases, have been substantiated by the recent reports in the BBC news.
Clearly at the end of the day, that is no different from what we have now. In addition, the NHS-UK is in trouble with many cases of the GP ‘gate-keepers’ being sued for unacceptable delay and denial of secondary care. The question of why Malaysia is adopting a model which has been acknowledged even by the UK government as riddled with problems remains unanswered.
2. Our prediction is that the healthcare cost will surely continue to rise and at a more rapid rate. This is exactly what is happening despite many decades of the NHS. The system has failed to contain costs. Healthcare cost in the UK continues to increase year by year resulting in more and more cuts which in turn is aggravating the ability of the system to efficiently deliver the care that it was designed for.
The creation of another bureaucratic layer in the form of the health insurance payers (another business entity) will add a substantial cost item to healthcare delivery. This is the middle-men that will be appointed to administer the cost in healthcare .We have already seen this happening in many other examples of privatisation in Malaysia. The additional cost involved will eventually be borne by the rakyat. So, why use this business model again?
3. With the proposed plan, the rakyat will be burdened with more taxes, whether direct or indirect. What seems to be buzzing around is perhaps a GST of 7 percent for healthcare? The contention that the patient need not pay is not correct, as at the end of the day, the payment comes from the patients and the public alike. The difference is you pay whether you fall sick or not.
What is clearly needed is for the government to increase the present budget allocation for healthcare. We are merely committing 4.3 percent of our GDP as healthcare expenditure compared to UK (8.2 percent), Australia (8.7 percent) and USA (15.3 percent).
To be realistic we need to increase spending to 6 to 7 percent of GDP in keeping with the increasing demands and cost of advances in healthcare today.
This, together with stringent and meaningful cost-efficient measures to improve the productivity of the public healthcare system, will provide the patients with a system far better than what the NHS-UK has to offer.
The excellent standard of care that many public hospitals have achieved should be made available to all needy patients by cutting red tape at all levels. At the same time the cost of private hospital care should be closely monitored and controlled with the appropriate market forces and necessary regulatory oversight.
Why the rush?
There seems to be a strong desire to have this transformation in motion within the next three years.
This is an unrealistic expectation and will surely upset the continuity of our present healthcare delivery. One must not forget that even the NHS-UK system took more than 30 years before it could be fully implemented by which time all the so called cost-cutting measures had been overtaken and neutralised by the rapid advances in medical technology, costly treatment modalities and patient-population demographic changes.
We propose that we evolve rather than transform our system which has been acknowledged by WHO as one of the best around. This claim has been regularly promoted by the Ministry of Health itself.
Our exemplary healthcare performance indices have been duly documented and acknowledged in the yearly National Healthcare Accounts.
Are we in the throes of a ‘new car syndrome’, where everything seems wrong with the old car once we have decided to buy a new one? Will appropriate servicing and change of parts to more than sufficient to keep it in pristine condition?
Should we transform the system or fix only what is broken?
We do feel that it is time for a public referendum on this issue as it ultimately involves the rakyat’s money and welfare.
The writers are members of the Federation of Private Medical Practitioners’ Associations Malaysia