Not enough money is being spent on healthcare every year, and any resistance against increasing the present government expenditure does not bode well, health experts said.

"The issue is not that we're spending too much, but that we're spending too little. The biggest problem to all this is the outflow of senior staff, due to overly modest renumeration," said Citizens' Health Initiative coordinator Dr Chan Chee Khoon.

"It's a real problem for the public sector. The perennial loss in senior staff cannot be replaced by an annual inflow of young doctors (new medical graduates). It's a chronic situation."

Chan pointed out that government expenditure on public health is at present well below recommended World Health Organisation (WHO) standards, which proposes that governments spend at least five percent of their gross domestic product (GDP) on healthcare.

Experts say that the real health expenditure for Malaysia is around 4.5 percent of its GDP - this is higher than the official estimates of 3.8 percent, which is considered by most as an underestimate, since private payments to the health system, ie 'out of pocket' payments, are difficult to account for.

And according to WHO, the government only pays for half of the 4.5 percent healthcare expenditure.

Which, said Chan, still puts Malaysia well below international standards on health expenditure.

No proper healthcare

Compound this with rising numbers of chronic illnesses nationwide, said medical academic Prof Syed Mohamed Aljunid, and you get a situation where patients do not in fact receive proper healthcare.

Syed Mohamed, who is also president of the Malaysian Public Health Specialists' Association, said the overworked public health system at present encourages patients to be sent home once they have received the minimum medical treatment.

All of this is a result of a very old problem that the government, despite all its intentions, have been unable to solve: the fact that the public service salary scheme remains unable to attract new doctors.

"Unless there is a separate salary scheme for doctors, outside of the public service department, we will not be able to retain our doctors," he said.

Already, the present doctor-patient ratio in government hospitals cuts a worrying figure at 1:5,000.

Job hindrances

Despite various efforts and discussions in the past to stem the brain drain, none has shown any effectiveness in stemming the tide, said Syed Mohamed.

"In fact, doctors may be worse off on account of these new efforts. Under the Sistem Saraan Malaysia (civil service renumeration system), doctors due for promotion are expected to sit for a public service examination, which has nothing to do with ensuring the quality of their technical skills."

According to him, the examination - a general knowledge test on items like the administrative system and the legal process - end up delaying the process of promotion and are often considered an unnecessary hindrance by those in the field.

"Worse of all, doctors are required to take two weeks off from work in order to sit for the examination - a sacrifice which the public health system can ill-afford to make. The government needs to scrap this requirement altogether," he added.

Early this month, Health Minister Chua Soi Lek announced the health government's latest proposal to keep senior doctors and specialists within the public service.

The government said it was looking into accommodating 'commercial private wings' in publicly-funded hospitals - a model which it hopes would provide specialists and senior staff the opportunity to obtain better pay, while remaining in government hospitals.

It is a move which would essentially create a two-tier system within the public health system, and runs risk of allowing the rich to obtain faster, and most likely better treatment, at a price.

Privatisation woes

But both Chan and Syed Mohamed argue that privatisation is probably not the right solution.

For one, said Syed Mohamed, examples abound of failed privatisation projects that have occurred in other countries.

"Privatisation has failed because of poor monitoring. Examples of privatisation projects implemented in other developed and developing countries have failed. None were able to meet the original aims of privatising, with costs going up and quality either maintained or fell."

Locally, the proposal of a private system within a public-funded one, raises the problem of whether the government can ensure that public resources are not misused for private profits.

"The idea of privatising hospitals wings is that public sector doctors can find opportunity to top up their income through private work. But firstly, are we able to monitor how much time a doctor spends in the private wing as opposed to the public one? Or whether private patients will get preferential access to operating theatres meant for the public?"

He pointed out that when UK privatised parts of their health system under Prime Minister Margaret Thatcher - similar to what Malaysia is proposing today - it resulted in much delay in the public waiting time, particularly for surgery.

"As a result of privatisation in the UK, the priority went to those who paid private. If we are not careful, it will also turn out that way," he said.

Malaysia's experience

According to Chan however, the problems in privatising healthcare have already made its mark in Malaysia..

"When we privatised our medical support services throughout the 1990s - such as the pharmaceuticals, medical supply and blood supply - the effort was 'rewarded' with a three to four-fold increase in cost," said Chan.

While it is difficult to speculate exactly how much of the cost increases are due to inefficiencies and how much are due to payments to concessionaires, the matter remains that privatisation will not be a solution until the government can show how such a move can bring about greater efficiency and lower costs, he said.

But as details are still lacking over the decision to cap government spending and the proposal to privatise, the government will need to be clear about what it is planning to do, and why.

"At the same time, the government needs to come clean on whether they are cutting back as much in other sectors like defence, or education."

Concerns over fiscal tightening have come amidst Thursday's announcement by the health minister that eleven new hospitals, expected to be built under the Eighth Malaysia Plan (2001-2005), will be scrapped.

His disclosure confirmed a malaysiakini report , which, in quoting an internal ministerial circular, revealed that all ministries have been asked to exercise cautioned spending and ensure that the 2004 expenditure remained at 2003 levels. The directive may result in the health ministry needing to reduce its spending by about RM3.8 billion.