Opinion: Looking for a healthy compromise

NST: How should the proposed National Health Financing Scheme work? Doctors and activists share their checklist with SANTHA OORJITHAM.

WHEN a patient visits a government polyclinic, he or she pays RM1 for an examination and up to two weeks’ to a month’s worth of medication. But the real cost, according to a government study, is RM45 per visit.
Malaysia’s population is aging, the cost of health care rising and the public health system creaking under the strain.
Although only 25 to 30 per cent of medical specialists work in government hospitals, they handle about 75 per cent of admissions.
"The Government is overwhelmed," says Datuk Dr Tan Kee Kwong, Member of Parliament for Segambut and chairman of the Barisan Nasional’s Backbenchers Club (BBC) Health Committee. "It cannot cope."
The Government calculates that the only way to meet health care demands is by sharing the workload with the private health care sector and sharing the cost with workers and employers.
The aim of the proposed National Health Financing Scheme (NHFS) scheme is to split the burden of provisioning between "stakeholders", although the Ministry of Health has promised that both the NHFS and the National Health Financing Authority (NHFA) that oversees it will be non-profit and will not be privatised.
Karol Consulting, an Australian firm, was appointed in March to study the details of the financing mechanism over the next 18 months.
The Government is likely to test the scheme with a pilot project, the most logical candidate for which is the densely- populated Klang Valley, suggests Tan.
The ministry gave a briefing on the NHFS in Parliament on March 24 to Tan’s committee and other "interested groups" — the Federation of Malaysian Consumer Associations, the Malaysian Trades Union Con- gress, the Coalition Against Health Care Privatisation (CAHCP) and representatives from the Association of Private Hospitals of Malaysia and Koperasi Doktor.
Other countries have based their schemes on taxation, insurance or both. The Government has said that it would pay for the poor, disabled, civil servants and retirees.
For the rest, the NHFS is likely to require special payments, probably monthly. These are likely to be divided between the employee or self-employed, the employer and the Government.
The amount is likely to be based on "community risk" (everyone pays the same amount no matter what his health status is) rather than "individual risk" (i.e. based on the individual’s health risk).
Tan stresses that payment should be tagged to income levels. He also suggests a no-claim bonus, so that people who don’t visit a doctor or receive any treatment will pay less.
Malaysian Medical Association (MMA) president Dr Teoh Siang Chin, however, says funding should be entirely from taxes.
"Since we are now financing public health expenditure from general taxation, it would be sensible to continue this allocation," he argues. "The proportion by Government must be increased, since the Government is the major employer and must also ensure access for the poor, sick, young and aged."
The Australian consultant, whose study is jointly funded by the United Nations Development Programme and the Malaysian Government, will also recommend what treatment should be covered by the scheme’s "essential health benefit package".
Tan, who trained as a general practitioner (GP), says coverage must include treatment for chronic diseases such as renal dialysis and chemotherapy.
In the past, the ministry has said the essential package could be supplemented with private insurance.
But, urges Tan, people who take out private insurance should not be exempted from the NHFS scheme.
The CAHCP is against private insurance: "It will increase the total cost but not the provision of health care," predicts coalition chairman Dr Subramaniam Pillay. "In the United States, for example, health care expenditure is 14 per cent of gross domestic product (GDP), yet millions are without adequate health care."
(At present, the Malaysian Government spends 1.8 per cent of GDP on health. The World Health Organisation recommends that developing countries should spend five per cent of their GDP on health.)
Teoh agrees that encouraging private insurance would be contrary to the NHFS: "Private insurance is motivated by profit. Social or national health insurance is primarily to ensure a safety net and a cross-subsidy system."
The Government is considering organising the NHFS under the "gatekeeper" concept, in which a patient first sees a GP (to whom he is assigned, depending on where he lives), who then directs him to a specialist if necessary.
Ideally, Malaysians should be able to choose from among a few GPs in their neighbourhood — or at least, to change GPs if they are not satisfied with the service. And since the Ninth Malaysia Plan says the scheme will "encourage greater flexibility and freedom of choice in obtaining care from both the private and public sectors", that is likely.
The NHFS may also pay for some treatment in private hospitals. The scheme might pay a lower rate, which would have to be topped up, either out of the patient’s pocket or by private insurance.
Subramaniam is against that idea: "The private sector will thrive if government funding goes to private hospitals," he says, warning of a greater brain drain of government doctors into the private sector.
But if it is implemented, he says, it should be similar to Canada’s scheme, in which the private hospitals cannot charge more than government rates if the Government is paying.
Finally, Karol Consulting will also have to study how the NHFS makes its payments. Will it pay per visit or give "capitation" fees (a fixed amount per year, based on the number of patients registered with a doctor) or funds based on the private or government hospital’s case mix? Will the patient also be required to "co-pay"?
Doctors recommend a combination: "If you pay per head, there is no incentive to work harder," says the BBC’s Tan. If doctors are paid a fixed amount per head per year, they could try to reduce visits or treatment to lighten their workload.
Noting that many employers already provide medical benefits, the MP suggests that an employee could pay a certain amount into the fund that would be topped up by the employer.
Tan welcomes the assurance at the recent briefing that interested groups will be "continuously briefed" by the ministry, which welcomes any feedback.
"People are worried and scared that in addition to all the other costs that are going up now, another component of basic living is going to shoot through the roof," he says.
Workers already have contributions for the Employees’ Provident Fund, Social Security Organisation (Socso) and income tax deducted from their pay packets.
Subramaniam stresses that the activists’ goals are similar to the ministry’s: "We all want a sustainable, quality health care system with equitable access, where all citizens regardless of financial ability are able to get adequate treatment for their illnesses."