A strain on the pocket

Star: Healthcare cost is expected to escalate in line with the rising cost of living and the Health Ministry is taking steps to raise public awareness on non-communicable diseases.
OF late, the Health Ministry has been raising public awareness on non-communicable diseases (NCD) chronic respiratory diseases, heart diseases, cancer and diabetes.
According to Health Minister Datuk Seri Liow Tiong Lai, the recent United Nations' high-level meeting on NCD in New York revealed that there would be a 17% rise in global prevalence of NCDs by 2025 if nothing is done to control it.
Recent statistics already show that 60% of premature deaths (below 60 years) in Malaysia were caused by NCD, he has said.
The focus is warranted not only because of the need to keep the population healthy and productive but also to keep healthcare cost, which is expected to escalate in line with the rising cost of living, manageable.
A World Economic Forum (WEF) study carried out with the Harvard School of Public Health shows that the cumulative costs of treating NCDs are expected to be US$7tril (RM21.9tril) from this year to 2025.
Mental health (which is not included in the list of NCDs but which the study found, along with heart diseases, to be responsible for nearly 70% of lost output) will account for US$16tril (RM50tril).

In Malaysia, the Government currently provides highly subsidised healthcare services to the general population while the poor are exempted from paying.
Liow says the current healthcare system offers a safety net from “catastrophic health expenditure” for those seeking treatment at government hospitals.
But Malaysia, like many other countries, is apprehensive that the present system of financing may not be sustainable in the long term due to rising health expenditure and the high out-of-pocket spending by the population, he reveals.
To ensure that people continue to get access and coverage to healthcare, the ministry is planning the 1Care programme, which seeks to address the issues and challenges of the current system.
“In 1Care, it is proposed that the health financing mechanism will keep healthcare inflation under control and reduce out-of-pocket expenditure at the point of seeking care,” Liow explains.
Under 1Care, it is envisaged that the population would have greater choice to seek care either at public or private health facilities. This could happen through mandatory contributions into a consolidated fund managed by the Government, Liow says.
“Healthcare providers will also be better motivated to practise in more rural areas, thus improving access and coverage of the population,” he adds.
“Primary healthcare providers will become family doctors responsible for providing long-term personalised services to their registered patients.”
1Care also envisages the use of a prepayment mechanism, implemented through enrolment in a Social Health Insurance (SHI) scheme, which will reduce high out-of-pocket payments at the point of seeking care when a person is already seriously ill.
SHI premiums, Liow explains, are community-rated and contributions will be based on a percentage of income. The Government will pay the premiums for the poor and vulnerable.
“SHI promotes equity in financing and access, where the amount contributed is based on the level of income and no one is denied access to healthcare due to their inability to pay. The scheme will deploy continuous monitoring and evaluation to ensure the goals of the health system transformation are achieved,” he says.
But there are challenges in implementing the scheme, he admits, citing as examples the recruitment of those in the informal job sector and determination of those eligible for government funding.
“Defining the benefits package and estimating the true cost of health services will also be challenging. Drawbacks include additional administrative costs compared to a public healthcare system funded adequately by general taxes, but the administrative cost is still lower than for privately managed systems,” he says.
Looking at private health insurance (PHI) companies, Liow says premium rates will increase if there are pre-existing conditions such as NCDs and mental illness. Those who buy PHI will have the option to purchase insurance packages specifically tailored to them but they need to be willing to pay higher premiums, he adds.
He assures that when the SHI is introduced, such issues will not arise as people cannot be excluded from joining the scheme because of any pre-existing conditions, age or ability to pay.

Universal coverage
Prof Dr Daniel Reidpath, professor of population health at the Jeffrey Cheah School of Medicine and Health Sciences, Monash University Sunway campus, says managing the future burden of NCDs requires both a prevention strategy and a care and disease management strategy.
“Both strategies need to target the whole population and should be seen as part of universal coverage. People sometimes, mistakenly, think about direct healthcare as the only concern of universal coverage,” he adds.
“The financial and health savings from successful prevention strategies, however, are so substantial that the two arms of prevention and care need to be considered simultaneously. The focus is healthcare, not sick' care.”
Universal coverage, he explains, is a concept based on “the need for all individuals to be able to access adequate healthcare with a focus on efficiency, which is the equitable delivery of relevant, high quality care at the lowest cost”.
Malaysia, he says, would need to consider not only types of preventive services to implement but how they are financed.
He adds that besides prevention delivered through clinical practice, there are also “enormous” opportunities to engage in prevention work through community-based programmes that encourage health and wellness, and structural and policy reform around policies on tobacco, transportation, food and agriculture.
Managing NCDs requires regular monitoring and ongoing treatment, which translates into clear guidance on what is considered “essential” healthcare and the types of services provided under universal coverage such as entitlement for regular kidney dialysis, chemotherapy or statins, he says.
Dr Reidpath says there is always a cost associated with universal coverage.
“The danger here is that knee-jerk responses to possible increases in healthcare costs may ignore the much greater economic cost associated with a loss of economic productivity.”

On Malaysia's healthcare system, he says there is a need to restructure the system, which previously focused on primary healthcare, to one which can deal with current health priorities such as NCDs.
“The great advantage for Malaysia is its network of primary healthcare centres. Appropriately restructured, the centres could become an integral part of any universal healthcare scheme delivering prevention and direct care for NCDs,” he says.
He also points out the misconception that Malaysians are over-dependent on the Government. Governments of the 10 nearest gross domestic product (GDP), including Turkey, Argentina, Mauritius and Mexico, spend on average twice as much, he says.
Dr Reidpath says that if universal coverage is to be seriously considered for Malaysia, especially for strategies to manage NCDs, the Government would have a significant role.
The role could also include direct financing, legislative and regulatory management of healthcare financing to ensure appropriate risk-pooling mechanisms that will protect the health of Malaysians.
He adds that the Government is also “well-placed” to support prevention strategies.
“Lack of good prevention and adequate healthcare cover for the whole population will ultimately be a far greater burden on Malaysia than any modest economic burdens that could occur now in order to ensure universal coverage,” he says.
On healthcare cover for employees, the Malaysian Employers Federation (MEF) executive director Shamsuddin Bardan says most major organisations have a cap on medical entitlement for their employees.
“It is according to the capability of the company to do this,” he says.