Seeking a better healthcare system — TK Khong

MalaysianInsider: JAN 19 — Having worked in various parts of the NHS for over 30 years, I know it in virtually every detail. As a health and social concept, the NHS is an unimpeachable undertaking.
However, the NHS in England today is facing severe difficulties caused not merely by demographic changes and medical advances but by the crippling cost of its administration and the inefficiencies of a dominant tax-funded system.
Despite the common belief that it is equitable and efficient, the reality is often the opposite. Although there have been huge increases in health spending over the past two decades, there has been little or no improvement in outcomes across a wide range of specialties, and even a worsening in patient experience in many areas.
The latest reform, with its montage of internal market and private providers, aims to restore some semblance of cost-effectiveness and improved efficiency through delegating the financial decision processes to the medical profession and delivery redesigns targeted at the main causes of ill-health.
The 1Care for 1 Malaysia plan to introduce a nationalised health service in Malaysia partially along the lines of the NHS is a laudable move. Although the per capita income may be rising, the reality is a widening gap between high- and low-income sections of society with poverty on the increase.
Indeed, Datuk Dr Hassan Abdul Rahman, Health director-general, expressed concern that “greater private health sector development would widen the gap of access to healthcare services for the rural population compared to the urban population and between those who can and cannot afford to pay” (The Star, December 3, 2011).
Social Health Insurance (SHI), devised to supplement the amount allocated to healthcare from Government General Revenue, is promoted as an attempt to address income inequalities which are considered as obstacles to accessing healthcare.
However, if as Dr Hassan says, “private investments and the continuous contribution of the private sector are encouraged”, then SHI represents an additional levy on many who are just able to afford their own healthcare but who would under the new regime be financially penalised and who would therefore migrate wholly to the public sector. This in turn will increase the burden on public sector healthcare provisions.
Another key feature of 1Care for 1 Malaysia is that primary care is at the heart of the reform with the GP as its focal point. This transformation is sensible, if only to increase the power of rationing, but co-payment for prescriptions and certain appliances lacks precision over the amount of money that is required from patients. Similarly, there is no clarity over what is within the defined benefits package of hospital care that is free of additional payment.
While commendable in principle, SHI contributions are dependent upon financial ability. Means testing is fraught with difficulties, while the thresholds and variations for additional levy on the rich and healthy have not been defined, nor has the quantification of the “cross-subsidy” been finalised.
Most importantly, it is unclear how much administration of the SHI “organisation” will cost and where the funding for this will come from. Only if the consolidated fund is ring-fenced for healthcare will the public be able to enjoy the full benefit of a properly constructed SHI.
Otherwise, there will be a major adverse impact on the amount of money available for healthcare as management costs will divert significant amounts of funding. Furthermore, there are no indications about commissioning and provision of services. For example, there are no statements on whether the SHI would develop its own provider wing or commission services from external private sector providers, and on the governance of cost and quality issues.
To achieve the success it deserves, 1Care for 1 Malaysia should not be unduly concerned about the ratio of government-to-private spending in healthcare being 55:45 and use it as a starting point for the financial reform of healthcare.
Indeed, the current growth in the private healthcare sector should be recognised as reflective of demand and competition, both of which are natural drivers of quality and restrainers on costs. Instead, the health inequality gap should be dealt with differently cognisant of disease prevalence, and 1Care for 1 Malaysia should focus its attention on detailed analyses and taxonomy of various diseases as causes of morbidity, mortality, emotional distress and economic burden.
The Malaysian government must demonstrate strong stewardship in public health and social care in such areas as care of the vulnerable, the frail and the elderly, those with learning disabilities and the physically handicapped. It should ensure a comprehensive strategy for major killers, such as infectious illnesses and cardiovascular diseases. Health education to promote healthy lifestyles should be a consistent feature in schools and at places of work.
With a safety net in place, Malaysians are then best served in health by reinforcing their financial autonomy and empowerment of individual choice. Rather than follow the path of the NHS and release a money-guzzling genie, the far better approach is for the Malaysian government to craft a robust public health and social care policy that provides for the needs of all Malaysians.
1 Care for 1 Malaysia must not become a wasted opportunity. Its success or failure is critical to the health and welfare of all Malaysians.

* Dr TK Khong, who is a Malaysian GP and a forensic physician in the UK, also serves as a board member of a clinical commissioning group and advises on health and social care policies.