THE CURRENT MALAYSIAN HEALTHCARE SYSTEM - A BRIEF REVIEW

This article will form the first of 3 articles on the present Malaysian healthcare system, and the recently proposed healthcare reform. The articles are targetted for the STAR newspaper over the next 3 sundays, under "Fit for Life ".

Introduction

Our colonial masters, before the days of Merdeka, had bequeath to us a healthcare system which have served us well ( with some modifications ) till this day. Numerous WHO reports in the 90’s and this new millennium, have praised the Malaysian healthcare system. It is often quoted that any Malaysian ( or even non-citizens ), should they need medical attention anywhere in the country ( East or West Malaysia ), can go to the nearest health centre ( 81.1%of the population live within 3Km radius from a static health facility ), for free treatment ( and may I add, without the need to first show your insurance card, or wait for insurance coverage verification ). And should he need to be seen for further assessment, that can also be arranged and he could have up-to-date tertiary care treatment for almost no cost. How many countries in the world can boast of that, at this point in time?.

Currently we have a growing private healthcare system, running along side a public system. The public system, comprising the many public general hospitals, district hospitals, health clinics, mobile clinics and clinic desa. The public system also takes care of disease prevention, preventive health, environmental health, dental health, food and water quality control, enforcement of standards and oversee the private system. In the public system ( or what Mr Obama may call the public option ), treatment is given at almost no cost to minimal cost ( ranging from first class to third class ). This safety net is tremendous and provides a very important aspect of looking after our poor and needy. It would be a great lost, not to have this safety net. The private system is mainly a fee for service healthcare providing system, where those who are ill, seek medical treatment, either at the primary care level or at the secondary or tertiary care level. In the private system, it is fee for service and many pay out of pocket. There is an increasing trend for some to buy health insurance, either through their employer or on their own. There is some concern that over the last 10 years, the proportion of population seeking treatment in the private sector has increase, raising the private healthcare expenditure. This is sometimes used as a reason for trying to justify re-structuring the healthcare system.

The cost of health in Malaysia.

Health is a basic right of every and all individuals. It must not be denied to anyone, irrespective of race, colour, creed or economical status. Equitable healthcare must be available for all who need, Malaysians or non-Malaysians alike. The more touchy issue is, not equitable healthcare but also equitable and equal standard of care. Undoubtedly, those who can afford will get the standard of care that they are willing to pay for. Malaysia is after all a capitalist society where market forces play a part in healthcare delivery. Paying for quality medical care to get well is cost effective, but paying for frills in “ boutique “ hospitals, that is another issue. Maybe the more important question to ask is, have wasted our healthcare budget? Spending billions and getting poor national health in return? Have our healthcare spending, rising over the years, kept pace with inflation and rising cost of services in other sectors, or put in another way, are we over-spending in healthcare, to the detriment of other service sectors?

Let’s answer the first question. Have we wasted our healthcare budget? Did we spend the money budgeted wisely? Some facts and figures are in order. We spend ( so it is reported in the National Health Accounts ) in 2008, 3.6% of our GDP on healthcare. Of this, 2.1% was spend on public healthcare sector. In 2006, 7% of the overall government spending was on health. These numbers are not very large. And yet, for this small amount of money spend, we have the following health outcome data reported by the Ministry of Health in their report for 2008.

Population of Malaysia 27,728,700

Average Annual Population growth rate 2.0%

Infant Mortality Rate 6.3% per 1,000 live births

Maternal Mortality Rate 0.3% per 1,000 live births

Perinatal Mortality Rate 7.3% per 1,000 live births

Live expectancy at birth

Males 71.70 years

Females 76.46 years

I am very please to note that these facts are all in keeping with an almost developed country ( we are not yet 2020 ). Yes, they are not as good as UK ( spend 8% GDP on health ), or USA ( spend 16% of GDP on health ). We are spending 3.6% of GDP on health ( way below average for a developed country ) and scoring outcome data almost as good as the developed country. So far, it seems that the money have gone into good medical care.

Now to answer the second question, have we over-spend on healthcare to the detriment of other services sector? Have healthcare spending kept paced with inflation? The answer is an obvious NO, we have not overspend. Here, the figures are a bit more difficult to find. When I reviewed the National Health accounts ( NHA ), prior to 2007, they was little emphasis of the private healthcare expenditure. Let me illustrate. The 2007 NHA reported that the total expenditure on Health was 4.7% of GDP ( spend 44.8% by public sector and 45.2% by private sector ). In absolute terms, the total expenditure on health ( public and private ) was RM30.2 billion. Of which RM 13.3 billion was spend in the public sector and RM26.7 billion was spend in the private sector.

Prior to the 2007 NHA, the numbers were not reported this way. Let me make a simplify chart for you to understand. Remember, these are all data taken from the Ministry of Health facts ( 2005-2008 ), to illustrate important aspects of healthcare spending.

2006 2007

Population 27,173,600 27,728,700

Doc : pop ratio 1 : 1,145 1 ; 1,105

Total Health Budget RM 25.5 Billion RM 30.2 billion

Public RM 11.2 billion RM 13.3 billion

Private RM 14.3 billion RM 16.9billion

Total private clinics 2,992 6,371

Total doctors in private 9,440 10,006

If these numbers are too be believed, then we must conclude that between 2006-2007, the healthcare budget has increased by approximately18%, and the private healthcare expenditure had increased by approx. 18%. Yes, there are leakages and wastage in the healthcare delivery system. Healthcare in the public sector is still very good and very cost effective. It could be improved, I am sure. We will come to that later. Healthcare in the private sector is quite another story. By design in the private sector, doctors fees are controlled and mandated by law ( The Private Healthcare Facilities and Services Act 1998 and Regulations 2006 ). Any doctor found to have transgressed the fees schedule can be hauled up by the Ministry of Health. What is very surprising is that private hospital cost are not declared, to safeguard the public. If one should be unfortunate enough to fall ill, and be admitted to a private medical center, upon your recovery, you will find that the total hospitalization bill has two main components. There is the medical consultant’s fees ( which usually forms about 15-20% of the total bill, and it used to be 30% previously ), and the hospital bill. The medical consultant’s fees is declared in the Private Healthcare Facilities and Services Act 1998. Surprisingly, the hospital portion is not. Private hospitals ( almost all of which are owned by government linked companies ), do not have to declare to us how they charge. The private hospital cost can change by the month. I am told that the surcharge ( or mark-up ) on drugs or consummables on some items in private hospitals can vary from 20% to 200% ( on some chemotherapy items ). Some “ boutique “ hospitals justify this by saying that they are 6 or even 7 stars. Sad to say, “ boutique ness “ , does not contribute to medical care. It may add to the ambience and “poshness” but that is not medical care. How then do we factor this “ luxury factor “ into healthcare expenditure. Could the rising cost of private healthcare be significantly contributed to by these 6-7 star hospitals, who view it as a service hospitality business, where fees and charges are more on a profit margin basis? The Ministry of Health know this and yet have done little to curb it. In fact, they maybe tacitly encouraging it. We have brought this point up with the previous Minister of Health, but little have been done to try and have a fees schedule for private hospital treatment cost. Private hospitals are only prepared to declare their hospital bed charges, which is no reflection on the overall treatment cost. We even when as far as to suggest that the Ministry of Health charge first class wards full rates ( without government subsidy ), and allow 3^rd class free treatment. This will then set a benchmark for hospital charges for the private sector. Alas, this also fall on deaf ears. For many private hospitals, healthcare is a for profit business, and the authorities have allowed it to be so. Could this be a reason why private healthcare cost is rising, and more and more companies are getting into the private healthcare business?

The other reason maybe that many hospitals ( as part of their branding ) purchase “ high tech” equipment at tremendous cost ( millions of dollars ) and begin to ask consultants to use them, whether indicated ( marginally indicated ) or not. Every headache coming to emergency room, gets a CT scan ( ordered by a private hospital employed medical officer ), even before a medical consultant is consulted ( and this is in a tertiary care hospital ). There must be more CT scans and MRI scans in the Malaysia ( per 100,000 population ) then in USA. Very often, “high tech” equipment are abused for profit. It is only fair to say that not all private hospitals abuse their “high tech” investigative equipment, but many do. Afterall, the bottomline is profit.

Undoubtedly, it is true that with medical advance, the cost of keeping patients alive and well has also gone up. What with new modalities of investigations and assessments, and new modalities of treatment previously unheard of. It is universally accepted that with all the medical advances, we all live longer and better.

Conclusion

Looking at it overall, the Malaysian Healthcare system is one of the best in the world and aptly suited to our needs. Around the ASEAN region we easily boast one of the better healthcare delivery system. In fact many from the surrounding region come to Malaysia for their treatment for heart diseases, cancer treatments and even normal deliveries. There are many tertiary care centers spread all over the country to cater to the “rakyat’s “ needs. No one need to go all the way from Penang or Padang Besar for treatment of heart illnesses in Kuala Lumpur as there is a very good cardiac unit in Penang General Hospital. Similarly for heart patients from Kuching. They do not have to travel to Peninsular or Singapore ( as in the bygone days ). There is a state of art Cardiac Center in Kuching.

We have weathered the A H1N1 storm, the SARS storm, heart disease rates have come down, cancer patients survival and quality of life have improved. Palliative medicine and pain relieve for the terminally ill is now widely available. Stroke rehabilitation and orthopedic rehabilitation is so much more available. Minimally invasive surgery and even robotic surgery is being practice in Malaysia. We have a good system at the moment.

Yes, there are shortcomings. We shall next write about the shortcomings in the Malaysian Healthcare delivery system. Things could be so much better.

Although there is obviously much room for improvement, but shabas to the Ministry of Health for a job well done.

Dr Ng Swee Choon

FPMPAM