THE CURRENT MALAYSIAN HEALTHCARE SYSTEM : STRENGTHS AND WEAKNESSES.

This piece was submitted to the Star Helath editor, for publication this weekend. I hope that it will come to print. As usual, I also published in the blog. It is my attempt to let the public become more aware of the healthcare system, and begin to participate in improving it. Do not forget, that a general election is due soon ( the signs are there ) and your vote goes a long way to influencing healthcare reforms.

OUR CURRENT MALAYSIAN HEALTHCARE SYSTEM – STRENGTHS AND WEAKNESSES


Introduction

The Malaysian Healthcare system, is ever improving. Once upon a time, we had to refer many of our patients overseas for bypass graft surgery, valve replacements, angiograms, cranial surgery, spinal surgery and even second opinions for some medical conditions. Nowadays we can do all of the above here, and even more, including minimally invasive surgery ( of all types ), liver transplantation, cardiac transplantation, robotic surgery and many other sophisticated treatment modalities some of which even I may not be aware of. Yes, some still choose to go overseas for treatment, but that is their personal choice. They have the money, they have the means, it is their health, so it is their choice. But, the Malaysian Healthcare system, though not perfect, have come along way, since 1957.

THE WEAKNESSES.

In a consumer survey conducted in 2008, patient satisfaction level decreased from 94.4% in 2004 to 89% in 2008. The rate of patient expectations being met was 38.5% in 2008. On the one hand, 89% of patients satisfied with MOH hospitals is not bad. On the other hand 38.5% expectation being met level is too low.

Undoubtedly, there are problems with our healthcare system, primary of which is :

1. The long waiting list.
Whenever I chat with friends at social functions about what ails the public healthcare system in Malaysia, the most frequent comment is the long waiting list. They are all very unhappy with waiting. Only once did I find someone ( retired government servant ) who was full of praise for the public hospital, in particular the Selayang Hospital. The majority are very unhappy with the waiting to get an appointment to see the consultant, the waiting at the outpatient department on the day of the appointment, the waiting list for elective surgery and in some instances, “ urgent “ surgery. Sometimes scheduled surgery are cancelled for very many reasons ranging from “ consultants not being available “ to no ICU ( intensive care unit ) bed or OT ( operation theatre ) time. Sometimes the reason is as flimsy as blood test results or ECG ( electrocardiograph ) not being available for review. There have also been instances of surgery being cancelled because senior consultants were called away “ on government duties “ at short notice and the juniors dare not proceed. Some waiting list issues are just due to poor human resource organization. The pilot project in some public hospitals to allow doctors in government service some private practice rights also did not seem to help much in the “ brain drain “ problem. Perhaps a re-think is necessary.

I will classify this weakness as an organizational, human resource and management problem, nothing that an increase in healthcare budget, a large dose of morale booster and working closer with the private sector doctors, cannot solve. If the Ministry of Health ( MOH ) is agreeable, many private doctors would be more then happy to devote one or two days a week, to help shorten the medical and surgical waiting list. I remember when the private doctors offered to help years ago, in the 90s, it was rejected as some in the MOH administration. In the atmosphere of the 90’s, the private sector was seen as a rival and threat to MOH. Now that we are in the 21st Century, perhaps it is time to breakdown the artificial wall dividing the public and private sector and let us all work together for the betterment of healthcare in Malaysia. An increase in healthcare budget, maybe to 6% of GDP, will certainly go along way to helping the waiting list issue.

2. Trained, competent doctors, nurses and paramedicals

I have often been told that besides waiting, the other biggest weakness with the public hospitals is the level of competence of the doctors, nurses and paramedicals. Patients wait for their turn to be seen by a medical officer or house-officer who do not even care to take a proper history or do a proper medical examination. In a minute or so, they are “shooed “ out of the consult room with a prescription. Medical officers, probably because of inadequate exposure, cannot set IV drips, set central venous lines or perform arterial cannulation safely.
In an earlier article, I have alluded to the fact that we are mass producing doctors, as medical education is a business and also politically appealing. With mass production, there are inadequate supervision of junior doctors leading to poorly trained house officers and. medical officers. In 2009, there are 3,139 fresh medical graduates going for housemen training. In 2008, there are 409 specialist in MOH hospitals, so each specialist will have to train 8 house officers, plus his own work and responsibilities.
Similarly with nurses and para medics. They are also being mass produced and mainly class room exposed. They learned whatever they can through books, charts and computer simulation in the classroom. They have minimal exposure to actual bedside patient care in their training. For very many reasons, the senior ones seek their fortunes elsewhere, leaving the junior ones to help the junior ones.

As I see it, this quality problem is strictly an administrative problem, maybe with some political over-tone. By the stroke of the pen, we can cut down the number of medical schools in the country ( there are 22 at the moment, for a population of 27million ). That will allow more to have better supervision and training by their seniors. What it means is that we go for quality and not quantity. Healthcare has to do with sickness, live and death. We should not compromise here. I can only plea, on behalf of the patients that healthcare should not be taken as a political game. Doctors must all be adequate trained to meet the level of responsibility that they are entrusted with. A half-baked doctor will harm patients.
Similarly, nurses must also be adequately trained. To begin with, nursing enrollment must have a higher entry criteria, if possible graduates only. Of course, the pay must be commensurate with a graduates pay. Each nursing school must have a hospital attached for their nurses to train, and the nursing board will have to be strengthened.

3. Overemphasis on curative care

I suppose, being a developing country, going towards 2020, we are still looking after our bodies only when it falls sick and malfunctions. The cliché is stale “ Prevention is better then cure “. But it is true. If only all of us will look after ourselves, there will be so much less sufferings and so much less expenditure. We abuse our body. We eat too much, especially carbohydrates and fats. The food advertisement is so appealing. We promote food as a form of tourist attraction. “ Bah Kut Teh “, “Teh Tarik “, “ Nasi Lemak “ . We refuse to exercise. We take the lift up 1 floor, or even worse, down 1 floor. We do not go for regular checkups until something is wrong with the body, or until we collapse. I am sure you all know what I mean.
The MOH should put more emphasis on preventive care. For starters, all males above 40yrs and all females above 50years should go and see his favourate GP for a full medical checkup. For the younger females, they should go for their annual pap smear and breast examinations. Even if these check ups have to be funded by SOCSO, so be it. It is still cost savings in the long run. All adults who do not fall sick or claim on medical bills should be given a tax rebate. It pays to stay healthy. All who do not claim on their health insurance, should get an insurance “ no claim bonus “ not unlike the motor car insurance “ NCB “. The “ Tak Nak “ campaign to stop smoking, must be more seriously enforced. One day, while in a no smoking air-con restaurant, a patron was smoking. I went to alert the restaurant owner. He could not care less. He thought that I was weird. The “ eat less sugar” and “ eat less salt” campaign must be instituted. Those who lose weight should be rewarded. Everytime a dengue endemic area becomes dengue free, that area should be rewarded with incentives and recognized with a plaque or something. Companies who harbour dengue larvae should be severely punished as an example, even if they are government institutions or government linked companies. In all these, education is important. We must educate our public on what is good health and how to maintain good health.

4. Lack of control of charges in private hospitals.

The most popular complaint of anyone getting treatment in a private hospital, is COST. As the country gets more affluent, more and more private hospitals are set up. Some private hospitals are set up as no frills hospitals where the trimmings of luxury are few and it is basically catering to the lower social economic group, to give affordable private healthcare. Lets call this group the 3 star hospitals. Then there are those who boast of their marble flooring and overhanging chandeliers and golden door knobs. They compete with each other, to be more luxurious than the next. These “ boutique “ hospitals or 6-7star hospitals, charge a lot for their services and their mark-ups can be 100-200 percent on some items. We have nothing against “ boutique hospitals “, but it would be very unfair to include the cost of care there into the healthcare budget as private healthcare expenditure. Afterall, healthcare is for making people well to return back to society, not to let them be pampered with luxury at our expense. There is no end to cost of luxuries and pampering all done to boost the bottomline.
One easy way cut the cost of private healthcare is to regulate the cost of treatment in private hospitals. Just as you can regulate doctors’ fees ( although you should not ), you should also regulate cost of staying in hospital to get well. It is possible to detail how much a CT scan should cost?, how much an endoscopy should cost? How much an angiogram should cost? How much a normal delivery should cost? How much a “ lap chole” should cost? It is possible. Then the health expenditure for the private sector will reflect cost of care, not cost of luxury and profit margin
I have always wondered whether it was possible for the government to gather a price list for cost of care ( unsubsidized by the government ) to let the public know the true cost of medical treatment. Another way, I suppose is to give tax incentives to 3-4 star hospitals who give affordable healthcare without the frills to encourage more of them. Let the hospital with the frills pay more taxes, and let them attract the tourist who come for treatment. Let them compete and earn foreign exchange, while our locals have good and relatively affordable healthcare. That will save healthcare dollar.
Recently, it was mentioned to me that some private medical centers are charging “ admin fees “ as a form of kick-back from doctors. The implication would be that doctors who give “ admin fees or kick-backs” to the administration would get more patients, so that in some way, against the spirit of good medical practice, medical care is being decided by kickbacks. This is bad.
I belief if there is a political will, the cost of healthcare in private hospitals can be easily controlled. Afterall, it does not escape notice that almost all the private hospitals in the country belong to government linked companies ( GLC ). A stroke of the pen, is all that is required.

5. Lack of control of high tech medical equipment.
At a simple count, there are 15-20 CT scan machines in the Klang Valley, a population of about 3 million people. The owners of the machines ( usually doctors with a business partner, or medical centers, openly advertise their machines to the innocent public even offering discount packages. Some of these packages are even tied up with credit card companies so that the patient does not have to pay any cash upfront ( so slick ). CT scans are done left, right and center for any trivial excuse. Firstly the scans are costly. Secondly they are potentially hazardous ( the radiation from a CT scan of heart arteries may be the equivalent of 500 chest X-rays ). Thirdly, they may not be as accurate as what it is touted to be. Scans are not cheap. They can cost a few thousand dollars each. Depending on the indication, it may not help in the care of the patient. They may just add to the cost of healthcare. Again, the proliferation of these machines can easily be controlled by the authorities, if the wish to control healthcare cost. Maybe the authorities should also consider that doctors who refer patients for scans should have no financial interest in the scan companies, to avoid a conflict of interest situation.

There are many more weaknesses to write about, but these are the main ones. However, the situation is not all bad. There are strengths too.

THE STRENGTHS

1. Equitable access to healthcare for all.

As I have said previously, one of the greatest strengths in our present healthcare system, which I tell all my overseas consultants is the fact that all who come to Malaysia, can be guaranteed access to healthcare should the need arise. There is no need to wait for insurance approval before treatment, no need to fill in numerous forms and phone calls. Yes, there maybe a bit of waiting, especially during peak periods, but you will be attended to. Very few countries can boast of this.
Should you need tertiary care, arrangements will be made for you. Yes, there maybe some waiting, but you will be attended to. All the way to specialist consultants and sophisticated surgery, including liver transplantation and cardiac transplantation. All for minimal fee or no fee.
Of course, in the private, waiting period is minimal and medical care is prompt, all for a fee.

2. No interference to medical practice.

The other strength that I can see is that medical consultants can do his best for the patient without being controlled by third party payers. The doctor sees the patient, orders ( and it gets done ) the relevant investigations, and with the proper diagnosis, carry out the proper therapy. In some other country where there is social health insurance, that is not possible. Every test needs clearance from the third party payer and every treatment, needs approval, sometimes, the approval is by nurses who advises insurance companies. I was once told by a neuro-surgeon that he wanted to remove a brain tumour which was deeply seated in the cranial vault. He filled in the insurance form, and proposed a two prong approach to removed the tumour safely. The insurance manager ( a nurse ) rang him the day before the surgery and asked why he was doing it through two incisions? Was he trying to earn more by doing two incisions? That’s the problem with third party payers. They often try and interfere with medical decisions. We will write more on this in the future segments.

In our current system, the doctor does what is best for the patient. The policing is by the Malaysian Medical Council. Yes, there are some doctors who also abuse the system of trust. But these are fewer and can be controlled.

3. Patient can consult whoever they trust to make them well and buy medication from whoever they trust.

We are really blessed that the present system allows a patient to choose whichever doctor of his/her choice. Trust is very important in medical therapy. That trust should not be simply broken. We each have our family doctor for primary care, our family pediatrician, our family surgeon etc.. They have been with the family for decades and so there is a certain bond and trust.
Also, the doctor may or may not chose to dispense. There are some doctors who prescribe but do not dispense ( you buy your medicine from the pharmacy ). Some doctors prescribe and also dispense. There are pros and con for each. Some patients, because of their trust with the doctors would rather buy the medications from the doctor, and have the doctor explain to them the effects and side effects. Because of their longstanding relationship and trust, they would more likely take their medication and get well. In some healthcare system, you have to buy the medication from a pharmacy away from your comfort zone and rely on some stranger to explain things to you. Sometimes the pharmacy may not have the right stock of drugs and pharmacies have been known to substitute ( generic substitution ) the prescribe drug with what they think is the generic equivalent. I must say that that is not good. It may be wiser to allow patients to exercise the choice of who they wish to dispense the medications to them
This is another strong point of our present system.

4. Cost effective use of healthcare funds.

As I had illustrated in the earlier article, for 3.6% of GPD and 7% of total government expenditure, we have actually used our healthcare dollar very wisely, so far. The health outcome data that we were able to achieve speaks of a good health standard in the country.

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

Conclusion

As with all public programs, there are always differing points of view, shortcomings and strengths. By discussion and brain-storming, we hope to develop a better system. Most of the shortcomings as outline can be easily corrected with some administrative adjustments and also some increase in healthcare budget. I suspect that with a complete transformation of the present system, the cost incurred would be so much more.
With the next article, we shall review healthcare by health insurance companies.