First steps to health reform
IN December 2017, the World Bank and World Health Organization jointly published a report on universal healthcare coverage and financing titled “Tracking universal health coverage: 2017 Global Monitoring Report”.
This report examines the worldwide performance of health systems in two major areas:
1. Universal health coverage (UHC), defined as the ability of people to get essential healthcare when they need it; and
2. Catastrophic healthcare spending, defined as out-of-pocket expenditures (OOP) exceeding thresholds of more than 10% to 25% of household total income or consumption.
These two factors combined measure the ability of people to access quality essential healthcare without risking financial hardship.
Malaysia scored a UHC index of 70 out of 100 points, ranking fifth out of 48 Asian countries and just behind Singapore, Brunei, Japan, Korea (>80), China (76) and Vietnam (71).
On the financial risk front, Malaysia was one of the best in the world, scoring 0.74 and 0.04 at the 10% and 25% threshold, which was even better than the UK (1.64; 0.48) and US (4.77; 0.78). These were achieved through a very low health expenditure average of 4.55% of GDP or 9.44% of the total government budget for 2018.
Total healthcare expenditure in Malaysia in 2016 was RM52.6bil, of which government contribution was 51.47%, private OOP expenditure 38.9% and private insurance 8%.
Data showed a rapid rise of OOP from RM2.93bil in 1997 to RM17.44bil in 2013, an average rise of nearly 29% per year.
Similarly, the private insurance sector recorded an increase of nearly 52% annually over the corresponding period.
These are worrisome trends, reflecting on public preference for the convenience of the private sector.
When OOP or private insurance is used as a complementary measure to access better amenities, doctor selection and continuity of care, it serves a “top-up” purpose for additional services over the already available public healthcare. It allows the public the liberty of choice and timeliness of their access to health services.
When people leave the public medical service altogether and use the OOP as substitutive care, it increases the health gap and inequality in the level of care, such that nearly 50% of the total health payment covers less than 20% of the population.
Further, OOP and private insurance are highly inefficient and expensive. A large part of the escalating cost of medical care can be ascribed to “health systems where a hands-off or laissez-faire approach to governance has allowed unregulated commercialisation of health to flourish”, according to Margaret Chan, for- mer WHO director-general, to the detriment of overall care.
Another problem is the inherent risk of economic downturns, which directly burden people’s health and cause serious repercussions in an OOP-dominant environment.
The seeds of increasing dichotomy in private versus public healthcare provision were sowed upon the implementation of laws on private healthcare.
Health Ministry (MOH) policies effectively created a situation where medical professionals were severely de-professionalised and marginalised. The vacuum was filled by the uncontrolled proliferation of private medical and allied healthcare schools, hospitals, insurers, pharmaceutical and equipment corporations, administrators and agents all aiming for larger shares of the limited healthcare resources.
This resulted in a large number of low-quality doctors and allied healthcare professionals, ever increasing insurance premium and retaliatory behaviour of the medical providers.
Our present system of healthcare financing is thus highly unstable and unsustainable.
While I would like to congratulate Dr Dzukefly Ahmad on his appointment as Health Minister, this unenviable job of “trying to cover 10 barrels with five lids” is no easy task. This is especially so when the other stakeholders are beyond the legal mandate of the MOH and the current state of our fiscal policy is unlikely to increase investment in healthcare within the next five years.
The priority of the ministry in the near term is likely to be in two domains:
1. Administrative reform and reallocation of its priorities, which entails a clear definition of the ministry’s public responsibilities, elimination of redundant services, reduction in wastage, clear definition of goals, and reallocation of resources. New mechanisms of feedback and an internal audit watchdog should be set up to “make every sen count”.
These targets were all stated in successive MOH strategic plans but never really carried out.
2. Attaining meaningful public-private cooperation with all stakeholders. This is far more difficult as it involves fundamental change of concept in all parties. The current state of rivalry among the stakeholders, the MOH included, is unhealthy and detrimental to public interest.
Free market competition in healthcare is incompatible with interest of the public and will eventually lead to the destruction of the system itself.
The key is shared responsibility and collaboration for the good of society. An affordable private system will reduce the burden of the ministry tremendously.