Proposed health insurance scheme: Primum non nocere (‘First, to do no harm’)

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Patients waiting even during the lunch hour at the BM General Hospital: the needs of local patients are often overlooked

If this goes ahead, the public healthcare system will get even more run down and the public will be saddled with high insurance payments, warns Jeyakumar Devaraj.

The statements emanating from the health minister and his deputy these past two months regarding health insurance are making several health activists extremely anxious.

Although clear details about the proposed health insurance have not been released by the Ministry of Health, information filtering through the grapevine suggests that the government is thinking of taking out insurance policies for the bottom 40% of families (B40) that will entitle these families to treatment worth RM10,000 per year at private hospitals.

There are three million B40 families. Assuming a fourth of these families use this insurance in a year, the total payout would be RM7.5bn (0.75 million x RM10,000) for a year .

Such a policy would be quite popular, initially at least.

The B40 families would be happy to have the option of getting some treatment in the private hospitals without having to make an initial contribution to the scheme.

The private hospitals would be more than delighted! They would get their marketing teams to advertise treatment plans to encourage the B40 families to use their insurance for screening, investigation and treatment that these families might not really need.

And the insurance companies would be ecstatic if they too could get a bite at the cherry.

So if everyone is going to be happy, why are people like me unhappy with this proposal?

It is because we see parallels to what happened in the late 1980s. At that time Prime Minister Dr Mahathir Mohamad liberalised the healthcare system by allowing for-profit private hospitals to be set up. Prior to that only non-profit private hospitals were allowed in Malaysia.

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The argument that Mahathir used then was that richer people should be encouraged to pay for treatment at private hospitals so that government expenditure on healthcare could be focused on the poorer half of society. Mahathir cited the case of rich businessmen coming to the government hospital in their Mercedes to get highly subsidised treatment. At that time, Mahathir’s arguments seemed reasonable to many Malaysians.

Only now can we appreciate how much that policy damaged our public healthcare system. Presently, only 10% of the specialist doctors with more than 10 years’ experience after specialisation remain in government service. About 90% of the experienced specialists are in the private sector, which caters for 25% of the in-patients in the country. This leaves 10% of the nation’s experienced specialists to handle the 75% of inpatients admitted to government hospitals.

Is it any surprise then that there are delays in getting specialist treatment in government hospitals or that mistakes occur because there are not enough specialists to adequately supervise the younger doctors?

A two-tier system of medical care has evolved in Malaysia, where the 25% who can pay, get prompt state-of-the-art treatment in private hospitals. (Sometimes they get more than they really need.) The remaining 75% who depend on government hospitals encounter delays, long waiting lists, difficulty in accessing the senior specialists in government service and the risk of serious complications because of sub-optimal care. This is the direct result of the policy change that Mahathir introduced.

The scheme being proposed by the health minister and his deputy will exacerbate some of the problems that the government healthcare system is facing. The boost in demand for private healthcare by RM7.5bn a year would accelerate the exodus of specialist doctors from the government sector.

This in turn will cause the quality of services in the government hospitals to deteriorate even further, exacerbating the crisis of confidence in government hospitals, which in turn will force even the B40 to top up the insurance that the government has initiated for them. This is because the RM10,000 they are to be given will not be enough to cover all the health needs of a family if a serious illness strikes.

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Over time, the public healthcare system will get even more run down and the Malaysian public will be saddled with high health insurance payments. In the medium term – 10 to 15 years – the proposed insurance scheme will seriously burden the very people (the B40) who are to be the recipients of this populist hand
out!

The problem with this insurance proposal, like the liberalisation policy Mahathir introduced 30 years ago, is that it does not consider the health sector holistically. Both proposals fail to appreciate that changes in the private sector will impinge on the public health sector in several ways.

We have to seek out the potential impact of such changes and avoid making decisions that might undermine the public healthcare system of our country. This is what the health minister should be most careful about, for it is his mandate to safeguard and further develop the public healthcare system. As the Latin saying goes, “Primum non nocere,” which means “first, to do no harm”.

I would like to appeal to the minister to make public the details of the insurance policy that the ministry is thinking of introducing, so that interested parties and individuals can debate it and give feedback.

Including it as a proposal in the 2019 Budget without prior consultation with “stakeholders” would be doing a great disservice to the Malaysian public as the issue would then be debated in a highly polarised arena, where giving in on a particular issue would be trumpeted as victory by the opposition and for that reason, resisted tooth and nail by government parliamentarians. It is not the venue where a major inflection point in our healthcare policy can be dispassionately and thoroughly debated.

We hold the Malaysian public health system in high regard. We feel that its intentions are noble, and that it is among the more humane and caring aspects of Malaysian society. As such, it should be protected and strengthened. Our prescriptions for improving healthcare in Malaysia include the following key points:

  • Increase the federal health budget by 15% every year till it reaches 4% of gross development product (GDP). It is currently only 2.1% of GDP (ie RM26bn out of a GDP of RM1,273bn). In his first press conference after being appointed, the health minister did say that he would seek a budget equivalent to 3.5% of GDP (The Star Online, 22 May 2018). It would be great if he could follow up on this idea.
  • Declare a moratorium on the further expansion of private hospitals. Allow the private hospitals that exist to continue, but do not allow them to expand their bed capacity or to set up new branches. Do not approve new private hospitals for now. That will partially staunch the hemorrhaging of specialists from the government sector.
  • Create a separate service commission for government healthcare workers and adopt the pay scale that the National Heart Institute (IJN) uses so that government service is more attractive for healthcare personnel. Also consider the provision of three-month sabbaticals for specialists every five years of service in government so that they can go abroad and pick up new skills.
  • Carry out a forensic audit of how medicines, other goods and services are being bought or supplied through third party intermediates. Many of us feel that a significant portion of the health budget is being siphoned off to private pockets through oversized contracts.
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All Malaysians who are concerned about social justice and want to build solidarity among our people should work towards the preservation (and strengthening) of a public healthcare system that will provide quality services to all, irrespective of their socio-economic status, so that ordinary Malaysians will not be forced to procure additional protection in the form of private health insurance. Defending our public healthcare system is a cause worthy of our time!

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