It’s now or never

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Women must get involved in the health financing debate as they are major care providers and recipients in the health care system. I was asked the other day why women should be concerned whether or not there was a national health financing scheme (NHFS). In other words, what has it got to do with women and why should they be asked to sign a petition protesting the privatization of health services? It startled me that the link between a health care delivery system in this country and the impact on women was not immediately obvious to the person asking the question.

What does it have to do with women?

The type of health care system in a country affects every citizen. Since women make up half the population in Malaysia, they will be directly affected by the health care policies of the government. Moreover, women are also major care providers, as well as care recipients. According to the Women’s Electoral Lobby, Australia Inc., a national independent political organisation to promote women’s participation in society:

“The current reality is that women are the main care providers in society. They access health services for the people they provide care for, such as their children, parents, in-laws, and later on, in many instances, their partners. Many of whom women provide care for tend to be economically vulnerable. Apart from being the main carers, women are also the main recipients of care. Women tend to use more medical services than men, partly because of their reproductive health needs, and partly because they experience more episodes of illness, suffer more economic insecurity, abuse and violence and live longer than men, using more services in old age.”

The same most probably holds true for women in Malaysia. If women are main care providers as well as care recipients in this country, it is obvious that a scheme that would determine how health care operates in the country will have a major impact on women.

A private sector bonanza?

The government is now in the process of completely revamping the way health care works in Malaysia. It argues that this is necessary because health care costs are rising and the present system can no longer cope with the health demands of the population.

The government is therefore proposing the NHFS, which means that new mechanisms will be established to collect money from Malaysians to finance health and a new body will be set up to administer it (a bit like the EPF). The scheme will operate along the lines of an insurance scheme, with everyone covered for a basic list of health conditions.

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However, there are a number of things about the scheme that are very unclear. These include how much each Malaysian will have to pay, what exactly will be covered, whether those who can afford it will get better health care at the expense of the majority of Malaysians and, related to this, whether the much-needed investment in the public sector will be provided.

Many fear that it will all amount to a private sector bonanza. It is also not clear whether the expensive consequences of certain privatisations within the health service will be tackled.

What are some issues of concern?

So why should women be concerned? Because access to and affordability of health care are as crucial to women as they are to men. We need to be very sure that any changes made to such an absolute essential service, one that is underwritten as a basic right of all citizens, properly protects the most vulnerable among us and properly includes all those it affects in the planning and implementation of such a programme.

Persistent social and cultural practices mean that, in many households, women still place their own needs last, subservient to their family. So what will happen when health care starts to cost significantly more money? Will women, allocating themselves an already disproportionate share of health care provision, increasingly forego health care because of the priority they give to their families and to other needs (food and other essentials)?

Further, the fact that it remains unclear at the moment as to exactly what the NHFS health package will actually cover is cause for concern. It is interesting to note that in private insurance schemes, reproductive health coverage can vary greatly. Under most private insurance schemes, childbirth is not covered and women tend also to pay higher premiums than men.

For example, in her paper on “Gender Differences in Private Health Insurance” (2003), Gerlinde Maurer describes how all private health insurances in Austria have gender specific differences. Women until the age of 50/55 pay about a third more for their contribution as compared to men of the same age who have entered into a health insurance contract at the same time. The industry justifies this by referring to the risk of costs for pregnancy and childbirth as well as women’s higher life expectancy.

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What can we expect?

So what can we expect from the NHFS for women? Would women have to pay extra for yearly medical consultations on reproductive health issues? Would they have to pay for preventive initiatives, such as pap smears or mammograms? Would risk adjustment for gender specific issues relating to preventive care, pregnancy, childbirth and reproductive health be included in the NHFS? Women (and men) need to know the answers.

We have seen a steady deterioration of the present public sector healthcare system, in terms of efficiency in delivery and quality of care. We have seen the drain of specialists from the public sector to the private hospitals. We have noticed the rising costs of health care, due in large part, to the privatisation of pharmaceuticals and support services. And we are aware of the relentless pressure on the public sector, which has to treat 75 per cent of all in-patients in the country.

Any revamping of our health care system needs to pay very close attention to this. Three quarters of in-patients – and that includes women! – use public sector facilities. Any further undermining of this sector will therefore have serious consequences on the availability and quality of health care to the vast majority of Malaysian women and the vast majority of Malaysian men.

In case you belong to the category of people who have private medical insurance and happily use private hospitals or clinics and wonder what the fuss is all about, just think of the vast number of Malaysians who cannot afford private hospitals, clinics or insurance. Will the facilities available to them continue to be under-funded and decline further?

So what are we asking for?

The worry is that the revamping of our health service is taking place in the context of The World Bank and other (non-Malaysian) agencies’ argument that ‘privatisation is good’ – despite all the evidence to the contrary. A private health care system does not protect the most vulnerable and marginal groups in a society (who are often the majority). Also of significant concern, the UNDP is funding the consultant who will advise our government on the NHFS. People all over the world, including health care professionals, have come together to argue that access to health care is an absolutely basic human right. The People’s Health Charter, a statement of the shared vision and goals of the global People’s Health Movement, states:

“Health is a social, economic and political issue and above all a fundamental human right. Inequality, poverty, exploitation, violence and injustice are at the root of ill health and the deaths of poor and marginalised people…. Governments have a fundamental responsibility to ensure universal access to quality health care, education and other social services according to people’s needs, not according to their ability to pay.”

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The Charter also observes:

“Health is a reflection of a society’s commitment to equity and justice. Health and human rights should prevail over economic and political concerns.”

Women as much as men need to be concerned as to exactly how all of this is to be reflected in the new NHFS. One of the key concerns regarding ‘gender’ generally is that women are too often marginalized in decision-making processes even on issues of fundamental importance to them. Given these considerations, it is not just important but crucial that the voice of women is heard in the deliberations of the NHFS.

Without this, women will continue to be major care providers and major recipients in the health care system, but will remain on the sidelines as that system is unraveled and changed. They are likely to be asked (by default) not just to cope with the inadequacies of the present system. They will also be asked to bear the brunt of increasing costs, decreasing access and more limited provision – which may well be the result of the NHFS.

Get involved – now!

We will only get a decent health care system if we come together and work for it. It doesn’t matter who we are or where we work: health is an issue that affects all of us.

And now is the time. With the discussions about the NHFS, it is now that the chance to help determine the shape of health care for ourselves, our children and future generations is upon us. If we wash our hands of involvement, if we carry on without questioning policies or debating issues or pushing for alternatives, we will only have ourselves to blame for whatever is decided, whatever is implemented. That applies equally to women as to men.

So get involved. Think about the issues, think about what is important in our health care system, think about the basic principles we want to protect. Think about the particular issues facing women and how we want to deal with them. And think about how we will contribute to the discussions – through holding talks, distributing leaflets and other materials, getting our family, friends, neighbours and colleagues involved. There is some material already on the website of the Coalition Against Health Care Privatisation.

Women hold up half the sky. That includes the health sky. So don’t stay out of this. It’s our future.

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