How does one take a position on one ‘wrong’ within a larger system of ‘wrongs’?
The ‘mother’ of all these wrongs is the concept that healthcare is just another commodity that can be traded in the marketplace.
This concept should be rejected in any civilised society because access to healthcare is not only a basic human right. It is also a transaction where there is a huge asymmetry in knowledge between the provider of the service (the doctor) and the recipient of that service (the patient).
More importantly, a decent healthcare system based on solidarity among all the people and which is independent of the patient’s capacity to pay does something undefinable to our sense of ourselves as a nation. It makes us feel we are a people, enhances a sense of belonging, and contributes to building a more harmonious society.
However, mistakes were made. Private practice was allowed in Malaya even before independence and general practitioners (GPs) set up clinics all over the country. They did provide a useful service to the community by making healthcare more accessible. They also earned handsomely, and the GPs were among the wealthiest 10% of the population then.
That began to change in the 1980s after then Prime Minister Dr Mahathir Mohamad encouraged the setting up of private, for-profit hospitals. These hospitals also provided outpatient care for any patient who decided to walk in.
The primary care system that was the practice in Malaysia before 1980, where a patient had to see a GP or a doctor in the government outpatient department before getting referred to the specialist (at that time almost entirely in government service) was supplanted by direct self-referral to private specialists.
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This trend is accelerating with the proliferation of private hospitals, and the income of the 8,000-odd GP clinics in the country has taken a hit.
GPs also used to have contracts with factories, banks and government agencies to be listed as one of the doctors on the medical panel of these institutions, which would pay the doctor a pre-negotiated rate for each patient seen by them.
The invasion of ‘third-party administrators’ into this space witnessed many employers switching to these administrators as they offered lower rates. These third-party administrators, which are large corporations with financial heft, now have the market power to force GPs to accept very low rates on a ‘take-it-or-leave-it’ basis.
As a result of these changes, GPs now make low five-figure monthly incomes or even only high four-figure ones, about five to 10-fold less than private hospital specialists. They now rank in the second or even third decile from the top, of the country’s income pyramid whereas they were previously in the top decile before. And they feel ‘short-changed’!
But really, how much should professionals earn or be paid? Sure, they had to work hard to acquire their knowledge and skills, but that knowledge was built on the contribution of many generations of men and women. That knowledge was not developed de-novo by these professionals themselves. They have equipped themselves with the collective intellectual and scientific inheritance of humankind to provide us their medical expertise.
The Socialist Party of Malaysia (PSM) is proposing that the top income in a society should not be more than 10 times the living wage, which in Malaysia today is set at about RM3,200 per month. Anything above 10 times that, should be seen as misuse of the skills and knowledge entrusted to the professional to administer the collective wisdom or knowledge of humankind.
Coming back to the GP’s march in Putrajaya, the straw that broke the camel’s back is the impending enforcement of the requirement to display the prices of medicines.
As the medical fees schedule has not been revised for the past 33 years, many GPs augment their income by hiking up the prices of the medicines they prescribe. Quite a number of GPs may be subsidising medicines for their poorer patients but charging their affluent patients more for the same medicines. The enforcement of price display of medicines would make this cross-subsidisation difficult and impede income augmentation.
Also, many GPs only label medicines by writing the symptom they are meant for – “fever”, “cough”, “headache” or “antibiotic” – without specifying the pharmacological name of the medicines supplied. This is purely a business strategy to prevent patients from buying further doses of the same medicines from the pharmacists (many of whom sell prescription items without a prescription).
It is difficult to blame any party here – for we, as a society, have encouraged practitioners (doctors and pharmacists) to treat healthcare as a commodity. It would be hypocritical of us now to take the high moral ground and criticise them when they act as business people.
But doctors should bear in mind that their stature in society is diminishing. Doctors are still respected, but an increasing number of people are starting to see doctors as selfish profiteers. This is reflected in the increasing number of litigations involving doctors.
Apart from fighting for better remuneration for doctors, the medical profession should speak up for the ordinary people who experience crowded government facilities, long waiting times, soaring medical costs in the private sector and financial distress because of the malfunctioning healthcare system.
Doctors should support the demands of the People’s Health Coalition which are:
- a 10-year moratorium on new private hospitals: This is to stem the massive out-migration of specialists from government hospitals to the private sector.
- initiation of a capitation scheme that allocates GPs diabetic and hypertensive patients to follow-up on, but at government expense, the medicines and investigations being borne by the Ministry of Health and the doctors’ professional fee covered by the capitation payment
- increase of the MoH budget to 5% of gross development product (GDP) over the next five years: That would enable the MoH to finance the above initiatives – the first requires funds to employ more specialists in government and expansion of hospital facilities so that the specialists can treat more patients.
The support of pro-people proposals for healthcare reform would help rehabilitate the image of doctors in the public’s eye.
We sympathise with the “Madani” (compassionate) government, as they have inherited a difficult situation arising from wrong policy decisions in the past.
But it is sad to see that the Madani government is still intent on promoting the “Rakan KKM” (Friends of the MoH) scheme and launching a new voluntary insurance policy. These are steps that further commodify healthcare and legitimise profiteering from it.
As we mentioned at the outset, treating healthcare provision as just another commodity to be traded is the root of many of the problems we are now facing. Resolution of these problems will have to be phased, and will take time. The genie, once out of the bottle, is difficult to be enticed back into it! But further commodifying healthcare is definitely a step in the wrong direction!
The Madani government should step back and take a hard look at the distribution of income in Malaysia at present. Only 29% of total national income goes to 97% of the working population, while 55% accrues to the corporations and the richest individuals (who make up only 3% of the working population).
The government should seriously study how a portion of the 55% currently being appropriated by the economic elite can be channelled to government coffers as taxes and used to improve the healthcare system.
- Tegakkan maruah serta kualiti kehidupan rakyat
- Galakkan pembangunan saksama, lestari serta tangani krisis alam sekitar
- Raikan kerencaman dan keterangkuman
- Selamatkan demokrasi dan angkatkan keluhuran undang-undang
- Lawan rasuah dan kronisme
The article thoroughly analyzes the crisis. Requiring clinics to display medicine prices is a classic case of treating symptoms, not the disease. M’sia is also the first globally to mandate this. However, I commend the EU/US for publicly accessible price list that is meant as recommendation/guide on their gov website.
Addressing the article: who actually profits the most in private healthcare?
A) Servicemen (physicians, nurses, pharmacists)
B) TPAs
C) corporate groups owning pharma and hospital networks?
It is a shame that solving healthcare cost/quality by directing fees (e.g., consultation charges) to professionals are ignored in a top-down decisions such as price display mandate that imo, do not address root cause of the issue.
The ‘nobel’ professions in security, teaching and healthcare have not usually been commodified. However, when we take human progress into consideration, especially technological, all the above ‘noble’ professions could and arguably will be replaced in a decade. Labour intensive jobs may be totally supplanted with technology. In that utopian sense, energy production would be the only cost factor and wide income disparities may become non existent.Why this may be important here,is,instead of focusing on level playing fields in healthcare,we should be working hard to attain a civilizational paradigm shift across the board with investments in renewable energy, high tech like AI powered humanoids thus making menial, repetitive jobs obsolete.IMHO
Way to revive our health care back to service people…. Good read. Hope it materialize