An overview of Malaysia’s healthcare system. A miracle or a disaster?

An overview of Malaysia’s healthcare system. A miracle or a disaster?

Part II of III – Healthcare Economics and How it Affects Us

Statistics from the World Bank and the Harvard Team in 1999 revealed that in 1996, the total expenditure in healthcare services (public and private sector) amounted to only 2.9% of the Malaysia’s GDP of which 1.4% was in the public sector and 1.5% was spent in the private sector. At first glance these statistics may appear to demonstrate that the decentralisation of healthcare services was successful, but upon closer investigation it clearly shows that it the proportion of expenditure is hugely disproportionate relative to the population size these distinct sectors service.

Pharmabiz (an online news service) in a report in 2004 estimated that the private sector in Malaysia only accounted for 20% of the countries hospital beds, yet it employed almost 54% of the doctors in Malaysia. Marzolf (1996), also observed a similar trend in the mid-1990’s, estimated that 75% of beds in the country were provided by government services, yet it only employed 45% of all doctors in the country.

Therefore, self-admittedly by taking a large leap of faith, I assume that it is fair to conclude that almost an equal share of Malaysia’s GDP (if not more spent in the private sector) was spent on approximately 20-25% of all patients in Malaysia, who sought services from private healthcare providers and on 75-80% of all patients in Malaysia, who sought services from the public sector. Clearly no one can deny the huge disparity that exists between private and public healthcare services. It is no surprise that services provided by the private sector in most fields are almost unanimously superior compared to service provided by the public sector. But, surely the huge disparity in quality, standards, workforce and expertise portrays the government’s insensitivity towards the masses and their inept ability to exert control over maintaining the balance between healthcare provisions supplied by the public sector vs. the private sector.

However is it fair to expect taxpayers and consumers of the public healthcare service to accept substandard care from the public services?

In March 2006, the Ministry of Health started a pilot project in Selayang and Putrajaya government hospitals, where these centres will remain open after normal working hours to provide private specialist care for full-paying patients. This project was designed to last for 6 months with the aims to reduce waiting lists for specialist care, with the hope that patients who can afford this option will choose to pay and avoid the long queues. At the end of the 6 months, it will be decided that if deemed successful this project would be expanded to other government hospitals as well. This ‘full-paying patient’ scheme have received mixed responses from various parties. The Coalition Against Health Care Privatisation (GMPKK) which is made up of various NGO’s, political parties and trade unions is amongst the key opposition of this project. Their arguments revolve around the fact that only 30% of specialists in Malaysia are employed by the public healthcare sector and have to deal with about 70% of the patient load in Malaysia. With these specialists burdened with a massive patient load, these extra hours for cash incentives will only over-work them and may affect the quality of care than the non-paying patients will receive. Also, patients may be threatened, pressured or even manipulated into paying for their treatment for ‘better’ care by specialists.

Prior to the introduction of the project, Deputy Health Minister Datuk Dr Abdul Latiff Ahmad said it was introduced to prevent government hospital facilities from being abused by people in higher income groups:

“For example, a patient who can well afford it, only has to pay RM3,000 for surgery as has been set now in government hospitals whereas he is capable of paying up to RM15,000...This will affect the chances of lower income groups from obtaining similar surgery or treatment.”

What I fail to understand is that the public healthcare sector which is funded by the government should cater for all income groups indiscriminately; simply because all income groups are taxed accordingly. Although the government has insisted that this project is only a pilot project, to determine its feasibility, it demonstrates the governments’ inability to continue its funding of its patients requiring specialist care and also insensitivity towards tax payers. This full-paying patient scheme can only be perceived as a system that imposes a ‘double-tax’ on patients who seek quality care from the public healthcare system. However, the project should have ended in September 2006, but what does the verdict say on the feasibility of the ‘full-paying patient scheme’?

As of now, the percentage of GDP spent by Malaysia on healthcare services still stands well below the 5% of GDP recommendation by WHO. Mafauzy M. in an editorial in January 2000 stated that Malaysia’s expenditure in public healthcare services in 1994 was about 2% of the GDP, compared to the US who spent 14% of their GDP and the G-7 who spent between 5-8% of their GDP. Meanwhile Phamabiz projections estimate that Malaysia’s healthcare expenditure may eventually reach 6% of GDP only by the year 2020

N.B I am obliged to inform readers that the statistics from Mafauzy M.’s editorial and Phamabiz did not cite their sources and therefore I caution readers that the inclusion of these statistics in my text is purely to triangulate the various sources in hope to gain a differing perspectives of our healthcare system.

Although these projections seems reasonable, we must understand that in this space of 15 years there will be tremendous changes within the healthcare needs of the Malaysian population, mainly due to changes in the population demographics as a higher proportion of our population will be older, evolution of diseases and medical advances, just to name a few. Furthermore, by consistently spending less than recommended, we can almost be certain that the Malaysian healthcare system will soon fall much further behind other developed countries (who is consistently spending a higher percentage of their GDP) and over this space of 15 years, I can only foresee this gap multiplying itself. By year 2020, which has been earmarked as the time to announce Malaysia as a developed country, I predict our healthcare system to be nowhere closer to one worthy of a developed country.

According to the Human Development Report in 2006 prepared by the United Nations Development Programme (UNDP), Malaysia was ranked 61/177 based on the Human Development Index which takes into account factors involving life expectancy, literacy and standard of living. The report revealed that in 2003 Malaysia also spent 3.8% of the GDP for healthcare services of which 2.2% was allocated to public health expenditure which ranked Malaysia at 124/175 based on percentage of GDP on public health expenditure. Private health expenditure amounted to 1.6% of GDP which ranked Malaysia at 123/175. Therefore I found it surprising that Malaysia ranked 75/175 in terms of total health expenditure (public and private sectors) per capita amounting to US$374 (adjusted for purchasing power parity).

N.B. Health expenditure per capita was adjusted for purchasing power parity (PPP) in US$ to allow a more valid comparison between countries and does not represent the absolute amount of expenditure per capita in RM.

However, there are signs of improvement in recent times. Although during the 1990-2004 period there were only 70 physicians per 100,000 population in Malaysia; ranking Malaysia at 101/175 in the UNDP 2006 Report, trends show that the ratio has improved greatly compared to those released by the World Bank, 1999 that show there were only 14 physicians per 100, 000 people in 1960 and 44 physicians per 100, 000 people in 1995; more than a 60% increase presently, in ratio of physicians to per 100, 000 people since 1995. Another crucial statistic that strengthens the claims of signs of an improving healthcare delivery is the population’s life expectancy since birth. The World Bank, 1999 showed that life expectancy in Malaysia since birth at 1962 and 1997 stood at 55.8 years and 71.6 years respectively. The UNDP 2006 Reports measured Malaysia’s life expectancy since birth at a hugely improved 73.4 years, ranking Malaysia at 58/175!

Ramesh and Holliday, 2001 in their article titled, ‘Healthcare Miracle: East and Southeast Asia’ applauded Malaysia (amongst Hong Kong and Singapore) for having achieved a remarkable health care status are a modest cost. The paper argued that the financing of the healthcare system is not the key factor for the performance, but rather concentrating the provisions on in-patient care, an expensive component but of considerable efficiency. Whereas on the whole, there was less importance placed on out-patient care; a feature common to the three healthcare system discussed. However, the paper was exact in recognizing its limitations and acknowledging that the improved markers of health status in Malaysia are not solely attributed to the contributions of the healthcare delivery system. On a separate note, I also believe it is worthy of mention that the paper also recognize and warn that with increasing efforts to privatisation, it will increase inflation and the cost of healthcare to the society as a whole, as discussed above earlier. In summary, Ramesh and Holliday marvelled at the manner how Malaysia continued to demonstrate improved health status markers despite contributing well below the 5% of GDP recommended by WHO.

The governments’ stand and approach to the future of the healthcare system in Malaysia also shows greater intent towards improving the healthcare system than previously. Mafauzy M. claims that the government allocates approximately 5% of the national budget to the Ministry of Health amounting to approximately RM2.6 billion, which I presume was true at the time her editorial was published. However, the Federal Government Budget in 2006 through the Operating expenditure Estimates by the Treasury Department of the Ministry of Finance, revealed that approximately RM7.4 billion was allocated to the Ministry of Health, which amounts to almost 7.3% of the entire budget. Of which, RM1.3 billion is allocated purely for development expenditure amongst which RM85 million to complete construction of hospitals in Alor Setar and Cameron Highlands, RM 229 million for building and upgrading clinics nationwide, and RM 131 million for upgrading hospital laboratories and equipment.

Also the Ninth Malaysia Plan 2006-2010 (Rancangan Malaysia Ke-sembilan) states that the Ministry of Health will continue to be the leading agency and main provider of health services and together with other healthcare service provides and NGO’s will receive an allocated 5.4% of the budget amounting to almost RM10.2 billion, of which RM3.3 billion will go into public health care, RM5.4 billion into patient care services, which includes building new hospitals and renovation and RM1.4 billion into other healthcare services, which includes training of staff. The 9MP also outlines a broad plan to cover areas of weakness within the existing system such as greater efforts into development, primary and secondary prevention, and improving the efficiency of the delivery. Also it shows greater sensitivity towards a more equal distribution of healthcare services and with aims to improve healthcare services delivery to rural areas.

However, before we marvel at statistics that have led to Ramesh and Holliday lauding Malaysia as ‘Southeast Asia’s Healthcare Miracle’, we must be aware that the healthcare system in Malaysia, as previously mentioned, focuses mainly on in-patient care, or tertiary care. Therefore by implication, it means areas of medicine such as primary care, primary and secondary prevention which often utilises out-patient services are less pronounced and less successful in terms of implementation. These areas of medicine usually involves long term management dealing with numerous chronic medical conditions, as opposed to the in-patient setting which can only deal with acute conditions.

Therefore, patients who suffer from conditions that are more often prevented or controlled via careful long-term monitoring which is not plausible within the in-patient setting, often are left to manage their own conditions, until an acute event which requires hospitalisation occurs. This often leads to a drastic disruption to the patients’ life, and can also lead to a poorer quality of life following recovery after the acute episode of the disease. Furthermore, cost-benefit analysis of numerous conditions have demonstrated that long-term management of chronic conditions with primary and secondary prevention methods are often more cost-efficient than treating the acute complications of these diseases within the in-patient setting. By failing to control these chronic diseases, numerous hospital beds are unnecessarily occupied and unavailable to other patients who might need them. The management of such acute-on-chronic conditions are mostly otherwise preventable, and avoids unnecessary incurred costs of treating them within in-patients.

The most successful form of primary care in Malaysia relies heavily on private general practitioners (GP) clinics that have mushroomed throughout the country. These are easily accessible in most parts of the country by anybody at all, requiring only a quick registration process and the GP is at your service. Unfortunately, the GP service is ultimately a privately owned business that provides out-patient care for anyone willing to pay. These clinics by large, are poorly regulated with huge amounts of ongoing concealed malpractice, out-dated medical practice, unprofessional behaviour, and conflicting interest between doctor and patient. Therefore, it is shocking that these privately own GP clinics are the only form of out-patient healthcare service that ‘reliably’ provides a long-term management of chronic conditions with the concept of continuity of care, allowing the patients and doctor to forge a relationship that allows the doctor to appreciate the individual needs of the patients and cater for them in a manner that the public healthcare service is unable to do. Although, this is not necessarily guaranteed because with the increasing competition amongst private healthcare providers, there is also a huge disparity within the standards of service provided by GP clinics, and consequently a shift of patients from one GP to another for better service and value for their money. Unfortunately, this disrupts the concept of continuity of care and thereby the most valuable service provided by the GP itself.

(to be cont.: Part III of III – The Professionals and a Conclusion