StarTwo journalist LOH FOON FONG received the World Health Organisation Journalism Fellowship recently and visited Switzerland and Sweden to study their healthcare systems. She submitted a report on Building an Innovative Healthcare System: Optiions for Malaysia which will appear in three weekly segments.
MALAYSIA'S healthcare system is considered one of the best among developing countries. Since the country achieved independence from the British in 1957, good healthcare structures were established and health services were provided to the entire population.
At the lowest level of the healthcare structure is the klinik desa (village clinic). Initially, when infant mortality was high, there was a midwife who saw to the needs of pregnant mothers and infants in remote areas while doctors went into these villagers once a week. The midwife status was later elevated to that of a nurse who took on more responsibilities in overseeing the health needs of a couple of thousand people while referring cases that needed further attention to doctors. These doctors then referred more serious cases to specialists in district or general hospitals.
In the urban areas, people have access to government hospitals as well as private clinics and hospitals. In fact, private healthcare institutions have mushroomed in the last decade.
Based on the 2000 World Health Organisation (WHO) record, Malaysia’s total expenditure on health was 2.5% of the Gross Domestic Product. Although very minimal, and insufficient by industrialised nations standard, Malaysia has achieved fairly good health results compared with other developing countries. Infant mortality rate is 11 per 1,000 births while life expectancy is 68.3 for males and 74.1 for females.
More than 98% of children are immunised against tuberculosis while about 90% of children are immunised against diptheria, measles and polio. Last year, the government began providing Hepatitis B immunisation for children.
Areas of concern
Government health services, financed by taxes, have achieved impressive coverage for primary healthcare. However, there is growing dissatisfaction with healthcare provided in the public sector. The main complaint is the long waiting list.
In a report headlined The Price to Pay, published in The Star in Malaysia on Oct 24, 2002, Datuk Dr S.K. Dharmalingam, president of the National Cancer Society, said cancer patients have to wait three to five months before they get any treatment and it is not uncommon for doctors in general hospitals to refer such cases to the society’s cancer treatment centre for more swift attention.
“Patients get good treatment in government hospitals but they have to wait for too long,” he said.
Dr T. Jayabalan, a representative from the Consumers Association of Penang (CAP) said: “The waiting list is between three and six months for many surgeries, X-ray results take a few days to be ready and patients have to wait for a month or two for CT scans.”
Even at the National Heart Institute, the first medical body to be corporatised to make it more efficient, it is common for patients to wait for at least six months for treatment.
A couple of decades ago, patients used to wait for about two hours to be treated by a government doctor but current feedback from patients in public hospitals revealed that those who take their queue numbers early in the morning only get examined by the doctors in the afternoon and most doctors spend less than five minutes on each patient due to the work load.
With limited budget, free and equal access to healthcare is not possible anymore. Moreover, some treatments are available in some states and not others. The aged tend to be given lower priority on the waiting list or are discouraged from seeking treatment.
In his paper, Models of Healthcare Financing, Dr K. Balasubramaniam, pharmaceutical adviser for Consumers International regional office for Asia and the Pacific, pointed out that while Malaysia’s average indicators are good in comparison with other developing countries, there are gross inequalities among states and among population sub-groups. For instance, based on World Development Report 1998/99, infant mortality rate in 1996 for Sarawak is 5.7 (per 1,000 live births per year) while the rate for Sabah is 14.1.
Dr Balasubramaniam also pointed out that the number of people per doctor vary from 366 (in the Federal Territory - Kuala Lumpur) to 4,315 (in Sabah).
Geographical distance from health centres is a problem especially for those living in rural areas especially in Sabah and Sarawak . In these states, doctors sometimes have to travel to remote villages by plane or boat.
The ratio of the incomes of the poorest and the richest in Malaysia is 1:20 and it is the widest in the Asia-Pacific region, said Dr Balasubramaniam.
These data indicate that while there has been improvement in the Malaysian health system in that the averages are good for a developing country, fairness is lacking.
A health system should give equal attention to four key functions (WHO Report 2000) providing services, generating the human and physical resources that make service delivery possible, financing healthcare and stewardship or leadership.
However, the Health Ministry has focused on the first two functions but neglected financing healthcare and stewardship and this has led to gross inequalities, said Dr Balasubramaniam.
The neglect started in the early 1990s when the government proposed certain healthcare reforms based on privatisation of healthcare and shifting the cost of healthcare from the state to the people. This move has been highly criticised by consumer associations, trade unions and other interest groups.
In corporatised hospitals and private wings in public hospitals, those who can afford it get more swift attention.
The RM1 for outpatient treatment and RM5 for specialist consultation in government hospitals reveal the high subsidy and benevolence of the government. While that is good for patients, those from the lower-income group have difficulty paying for expensive implants, gadgets and essential drugs which are not provided for. Out-of-pocket expenditure on health is high. It makes up 41.2% (WHO Report 2000) of the total expenditure on health. As a result, many patients who could not afford treatment appeal for public donations through the media and many cases are highlighted regularly.
“Although government hospitals operate on high subsidy rates, they cast a different light on the out-of-pocket payments of Malaysians at public healthcare facilities,” said Dr Chan Chee Khoon, co-ordinator of Citizens’ Health Initiative (CHI), a body which is concerned about healthcare reforms in Malaysia.
“Annual increases in public allocations for healthcare do not seem to translate into better and expanded patient services,” he said.
“Although Malaysia was ranked as 49 out of 191 member states by WHO in terms of healthcare quality, the country was ranked 122 out of 191 in terms of high out-of-pocket payments,” said Tan Sri Ramon Navaratnam, a member of the Human Rights Commission in his paper Financing Healthcare in Malaysia: The Way Forward which was presented in a conference on national healthcare financing recently.
While patients, consumer and interest groups feel that the large out-of-pocket payment is detrimental to the welfare of the lower-income group, the government is worried about rising healthcare costs. Government budget allocation , increased from RM1.034bil in 1983 to RM7.55bil last year. The government subsidised 97% of public healthcare costs last year.
In 1997, there were 6.8 physicians per 100,000 population/year, 113.3 nurses and 27.1 midwives. While that is not sufficient, many medical personnel from the public sector quit to join the private sector in the last decade for better remuneration and this worsened the brain drain problem.
The brain drain in government hospitals is a longstanding problem. The government has declined to increase salaries of medical personnel despite calls by the public. Nevertheless, the government experimented with other methods such as setting up private wings in public hospitals and increasing doctors’ allowances. While that may help doctors, the waiting list is still not getting shorter.
Next Thursday: Going for health insurance
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