Two significant announcements on the health sector were made in the Finance Minister’s budget speech in November 2018, i.e. the B40 Health Protection Fund and the nationwide health screening programme, Skim Perlindungan Kesihatan (Peka).
The minister stated that “the Government will pilot a national B40 Health Protection Fund to provide free protection against the top four critical illnesses for up to RM8,000 and up to 14 days of hospitalisation income cover at RM50 per day”.
Since then, it has been announced that the number of illnesses has been increased to 36.
Illness does not recognise classifications into B40, M40 or T20, which is based on a monetary number and does not take into account family size, cost of living at place of residence, etc.
Everyone knows that the same ringgit has different purchasing power in different parts of the country.
Many Malaysians have incurred catastrophic health expenditure (CHE) when there is a critical illness like heart attack, stroke, cancer, etc.
Some households have had to borrow money or sell assets to finance their healthcare; earn less due to deteriorated health condition(s); become impoverished after paying for healthcare services; and become even poorer for those already below the poverty line, due to healthcare expenditures.
The reports of CHE studies in Malaysia are disturbing, to say the least.
An Asean study reported that the proportion of previously solvent patients who experienced economic hardship following a cancer diagnosis was highest in Malaysia (45%) and Indonesia (42%), and lowest in Thailand (16%).
A National Heart Institute (IJN) study concluded that the economic impact of ischaemic heart disease (IHD) in Malaysia “was considerable and the prospect of economic hardship likely to persist over the years due to the long-standing nature of IHD”.
B40 Health Protection Fund
Whether the B40 will benefit from the Health Protection Fund is a moot question when they already have access to virtually free healthcare at public healthcare clinics and hospitals.
Whether consideration has been given to the size of private hospital bills is pertinent.
The total bill for some acute conditions in private hospitals may amount to RM8,000 or less.
However, many private hospital bills exceed RM8,000, particularly in critical illnesses that are chronic in nature, e.g. heart attack, stroke and cancer.
When the insurance or personal financial limit is reached, transfer to a public hospital will almost always be inevitable.
However, the fact that has not been made known is the current practice of the imposition of the First Class treatment charges under the Fees (Medical) (Amendment) Order 2017 on all patients referred from private hospitals.
These First Class treatment charges are considerably higher than those for patients referred from public clinics or hospitals.
Unless the practice is changed, anyone in the B40 Health Protection Fund can end up saddled with hefty bills, i.e. CHE from both private and public hospitals, particularly when there is a chronic condition.
It would be more advantageous for the B40 not to enrol in the Health Protection Fund and continue to access healthcare from public clinics and hospitals as they are doing now.
The other announcement was that the Health Ministry will pilot a nationwide health screening programme, Peka, for 800,000 individuals aged 50 and above in B40 households at a cost of RM100 million.
According to the 2015 National Health and Morbidity Survey (NHMS), about two-thirds of Malaysians have at least one of three non-communicable diseases (NCDs), i.e. diabetes, high blood pressure (hypertension) or high blood lipids (hypercholesterolaemia).
More than one in four (26.3%) have at least two of these NCDs and 7.2% have all three NCDs.
These three NCDs are not confined to the B40, but are also prevalent in the M40 and T20.
The prevalence in those aged more than 18 years of age for:
• high blood pressure was 30.3%.
The condition was diagnosed in 13.1% and undiagnosed in 17.2%, i.e. for every two persons diagnosed with high blood pressure, there were three undiagnosed.
• diabetes was 17.7%.
The condition was diagnosed in 8.3% and undiagnosed in 9.2%, i.e. for every eight persons diagnosed with diabetes, there were nine undiagnosed.
• high blood lipids was 47.7%.
The condition was diagnosed in 9.1% and undiagnosed in 38.6%, i.e. for every one person diagnosed with high blood lipids, there were four undiagnosed.
Of those diagnosed with:
• high blood pressure, only 35.7% had been on treatment, and 9.6% had blood pressure controlled under treatment
• diabetes, only 38% had blood glucose levels within treatment targets (NHMS 2015).
• high blood lipids, only 45% and 37% of those treated at public hospitals and private clinics respectively, had their total blood cholesterol levels controlled.
However, this data from the NHMS 2015 was limited by no distinction between LDL and HDL cholesterol.
In short, the prevalence of undiagnosed high blood pressure, diabetes and high blood lipids was high, and of those who were diagnosed, control was poor.
Everyone whose NCD is diagnosed and well-controlled will benefit from better health and fewer complications.
Consequently, the country’s disease burden and expenditure from secondary and tertiary care will be contained, if not reduced, with early detection and better control.
Better value for money
A reassignment of the allocation for the Health Protection Fund to reduce undiagnosed and poorly-controlled NCDs will ensure that the B40s are not saddled with CHE.
It will also contain and reduce the disease burden of NCDs; and contain the country’s healthcare expenditure in the medium and long-term.
The private registered medical practitioners (RMPs) can play significant roles in this respect.
Their closer relationships with patients, as compared to their public sector counterparts, will contribute to better screening, diagnosis, treatment and its compliance, and health education of diagnosed and undiagnosed cases of these NCDs.
The private RMPs’ involvement, within the parameters of a protocol agreed between the Health Ministry and the private RMPs, will also decongest public clinics and hospitals; and allow more time for public specialists to take care of complicated cases.
It would also be logical to extend Peka to the M40 as illness does not recognize such classifications.
The axiom “First do no harm” is applicable not only to clinicians, but also to policymakers.