Budget 2020: Dear Health Ministry, here’s how to spend your money

Strategic areas for proposed Health Ministry spending include setting up an inter-ministry unit for sustained collaboration, and emphasising primary care by giving it a dedicated division.

IN previous columns, we’ve already built a realistic funding mechanism that guarantees a predictable, generous and gradually increasing sum to the Health Ministry (MOH).

Now we get to do the fun stuff: Spend money!

I’ll be proposing six strategic areas for MOH spending. This week, we’ll look at the first three strategic areas, all of which support a multi-year reform of MOH’s organisational and delivery structure.

The first strategic spending area is to create, staff and run a formalised inter-ministry collaboration.

Let’s call it the Coordinating Unit for Health Reform (CUHR) for now.

CUHR will bring together relevant officers from four ministries – Health, Education, Finance, and Economic Affairs – and the Public Service Division (JPA).

It could be housed under the MOH and led by a director-level officer.

It is intended to resolve a current gap, by formalising a new channel of collaboration between ministries that adds a layer of operational detail.

Currently, there are some minister- and director-general (DG)-level conversations between ministries, but these generally discuss only high-level strategy and often only on a one-to-one and ad hoc basis.

Understandably, silos, imperfect communications and the distraction of daily routines get in the way of any implementation.

CUHR will resolve these problems by instituting a predictability to inter-ministry interactions.

It will run as a secretariat of sorts, to coordinate various ministries in a predictable and structured way.

It should not generate new policy documents, but exist merely to coordinate.

For example, CUHR will receive a set of targets decided at the Cabinet level, like “reduce the over-supply of doctors”.

As a suggestion, CUHR will coordinate and host a monthly meeting at the director level between relevant departments and units in the five ministries.

There could also be a quarterly meeting at the DG level, and a six-monthly meeting for ministers.

These meetings could discuss implementation status and allow collaboration and relationship-building in a predictable and structured way.

Going back to the example of too many doctors, MOH alone cannot solve this problem without a formalised (versus ad hoc) collaboration with the Education Ministry and JPA.

As another example, any reform of health financing cannot happen without the ministries of Health, Finance, Treasury and Economic Affairs working together on a regular and coordinated basis.

In large bureaucracies, silos are inevitable. To break these silos, some countries have already changed the structure of their ministries.

For example, Singapore now has a Coordinating Minister for Social Policies, who coordinates health, welfare and education.

For Malaysia, an effective CUHR is a good first step to break inter-ministry silos and encourage Health in All Policies.

Shall we say RM10-20mil to start it up in Budget 2020?

A unit for reform

The role of CUHR starts with inter-ministry collaboration, and continues with MOH internal reform.

Let’s first build a case for why MOH reform is needed. Many people have spoken about the need for reforming the MOH, and the reasons are worth repeating.

The current organisational structure was purpose-built for the 1960s-1990s and not adequate to bring us to 2030.

There have been many add-ons and workarounds built into the organisational structure over the years, but in a piecemeal and reactive fashion.

Therefore, there is a need and an opportunity to reform and restructure MOH in a more deliberate, thoughtful and methodical manner.

The needs of the health system have evolved over the decades, and the system that got us to 2020 won’t get us to 2030.

Having established that MOH reform is needed, we need a “central coordinator function” to make it successful.

The reasons for this are equally clear. It’s impossible to conduct reform AND daily operations at the same time, and do both well.

We’ve seen that MOH is gargantuan, and reform is akin to performing surgery while running a marathon.

All the existing units within the ministry are fully occupied in delivering routine services and daily fire-fighting, and they understandably cannot focus on any reform.

Enter CUHR.

It will not develop a reform plan itself, because that is the job of technocrats and political leaders.

What it will do is to take the reform plan and project-manage it to completion.

It will set meetings, pressure the many MOH divisions, programmes, departments and units to meet their deadlines, and break the silos to ensure that people work as “One MOH”.

In other words, CUHR will provide mission discipline and keep reform on the agenda and the daily routines of the 270,000 MOH staff members.

In future columns, I will be proposing a reform plan for a future-proof MOH organisational structure that can bring us to 2030.

There are probably already a few reform plans in existence, generated by institutions such as the Planning Division, the Institute for Health Systems Research or the Health Advisory Council.

All these plans will sound ideal on paper, but will not survive contact with reality.

Regardless of whichever plan is ultimately chosen, CUHR can help deliver it.

Separating out primary care

I’ll start this third idea with a disclosure: I have a Master’s degree in Public Health. Despite that, I firmly believe that separating primary care and public health in the MOH structure is both desirable and inevitable, and Budget 2020 can help transform primary care.

Primary care is crucial. Tomes have been written about how it is the cornerstone for Universal Health Coverage, the Astana Declaration, and to meet Sustainable Development Goals. They are all true, and I will not repeat any of them.

I will however repeat one belief: increasing MOH allocations across the board will only magnify the inefficiencies in the current MOH structure.

Instead, targeted increases in a new and more efficient MOH structure will use our money better.

Here is one example of a targeted increase to strengthen a new MOH structure: primary care should have its own Deputy DG for Primary Care and receive a targeted ring-fenced allocation in Budget 2020.

Here is the back story.

For legacy reasons, Primary Care is one of many sections in the Family Health Development Division (BPKK).

BPKK is one of five divisions that report to the Deputy DG of Public Health (others include Disease Control and Public Health Development).

In short, primary care was historically and conveniently housed under the Public Health Programme.

Right now, it’s buried deep inside the Public Health Programme. Under this structure, it’s inevitable and understandable that primary care is de-prioritised, leaving it under-resourced and perhaps even marginalised.

Over time however, primary care has grown in sophistication, complexity, importance and stature.

It’s now time for us to separate it into its own Primary Care Programme, led by its own Deputy DG.

Now, no one is saying that primary care is more important than public health, or vice versa. They are both equally important.

It’s obvious that they are different entities created for different purposes, and they need clear boundaries, adequate resources, appropriately-trained staff, and enough political stature.

In other words, both entities should be equally powerful.

We’re not adding any new civil servants; only rearranging the organisational structure.

The Public Health Deputy DG will not lose any power or stature either.

This step will allow primary care to truly have the resources, decision privileges and agility to decide its own direction.

As a bonus, there’s almost negligible impact to MOH salary and pension commitments.

Budget 2020 can allocate additional funds (perhaps RM50-100mil) ring-fenced only for primary care services, conduct research into how a separation from public health can take place, propose the integration of the public and private primary care sectors, and begin some pilots for a transformed primary care.

It’s time to put our money where our mouth is!

Dr Khor Swee Kheng has postgraduate degrees in internal medicine and public health, and has worked in five health sectors across three continents. He is currently specialising in health systems and policy in a public university and a local think tank. The views expressed here are entirely the writer’s own.

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