Is our healthcare system in crisis?


  • Vital Signs
  • Tuesday, 10 Dec 2019

I’m a trained doctor. Ordinarily, we’re not excitable people prone to panic. However, two very recent news in Malaysia caused me concern that our health system could be fraying.

The first is the polio case in Sabah, which is Malaysia’s first in 33 years.

The second is the sudden and unexpected announcement that the Cabinet has approved the decision to stop regulating the consultation fees of private doctors and dentists.

No more polio-free

Crises and dangers often announce themselves quietly.

The three-month-old Sabahan boy currently in Hospital Tuaran has a diagnosis of polio, the first in Malaysia since 1986. The three cases in 1992 were imported ones and not of local origin.

This is a quiet announcement of a very real crisis for Malaysia, and we cannot ignore it.

We don’t have enough information now to accurately determine how this infant contracted the disease. We’re unsure about his vaccination status, his living conditions, access to healthcare services and so on.

These facts are important for this infant, but can be trivial compared to the solutions for an entire population of 32 million Malaysians.

What’s certain is that this strand of polio only happens when populations are under-immunised.

Unfortunately, Sabah is also the state with some of the worst health outcomes, as well as fewest medical professionals and facilities, in Malaysia. It also hosts many non-Malaysians and stateless people.

All these facts are more relevant for the entire population.

The battle has begun

This means that Sabah could be the frontline of Malaysia’s latest communicable diseases outbreak.

We can win this fight, but it’s against the backdrop of some poverty and statelessness, and an under-resourced health system.

One part of that fight is a more aggressive stance against the anti-vaccination movement wherever they may be in Malaysia.

It may be necessary that emergency mandatory polio vaccinations be instituted in Sabah to get the population up to the herd immunity levels of more than 95% vaccinated.

We will have to win the social media war and build an unlikely coalition of health professionals, religious scholars, community leaders, parents, teachers, politicians, media celebrities, and even grandparents to fight this battle.

The anti-vaccination movement can no longer be treated with too much respect or distance.

Building clinics, enhancing access or education campaigns are all well and good, but we must take the fight to the anti-vaccination movement.

Beyond addressing this movement, we must also consider that the health rights of non-citizens of Malaysia are crucial, for humanistic, ethical, legal and public health reasons.

These difficult topics must be a part of our national discourse, because our health depends on it.

Too much deregulation too fast

The second decision that concerns me is the deregulation of consultation fees in the private sector.

The decision could be directionally correct, but is definitely too much, too fast and too sudden.

I have several problems with this decision.

One, this is a sudden decision that appears to have caught almost everyone off-guard and did not involve enough stakeholders.

Two, the Government appears to have chosen deregulation as an easy way out, rather than undertaking the hard work of amending Schedule 7 and 13 of the Private Healthcare Facilities and Services Act 1998 (which was the original perfectly reasonable request from the medical profession).

Three, this appears to be the latest reactive short-term tactical decision by the Health Ministry (MOH), because it doesn’t seem to be part of any coherent long-term strategy.

Four, the MOH continues to disengage from the private sector, leaving Malaysia’s health system without a coherent ideology for how the public and private sectors can co-exist.

How can this move reduce healthcare cost? What is the masterplan for integrating the public and private healthcare sectors? Is it “MOH for Malaysia”, or “MOH only for public sector”? What is the government’s ideology and position for the role of private sector healthcare in Malaysia?

These are questions for our Health Minister.

An imperfect market

There are two important facts hidden behind the reactions of doctors, consumer associations and the public.

Firstly, the implementation date is not announced, because it still requires a formal approval by Parliament.

Secondly, the procedure fees of private doctors and dentists remain regulated, making it the only remaining fee category to be regulated by the Government.

I’m pro-market, but healthcare is full of market failures requiring government intervention.

As two examples, if you’re sick, you’re at the mercy of the nearest hospital or clinic (“captive market”). And even if you have lots of time and can understand medical jargon, you’ll still defer to a trained doctor (“information asymmetry”) and pay anything to get healthy again.

These market failures exist not because doctors are unethical, but because of the way the world works. There is no enemy at all, so we can focus on fixing the problem.

Previously, I’ve shown how price controls alone aren’t enough to control rising healthcare costs, and proposed price transparency and a new health financing system to correct for the market failure of imperfect information for patients.

This sudden deregulation of consultation fees without a proper check-and-balance mechanism of price transparency is more likely to lead to increasing healthcare costs, rather than reduced costs through increased competition.

Here’s what’s most likely to happen, in a sequence of unintended consequences.

Pressure will build on the Government to deregulate the final category of doctors’ procedure fees. This is reasonable because the Government has already set a deregulatory precedent. In 12-24 months, all fee categories could be solely determined by market forces.

We imagine the consumers and insurers can fight against rising charges, but this New York Times article shows the different ways in which healthcare charges can rise, without being fair or logical. Without price transparency in Malaysia, consumers and insurers can’t check any rising costs.

What we need is a new health financing system that helps integrate public and private facilities, and a restructuring exercise in the public healthcare system.

What we also need is for MOH to be more predictable and to make policies for all of Malaysia.

Keeping alert

In Ernest Hemingway’s novel The Sun Also Rises, one of his characters was asked how he went bankrupt. His answer was: "Two ways. Gradually, then suddenly."

Malaysia’s health system remains strong, but we must be alert to small signals of incoherence from the political leadership and be thoughtful of the unintended consequences of short-term reactive decisions.

We cannot be complacent about the anti-vaccination movement and the health of non-citizens in Malaysia, and we cannot let our children down.

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 reading Public Policy at the University of Oxford. The views expressed here are entirely his own. The column will resume its regular schedule on Dec 18.

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