Imminent Corporatization of Public Health Services—Causes for Concern

Dr David KL Quek

dquek@pc.jaring.my

The most recent disquietude to affect the health and medical industry is the insidious announcement of the coming corporatization of public health services including most Ministry of Health hospitals and facilities by January 1st 2000.

Yes, not only will the Malaysian public be subject to the uncertainties of theY2K bug, the new millennium will also see previously public-owned and run health care services becoming corporate bodies, each answerable to the dictates of an increasingly commercial world.

Patients who in the past have relied on these facilities will have to depend upon the vagaries and strictures of the new establishments. These have broadly been categorized as private concerns, with the bottom line being the ability to sustain itself and keep solvent while providing a service which has sometimes been likened to a bottomless pit. How this will affect the poor and indigent, or for that matter, even ordinary folks, can only be guessed at.

But as past historical experiences have shown, it will certainly cost more than previously, when our public health services were funded through public coffers. In a corporate entity, prices of all services, and consumables including itemized costing (professional fees too) will be attached to all and sundry. It is therefore, hard to visualize how these facilities can be any more affordable to ordinary Malaysians, without substantial injection of subsidies from the government or Treasury, as in the case of IJN or the National Heart Institute, for example.

Furthermore, it is still unclear who are the new managers and owners of such corporatized health facilities, and how much regulatory control the government can have over them. How they propose to transform hitherto publicly owned service-oriented hospitals and other amenities, into self-reliant, efficient yet self-funding entities, perhaps with a profit-driven motive, remains matters of grave concern to the medical profession.

It is useful to remember that the corporatization exercise itself is not simply the ability to pay health care workers marginally better emoluments and benefits. More crucially, one wonders how the less-well-off citizen can be better served without jeopardizing his legitimate right for good and affordable health and medical care. Who will help fund the expected rise in cost of medical and health care and treatment?

What about critical preventive health measures (such as maternal and child health care, compulsory vaccinations, antenatal and postnatal checks) which are usually not fund- or profit-generating in the short term? Health care for the elderly is another area of gray concern. Will these be sacrificed and will all our previously hard-won benefits dissipate with this hurried action by the Health Ministry?

What safeguards have been implemented to ensure non-abuse and arbitrary denial of services in the name of cost-constraints or inability to pay? Will a nationwide medical insurance have been in placed by then? Will the insurance cost be hoisted upon the Malaysian public yet again, through another form of compulsory deduction? What about those who are unemployed, retired or not employable? What mechanisms will there be to answer to their needs?

How equitable will such a health care system be, particularly to those who cannot afford these services? Might we see a pathetic withdrawal of the indigent from seeking such prophylactic measures (e.g. vaccination), when they deem these as luxury that they can ill-afford? Dare we risk outbreaks of infectious diseases which have hitherto been well contained because people cannot or are unwilling to pay for such preventive measures?

What about the less profitable or money-losing services such as treatment of catastrophic ailments e.g. cancer, kidney failure, heart failure, transplant surgeries, etc.? Anticancer therapies and their repeated courses are notoriously expensive. How can these be funded? In times of epidemics such as the recent Nipah encephalitis outbreak, who will be responsible for such massive undertakings—fogging, case tracing, laboratory investigations, vector and host controls, etc.?

The MMA has been inundated with queries and brickbats from concerned physicians concerning this suddenly accelerated course of events. Many cannot understand how the Association has ‘allowed’ such a potentially disastrous unilateral decision to be made. Indeed, many wonder as to how there can be seemingly no input from the Association to stall or even to discourage such a development, which they view as being thrust down the throat of shell-shocked Malaysians. To make matters worse, our mainstream media or newspapers have either been blissfully uninformed or they have chosen to sidestep these issues as if they were not sufficiently newsworthy!

That the MMA has fought against such a hurried implementation has been widely known. For years, the MMA has requested the government to be more transparent in its formulation of policies regarding the direction and execution of our national health plans. For years, we have argued that a National Health Plan be publicly debated and formulated.

We have pleaded that our public health facilities be maintained as they have been proven to be exemplary to the rest of the developing world as a beacon model of primary health care. Near universal and easy access to medical and health care has always been touted as a rightful pride for Malaysians. Now, we risk losing all these, just so as to realize the dream of devolving and corporatizing our Public Services.

Some physicians in their unfounded anger and desperation have accused the MMA leadership of dereliction of duty, or being impotent, inconsequential, and worse of being only a ‘talk shop’. How little do these physicians know or care to know of the underlying currents of despondent reality that the Association has endured. Cries of betrayal only show up the ignorance of the uninitiated, the fence sitters and the armchair critics.

Yet, if the MMA has failed, it is in some ways because, doctors as a whole have been emasculated by the eroding dignity and image of the profession by both the public and the government. It is increasingly seen that the authorities brook less and less tolerantly with the mistakes and failures of a miscreant few.

Worse, we appear to have become only one of the "trade unions" that they nominally and perfunctorily have to dialogue with—they need not accept or listen when they choose otherwise. More disconcerting is the fact that policies are increasingly decided without thorough feedback from the medical profession. Our views were often summarily dismissed, as being too partisan and biased of self-interest.

This is sad because, the leaders of our medical profession have consistently been the strongest advocates for our patients’ interest. Our patients’ interest is paramount, and we have always stated and espoused such, particularly for the less-well-to-do, and the poor. As doctors we have been wary of rising health costs and have been striving to contain them.

In fact, doctors’ fees have fallen far short of the inflation index for the nation. Yet recently, when some minor adjustments were made, we have been accused as being heartless and greedy. Furthermore, the treatment and remuneration of doctors in public services have been so lackadaisical that it is a wonder that the Ministry has not lost more doctors to the private sector. One can have a glimpse of their angst and frustration by reading the MMA News Schomos column. That these doctors are still in service is testimony to their tenacity and their public spiritedness. So it is surely untrue that doctors don’t care—they do, at great personal sacrifices!

Of course, we do share the government’s concern that some new financing and health management schemes may have to be wrought, soon. But, this obviously requires the most delicate and sensitive touches, so that in dismantling the previously working model, we do not create or unleash a potentially untamable, unbridled and amoral fiend. As caring people it would certainly be demeaning for us to abdicate our principles and our guardian role.

This time, the MMA and some government doctors are once again spearheading another challenge to try and stall or even reverse the timetable for corporatization of the health services. We are genuinely concerned that this misdirection is not yet the best possible solution for the nation’s health and its services. There are still so many issues that need to be addressed and perhaps modified, to suit our unique Malaysian paradigm. We must convince the government that we all need a time-out.

Hasty implementation should not take the place of sane reason, and humanitarian concern. The government cannot whimsically abdicate their social contract, without winning over the main players in the revamp of our health system.

In this regard, the coming AGM will discuss endorsement of the Citizens’ Health Manifesto, which among other things, strive to highlight the perspectives and prerogatives of the Malaysian citizens vis-a-vis our right to easily access affordable health care without compromise.

The government is urged to take note of our grave concerns and heed our calls for a moratorium on this urgent issue. To steamroll such a premature implementation at the expense of goodwill and reason could have dire consequences for the final health of the nation. Our entire Health Services should not be subject to precipitous Corporatization, just to comply with a deadline. An urgent reappraisal and dialogue is prudent.

24 May, 99

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