Prudent Use of Public Funds for Costly Medical Care… A Consistent Public Policy is Needed

By Dr David KL Quek


"Where the mind is without fear and the head is held high; Where knowledge is free; Where the world has not been broken up into fragments by narrow domestic walls; Where the clear stream of reason has not lost its way into the dreary desert sand of dead habit; Into that heaven of freedom, my father, let my country awake."  – Rabindranath Tagore


“We must not be afraid to go too far, for truth lies beyond.” – Marcel Proust


Malaysia suffers the dubious distinction of having arguably the region’s most comprehensive and accessible healthcare to most of its citizens, but perhaps also the most rampant public display of begging for money to help defray health care costs or hankering after abstruse medical care by all and sundry.


Our daily newspapers are replete with sad and harrowing tales of sufferers of various ailments, all seeking financial assistance to undergo special expensive medical treatment or investigations. All these entreating public displays appear to be urgent or even life-threatening, if undue delay were allowed to pass. Yet this paradox undermines the supposed excellence and purported adequacy of our healthcare system.


At the risk of being accused of being heartless and insensitive, I venture to say that Malaysians have allowed themselves to become too tenderhearted. We then fall easy prey to tear-jerking sob stories, which may not entirely be good for our near-developed world status and psyche. Yes, there are indeed many ill people out there, who cannot afford some form of expensive treatment or another, especially when managed in the private sector.


I do not mean to imply that these patients should be left to their own devices. And there is no doubt that many Malaysians are truly generous people who would like to help out as much as possible, the less fortunate or the needy. However, by pandering to such sporadic and piecemeal pleadings, we let ourselves be sucked into a cyclical mindset of impatient hopelessness, easy despair and knee-jerk resorting to public pan-handling.


A case in point refers to the recent celebrity who through the media managed to secure some RM 392,000 in one week, for some purportedly necessary expert treatment in Australia. The Malaysian Orthopedic Association and the Asia Pacific Orthopedic Association had reacted strongly and raised some alarming viewpoints which question the need for anyone with similar ailment to expect such expensive treatment overseas. They have emphasized that similar quality therapy can be obtained more cheaply and reasonably in Malaysia.


In their press releases, they have justifiably stressed that when public funds are sought, then relevant specialist bodies have the responsibility and duty to inform the public that such an ailment can be treated within the country, and at a more cost-effective rate. They are not against anyone seeking medical treatment anywhere, if they have the financial means. However “poor patients seeking public funds” should first seek treatment at government hospitals, unless these services are unavailable there. A neutral body should manage the funds and must be held accountable to the public.


I strongly commend these associations for their strong and prudent stand which reflects maturity and concern for the state of medical and health care in the country. Like them, I am aghast as to the erosion of public confidence in our health system; and the alarming growth of wanton public expectations regarding so-called expert medical care. Extravagant demands for instantaneous and unrealistically high standards of healthcare cannot be justified on a public scale. We are losing touch with economic reality and treading dangerously down the slippery slope of profligacy, with no concern as to costs, and natural justice.


More and more people are resorting to the compassionate if overly credulous media to highlight their plight and are expecting—as of their birth right—donations to help them get medical care by bypassing the usual channels. Wastage and shortchanging other more long-suffering but less demanding patients with similar ailments are often not publicized. And sadly, we are encouraging this generosity of our more sympathetic souls, by titillating their consciences and sensitivities when other more worthwhile charities remain orphaned and forgotten.


Many of our neighbouring colleagues (with even fewer and less developed healthcare facilities and expertise) are puzzled at such public outpourings of grief, pity and beseeching for medical therapies which by all intents and purposes are readily available in most parts of Malaysia. This gives the impression that our healthcare services are severely lacking and cannot meet the demands of our increasingly expectant citizens. Surely this is not true.


I fervently believe that this vortex of shame must stop. Private healthcare facilities and physicians alike must stop colluding with or resorting to such pleas on behalf of their less financially well-off patients so as to gain public funds to carry out procedures or treatment which they can ill afford. Malaysian patients must be made to have pride and confidence that there are sufficient public healthcare centres with enough expertise and facilities, to take care of them as a matter of public health policy. Not everyone can simply pick and choose without some form of restraint and disregard cost, availability, opportunity or appropriateness issues.


They must be made to understand that some delay inevitably exists even in the most advanced and richest of all countries. Some rationing of healthcare and queuing for their turn in terms of medical need always exist, and must be part of the social contract between social services and the government. Of course, we must minimize such unnecessary delays, but we cannot allow anyone and everyone to seek instant gratification for perceived must-have medical treatment—often very expensive, and sometimes even of questionable value or benefit, without independent and disinterested medical assessment as to need or urgency. This is particularly important when extra public funds are demanded or sought after.


With the onslaught of ever-changing medical technologies and development, health care costs will continue to escalate. But they cannot be contained or managed, if there is a free-for-all approach to having unfettered access to every healthcare choice, anytime, anywhere, and at whatever costs, by any and everyone. Such is the problem with the U.S. model of indiscriminate limitless health right, which has left some 45 million Americans uninsured and under severe privation of even the most basic of healthcare services.


We must re-educate our physicians and patients alike. Our Health Ministry can be more focused in trying to alleviate the misplaced fears of our people, that healthcare as a service commodity must be rationally and fairly distributed. Our citizens must be reassured that in the event of medical emergencies or life-threatening ailments, good quality medical care will be provided, and access will never be denied anyone.


However, many other perceived medical urgencies are often less certain, and may not necessarily be critically life-endangering; thus, some waiting time is allowable and indeed unavoidable. Nevertheless, it has been shown that such delay need not necessarily imperil lives or have any adverse long term effects. This has been shown in a number of reviews comparing the disparate US and UK experiences in access to tertiary medical care such as coronary bypass surgery or angioplasty, even knee or hip surgery. Perhaps the only difference is the morbidity experience which is somewhat higher in the UK due to the delay in definitive treatment. Then again, the majority of UK patients are also less inclined to be so demanding. Many appear to believe that their healthcare experience is still adequate and acceptable. Thus, differing expectations can influence a population in their demands for varying degrees and speed of specialized health care access.


A proper rational and balanced perspective should be made known to the public, and must underpin the social contract of any government or authority in charge of health care. Our Ministry of Health must engage in a realistic dialogue to set an acceptable benchmark, and allow the public to form a sensible expectation of their needs and wants vis-à-vis medical care and its cost-effectiveness. Superlative and unbridled medical therapy is a bottomless pit which can bankrupt any economy.


The time to reevaluate our healthcare system is perhaps best carried out now. Begging for public funds to have quicker or more costly medical treatment of any sort cheapens and undermines our health care system which is already commendable by many reasonable measures. Of course we can improve on our presentation and our strife towards excellence. But we cannot really afford luxurious medical care for all, with the current rate of our healthcare spending. Nor is it justifiable in the long run to be wasteful, simply to pander to a few... Our media can play their roles by helping to reshape the sensitivities and correct the misguided mindsets of our public, and not over-dramatize the plights of individual sufferers, without checking on the authenticity of need.


Perhaps this is the time and juncture to set up an independent tax-exempt centre to coordinate donations for the explicit purpose of helping the poor and the less privileged to gain access to special health and medical care. Catastrophic illness can be extremely expensive and financially-draining. Understandably, we do desperately need a hassle-free yet professionally-run charity or community chest—our very own Pusat Penyayang, or such like. This Charity can then serve as the centre for the public to channel their generosity, and for others to gain quick and efficient access to reasonable funds, when these are judged as medically-warranted. Because public funds are solicited and utilized, these funds must be carefully utilized and scrupulously accounted for and managed. Administrative and other extraneous costs must be kept to a bare minimum so that the bulk if not all of the monies collected can be disbursed to as many of the needy as possible, without too much wastage. The priority must be to best cater for as many of the truly needy as possible.


This means that most of the required medical procedures or surgeries should be carried out in our public hospitals and facilities, where good expert care is available, and may be obtained at the most reasonable cost. Having said this, uncomfortable and prolonged delays must be made as tolerably short and humane as possible. There should also be systematic and appropriate expansion of our healthcare services to tackle such bottleneck areas of specialized medical care. Such critical services must be recognized and appreciated by one and all. They must be made sufficiently rewarding for physicians, surgeons and technical staff alike, so that the public health care facilities can staunch the haemorrhage of untimely resignations of qualified, highly-trained but frustrated staff to the private sector. Mechanisms to curb such attrition of expert manpower must be put in place more generously and aggressively.


For private facilities which may wish to participate in this, they must offer substantial discounts and preferably allow the involved specialists to exercise their social and humanitarian conscience, by offering their expertise at the lowest rates possible and preferably gratis and from the heart—after all, these will not in any way diminish their economic cake or social standing. Conversely, this can further showcase the increasingly hidden but noble face of our much maligned specialist medical practitioners…


Perhaps it is time the Ministries of Health and/or Social Welfare together with other interested philanthropic or society leaders make such a Charitable Trust or Community Chest a reality. The appropriate time to act is now.


"Human beings, by change, renew, rejuvenate ourselves; otherwise we harden." – Johann Wolfgang von Goethe


“Relationships evolve over time – readers’ demands for information, erudition and entertainment grow and change – and newspapers must keep up, not just in parlaying news, but in how this impacts on the reader. So the changing role of the media consists of two equal parts: readers and their societies, and the industry itself. … the changing role of the media rests on how it handles and articulates public opinion, and how this will contribute to democracy and strengthen its institutions. That is a very big responsibility…” – Tan Sri Abdullah Ahmad, Message makes the medium, New Straits Times, 31 July 2002, p10.


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