Monday, October 30, 2017

醫療旅遊對國人是利還是弊?

本週檳中對專欄的文章由我撰寫,我就寫有關醫療旅遊的研究心得。可惜主編放了一個相當‘聳/俗氣’的標題。我的文章是要探討醫療旅遊的利與弊。加上週五的預算案,財長納吉也宣佈撥款發展醫療旅遊,所以更值得我們關注這所謂的‘經濟領域’。
以下是我的文章,附上原標題和副題。
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醫療旅遊對國人是利還是弊?

近年来我国的百货物价上涨,再加上经济仍缓慢成长,中下阶层的人民频感生活压力。若不幸碰上疾病缠身,更是雪上加霜。要寻求治疗,不少公立医院人满为患已是司空见惯的场景。问题是,在檳城,即使求医者来到私人医院,也未必能如愿顺利就医。
一些私人医院採取领號码排队制度,竟传闻有跑腿代领號码的服务;另一些医院,即使有预约,或许也得等上一两个小时才能见到属意的专科医生。在檳城,尤其是在某些大型的私人医院,处处可见眾多的外籍医疗旅客一起排队等候见医生。笔者常听闻有人控诉这些旅客已侵佔了本地人的医疗资源,但也有些人发现要批评却有口难言因为担心会给人排外的印象。具体的政策还是得有人分析,到底医疗旅游业对当地人是利还是弊?
一个政策或商业活动若完全不利於所有人,大概不可能会有任何基础可持续下去。其实更该问的是,到底是谁会从中得利,和多少人受惠?

经济效益大
从国家经济的角度来看,医疗领域被纳入12个国家关键经济领域(NKEA)的其中一项。
仅是来自私人医院的收入,在2015年已贡献了国家90亿令吉,其中12.9亿令吉来自檳城。而同年的马来西亚医疗旅游理事会(MHTC)数据显示,私人医院从到访檳城的医疗旅客赚取了3.5亿的收入,相等於27%整体私人医院的总收入。对於檳州2015年州內总產值761亿令吉的经济体来说,来自私人医疗和医疗旅客的收入相当可观。
外籍医疗旅客和伴隨著的亲友,来到目的地除了往医院走一趟寻求护理治疗以外,还得安排膳宿和交通。所以传统上与旅游业相关的服务业,例如航空业、交通服务业、酒店饮食业和观光旅游业等都可能分得一份羹。
根据檳城环球旅游机构2016年度的《檳城旅客调查》统计,医疗旅客在檳城的平均消费是一般外国游客的2.2倍,而且將近3/4的受访者已重访檳城。所以,对从事旅游业的业者来说,他们对医疗旅客与亲友的到访趋之若鶩无需感到意外。

本地人有更高的服務要求
撇开旅游业不谈,医疗旅游业同时也增加了医疗护理相关的就业机会。2015年,檳城的私人医疗服务业就僱用了1万1143人,其中包括1118位医生和3928名护士。医疗旅游或许同时促使檳城私人医疗界增码投资,除了提升医疗设施,也增加医疗人力资源,凝聚最佳的专科医生和医护人员。
成果是,檳城的医生和护士对人口的比率比国內平均值和大多数州属还低,意味著檳城人拥有更多的医护人员提供服务。此外,根据2016年的另一份调查,有96.7%的受访者表示可以在住家的方圆5公里的涵盖范围內寻得公立和私立的医疗护理服务。
以上所提及的医疗发展好处,对正寻求医疗援助的当地人来说,他们会直接感受到吗?或许一些人认为在私人医院求医需付费,所以要求和期望就自然越高。2015年的《国家卫生和病態调查》报告透露,有高达9%的檳城人不满在私人医院的等候时间,另外55.1%的受访者不满其医药账单。这些给予私人医院「差劲」评价的檳城人比率,明显比全国平均值高出二至三倍。
比起门诊病人,住院病人通常所需的医护资源是最多的。檳城卫生局2016年的数据显示,檳城私立医院的住院人数(15万7495)高於公立医院(13万3095)。这与全国和其他州的比率趋向是相反的,如在2015年全国公立医院的住院人数是私人医院的2.5倍。
另外,MHTC的数据指出,医疗旅客来檳城的人数(不分门诊或住院者)从2011年的26万8600增至2016年的30万400,涨幅有大约40%。根据檳城研究院尚未公佈的研究分析显示,横跨癌症、循环系统(包括心臟病和中风)和肌肉骨骼系统三大疾病类別,可见医疗游客的住院人数和比率自2009年起逐年增加。
儘管住院比率下降,本地人对私立医院的床位医护需求依然有增加。如此的趋势延伸下去,倘若医疗旅客增长的速度更快但本地人的需求也同时增高,医院却又无法在硬体设施和人力资源方面跟得上,人民对医疗旅游政策的不满积怨就更深。

挖角专科医生
一些私人医院常强调他们能召到不少长期在海外服务的资深专科医生回国,笔者相信这不可能是医院的一般作业,因为这类的大马籍海外专才毕竟还是非常有限,有念头要回国的或许更少。
根据笔者的研究发现,儘管在公立医院服务的医生总人数较多,私立医院拥有的专科医生数目几乎是公立医院的两倍。
由於我国法律的约束,院方不能够隨意或轻易地聘请外国专才,只好从我国有限的人力资源里(不管是来自公立或其他私立医院)挖角一些资深的医生。既然是零和博弈,难道檳城私人医院的挖角就不会影响到公立医疗和其他州属的专科医生人手分配吗?
无可否认,医疗旅游业带来的经济效益是正面的,但这行业伴隨著的社会挑战不小,尤其是如何规划得体应付逐年增长的医疗旅客和本地人的医疗需求。再说,若医院对待医疗旅客和本地人都一视同仁,假设本地人已不满其医疗服务了,难道医疗旅客会满意?


刊登于《東方日報》東方文薈版2017年10月29日

Tuesday, October 10, 2017

撥款不足拖累「全球最佳醫療系統」

預算撥款直接影響公共衛生和醫療護理兩大項目的表現。如果衛生部繼續在資源匱乏下操作,基本化驗樣品和醫藥補給撐不到年底就用完的窘境,最後可能變成常態。這不可能是「全世界最佳的醫療系統」的操作方式。一個負責任愛民的政府應當懂得分輕重,知道哪些公共服務應優先,確保財力資源的投入與承諾的長遠政策相符。當2018年度財政預算案揭曉時,期待衛生部能獲得公平合理的撥款,實際反映出其需要;也希望即將來臨的政府總預算不會花得不知所謂,都消耗在明年大選。

【文/林志翰】
記得今年初,首相納吉風光滿面地宣佈馬來西亞擁有全世界最佳的醫療系統,他的憑據是一份國際雜誌International Living月刊的評估,結果遭受網民冷嘲熱諷。這或許反映出國際雜誌對國內公共和私人界醫療的評估,與一般老百姓的實際體驗或印象有著極大落差。納吉這項宣佈也被譏為「一令吉肉雞」般的務虛政治秀。
其實,大部分國人也不怎麼計劃本身的醫療保健事項,更遑論分析醫療政策——只有當病痛找上,才慌張尋找醫療援助。馬來西亞人何其幸運,因為我們的醫療系統是襲自前殖民國英國的貝弗里奇(Beveridge)模式。在這系統裡,政府不但是資方,同時是主要的醫療服務供者,也是公共醫療衛生的策劃者、監管者和執行者。公共衛生是排在國民教育服務之後,政府(幾乎免費)提供且耗資第二高的福利項目。在我國,求醫看病被看成是人民的權利,因為有政府作為靠山。反之對比鄰國新加坡和印尼,較常強調個人對健康的責任,國民更意識到自身的醫保存款、保險金和共同付款(co-payment)金額,是否足夠應付醫療服務的不時之需。
衛生部經常宣稱我國衛生系統是進步(progressive)和扶貧(pro-poor)的,因為公共衛生的財源主要來自一般稅收(我國稅收架構理論上應是越富有的被課稅越多)。這再對比公共醫療的主要使用者是來自最低的40%社會經濟階層人士。我國的共同付款費用價單自1982年以降已不曾調整,如今已幾乎是象征式收費(一令吉看外科,五令吉看專科)。這些收費匯集起來,估計只達政府用在醫療衛生上的2%開支。
至於國人對我國醫療系統有何要求?大概可歸納為:
一、距離合理:醫療設施與居住社區保持在合理距離以內;
二、可負擔:治療費合理並有可能讓家庭負擔得起;
三、有效率:等候期間和治療需時合理,不至於影響病患者的工作和生活;
四、優質護理服務:以最有效和專業的方式治療護理,同時也尊重病患者。
問題是,衛生部是否已準備好充足「銀彈」,憑著長遠全面的策略計劃來提升硬體設施、增加醫療勞動力以及改進醫療服務效率(即提高產量又控制開銷)?
錢要花在刀口上,是一般生意人熟悉不過的概念。政治上何嘗不是如此?財政預算案就是檢驗一個政府對政策的執行誠意,尤其在資源有限下更能體現政府對各政策拿捏的優先態度。
近來,衛生局總監諾希山公佈2016年政府醫院的外科診戶訪次比起2015年高出一千萬,或22%的需求增長率。正因如此,衛生部長蘇巴馬廉埋怨2017年預算案撥款給該部門並不足夠,敦促政府明年撥出更高預算。
醫藥費上升是全球趨勢,國內私人醫療界也感同身受。2017年的《全球醫藥趨向走勢》報告(Global Medical Trend Rates)預測馬來西亞的醫藥通膨率可達12.0%凈成長,是亞洲區的兩倍(6%)。這無形中也給衛生部增加更大壓力,因為今年的預算只見區區7.7%的成長。
據報導,2016年私人醫院病患者訪次下降了20%至30%,只因更多人寧願選擇公共醫療服務。可見私人醫院本身也是醫藥通膨的受害者。近年來政府大力鼓吹醫療旅遊(medical tourism),對外宣稱我國醫藥費多麼的廉宜可負擔,惹惱了不少本國人。早前2015年《國家衛生與病態調查》報告(National Health and Morbidity Survey)顯示,公眾對私人醫療治理收費的印象傾向負面,高達25.9%的全國受訪者直接給予「差勁」(poor)的評分。這說明了國家經濟停滯不前,更多尤其來自中低家庭收入階級者無法負擔私人醫療,更甭說當發生大病急症。奈何在2015年全民醫療開支帳目裡,只有8%的付費來自私人醫療保險,未雨綢繆投保的人口估計少於10%。政府對此責無旁貸,必須準備好在來年迎接更多病人從私人界「回流」到公共診所醫院。
衛生部官員雖常辯稱更多財政資源無法保證醫療服務素質的提升,不過事實上,去年提呈的「縮水」預算直接影響了公共衛生和醫療護理兩大項目的表現,因為絕大部分的物資和服務供應項目皆被大打折扣。試問在這種情況下,醫療服務素質有可能會提升嗎?如果衛生部繼續在資源匱乏下操作,基本化驗樣品和醫藥補給撐不到年底就用完的窘境,最後可能變成常態。這不可能是「全世界最佳的醫療系統」的操作方式。
為了舒緩醫療系統的強大公共需求壓力,政府應助衛生部一臂之力給予更多發展撥款來提升硬體兼軟體設施,尤其是目前擁擠爆棚的大都市政府醫院。自2010年,衛生部的發展撥款卻不增反減,2017年的13.4億令吉更是八年來最低的數額(見表一)。
參考了多項因素包括預估的15%醫藥通膨率、各部門10%至20%的薪金調整,加上預計中更高的人民需求後,衛生部必須爭取到比2017年還多出15%以上的撥款預算。換句話,該部門明年的預算得大於285億令吉才能安心運作。

一個負責任愛民的政府應當懂得分輕重,知道哪些公共服務應優先,確保財力資源的投入與承諾的長遠政策相符。我個人寄望,當2018年度財政預算案揭曉時,衛生部能獲得公平合理的撥款,實際反映出其需要。希望即將來臨的政府總預算不會花得不知所謂,都消耗在明年大選。

Sunday, October 01, 2017

Bigger budget health allocation an absolute necessity


WHEN Prime Minister Datuk Seri Najib Razak proudly declared that Malaysia has the best healthcare system worldwide (as rated by a monthly magazine, International Living), many social media users responded to his statement with cynicism. This reaction was perhaps due to the discrepancy between the magazine’s evaluation of public and private healthcare and the reality experienced or perceived by Malaysians.
Most people do not give much thought to planning for their health, let alone healthcare policies, until illness strikes and the need for medical assistance arises. Perhaps we Malaysians do not realise how fortunate we are.
In terms of health systems, our country’s model has inherited the Beveridge model from the UK, in which the government acts as the major healthcare provider and payer in addition to the roles of public health planner, regulator and enforcer.
In this welfare-based system, many Malaysians may have taken their right to health for granted, unlike in Singapore and Indonesia, where individual responsibility is more heavily emphasised. There, citizens are more mindful about their own health savings, insurance premium and co-payments for healthcare services.
Those of us who utilise healthcare services would typically rate the system according to the following factors: (i) Accessibility: whether facilities are located within a proximate distance to their community, (ii) Affordability: whether fees charged are reasonable and in accordance with their household income (iii) Efficiency: the waiting period to receive treatment should be reasonable and not impede the patient’s work and life, and lastly (iv) Quality care: care should be delivered in an effective and professional manner, and the patient treated with respect. 
Our Ministry of Health (MOH) often claims that Malaysia’s health system is progressive and pro-poor, as public health financing is largely derived from general taxation (where the richer get taxed progressively more) and public healthcare majority users are mostly from the lowest two socioeconomic segments (Quantile 1 and 2, poorest 20% and the next 20%) of society. Moreover, co-payment user fees (unrevised since 1982) are extremely nominal (i.e. RM1 for outpatient visit, RM5 for specialist visit). This amounts to approximately 2% revenue collection against healthcare spending.
The crux of the issue is whether the MOH has adequate finances to meet the rising demand, and a holistic long term strategic plan to (i) expand the infrastructure and facilities capacity (ii) increase the health workforce while (iii) improving efficiency of healthcare delivery (i.e. containing cost but increasing productivity).
The global rise of medical costs is being felt in Malaysia’s private health sector too. The 2017 Global Medical Trend Rates report has forecasted Malaysia’s medical inflation rates to experience a 12.0% net increase, twice the Asia net average (6%). This increases pressure on the MOH to contain costs, especially given the mere 7.7% increase in allocation in the 2017 Budget.
Recently, the Director General of Health Dato Dr Noor Hisham Abdullah told the media that “(the MOH hospitals are) seeing an additional 10 million outpatientslast year compared to the 45 million received in 2015”. This number translates to a 22% increase in service demand.
To that end, health minister Datuk Seri S. Subramaniam was right in claiming that the 2017 budget allocation was not enough and to urge for greater resource allocations next year.
Private hospitals are also the victims of rising medical cost. Last year, these hospitals suffered a 20-30% drop in patient volume as more patients opted for public health service. The National Health and Morbidity Survey 2015 found public perception towards treatment charges in private healthcare to be somewhat negative, with 25.9% respondents nationwide giving it a ‘poor’ rating.
An increasing proportion of those from middle and lower household income classes could not afford to utilise private healthcare services, let alone in the event of a catastrophic illness. Out of the total population health expenditure in 2015, only 8% of contributions were made from private insurance. While not entirely conclusive, one may safely assume that under 10% of citizens had private insurance coverage. A greater volume of patients may turn to public health facilities in coming years. The government must be prepared for this increased pressure on health services.
Granted, greater financial resources does not necessarily guarantee an improvement of services; nevertheless, last year’s stretched budget did affect Public Health and Medical Care, with across-the-board reductions for most services and supplies line items.
If MOH still continues to operate under-resourced, the likelihood of basic test materials and medical supplies running out of stock may become a more frequent and familiar scenario. In line with the increasing public demand for healthcare services, more resources should be given to MOH’s development budget to expand the current capacity of the healthcare system as well as to alleviate the current stress in the system.
After considering various adjustment factors such as the forecasted 15% medical inflation rate, typical salary  increases of between 10-20% per department, and a projected higher healthcare demand from the public, the MOH should minimally secure a 15% larger budget allocation compared to what it received last year (in other words, more than RM28.5 billion).
Spending priorities should be to ensure that at the very least, all drugs listed in the National Essential Medicine List (NEML) and basic test reagents are readily available at all times. Furthermore, MOH should channel an appropriate level of funds towards increasing capacity and improving service delivery in all its healthcare facilities, especially in congested urban hospitals.
A responsible government should set its priorities right for the type and amount of public investments to make, to reflect how much they care for the well-being of the people. For this, long-term strategic planning, not firefighting, is the way to go. It is my hope that, when the 2018 Budget is tabled, the MOH receives a fair allocation that matches its needs.