Tuesday, July 03, 2018

Specialist brain drain a public healthcare woe

HAVE you ever wondered why private hospitals not only survive, but thrive, even though the federal government provides our people with close-to-free or highly subsidised public healthcare?

This phenomenon is largely observed in more urbanised, advanced states, where private care is highly concentrated, such as Kuala Lumpur, Selangor, Penang, Malacca and Johor. The question is, what is it that makes locals willing to look past the additional expenditure, and bear the brunt of paying expensive private hospital bills?
According to the 2015 National Health Morbidity Survey, Malaysians who would rather admit to private hospitals tend to belong to one or more of these groups: urban dwellers, aged 30 to 59 years, ethnic Chinese or Indian, private employees, tertiary-educated, and middle-upper household income.
Statistics indicate that private hospital clients are financially better off and at the career-development life stage. The survey also revealed several reasons why people are unhappy with public hospitals: long waiting time for doctors, not being allowed to choose a doctor, difficulty in choosing wards, among others.
When it comes to private hospitals, besides possessing an established reputation, a comforting interior design and space, and state-of-the-art equipment to treat patients, the largest “asset” is actually the line-up of medical specialists, or more accurately, experienced and well-known medical consultants. Once a loved one’s health is at risk or their life is on the line, most of us would go to all lengths possible to ensure our loved one gets the best possible treatment and the highest chances of recovery. Money might matter less when life is at stake.
Seen in this way, there is a certain impression that specialists are the faces – “brand recognition” – of the host institution (private hospitals), and a major factor in pulling revenue.
Paying more for private healthcare might not always be a rational decision, however. According to Malaysian National Health Accounts statistics, out-of-pocket expenses for private healthcare amounted to RM19.6 billion in 2016, and 78% of private hospital patients decided to pay in this way.
What can we make of the general public’s distrust of government hospitals? The following is my analysis, based on perspectives collected from practising specialists, and data on their movement and numbers.
According to a parliamentary reply from the former health minister, up to December last year, Malaysia had a total of 9,632 specialists registered under the National Specialist Register. Out of these, only about 50%, or 4,843, have remained under the Health Ministry (MOH).
MOH specialists appear to carry the burden of handling about 70% of nationwide admission numbers and a larger proportion of outpatient numbers, day in and day out.
Between 2015 and end-January this year, a total of 502 MOH specialists had quit the public service. A quarter of this number directly cited “transfer to private hospital” as the reason for their resignation.
MOH has admitted that the majority of the resigned specialists held civil servant rankings of Grade UD54 and above, meaning they had served the government for at least nine years and were considered relatively highly experienced. Assuming that these specialists did not emigrate to take up better positions aboard, this brain drain from the public sector almost directly translates into the private sector’s gain.
The widening experience and skills gap between public and private healthcare may explain why certain segments of the public have a poor perception of the public healthcare sector, when they see excellent and experienced specialists crossing over to private hospitals one by one.
Taking Penang as a case study, I observed that in 2016, not only was the number of specialists in private hospitals twice those working in MOH hospitals, but in terms of average career experience, private specialists also outstripped their MOH colleagues by seven years!
This was in spite of the fact that MOH hospitals in Penang provide 45 specialty and sub-specialty services, while private hospitals only cover 35 of the more “popular” specialties.
The public sector specialist brain drain must change, especially now, after the watershed 14th general election, and the dawn of a new government. If the government is serious about changing the public’s negative perception of and bias against public healthcare, it should first and foremost keep specialists in public service.
In my opinion, it is unreasonable to expect the government to raise the salary of its specialists to be on a par with those working in private hospitals. A better and more effective approach to tackle the issue is to adjust the emolument and promotion system. It would be better if MOH could decouple from the current rigid civil servant grading system, which is tied to salaries.
It is unfair to the government and taxpayers that while MOH commits considerable sums of money and time to train medical specialists each year, all this goes down the drain when private hospitals can easily lure away the top crop of experienced specialists.
To address this, I would like to offer a bold proposal, that the government impose a “transfer fee” on private hospitals that hire former government-employed specialists, according to the specialists’ experience and skills. The monies accumulated from these fees could go into a foundation to reward deserving MOH specialists, who have a track record of outstanding performance and service. This will surely generate positive recognition, and encourage them to stay and continue serving in the public sector.
Also, to circumvent the permanent loss of experience and skills of talent lured into the private sector, the government should encourage, perhaps, even mandate, specialists in the private sector to clock in a fixed number of hours in public hospitals. This would also enable them to widen their exposure to different and new case studies. 
Additionally, private specialists should help shoulder professional social responsibility, by training housemen and specialists or conducting clinical studies. This would be seen only as fair to their colleagues in the public sector, who are still struggling to keep up with their additional duties.
The edited version is published here at The Malaysian Insight, Voices, July 3, 2018.

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