Is the 2019 health budget well placed?

On November 2, Finance Minister Lim Guan Eng presented the first budget from the new ruling Pakatan Harapan coalition, including allocations of operating and development expenditure to the Ministry of Health (MOH). Most observers expected the government to fulfil its pre-election manifesto promises, such as increasing MOH’s budget allocation to 4% of GDP; the implementation of “Skim Peduli Sihat”; the tackling of non-communicable and rare diseases; and strengthening partnership and collaboration with the private sector and NGOs.

I analysed the MOH budget from two perspectives: first, through the policies and programmes announced in the speech, and second, the estimated federal budget for each department within the MOH. Both the share and absolute amount of the budget allocation are important determinants.

Happily, the MOH allocation for 2019 has reached historic heights, totalling RM28.7 billion. Compared with Budget 2018, the health budget has increased by 7.9%, and takes a 9.1% share of the total federal budget. However, the current allocation equates to only 1.87% of GDP – an almost unchanged figure since the last budget. Health Minister Dr Dzulkefly Ahmad conceded that this round of allocations is unlikely to fulfil Pakatan Harapan’s manifesto pledge to devote 4% GDP spending on the public healthcare sector; instead, he proposed to establish the Real Estate Investment Trust (REIT) to raise an additional RM3 billion. In the budget speech, the finance minister only mentioned the airport REIT, while hinting that hospitals could also be a possibility in future. Raising public funds through this REIT approach sounds as if the government is doing business, and some in the public might not approve of such a controversial plan.

Prior to the budget, the “Skim Peduli Sihat” proposal had been widely discussed. In his speech, the finance minister had announced and rebranded it as the National Health Protection Fund (NHPF). This is a medical-related social welfare programme aiming to help people from the bottom 40% low income households (B40). Unexpectedly, a private healthcare insurance company will contribute RM2 billion in initial seed funding to the same fund managed by Bank Negara Malaysia (BNM). Some have reservations if such a fund pooling mechanism would present a conflict of interest. According to The Edge, the company is looking to negotiate a deal with the government to be exempt from the new requirement of maximum 70% foreign ownership of local insurance businesses, with this contribution. 

The NHPF programme will provide medical care in private medical institutions free of charge only for four critical illnesses. The maximum annual claim threshold given per person (or household?) is capped at RM8,000. This is contrary to the news reported few months ago that the programme will provide the B40 with between RM10,000 - RM20,000 per household, for in-patient care at private hospitals – without stating the restriction of illness categories. To date, which four illnesses the MOH intends to cover is still uncertain, but if these were serious and critical illness, RM8,000 is a mere drop in the bucket. What if these B40 patients find that their medical fees heavily exceed RM8,000 – should they be held liable? What is the claim mechanism for the benefits? Can a B40 patient go directly to a relevant specialist in any private hospital? If the government does not have a good system of claims management, in addition to government provision of RM50 daily hospitalisation income (maximum of 14 days per year), private hospitals are likely to receive a higher number of B40 patients with these critical illnesses and ultimately gain the most benefits from this programme.

Living up to MOH’s commitment to reduce the incidence of non-communicable diseases, a few progressive policies have been proposed, such as the sugar-sweetened beverages excise tax. The sugar tax is fixed at 40 sen per litre, if the beverage exceeds a certain concentration of added sugar content. In my opinion, the magnitude of the excise tax is not large enough to disincentive consumption. Unless the government continues to campaign heavily against high sugar-laden food and beverages, we should not expect this policy to significantly alter people’s food-consumption behaviour, or reduce obesity levels. On the other hand, the government’s determination and efforts at meeting its goal of a smoke-free Malaysia by 2045 are more obvious, with stringent measures to curb smoking in public.

Furthermore, the government should be applauded for a special budget allocation to treat rare diseases, strengthen primary healthcare, and provide health screening services to B40 senior citizens aged 50 and above. These actions reflect the ruling coalition’s election promises, and more are appropriate and timely public health policy directions to take.

Preventive care ensures residents become healthier in the future. However, for those who are currently suffering from various diseases, there is still a need for affordable, accessible and quality medical care. The current budget allocates RM10.8 billion for drugs and supplies purchases, as well as funding to upgrade and improve the quality of healthcare services in government clinics and hospitals. Comparing allocations between Budgets 2018 and 2019, MOH will have RM88 million more in funding for the purchase of drugs and medical products. 

Allocations for public health reflect the government’s policies in strengthening preventive care and primary healthcare, such as providing wider selections of free vaccination and health screening services. The current MOH budget has seen an increase of RM130 million to its public health pharmacy and supplies division, though this is mainly for purchase purposes.

For development expenditure (DE), the government will allocate RM800 million to upgrading and expanding hospital facilities in 2019, amounting to a RM132 million increase in funding. The allocation for building new hospitals has doubled, by an increase of RM140 million. Whether this is sufficient to meet the demand is uncertain, looking at the current situation where many government hospitals are overcrowded and facilities and equipment are desperately in need of repair and maintenance. In any case, the additional DE funding is crucial and pertinent. At least the government has tried its best to increase the allocations despite current budget constraints. 

Budget documents are useful indicators for understanding the government’s departmental operations, policy direction and priorities, as well as political determination for the upcoming year. Whether or not the MOH will manage its financial allocations well and achieve its policy targets by the tabling of Budget 2020 remains to be seen. As the idiom goes, put your money where your mouth is.

The article was published here at The Malaysian Insight, Voices, Nov 13, 2018.

'Samurai' Loans and Mahathir

R:

Any thoughts on the Japan ‘samurai’ loans? PM is back in Japan for the third time. Possible he’s raising more loans from Tokyo?

CH:

It is perhaps the only possible avenue for PM Mahathir to raise loans in favourable terms. Since he took over the premiership, his stances on various mega-project deals with China possibly had angered the leadership in Beijing. After his visit to China, things are still uncertain and nothing is brought back to the country. 

PM is long known to have close ties with Japan since his first stint as PM. In the past, he brandished himself as the third world leader or hero did not augur well with western power especially the US. More so, occasionally his remarks were close to anti-semitic, this does not sit well with many powerful financial institutions in the US. 

The overblown-mentioned and often-exaggerated national debt and liabiliaty/ contigency issue , also does not help Malaysia secure loan deals in favourable terms. Therefore, it is best for him to stick with his best ally and perhaps few friendly (and rich) partner.

R:

Ahh. That’s interesting

How good are the deals btw?

Interest is definitely low at 0.65%, but what else is there?

CH:

RM7.4 billion at 0.65% is definitely a kill....given the scale of loan.

A prudent government should always know how to handle their national debt by refinancing with better loan deals.

But this favourable loan deal must be seen in the context of Japan-Malaysia diplomatic relationship, perhaps there will be more bilateral agreements to go along with, which would be in the interest of Japan too.

R:

Is a yen loan considered to be safe? I’ve heard how a ‘strong yen’ and a ‘weak yen’ can greatly affect the Japanese economy

CH:

i dont know what is the loan release mechanism over 10 year period, yes the currency fluctuation might be a risk, still it could be a risk worth taking given such floor interest rate.

R:

Ah okay, thank you Chee Han

He's also getting a medal, second highest honour

Is that a sign that they really admire him?

CH:

This is a symbol of appreciation to Dr M for forging a cordial relationship between Japan and Malaysia. Indeed Dr M has done a lot (that must have also drawn irks from China)

R:

Hahaha true

Looking at the past recipients of the award, it seems well curated

The Japanese don't simply throw medals to just about anybody

CH:

in half year 3 visits to Japan as a PM, that record deserves a medal already lah 😂

Minimum Wage and its implications to Singapore

Last week, I had accepted a written interview with a journalist from a Singapore press, questioning me on issues related to Minimum Wage, and what would be the implications to Singapore.

Below are my full responses given, but understandably, she only quoted me on two occasions because she had also other interviewees to give inputs.

***

1. I understand there are plenty of reasons for and against minimum wage. But at the core of it is about social inequality - can minimum wage narrow the income gap? What is a minimum wage policy supposed to achieve actually?

CH:

According to International Labour Organization (ILO), minimum wage is defined as “the minimum amount of remuneration that an employer is required to pay wage earners for the work performed during a given period, which cannot be reduced by collective agreement or an individual contract.”

The core function of minimum wage is acting as a form of workers protection mechanism against unduly low pay. The amount of pay signifies a minimum expectation of a fair and just compensation to the fruits of labour regardless of which sector one works in, and who are employed (domestic and foreign, too, should be equally applied). Some coin it as minimum living wage to hedge against poverty, to allow a worker to live with dignity with at least that amount of remuneration to survive.

If the ‘social inequality’ you referred to (in the first part of your question sentence) means income inequality, implementing or raising the minimum wage could have cascading effects on the lowly paid jobs at the most bottom of labour market (ie. jobs which are paid slightly above the minimum wage would usually be pressured to adjust accordingly), and it should effectively help increase the income of low income workers, periodically.

Whether or not the so-called income gap could be narrowed, actually that depends more on the growth rate of top and middle income tiers. Periodic adjustment of minimum wage is usually at most a couple of hundreds if not at least tens of dollars, compared to middle and top income earners their salary increment could be in the range of few hundreds to tens of thousands during the same period. If that is the case, in real term, the income gap could be also widen even if minimum wage is implemented.

2. Can minimum wage be effective without supporting policies like capping top wages? What about protecting price inflation as a result of minimum wage?

CH:

The purpose of implementing minimum wage is not to reduce income equality via restricting or capping on top wages, but uplifting the low income households.

In the reference formula for setting a minimum wage rate in Malaysia, it clearly considers a few key macro- and microeconomic factors such as labour productivity , consumer price index (inflation rate), poverty line income , average number of workers per household, and median wage (for bottom income tier).

One should also consider what is called ‘social wage’ where certain basic public services (as social safety net) are provided to citizens so that the low income earners do not have to fork out their precious little wage to pay for such services. Effectively, living in such society with good public and social support in many ways could help increasing disposable income and relieving the household financial burden, particularly meaningful to the low income households.

3. Proponents of minimum wage believe that wage would drive demand and spending, spurring the economy. How true is that across economies? Meanwhile, the other side believes profit drives demand, and spurring demand for businesses would drive employment and wages rather than having a minimum wage.

CH:

With the implementation of minimum wage, low income earners would expect better and more stable income prospect in supporting their ever-increasing living cost.

The establishment or increment of minimum wage would contribute additional financial resource to low income earners, but most likely they will spend or cross-subsidize most of it on rather essential items purchase.

For example, according to Household expenditure survey 2016 in Malaysia, household income class lower than RM2,000 per month had already spent more than half of their income on food , housing utilities and transport.

So, additional amount of wage could be translated to additional household expenditure, and this could help spurring or favouring certain sector or industry rather than across the board. Small businesses such as hawker food stalls and petty traders are more likely to capture the extra amount of household expenditure. Thus, as a result of minimum wage policy (if the amount is appropriately set), it could have positive effect in encouraging  businesses and employment, rather than forcing businesses to shut down.

4. I know policy makers are most afraid that minimum wage will result in reduced employment or illegal work

CH:

For the case of Malaysia, the total number of employment is actually increasing after Malaysia first implemented the Minimum Wage in 2013.

This policy may be partially responsible for the improvement in labour force participating rate (LFPR) from 65.6% in 2012 (pre-minimum wage policy) to 67.7% in 2016. The implementation of the minimum wage policy also coincided with an increase in women’s participation in the labour force, where female LFPR reached 54.3% in 2016, up from 49.5% in 2012. The number of employed persons in Malaysia also increased from 12.8million in 2012 to 14.2million in 2016. This clearly shows that employment opportunities and labour participation in Malaysia were not negatively affected by the minimum wage policy.

For the case of Singapore, if the minimum wage policy were implemented, most likely it will only positively affect the low income earners, together with foreign migrant workers (who hold work permit - 965,200 and S-pass - 184,400, as of Dec 2017). Given that Singapore has a large foreign workforce and many are in the low income categories, the minimum wage should be set at appropriate rates in the most transparent manner. If the employers feel ‘too expensive’ to continue hiring foreign workers (such as in the construction and domestic works) perhaps they really pay too low to workers, or they should consider hiring local Singaporeans who still want to work if the minimum wage is decent enough for living. In this way, perhaps Singapore could be more self-reliant in local labour market, or pay a right price for foreign labour.

I do not think that the Singapore authority could tolerate illegal work, and most probably local Singaporeans would not accept a lower paid job than the minimum wage. For foreign workers, I doubt that they can do illegal work easily in a city state which is rather tight in immigration control.

5. ...and make the country uncompetitive for MNCs to take root?

CH:

I believe most of the MNCs Singapore attracted are not in labour intensive low-skilled industry, thus most likely their staffs/workers are not near the minimum wage. Labour policy could be a consideration for MNC to invest and grow in Singapore, but probably more towards the existent supply of middle to high skilled workers, such as those in the finance, education, health and IT sector.

The minimum wage could have uplifted many low income local Singaporeans who do not have much bargaining power to their employers, and yet face wage depression due to differential payment to foreign and local workers. They need some kind of workers protection in term of wage arrangement in order to live with means in an increasingly more expensive city.


6. At the core of it, is the basis for minimum wage a moral argument?

CH:

I do not think it is JUST a moral argument, but a fundamental labour right. If the labour do not have strong and independent unions, the compensation for their fruits of labour (in terms of wage) would just leave it to the market to determine, however due to very unequal power heavily-tilted to the employer side, the workers would most likely get unfair deal and undercut. This would actually reduce the welfare of workers in the city. Making their life harder is not going to make them happier, there would be a social cost and negative externalities to that policy.

I think the government should take pro-active approach to protect the welfare of workers, show the care by standing on the workers’ side to prevent them from being abused by the market.

7. Just want to check if there is any data on impact of minimum wage on Malaysian SMEs?

CH:

Malaysia has introduced minimum wage on 1st January 2013 (RM900 for Peninsular Malaysia; RM800 for East Malaysia) and revised on July 2016 (RM1,000 for Peninsular Malaysia; RM920 for East Malaysia). 

The annual growth of SME GDP actually shot up in 2014 and 2017(p) after the introduction and revision of the minimum wage rates. In terms of SMEs contribution to GDP, the percentage share of SMEs is growing year-on-year, even after the intervention of minimum wage policy. Biggest jump was in 2014, a year after the introduction of minimum wage.

 

Source: Department of Statistics, Malaysia

According to Economic Census, there was a 42% increase in number of SME establishments in 2015 compared to 2010, after the introduction of minimum wage policy. Numbers of value of gross output, value added, total persons employed/engaged were also increased, compared to 2010.

Source: Economic Census 2011 & 2016, Department of Statistics Malaysia

This shows that the minimum wage policy did not negatively affect the growth of SME industries (as a whole) in Malaysia, the economic growth for SMEs continues and maybe for better. Besides, the policy might have produced more social values that cannot be captured by the economic values stated in the statistics.

健康關懷計劃的隱憂

注：這文章隨著財政預算案和最新計劃內容的發佈，現在已‘過時’了。當初是為了配合英文文告一起推出，怎知來不及。就放在此當作記錄。

健康關懷計劃的隱憂

前天，希盟新政府財長林冠英在國會提呈了首份財政預算案。衛生部的預算也包括在其中，最受矚目的是新政府欲落實的大選承諾——‘健康關懷’計劃（Skim Peduli Sihat, SPS）。這是一項針對家庭收入最底層40巴仙 人民（B40）而策劃推行的醫療福利計劃，主要是為了減輕低收入病患者的醫療費用負擔并提供另類選擇，同時舒緩那些擁擠爆滿的政府醫院。預料這計劃將會獲得相當可觀的撥款資助，但由於本文作者在截稿之前無法窺探而知準確數目，以及其執行落實方式，所以本文在此僅梳理該SPS計劃可能帶來的隱憂，同時論述它如何進而影響整體的公共醫療體系。

對於一個估計耗資大約14億馬幣的大型福利計劃‘重頭戲’，可惜公眾不太清楚甚至不知道有如此的計劃，甭說政府咨詢他們的意見。在公開場合，衛生部部長和副部長對該計劃的描述不多，僅說明如今政府的新計劃會比雪州政府的原版計劃更佳，而計劃細節將在預算案當天公佈。據了解，B40成員將可獲得免費醫療，包括在私人醫院接受治療。此外，政府還雄心勃勃為B40添加預防性治療、保健宣傳以及與非感染疾病有關的健康檢查服務。政府也不時暗示著這計劃將會是挺進國家保健計劃的第一步，就先從B40低收入群開始著手。

公共醫療發展撥款或受影響

在有限的訊息情況下，我和夥伴針對該計劃完成和發佈了一項研究，欲告知公眾這計劃存在著非永續性的高風險，即使就僅提供給B40群私人醫院入院服務而已。首先，我們根據2015年《國家衛生和病情調查》報告裡的尋醫選擇行為和頻率，計算和預測了B40對私人醫院的住院和門診治療需求。然後我們再對照原版雪州SPS模式的粗略預算，即每B40家戶可獲每年五百令吉的資助。如此一來，該計劃的最高預算可達14億令吉，或相等於2018衛生部預算撥款的5.3巴仙。

我擔憂的是如果兩天前公佈的明年財政預算僅僅是數目調整而沒有遵循競選宣言里承諾顯著提升撥款，那麼該SPS計劃的撥款不是要與其他現成的營運和發展項目競爭嗎？

我也擔心，推行如此的計劃將加劇其他方面的撥款削減，特別是衛生部的發展撥款。我國的公共醫療設施要持續提升擴張和發展，這也是政府一再向人民保證的承諾，其重要性不在話下。可是，SPS計劃的撥款若非全部就是絕大部分都會注入私人醫療界，政府又如何自圓其說解釋其矛盾呢？

津貼不足付給手術費

根據統計，2015年B40人口的入院治療普及率是7.8巴仙。我國的平均家戶人口是4.1人，這將意味著每年大約有28.3%或相等於80萬6千的B40家戶將求醫入院治療。同時根據2015年的報告，B40印象中在私人醫院里的重大手術費平均都已超過1萬令吉。這也表示，若SPS計劃提供的家庭補助津貼頂限為1萬令吉，將會有一半以上的B40病人將不足以償還手術治療費。如果說一萬令吉都已不足夠補助一個家庭成員，那麼我國平均家戶人口是4人，一個人耗盡了全家的全年補助後，其他的成員將何去何從？

再說，目前的B40的私人醫院入院率為10巴仙（九成仍依賴公共醫療），家庭收入最高20巴仙階層（T20）人民則為40巴仙。如果就僅依據目前B40的私人醫療使用率，這已達最高SPS預算的56.6巴仙了。但是若有了這SPS計劃提供的津貼，有兩倍到4倍以上的B40成員改變了求醫習慣和選擇呢，會有什麼情景？我們的研究發現，這趨向將會讓該計劃的預算透支破產。尚且這只是入院治療的情景推算，還沒包括門診和健康檢查費用。

政府應控制成本

若津貼索償機制純粹建立在‘有償服務’(fee-for-service)的基礎上，而政府又沒有任何控制成本的措施，我們擔心私人界將有心利用這個制度漏洞，誘發更多B40成員的需求推薦很多不需要的掃描診斷和治療以期獲得最高利潤。這將損及政府的利益。

另一個可能的負面結果是，B40群將會更依賴私人醫療界，從而加劇政府與私人醫院的資源鴻溝，變相鼓勵更多有經驗的專科醫生和護理助手從公共領域轉入私人醫療。無形中，這將造成公共醫療在財務上和各類資源上更落後匱乏，變成某些人民的低劣素質和不得已的選擇，這是政府樂見的嗎？目前的公共醫療仍算是普及，絕對是對人民較廉宜的選擇。

這裡我想給衛生部的建議是，首先必須要賦權初級保健公共領域醫生為‘看門人’，意即SPS受惠人必須先得到醫生的轉診推薦才能前往指定（和已協商過）的私人醫院治療使用津貼。

其二，津貼索償機制不應建立於‘有償服務’，而是相關疾病組費用（Disease Related Group）。這代表醫生或醫院只能根據診斷獲得一筆固定費用治療某病人，而不是根據治療程序和材料。這可間接避免濫用系統和誘發需求。

其三，衛生部應同時向B40成員收取有如目前衛生部的共付額（co-payment），如果後者在私人醫院使用SPS津貼。我們深信這樣才對公共醫院使用者公平。

應優先發展公共醫療

總的來說，我同意衛生部應有伸縮性選擇與私人醫療界共享資源，尤其是當有需要的時候，付費給後者使用他們未充分使用的先進儀器配備和服務。雖然我很高興衛生部致力於提供醫療服務給有需要的B40低收入階層，我還是對SPS計劃的財務永續性和長遠的影響抱有顧慮和保留。特別是當牽涉到如此龐大的財政預算，以及顯著的改變醫療財務系統（往社會保健制度），衛生部應該要更透明和開放給利益相關者和公眾洽詢和質問，不應該先提呈至國會就宣佈了。

我認為衛生部應認清優先處理事項其實是改善和捍衛我們的公共醫療。因此，一個更充分獲得撥款發展的公共醫療系統總比目前的SPS計劃來得更有利益和好處。

点评卫生部財政预算

前天，希盟政府財长林冠英在国会提呈了首份財政预算案，卫生部的预算也包括在其中。最受瞩目的是新政府欲落实的大选承诺，例如把卫生部的预算拨款提升至国民生產总值的4%、「健康关怀」计划 （Skim Peduli Sihat）、关注非感染疾病和罕见疾病，同时加强私人界和非政府组织的合作参与。

点评卫生部政策和財政预算，首先必须从两个层面来分析。一来是財长演说词里所提及的政策和计划事宜，二则是联邦財政预算档案下，卫生部各部门和各目的的拨款分配和数额。

没错，明年的卫生部財政预算是账面上的歷史新高，达到286.8亿令吉。比起今年，涨幅是7.9%，占政府財政预算的9.1%，继续成为获拨款第二高的政府部门。可惜，卫生部的预算数额预料仅达明年的1.87%国民生產总值，几乎还在原地踏步。

卫生部部长祖基菲里早前已默认，不可能圆满大选承诺的4%，甚至向財政部献议要成立房地產投资信託基金会（REIT）来筹资额外的30亿令吉。但在这次的预算案里中，財长仅提出成立机场的REIT，轻描淡写地提及医院会是未来的可能之一。相信以这种「政府做生意」的方式来融资发展，会是未来的趋势，但公眾未必会认同此措施。

B40群体福音？

早前各方密切关注的「健康关怀」计划，在財长的宣佈下已转型称为「国家健康保护基金」（National Health ProtectionFund）。这项针对家庭收入最底层40%人民（B40）而策划推行的医疗福利计划，最后竟然出乎预料，由一家私人保险公司先承担20亿令吉的保费「贡献」给该基金会。

財长还说，这个由国家银行管理的基金会，未来不排除与其他保险公司合作，並寻求补足基金。这难免让人民起疑，到底类似汇集基金的方式对政府来说有没有任何利益衝突，以致该保险公司愿意「奉献」那一笔大数额？除了可让该公司贏得「企业社会责任」公关手法的讚誉，还有没有其他的好处？

再说，让人失望的是，该计划仅针对四个危重病免费提供给B40群在私人医院接受治疗，但津贴控制在顶限数额8000令吉。

转型国家健保制度

过去几个月，在多个公开场合，部长和副部长放出的风声说，这计划將提供每户B40一万至两万令吉的医疗津贴顶限，从未提及疾病数目的限制，曾让不少B40群喜出望外。

笔者暂且未知所谓的四个危重病是哪个，但可以想像如果真的是重大疾病，8 0 0 0令吉根本就是杯水车薪。万一入院了，B40病人发现医疗费远远超过8000令吉，那该怎么办？索取津贴的机制是什么？B40病人可以直接去任何的私人医院找专科医生吗？笔者担心，若政府没有良好的索偿机制和资格条件管理，再加上政府还会提供全年14天、每日50令吉入院津贴给B40的计划受益者，私人医院或许会诱发B40对这四个疾病的需求並从中捞取好处。

財长在讲词里，也提及去年国家银行推出的「安心保护」（PerlindunganTenang）的健康保险计划。他说，该计划的每月保金甚至还便宜过一盒香烟，应可负担。財长还提出购买保险免税的新措施和好处，大力鼓吹人民受保。卫生部从过去到现在，內部一直有一把有力的声音，要把国家的医疗財务制度从目前的「国家税收拨款」，过渡转型至人民直接付费参与的「国家健保制度」。相信政府这次所提的计划正嚮往该政策目標挺进。

减少非感染疾病

不过，笔者对卫生部重视非感染疾病，而提出几个好政策讚赏有加。例如，政府提出征收「附加糖分饮料」税务，目前定率在每公升40仙，如果该饮料拥有超过某个份量浓度的附加糖分。笔者认为，这「糖税」的徵收额不高，除非政府继续高调宣传高糖分饮料和食物的坏处和祸害，不然这政策预料不会改变绝大部分人的饮食习性，痴肥问题依然会严重。反观政府重点打击和「社会歧视」烟民，迈向2045年无烟国度的目標，更能表达政府的决心。

此外，政府推出政策针对性拨款治疗罕见疾病、加强初级护理，並提供全国健康检查服务给50岁以上的B40长者。其实都在某个程度上，落实执政党的大选竞选宣言。更重要的是，这是正確且合时宜的公共卫生政策主轴方向。

预防性医疗是为了未来更健康的国民社会，现今身受百病缠绕的国人仍需可负担，且方便有素质的医疗服务。財长宣佈提供了108亿令吉来购买药物，以及提升改进诊所和医院的医疗服务素质。翻开政府的预算案档案数据来对照今年的拨款，笔者发现相对于今年6600万令吉的拨款，明年政府將发放更多的资金，即8800万令吉来添购药物和医疗產品。

政府在公共卫生拨款方面更为积极，这与他们宣佈要加强预防性医疗和初级护理的政策相辅相成。例如，提供更广更多的免费疫苗注射和健康检查服务。为此，卫生部增加了1亿3000万令吉拨款给「公共卫生药剂和供给」部门，用于採购项目。

在提升和扩充医院设施方面，明年政府拨款了8亿令吉，比起今年增加了1320万令吉。而在增建医院的发展开销方面，政府也几乎翻倍地拨出额外的1400万令吉。无论是否足以应付需求，在目前政府医院拥挤爆满、不少设施设备残旧久未修復，这笔发展拨款的重要性不在话下，至少政府已努力增加发展拨款款额。

俗语说，「把钱花在刀口上」。由于大部分的政策都需要人力和財力资源配合方才能执行，所以欲瞭解政府未来一年的政策方向、政治决心和优先处理安排的事项，財政预算案是公眾应参考最中肯和准確的文件，也是反映当今政策和政府运作的最好指標。

刊登于《東方日報》東方文薈版2018年11月3日

Peduli Sihat-style health insurance scheme may be unsustainable

We view with great concern that the public has been generally left uninformed over the new government’s plan for providing healthcare to the B40s.

At the time of writing, Malaysians still do not have any concrete idea (or worse, have not heard) regarding the previously hinted at healthcare scheme which was listed in one of Pakatan Harapan’s pre-election promises to be implemented within the first 100 days.

The new health minister, Dzulkefly Ahmad has since remained tight-lipped about the development of B40’s healthcare, except to promise that a national healthcare financing scheme for the B40s would be included in the pending Budget 2019 and would be "better" than the Skim Peduli Sihat initiated by the Selangor state government.

He also announced that B40s would enjoy free healthcare under this scheme, which would also include tertiary care in the private sector.

Yesterday, in a press conference he coined the programme a “Social Health Insurance scheme” for the B40 low-income groups, which also includes preventive care, health promotion, health screening especially related to non-communicable diseases.

Based on the limited publicly available information about the operation and allocation of the soon-to-be rolled out federal healthcare scheme, we have produced a study to inform the public about the potentially unsustainable nature of this scheme for the B40s, even if it were to only include tertiary care services.

First, we calculated the B40 healthcare demand projection for in- and out-patient services in private hospitals, based on B40 healthcare and prevalent patterns recorded in the 2015 National Health and Morbidity Survey.

This projection calculation was done to match the estimated budget following the promised original Selangor model whereby every B40 family will be provided with RM500 per year. In this case, the maximum budget could go up to RM1.4 billion (equivalent to 5.3 percent of the Ministry of Health’s 2018 budget) in the current year.

If the MOH budget allocation for the next year is only adjusted nominally and does not get significantly improved as promised in the Harapan manifesto, will we see the allocation for this Peduli Sihat scheme come also from the same MOH budget?

We are worried that the introduction of such a healthcare scheme would result in further cuts to the MOH’s development expenditure, which is crucial to the development, upgrading and expansion of our public healthcare facilities. If not, how could the government justify when most, if not all, Skim Peduli Sihat funds would be spent on the private sector?

In 2015, the prevalence of in-patient utilisation by the B40 population was 7.8 percent. Since the average household size in Malaysia is 4.1, this would translate to 28.3 percent of B40 households equivalent to about 806,000 B40 households needing annual access to hospital care.

Also, according to the 2015 survey, the B40 average perceived the costs for major surgery in a private hospital to be slightly over RM10,000. This indicates that more than half would not have enough to cover their hospital expenses, if the maximum claim threshold limit for the Skim Peduli Sihat were to be set at RM10,000 per family per annum.

When one is diagnosed with major illness or if major surgery is required, RM10,000 is probably inadequate even to treat one person. Malaysia has an average household of about four persons, so if the B40 patient has exhausted his or her family’s annual limit, where would that patient or other sick family members go?

Currently, the B40 utilisation rate for private hospital in-patient services is about 10 percent (i.e. 90 percent seek public healthcare), T20 households are at about 40 percent.

If it is based on the current rate, it would exceed 56.6 percent of the maximum Skim Peduli Sihat budget. But with access to the Skim Peduli Sihat programme, what if the B40 population were to increase their visits to twice or four times the current rate?

Our findings show that it would bankrupt the scheme even if the annual household claim limit is set at RM10,000 for just in-patient services, what more out-patient and health-screening services.

Thus, if the claim mechanism is based on a fee-for-service premise, and the government does not have any cost-containment strategies, we are afraid that the private sector might wrap up the system by inducing demand from the B40 population probably for unnecessary diagnostic scans and treatments, just to maximise profit at the government’s expense.

An unintended consequence of the scheme could be that the B40 group might become more reliant on private sector, this could, in turn, widen the resource gap between public and private hospitals and encourage a greater exodus of experienced specialists and allied health practitioners from the public to private sector.

The result will be that public healthcare becomes more financially and socially deprived, more like an inferior, ‘last resort’ choice for certain groups, even though it is universal and definitely a cheaper option for the rakyat.

Our recommendations for the MOH are, first, to create a mandate for public doctors to act as “gatekeepers” at the primary-care level, such that Skim Peduli Sihat claimants would first need to obtain a referral from the doctors before utilising the claims in pre-determined and pre-negotiated private healthcare facilities.

Second, the claim mechanism should not be based on fee-for-service, but rather on Disease Related Group (DRG), to prevent system abuse and/or induced demand.

Third, the MOH should collect co-payment as low as the current MOH rate for Skim Peduli Sihat claims when patients use private service. We believe that this would only be fair to public hospital users.

Generally, we agree that the MOH should flexibly share resources with the private sector, by paying them to use their underutilised equipment and services when in need.

While we applaud the MOH’s efforts to give greater access of healthcare, especially tertiary care, to the needy B40s, we are most of all doubtful about the financial sustainability and the long-term implications of such a scheme.

With huge budget allocations involved, and the significant shift of the healthcare finance system (in terms of the “social health insurance scheme”), MOH should be more transparent and open to multi-stakeholders and public consultation, before the policy motion is tabled to the Parliament.

Most of all, we believe that MOH’s priority should be enhancing and defending our public healthcare. To that end, a well-funded public healthcare system would provide greater benefits compared to the current Skim Peduli Sihat scheme that is on the cards.

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This article has been written by Lim Chee Han (senior analyst) and Kenneth Cheng Chee Kin (analyst), of the Penang Institute.