Encouraging substantive discussion on health reform in Malaysia (original unedited article)

Encouraging substantive discussion on health reform in Malaysia

The Health White Paper, which has been the brainchild and effort of Khairy Jamaluddin since he was appointed Health Minister, was finally published and tabled in Parliament on 13 June. The fact that it could survive under different ministers and governments after rounds of consultations and feedback from many stakeholders, is no easy feat.

The 57-page document, currently only available in Bahasa Malaysia, is a landmark publication by the Health Ministry, probably the boldest for systemic and structural reform since the Ministry proposed 1Care more than 10 years ago. But this document also shows that the Health Ministry and its civil servants can critically acknowledge what the health challenges and issues are in this country without the government having to spend precious taxpayers’ money on a particular international consultancy firm to carry out a study or ‘advise’.

The Health Ministry has learned the lessons of 1Care in the past, it has engaged with and listened to many stakeholders in developing the Health White Paper, and it is now determined to build cross-party support in Parliament for the 15-year plan.

There are many big calls made in this document: Separation of the Ministry's roles as service provider and purchaser; autonomy for hospitals and Primary Health Care (PHC) teams; creation of a dedicated public account for the health fund; creation of a new Strategic Purchaser entity; greater collaboration and integration between the public and private sectors and NGOs in service delivery; a paradigm shift from 'sick care' to promotive and preventive health care through the establishment of community-based PHC teams; adoption of the use of Electronic Medical Records and Electronic Lifetime Health Records; and others.

Given the limitations and challenges of the existing health system and larger government operations, as well as the social demographic and health trends outlined in the first chapter of the document, it is clear to the Health Ministry that maintaining the status quo is unsustainable and no longer a good option.

The proposals they call for are not without challenges: to increase public investment in health to 5% of GDP, the Paper suggests not relying on one source (federal budget allocation to the Health Ministry) but diversifying and pooling resources: GLCs, individual contributions, wakaf, foundations and donations. The exact details of the mechanism for the so-called 'National Health Contribution Scheme' (‘skim caruman kesihatan negara’) are not mentioned; it could be controversial, as the Paper has already called for the adjustment of the fee structure under the Fee Act. The scheme reminds some of the 1Care proposal, where it was met with many objections.

In principle, I agree that there should be cross-subsidisation of health expenditure, that higher income households that can afford to pay for health care should not be subsidised as much as lower income household members. It may not be easy to get the message across to ask a certain income segment of the household to start paying or contributing to a certain health fund. I can imagine that the more populist politicians would exploit this sentiment and portray it as an unfair loss for the affected households.

However, I am not sure whether the scheme would have the compulsory health insurance feature of the 1Care proposal. I would not vouch for it, given the high administrative costs of running an insurance-like system, some members could easily be left out and marginalised by the system. So it would be interesting to see how the so-called 'health benefit package' mentioned in the Health White Paper actually works out, whether it is similar to the current PeKaB40 packages where people do not have to pay for the health screening services provided.

There are many promises of reform in planning and management based on evidence, value and need. There is much emphasis on better integration, resource sharing and collaboration between the public and private sectors. My concern is that if the private sector puts its own vested interests ahead of the public interest, would the public-private partnership deals really benefit the people? What would be the potential risks and costs? Would the private sector fully trust the government? How much does the government have to give in to the demands of the private sector?

Even in terms of separating the Health Ministry's roles as provider and purchaser, I would be interested to see how this could be done effectively without adding layers of bureaucracy that would impact on the efficiency of health service delivery. I understand where the narrative of avoiding the so-called 'conflict of interest' comes from, probably in the narrow sense of resource demarcation of federal budget items, although both roles should still largely work for the public interest and demand. I am concerned that the role separation can lead to gatekeeping, where the 'purchaser' can limit or deny more genuine demand for services.

Nevertheless, I welcome this as a serious and sincere effort by the Health Ministry to reform and transform our health system to make it more sustainable and deliver better health outcomes for the population. This should be the beginning of a substantive discussion on what the health reform should look like.