Open protest is a vital social movement strategy for CSOs to succeed (unedited article)

Fighting for a social cause until the desired change in policy and law is achieved is never straightforward or easy. It may even take years or decades, or it may not even bear fruit at all.

We live in an electoral democracy, where democratic voices can be very diverse, competitive and sometimes conflicting. Sometimes the loudest voices can come from a small group of interest lobbies, and these can be influential in influencing lawmakers and their political parties, although this phenomenon is an anti-democratic practice. Or there are social movements that go in the opposite direction and may seem more popular and influential than what some are working on.

It would be naive to assume that a social movement can achieve its goal simply by talking to or presenting its point of view or even research to those in power and along the power corridor (e.g. ministers, deputies, MPs, top civil servants, party leaders), without making the movement even bigger to gain the popular support and get more people to join the cause.

However, in order to determine whether a social movement is successful, it is necessary to look at how far the movement has come towards achieving the desired changes in policy and legislation, and whether the current approaches and strategies are working to bring the movement closer to the goal and target of the social cause.

Outgoing Bersih chairman Thomas Fann's statement on his resignation and the direction of the once popular movement has sparked some discussion and debate on how a social movement should proceed in the event of political change.

Thomas' ideal direction for Bersih to be the 'people's institution' seems to suggest that advocacy in a more professional and organised way, using its internal channels and network, acting as a lobby and sending its own people into the system, would make political reform take root and be implemented.

His rejection of his new deputy's vision of a 'people's movement' may explain why Bersih has not called for open (street) protests after the first change of government to Pakatan Harapan and currently under the so-called unity government, despite the apparent failure of successive Pakatan Harapan-led governments to do enough or sometimes not even wanted to implement the reforms they once promised. While the intention may be to keep connections and internal channels open, open and loud protest may seem to undermine the efforts of these advocates or jeopardise relations with those in power.

Bersih's first objective is to campaign for clean and fair elections in Malaysia. After the first transition to the Pakatan Harapan government, it is not fair to say that there has been no progress or gains in terms of policy changes through its advocacy approach (e.g. automatic voter registration, postal voting, cleaning up the electoral rolls), but too little to show for it, frustrating activists and the general public who still yearn for institutional reforms.

Some reform proposals may be quite familiar to some federal and state ministers who may have come from activist backgrounds and understand the issues. But when the position has changed from opposition member or activist to power holder in government, politicians have different concerns about party self-preservation and self-interest, with the aim of retaining power and increasing their influence and resources. Obviously, repeatedly presenting them with similar positions will not work, not because some politicians do not understand the issues and what might be better for the system or the public interest, but because doing what the advocates want may not be in their own best interests.

When politicians in power drag their feet on a particular reform agenda, civil society has to do what is necessary - build and demonstrate public support for a particular reform policy. This is where the power of the people and external public pressure would come into play, helping advocates to create impetus and urgency for those in power to deliver on their reform promises.

After all, politicians are still under pressure to meet the demands and expectations of the electorate, and a public image of poor performance and lack of political will could work against them at the next election, threatening their security of self-preservation. If open and street protests would help the cause, build the movement's momentum, educate and expand the popular support base, a serious activist should not dismiss the importance of this prong of strategies.

The emergence and victory of Yan Ke's team members elected to the Bersih Steering Committee should reflect the internal voices of the member organisations on what they think about the effectiveness of the previous approach, and their decision to bring in new ideas to make Bersih work better to achieve the coalition's goals.

If it were a football team, Yan Ke and new elected members would be the substitutes sent out to help the coalition score goals, given the new role of strikers or attackers that the previous Bersih team lacked. However, this does not mean that the previous members of the experienced midfielders, defenders and goalkeepers should quit the field. Although I can understand and respect this, I am still disappointed that the captain does not want to continue to lead the new team with added strength, and perhaps he does not see it that way.

Open protests vital for civil society groups’ success

Fighting for a social cause until the desired change in policy is achieved is never straightforward or easy. It could take years or decades, or not happen at all.

We live in an electoral democracy, where voices can be diverse, competitive and sometimes conflicting.

Sometimes, the loudest voices can come from a small group of lobbyists, and these can be influential in persuading lawmakers and their political parties, although this phenomenon is an anti-democratic practice.

There are social movements that go in the opposite direction and may seem more popular and influential than others.

It would be naive to assume a social movement can achieve its goal simply by talking to or presenting its research and point of view to those in power (ministers, deputies, MPs, top civil servants, party leaders) without growing the movement to gain more support.

However, to determine the success of a social movement, we must look at how far the movement has come in achieving its desired changes in policy, and whether its approaches and strategies are effective in bringing it closer to its objectives.

Outgoing Bersih chairman Thomas Fann’s statement on his resignation and the direction of the once popular movement has sparked some discussion and debate on how a social movement should proceed in the event of political change.

Fann’s ideal direction for Bersih to be the “people’s institution” seems to suggest that advocacy in a more professional and organised way, using its internal channels and network, acting as a lobby and sending its own people into the system, would lead to political reforms.

His rejection of his new deputy’s vision of a “people’s movement” may explain why Bersih has not called for street protests after the first change of government to Pakatan Harapan (PH) and after the so-called unity government was formed, despite the apparent failure of successive PH-led governments to do enough or, sometimes, not even want to implement the reforms they once promised.

While the intention may be to keep connections and internal channels open, loud protests may appear to undermine the efforts of these advocates or jeopardise their relations with those in power.

Bersih’s first objective is to campaign for clean and fair elections in Malaysia. After the first transition to the PH government, it is not fair to say there has been no progress or gains in terms of policy changes through Bersih’s advocacy (e.g. automatic voter registration, postal voting, cleaning up electoral rolls), but there is too little to show for it, which has frustrated activists and the general public who still yearn for institutional reforms.

Some reform proposals may be familiar to federal and state ministers who come from activist backgrounds and understand the issues.

But when the position changed from opposition member or activist to power-holder in government, politicians have different concerns around their parties’ self-preservation and self-interests, with the aim of retaining power and increasing their influence and resources.

Obviously, repeatedly presenting them with similar positions will not work, not because some politicians do not understand the issues and what might be better for the system or the public interest, but because doing what the advocates want may not be in their own best interests.

When politicians in power drag their feet on a particular reform agenda, civil society has to do what is necessary – build and demonstrate public support for a particular reform policy.

This is where the power of the people and external public pressure would come into play, helping advocates to create impetus and urgency for those in power to deliver on their reform promises.

After all, politicians are still under pressure to meet the demands of the electorate, and a public image of poor performance and lack of political will could work against them at the next election, threatening the security of their position.

If open street protests would help the cause, build the movement’s momentum, and educate and expand the popular support base, a serious activist must not dismiss the importance of such multi-pronged strategies.

The emergence and victory of Wong Yan Ke’s team members, who were elected to the Bersih steering committee, should reflect the internal voices of member groups on what they think about the effectiveness of the previous approach and their decision to bring in new ideas to make Bersih work better to achieve the coalition’s goals.

If it were a football team, Wong and newly elected members would be the substitutes sent out to help the coalition score goals, given the new role of strikers or attackers that the previous Bersih team lacked.

However, this does not mean the experienced midfielders, defenders and goalkeepers should be benched.

Although I can understand and respect this, I am still disappointed the captain does not want to continue to lead the new team with added strength, but perhaps he does not see it that way. 

184th article for Agora@TMI column, published on The Malaysian Insight, 11 Dec 2023 

The Health White Paper: Is an employment-taxed health financing scheme the right solution?

 KHAIRY Jamaluddin was health minister for barely 15 months (Aug 30, 2021–Nov 24, 2022), yet with the Health White Paper (HWP) tabled in Parliament on June 13, 2022, he has probably made his mark as the first health minister to have made headway — through a call for bipartisan support — with the long-standing agenda for healthcare reform.

Since the mid-1980s, healthcare reforms have been an aim of the Ministry of Health (MOH), with numerous consultant reports and various incarnations of plans, each of which proposed to change the country’s tax-based healthcare financing system to social health insurance. These proposals rarely made it beyond the planning stage, reflecting, observers note, their questionable political viability.

The last was the 1Care proposal, which was launched in 2010 during the Najib Razak administration’s 1Malaysia initiative, and met with an ignominious end in 2013 in the face of strong objections. With the current proposal — the HWP — it would appear that the MOH has learnt valuable lessons from this previous exercise, as it has taken care to engage in various stakeholder consultations at the preparatory stage.

To be clear, the HWP reforms, to be implemented in the next 15 years, include many progressive measures such as establishing community-based public healthcare teams, putting emphases on promotive and preventive care, and moving to electronic medical and health records. Our contention is not with the reforms proposed for healthcare delivery, but with its aim to fundamentally change our tax-based health financing system to a social health insurance system.

The social health insurance scheme in the HWP-proposed healthcare financing is denoted by a dedicated health fund that will be managed by a strategic purchaser procuring services from both private and public sectors for beneficiaries who will be entitled to a basic benefits package. The health fund will be financed primarily by government allocations in the initial period, later ‘enlarged by contributions from large donor organisations’, and finally through a ‘national contributory scheme’ that will eventually be set up.

A dedicated health fund would serve to ring-fence funds for healthcare, arguably giving the MOH some protection from the competitive demands of other ministries. The question, however, is whether and how funding for healthcare could be substantially increased. There is no doubt that public healthcare services have been severely under-funded for the last few decades, and the HWP laudably aims to increase ‘publicly managed health funding from various sources including the government, individuals and companies’ to 5% of gross domestic product (GDP).

Actually, in 2021, the MOH already estimated total health expenditures to be 5.1% of GDP (2.9% public sources, 2.1% private). If we take 2021 figures (the latest available) as indicative, the aim as set out in the HWP therefore is not so much to increase total health expenditures as to shift the bulk of private expenditures into ‘publicly managed health funding’. Nevertheless, 2021 is a year when public spending due to the Covid-19 pandemic was still high.

If we use 2019 statistics, when total health expenditure was 4.3% of GDP (2.3% public, 2.0% private), then the targeted increase would be about 0.7% of GDP, assuming that most of the private health expenditures could be shifted into publicly managed health funds. Currently, about 75% of private health expenditures are out-of-pocket spending by households, 17% from private insurance, and the balance from corporations and agencies (presumably as employers).

The HWP is therefore not only calling for a much-needed increase in public health spending, but for that health spending to come from a new collection through a ‘national contributory scheme’. Most social health insurance systems are based on payroll contributions with specified rates from employee and employer, constituting in effect, an employment-based tax. In Box 1, we set out some rough estimates as to what the quantum of this would involve.

We do not dispute the need to increase funds for healthcare, but would an employment-tax financing system be the best way to do this? The arguments against this are many. First, the new collection system would entail a whole bureaucracy for collecting and disbursing funds, and for assessing the veracity of claims from the various healthcare providers, inevitably increasing the costs of healthcare.

Second, Malaysia has a large informal and self-employed sector from whom it is extremely difficult to collect contributions, thereby limiting the tax base. Third, employment-tax financing schemes are vulnerable to changes in employment levels, with collection diminishing during times of high unemployment rates. Furthermore, when social health insurance is implemented, employers tend to hire more labour as casual labour in order to circumvent the mandatory health payment.

The HWP claims that a universally available benefit package financed by a health fund will allow for a more equitable system due to greater pooling of health and financial risk and wider cross-subsidisation. This is only true if it is compared to a situation where private health insurance dominates, because unlike social health insurance which is compulsory, private health insurance is voluntary, covering only small sections of the population.

If social health insurance is compared to taxation-based health financing, the latter has greater capacity for risk-pooling and cross-subsidisation. Furthermore, social health insurance is equitable only to the extent that the benefit package covers the medical services that are needed. How can it be equitable for patients whose disease conditions are not covered by the benefit package?

These issues notwithstanding, the HWP argues that the proposed financing system will integrate the public and private health sectors through a common payment scheme controlled by a strategic purchaser. It is true that Malaysian healthcare has been polarising into a two-tier system, with the gap in workload and personnel remuneration widening between the public and private sectors.

The strategic purchaser, it is hoped, will rationalise the utilisation of health services in both public and private sectors through a gatekeeper system, and by paying similar rates for both sectors, lead to a narrowing of the gap. But this effect will be limited by the extent to which patients are willing to pay additional co-payments or buy private insurance to cover the higher prices in the private sector.

There are fundamental differences between public and private healthcare as they now exist in the country. First, they have different aims — for example, the private hospital's main aim and responsibility (to its shareholders) is to return a profit, whereas the public hospital's main aim is public service and to keep the population healthy.

Second, in the currently existing system, private specialists essentially function as owner-operators of businesses (businessmen-entrepreneurs), while public sector doctors are employees (of the government). Objectively, these two categories of people are incentivised in very different ways.

With a new financing scheme, a new incentive system is put in place, and things could change in unanticipated directions. Although the plan is for greater integration of private and public healthcare, the opposite may occur. With publicly collected and administered funding available for utilising private healthcare, this could lead to increased demand for, and further expansion of, the private hospital sector, thereby continuing the leaching of expertise from public sector hospitals.

The Malaysian public healthcare system is relatively equitable and accessible. The HWP-proposed financing system, in providing a channel for publicly collected and administered funds to be utilised for private healthcare, risks this equitability. We propose instead an alternative scenario, which is to use the dedicated health fund to strengthen our public healthcare system.

Rather than a strategic purchaser paying both private and public sectors for services, the dedicated health fund should be used to improve the remuneration and service conditions of public healthcare personnel, expand public health facilities, re-vamp and re-orientate towards primary healthcare, and re-invigorate the public health sector in all the ways that have been proposed, and more.

 

BOX 1

Estimate of individual contribution and challenges to the collection of the health fund

The Health White Paper states on page 46 that "Publicly managed health funding from various sources including the government, individuals and companies needs to be gradually increased to 5% of GDP." If this target were to be achieved in 2021, publicly managed health funding would be in the order of RM78 billion, leaving a shortfall of RM32 billion that would have to be pooled from somewhere.

In 2021, 75% of the public health expenditure, amounting to RM33.8 billion, was actually spent on healthcare services. Imagine if we have the new target of increased public health funding, 75% of the RM78 billion would be RM58.5 billion. Assuming that this is the amount that would be needed in the dedicated health fund for the strategic purchaser to buy health services from both public and private sectors on behalf of the beneficiaries, there would still be a shortfall of RM25 billion to be raised from "individuals and large donors". RM25 billion is equivalent to 74% of the revenue collected from personal income tax in 2022, not a small amount.

Let's assume that the government would pay for all B40 household members and automatically enrol them. Then it's most likely that the 9.3 million non-B40 workers will have to fill the RM25 billion funding gap. If the 'large donors' don't meet expectations to contribute financially, then each non-B40 worker would have to pay RM224 per month or RM2,688 per year towards the health fund!

The number of tax payers in 2022 is only 4.2 million, which means that about 5.1 million employees are not taxpayers.

In many social health insurance countries, health payroll taxes are the most effective way of collecting contributions. In Malaysia, given the sheer number of employees who are not regular taxpayers, it will be a challenge to collect the social health insurance premium.

The question remains as to how the strategic purchaser can effectively fill the funding gap by collecting individual contributions. Will the non-B40 families be happy to make such hefty monthly payments for healthcare services?

 

Dr Lim Chee Han is a health policy researcher working on access to medicines, with a particular interest in health financing and public health issues. He is currently a senior researcher at Third World Network and co-founder of Agora Society Malaysia.

Dr Chee Heng Leng was one of the founding members of the Citizens' Health Initiative in 1997. She has been advocating for an equitable healthcare system since then. She works with other healthcare advocates in the People's Health Forum.

Original article was published at The Edge Malaysia, on 1st Dec 2023: https://theedgemalaysia.com/node/692322

社会医保非解决大马医疗体系问题灵丹妙药

卫生部长期以来一直面临资金不足，资源和人力紧张的问题，尽管如此，它仍为马来西亚大多数人口提供医疗保健和公共卫生服务。 

尽管每年的预算都在增加，但过去20年间，卫生部的拨款占联邦预算比例从未超过10.5%，这加重了公共卫生服务的压力。2022年，政府的税收仅占国内生产总值的16.4%，与不断增加的联邦债务相比，显得微不足道。 

倡导医疗融资改革的人士怀疑联邦政府是否有能力充分优先考虑和资助公共卫生领域，因此，他们认为转向社会医疗保险势在必行。近期，全国医疗保险制度的讨论再次引起了公众的关注，尤其是今年6月提交给国会的《卫生白皮书》。该白皮书强烈暗示将目前的医疗卫生制度改以保险为基础，其中提出了包括策略购买者、福利包、累进缴费计划和建立医疗基金等一系列建议和措施。

虽然社会医疗保险可能会使得除了卫生部拨款以外的医疗基金有所增加，但其成本效益以及对公众健康和就业的社会影响令人担忧。如果在像美国这样的国家，人们必须通过私人医疗保险和自付来承担医疗费用，那么社会医疗保险制度无疑将是一种巨大的改进。然而，在马来西亚，目前以税收为基础的制度已经确保了基于权利的医疗保健得到大量补贴。人民只需出示身份证，就可享受医疗服务，无需面临其它的官僚障碍。

在以保险为基础的系统中，病人会被询问是否已加入该健保计划、是否支付了保险费、所需服务是否包含在所涉及的健保配套福利当中，又或者是否需要额外“补贴”才能在私人医疗所享受“更高级”的医疗服务。 

社会医保和私人医保模式的区别在于，前者更具包容性，它会考虑社区风险，而不是根据个人的过往病史进行定向排除。然而，与社会医保不同的是，现行的公共医疗系统并不需要政府花费额外的人力物力来进行行政工作和宣传活动。具体来说，政府无需介入管理参保手续、收取保费、核实或承保来自不同服务提供商（如私人诊所和医院）的医疗索赔。

根据世界银行2009年的一项广为引述的研究，当一个国家从基于税收转变为基于社会保险的筹资方式时，人均医疗支出可能会增加3-4%，但医疗效果并不会有相应的改善。额外的行政成本是导致这医疗支出增加的主要原因。

中产阶层医保费

换言之，如果我们要达到《卫生白皮书》中提出的目标，即公共卫生资金占国内生产总值的5%，那么这意味著卫生基金在2021年应获得780亿令吉的经营资金，其中585亿令吉用于提供医疗服务。

设想一下，由于增聘行政人员造成的3%的效率损失将达到18亿令吉，这笔费用本可以用于其他卫生服务和发展的资金。

医疗基金董事会的成员和决策者将面临来自私人医疗界的激烈游说和谈判。回顾新冠肺炎医疗基金近年与私人界的交往经历，我们对公平交易和降低公众成本的前景感到越来越悲观。近期，政府甚至在面对烟草和电子烟行业（针对《烟草控制法案》）以及私立医院和诊所（对强制药品价格展示政策）的利益游说时，显得无力抵挡。

假设政府为B40家庭的所有成员支付医保费，并自动将他们全部登记，然后所有其他非B40的雇员则必须在政府拨款后的基础上，自行填补资金缺口。这意味著他们需要承担平均每月224令吉或每年2688令吉的医保费。特别是对M40家庭来说，他们是否愿意在目前享受的公共医疗服务上额外支付类似于税收的费用？ 

为了提高社会医保的效率，常见的做法是向雇员和雇主登记并收取医保费。然而，世界银行的研究还发现，改用社会医保可能会导致正规部门的就业率下降8-10%，这意味著一些雇主可能会将某些全职职位改为兼职或短期合同，以规避为其雇员缴纳强制性的医保费用，M40职工可能会再次受到影响。 

如果医疗保健需求大规模地转移至私人医疗机构，如同社会医保制度所允许的那样，那么医疗消费的态势会发生怎样的变化？小城镇和乡村地区的公立医院资金将会遭遇怎样的影响？如果越来越多的人选择使用以盈利为目标的私人医疗保健服务，我们是否真的可以坚信社会医保制度能够有效地降低医疗保健成本？这是值得我们深思的问题。

刊登于《東方日報》《群議良策》專欄2023年12月6日 

東方臉書鏈接

Social health insurance no panacea for Malaysia’s ailing medical system

The public health sector is underfunded, overstretched in terms of resources and manpower, and has been in this chronic state for a long time serving the majority of the Malaysian population. 

Despite annual budget increases, allocations to the Health Ministry (MOH) have never exceeded 10.5% of the federal budget in the past two decades, exacerbating the strain on public health services. 

The government’s revenue collection, a mere 16.4% of GDP last year, pales against the escalating federal debt.

Advocates of health financing reform argue that a shift to social health insurance (SHI) is imperative, given their scepticism on the federal government’s ability to adequately prioritise and fund public health. 

The idea gained traction with the recent renewed interest of discussions on a national health insurance system, and the Health White Paper tabled in parliament in June also strongly hinted at an insurance-based system, using terms such as strategic purchaser, benefit packages, progressive contributory scheme and the establishment of a health fund.

While SHI could potentially boost the health fund beyond MOH allocations, there are concerns about its cost-effectiveness and societal impact on public health and employment.

If a country is like the United States, where people have to pay for their own healthcare through private health insurance and out-of-pocket spending, then SHI would be a big improvement for them. 

But Malaysia’s current tax-based system ensures heavily subsidised healthcare based on entitlement, as simple as showing an ID card, with no other bureaucratic hurdles.

In an insurance-based system, the patient would be asked whether he or she is enrolled in the system, whether the premium has been paid, whether the service required is included in the package of benefits subscribed to, or whether any “top-up” is required to enjoy “more premium” health services in the private sector.

The SHI model would differ from the private health insurance model, in that the SHI would be more inclusive, as it would assess community risk and not exclude people based on their pre-existing medical history. 

However, unlike SHI, the current public health system does not require the government to spend money on additional staff to do the administrative work and campaigning to enrol people, collect premium payments and verify or underwrite medical claims from different service providers.  

According to a widely cited 2009 World Bank study, there is a 3-4% increase in per capita health spending when a country shifts from tax-based to SHI financing, but without a corresponding improvement in health outcomes. The additional administrative costs alone are the main cause of the increase.

To put this in context, if we were to achieve the 5% of GDP public funding target for health as outlined in the Health White Paper, this means the health fund would have RM78 billion to operate in 2021, of which RM58.5 billion would be for the provision of health services. 

Imagine that 3% of the efficiency loss due to additional hiring of administrative staff would be a sum of RM1.8 billion that could otherwise be better spent on other health operations or development purposes.

Health fund board members and decision makers would face intense lobbying and negotiation from the private sector.

Looking at the recent history of the Covid health fund’s dealings with the private sector, one can only be more pessimistic about getting a fair deal and reducing costs for the public.

Recently, the government couldn’t even fend off vested lobbies from the tobacco and vape industries on the tobacco control bill) and private hospitals and clinics (on the mandatory drug price display policy). 

Let’s say the government pays for all members of the B40 household and automatically enrols them all, and all other non-B40 employees and workers have to fill the funding gap after taking into account the government’s allocation, which would mean an average premium of RM224 per month or RM2688 per year, would the M40 household in particular be happy with such an additional tax-like levy on the public health service they currently enjoy?

For SHI to be more efficient, enrolment and premium collection from employees and employers is common practice.

The World Bank study also found that a shift to SHI would reduce the formal sector’s share of employment by 8-10%, meaning that some employers would resort to casualising certain positions to part-time or short-term contracts in order to avoid contributing to their employees’ compulsory health insurance. Once again, M40 workers would be the most likely victims.

What would happen to the dynamics of healthcare consumption if there were a large shift in demand for healthcare to the private sector, as permitted by the SHI system, and what would happen to the funding of public hospitals in smaller towns and rural areas? 

Can the SHI really be realistically trusted to keep health care costs down if more and more of the population shifts to using the services of the profit-driven private health care sector? Think again. 

180th article for Agora@TMI column, published on The Malaysian Insight, 13 Nov 2023 

Social Health Insurance is not a panacea for Malaysia's ailing healthcare system (unedited article)

The public health sector is underfunded, overstretched in terms of resources and manpower, and has been in this chronic state for a long time serving the majority of the Malaysian population.

Despite annual budget increases,  allocations to the Ministry of Health (MOH) have never exceeded 10.5% of the federal budget in the past two decades, exacerbating the strain on public health services. The government's revenue collection, a mere 16.4% of GDP in 2022, pales in comparison to the escalating federal debt.

Advocates of health financing reform argue that a shift to social health insurance (SHI) is imperative, given their scepticism about the federal government's ability to adequately prioritise and fund public health. The idea has gained traction with the recent renewed interest of discussions on a national health insurance system, and the Health White Paper tabled in Parliament in June this year also strongly hints at an insurance-based system, using terms such as strategic purchaser, benefit packages, progressive contributory scheme and the establishment of a health fund.

While SHI could potentially boost the health fund beyond MOH allocations, there are concerns about its cost-effectiveness and societal impact on public health and employment. If a country is like the United States, where people have to pay for their own health care through private health insurance and out-of-pocket spending, then SHI would be a big improvement for them. But Malaysia's current tax-based system ensures heavily subsidised healthcare based on entitlement, as simple as showing an ID card, with no other bureaucratic hurdles.

In an insurance-based system, the patient would be asked whether he or she is enrolled in the system, whether the premium has been paid, whether the service required is included in the package of benefits subscribed to, or whether any 'top-up' is required to enjoy 'more premium' health services in the private sector.

The SHI model would differ from the private health insurance model in that the SHI would be more inclusive, as it would assess community risk and not exclude people on the basis of their pre-existing medical history. However, unlike SHI, the current public health system does not require the government to spend money on additional staff to do the administrative work and campaigning to enrol people, collect premium payments and verify or underwrite medical claims from different service providers. 

According to a widely cited 2009 World Bank study, there is a 3-4% increase in per capita health spending when a country shifts from tax-based to SHI financing BUT without a corresponding improvement in health outcomes. The additional administrative costs alone are the main cause of the increase.

To put this in context, if we were to achieve the 5% of GDP public funding target for health as outlined in the Health White Paper, this means that the Health Fund would have RM78 billion to operate in 2021, of which RM58.5 billion would be for the provision of health services.

Imagine that 3% of the efficiency loss due to additional hiring of administrative staff would be a sum of RM1.8 billion that could otherwise be better spent on other health operations or development purposes.

Health fund board members and decision-makers would face intense lobbying and negotiation from the private sector. Looking at the recent history of the Covid-19 health fund's dealings with the private sector, one can only be more pessimistic about getting a fair deal and reducing costs for the public. Recently, the government couldn't even fend off vested lobbies from the tobacco and vape industries (on the Tobacco Control Bill) and private hospitals and clinics (on the mandatory drug price display policy).

Let's say the government pays for all members of the B40 household and automatically enrols them all, and all other non-B40 employees and workers have to fill the funding gap after taking into account the government's allocation, which would mean an average premium of RM224 per month or RM2688 per year, would the M40 household in particular be happy with such an additional tax-like levy on the public health service they currently enjoy?

For SHI to be more efficient, enrollment and premium collection from employees and employers is common practice. The World Bank study also found that a shift to SHI would reduce the formal sector's share of employment by 8-10%, meaning that some employers would resort to casualising certain positions to part-time or short-term contracts in order to avoid contributing to their employees' compulsory health insurance. Once again, M40 workers would be most likely the victims.

What would happen to the dynamics of healthcare consumption if there were a large shift in demand for health care to the private sector, as permitted by the SHI system, and what would happen to the funding of public hospitals in smaller towns and rural areas? Can the SHI really be realistically trusted to keep health care costs down if more and more of the population shifts to using the services of the profit-driven private health care sector? Think again.