实施针对性燃油补贴的错误示范

 一个人能拯救国家吗？我不这么认为，或许你也不会这么认为，除非这个人名叫安华依布拉欣。 

最近，首相安华在回应关于针对性燃油补贴政策的批评时声称，历任首相都认同这一政策的必要性，但没有一位首相有实施该政策的政治意愿。他说，这项政策虽不得人心，他别无选择，为了拯救国家而必须推动实施。

诚然，作为首相，安华处于拯救国家的重要位置，掌握著最高的行政权力。他和他的联盟同事在上次大选中作出了许多承诺，这些承诺帮助他们赢得了选举，其政策和制度改革确实有可能改善国家现状（救国）。然而，迄今为止改革政策的实施不力，安华有什么解释？尽管昌明政府已经执政一年半，但我们几乎没有看到这些改革取得显著进展。这是否也与缺乏政治意愿有关？

腐败导致的资金流失和任意挪用对任何政府来说都是一项艰巨的挑战。若不进行体制改革以加强反贪力度，并使大马反贪委员会等公共机构独立，安华的反贪立场就只能停留在口头承诺上。为何在取消燃油补贴问题上，他可以果断迅速地应对愤怒的民众，但在面对政治精英时却似乎投鼠忌器，满足于维持现状？ 

政府表示，仅柴油的针对性补贴就能为国家节省40亿令吉。我并不反对补贴合理化的政策，但这个政府的执行方式几乎是鲁莽的，甚至可说是自杀式的，无视柴油价格突然大幅度上涨对经济和商业各方面的冲击。过去，当国际原油价上涨时，政府通常会选择分阶段逐步提高燃油价格，以避免让人民感受到突然的压力，同时让经济更容易适应这种变化。

讽刺的是，昌明政府上台后，曾自豪地宣称关心人民的生活成本，并誓言将降低生活成本作为政府的优先政策事项之一。政府甚至恢复了跨部委的国家生活费行动委员会（NACCOL），该委员会定期开会研究人民生活费问题。然而，我不知道他们是否考虑过应对交通使用最常见物品之一柴油价格波动的机制，以及该政策对通货膨胀和人民生活费的中短期影响。 

即使是纳吉领导的时任国阵政府在2015年4月实施的最具争议性的消费税政策，政府也早在2012年3月推出了所谓的一个马来西亚人民援助金（BR1M）。你可能觉得BR1M派发的现金不够，但这是在为期三年的缓冲期内实施的，至少提供了一定的社会安全网，以尽量减少对经济和人民生活的冲击。

政府缺乏良好政策规划

回到全面取消柴油补贴的问题上，许多运输商在柴油价格上涨的前一天就匆忙注册了车队卡(Fleet Card)。据报道，截至6月12日，约有20万辆汽车获准在国内贸易和生活成本部的柴油补贴控制系统（SKDS）计划下注册。政府意识到，匆忙办理车队卡会导致受惠者因分配和交付车队卡延迟而无法及时收到补贴。因此，政府通过财政部制定了一项措施，向尚未收到车队卡的符合条件的运输车主发放补贴。这些受影响的车主可以从7月1日起申请补贴发放。 

有人认为，另外设立一个"BUDI MADANI"(昌明柴油援助计划)网站来处理发放柴油补贴是件有趣的事（虽然并不好笑），并怀疑在大肆宣传PADU其强大用途之后，是否应该由PADU来负责寻找补贴的合法受惠者？对于SKDS计划来说，这或许可以理解，因为运输车辆通常归公司所有，车队卡也不是直接发给司机，而是通过公司发放的。但BUDI Individu计划又该如何解释？难道交通部不清楚谁驾驶的柴油车型和谁符合资格获得补贴？为什么不由PADU来确认并发放补贴？

一个特大问题是，是否可通过节省的40亿令吉来拯救国家？我对此不确定。拯救国家，但拯救的是谁？

 刊登于《東方日報》《群議良策》專欄2024年6月24日 

東方臉書鏈接

我国必须为人口老龄化做好准备

到了2030年，马来西亚60岁及以上人口预计将占总人口的15.3%。然而，这一年龄群体的声音和社会需要却似乎被忽视甚至压制。主流政客们往往用华丽辞藻来吸引年轻人的选票，宣称年轻人是国家的未来栋梁和希望。

对比之下，老年人常被贴上“不事生产”、“更高福利支出”、“需要更多的照顾和关注（尤其是健康问题）”、“依赖性强”、“造成负担”、“保守”和“固执刻板”等负面标签。但人们却忘记了，他们曾经也是青年，是为国家和社会做出贡献并奠定基础的一代人。

每个人都会变老，总有一天我们皆会成为老年人。有人说，我们如何对待上一代人，特别是家里人，就是示范给下一代人看今后他们该如何对待我们。这并不是说老年人就不能有所作为。他们依然可以老当益壮、充满活力、积极并保持独立生活，有些老年人甚至可以活得自由洒脱。

然而，社会、政府和政策应该为老年人做好规划和准备，让他们能够与其他人一起生活，充分发挥他们的潜力，过著有意义的生活，而不让现实成为他们的障碍，罔顾他们的需求。要求老年人表现得像青少年一样是不公平的（尽管他们可能仍怀有青春精神），就像我们不会要求幼儿表现得像成年人一样。社会、城市规划和政策必须具有包容性，考虑到所有社会阶层，特别是弱势群体和少数群体的需求。

2023年政府的官方统计数据估计“老年抚养比率”达10.6%，即每10个15-64岁的成年人中就有一个老年人。无论如何，在这个社会里，老年人都是具有独特处境的个体。在现实生活中，他们未必总是幸运地有家人可依靠。2019年的统计数据令人担忧，显示单身老年人（60岁及以上）的一人家户数量逐渐增加，达到了3.3%，而仅由老年人组成的多人家户则达到了4.9%。在这些“独立”的老年人当中，有些是出于自愿和个人偏好选择独居，而另一些则出于无奈被迫独立生活。

在郑丽云（Evelyn Teh）执导的2022年纪录短片《银发尺度》（Grey Scale）中，她将镜头对准了自己独居在槟城乔治市的姑姑，讲述了她如何独自应对日常挑战。从购买日常用品到去政府诊所接受医疗服务，她都得一一面对；甚至还需防范并处理一场特别严重的闪电水灾，洪水影响到她家的一楼。郑丽云的作品还触及独居老人的心理健康问题，强调健康不仅仅是指身体是否有疾病。孤独是影响老年人健康的一个主要问题。

政府应提供支援

在符莉莉（Lily Fu）执导的2020年纪录短片《迟暮之年》（Meniti Senja）中，她关注位于蒲种的一家私人经营的老年护理院，记录了老人共同生活的日常，并采访了一些住户和创办人，深入了解他们的故事。由于缺乏知识、技能、时间或金钱，越来越多的老人被家人遗弃，这是一个令人担忧的趋势和社会问题。尽管许多老年住户明白自己的处境，但他们仍然渴望子女的探望。幸运的是，这家养老院由一位经验丰富的前护士掌管，她让工作人员和入住老人打成一片，让每个老人都能感受到社区的支持、关怀和共同的生活目标。

我经常接到各方养老院来电或传送的信息要求捐款以帮助他们支付日常运营中的许多未付账单。这让我感到非常难过。对于那些愿意提供小额捐助来帮助解决财务问题的人来说，这简直是个无底洞。虽然养老院对公众慷慨解囊的慈善精神逐渐褪色感到遗憾，但他们不能也不该随便放弃那些由他们照顾的老人。然而，他们（养老院）也不该被迫独自承担筹款的重任。现在是时候政府介入，提供必要的支援（包括资金），至少满足老年人在住房、食物和健康方面的基本需求。越来越多没有执照或财务不稳定的养老院为无助的老人提供膳宿，这是一个令人担忧的现象，预示著可能会有更多老人因得不到妥善护理而受苦。 

政府必须放眼未来，为应对人口老龄化做好准备，必须确保基础设施、资金、政策和立法到位，以便能更有效的规划和实施政策。

政界人士特别是人民代议士，请包容各方，记住你们代表全体选民。请展现你们对关怀老年人的承诺，而不仅仅在竞选期间才想著老年人的选票！

注：本周六在吉隆坡亚答屋84号图书馆，群议社将举办一场电影放映和分享会（主题：拒绝衰老的城市），邀请郑丽云和符莉莉导演到现场分享心得，入场免费，欢迎出席。

刊登于《東方日報》《群議良策》專欄2024年7月4日 

给明福的信

亲爱的明福， 

很欣慰在十五年后还能写信问候你。你依然活在我们的记忆中，我们从未放弃为你寻找真相与正义。 

感激你在十五年前最后一次致电我的办公室，警告我们（时任）黄洁冰州行政议员团队即将面临反贪局的调查。我们为调查做好了准备，却未曾预料到与你分离。我们成功捍卫了首届民联雪兰莪州政府，阻止了联邦政府的威胁，但你却为此付出了最沉重的代价。我知道你肯定明白悲剧的原因。我们正在努力揭开真相，一定会有人需为你的死负责！

十五年是漫长的一段时间，尤其是在政坛。我不知道你会作何感想，你所在的政党在这期间两次当选为联邦政府执政联盟的一员，其中包括安华担任首相的现任政府。

是的，政治的真实面貌有时比小说情节更离奇！15年前，你和我万万不会想到，曾经引领国阵独裁统治的马哈迪，会有一天带领你的政党在布城取得突破，尽管执政时间只有短短的22个月。有人说时间不够，被那个带他们去布城的人背叛了，所以没能解决你的冤案。

你无法想像接下来发生的事情——你的政党现在竟然与巫统合作，共同执掌联邦政府，迎来了希盟执政的第二任期！甚至在最近的补选中，候选人都身著印有希盟和国阵标志的外套。我们曾奋力抗争的政党，居然成了共同的盟友！

策划推翻我们竭尽全力捍卫的民联雪兰莪州政府阴谋的主要嫌疑人依然在狱中。现今，被称为“昌明”政府的这个绝对多数大联合政府已执政18个月，然而你的家人仍未能见到首相安华。若不是因为7月15日由赵明福民主促进会举办的“正义之行”在国会门前发生的警方冲突事件，你的家人可能仍在等待会面的机会。赵明福民主促进会是以你的名字命名的组织，一直是为你和其他政治暴力受害者伸张正义的主要推动者。

你一定在纳闷，贵党拥有40名国会议员，远比巫统多出14名，理应牢牢占据联邦政府的主导地位，为什么会如此困难？别问我，我不知道。的确，现任政府中的许多人，包括贵党和希盟内不少政治人物，当身处反对阵营时曾誓言要为你讨回公道，但现在他们当中的许多官运鸿达、仕途顺畅，已经对此保持沉默。甚至贵党秘书长陆兆福，15年前在担任社青领袖时为你大声疾呼，也未能在今年赵明福民主促进会安排的农历新年登门拜访中见到你的家人。或许你的政党在“政治上的不便”或缺乏继续为你争取的政治意愿。他们可能希望你相信他们在幕后努力争取，但很遗憾地告诉你，若不是我们民间社会持续努力，过去18个月中根本不会取得任何进展！

亲爱的明福，不要因为所谓的政治现实而感到沮丧。作为一个政治工作者，你或能够理解贵党同志的苦衷。我不是政治人物，可能无法完全理解贵党在为你伸张正义时需要作出的妥协。我只能继续支持你，坚持我的原则和承诺，请你放心，我一定会要彻查案情，将那些直接或间接导致你死亡的罪魁祸首绳之以法。

我也在努力与其他社运同仁一起改革反贪委员会，使其更加独立，改变公众认为其服务于政治主子利益的印象。你我所熟悉的“烈火莫熄”（reformasi）口号，现在在希盟的政治活动中几乎销声匿迹了。要知道，改革并没有取得多大成效——在希盟1.0政府执政的22个月里没有，现在安华领导的昌明政府期间也没有。你会对此感惊讶吗？我不知道。即使在希盟1.0政府之后，我已将期望降低，但万万没想到安华-希盟领导的政府会如此令人失望。坦白地说，15年前我们都不会相信会有今天这样的政治结果。 

无论如何，请继续对我们保持信心，我的朋友。不要担心，虽然执政党中的某些政客可能会辜负期望，但你始终在我们的心中，我们绝不会忘记你。我们将一如既往地为你而奋斗。我们民间社会还有许多人与你站在一起。 

请保重，

你的朋友
志翰 敬上 

2024年7月21日

刊登于《東方日報》《群議良策》專欄2024年7月26日 

東方臉書鏈接 

刻不容缓：落实大马母亲海外产子公民权修宪承诺

 大马籍母亲在海外生子的子女公民权修宪法案迟迟未能在国会通过，但内政部长赛夫丁宣称，已有超过3000名大马籍母亲的孩子获批公民权申请。尽管一些人对部长在现行宪法框架下的努力表示赞赏，但普遍仍存在担忧，因为许多在海外生活和工作的母亲之孩子公民身份申请被拒绝，还有不少母亲正在等待申请结果。 

在法律修正之前，这些母亲及其在海外出生的孩子将继续面临困境。目前，大马籍母亲若要为孩子获得公民身份，必须返回马来西亚生育。那些在海外分娩的大马籍妇女将面临与那些仍在等待孩子公民身份申请结果的母亲相同困境。

她们只能等待，希望政府能尽快解决她们切身问题。这些问题包括：孩子被视为非公民，长期需要更新居留签证，无法享受免费公共教育和低廉的政府医疗服务等。 

此外，居住在海外的母亲很难摆脱暴力婚姻，因为她们完全依赖外籍丈夫为子女提供当地的公民身份。一旦婚姻破裂，孩子的非马来西亚公民身份成为大马籍母亲获得子女监护权的重大障碍。

修正法案须具追溯力 

早前在国会提呈的修正法案因不具追溯效应，引发了母亲和孩子们权益可能继续受影响的担忧。如果此版本的法案通过，将对目前根据宪法第15(2)条提出的子女公民权申请但尚未处理的母亲产生影响，尤其是那些无法在布城重新提交申请的海外母亲，以及在申请公民权时遇到障碍的母亲。受影响者人数成千上万。 

这些海外申请者中，有些是离婚或丧偶的大马籍妇女，她们迫切希望带著有公民身份的孩子回到家园。

值得注意的是，没有追溯力的法案将排除那些大马籍母亲在海外所生、现已超过21岁的子女，他们从此无法凭血缘关系申请入籍，这其中还包括失去母亲的子女。 

现行法律没充分保障儿童公民权

一些人认为，根据联邦宪法第15(2)条的规定，尽管内政部长拥有一定的自由裁量权，仍然可以继续为孩子申请公民权。然而，许多人不知道的是，这意味著即使申请人符合所有标准，也不是每个人的申请都能获得批准。 

根据《星报》最近的一篇文章，国民团结部副部长莎拉斯瓦蒂指出，虽然宪法赋予内政部长特权，但这些案件的文件经常卡在官僚下属手中。如果这些文件没有被递交上去，部长如何能够处理这些案件？ 

我认为有必要对这些官僚作风的技术问题进行彻底调查。尽管内政部长曾在2024年3月保证，所有拒绝信都会附上拒绝的理由，但许多母亲收到的拒绝信中，政府依然没有提供任何解释。

根据家庭前线组织通过其联络网汇编的数据，大部分母亲收到的拒绝信来自海外居留（40封中的34封，即85%）。显然，这是对那些基于现实需要生活在海外的大马籍家庭歧视。然而，根据宪法第15(2)条款，并没有规定母亲必须居住在马来西亚，才能让其子女获得公民身份，这并不是一个先决条件。 

家庭前线组织提出了一个案例：他们接触的一位母亲，她的一个孩子的申请被拒绝，而另一个孩子的申请却在三天内顺利获批，尽管他们的申请几乎完全相同。这种情况往往让母亲们难以确定到底哪个申请环节出现了问题，只能在不确定的情况下一次次重新提交申请，陷入无尽的失望循环。

履行承诺 落实理念 

在第15届大选中，昌明政府的主要政党联盟——希盟与国阵——均将母亲传承公民权纳入其竞选宣言，承诺如若胜选会修正相关法律。事实上，包括土著团结党在内的在野联盟国盟也在竞选宣言中作出了同样的承诺。这俨然已成为朝野的共识。然而，直至今日，公民权的问题仍未得到解决。此时，正是昌明政府重申其对既定价值观和履行承诺的一次重要机会。 

此外，昌明大马理念的核心——Madani中的“I”代表Ihsan，意为怜悯之心。但是，现行法律并未充分体现这一原则，导致母亲和孩子容易被分离，并面临多种困难和挑战。如果政府能够优先考虑修正这项法律，将彰显出其对家庭和谐及母亲护家权利的尊重，确保这些母亲和孩子受到法律保护。这将是对昌明大马理念中怜悯和正义价值观的一次重大考验。

若修正案获得通过并具有追溯效力，这将标志著马来西亚在妇女和家庭福祉方面迈出了重要而积极的一步。此修正案将使法律更加符合当前的社会价值观和司法标准，确保所有大马籍母亲及其子女都能获得公平对待。从国家社会利益来看，这将保留大量有潜力的大马孩子，让他们将来成为对我国社会和经济有贡献的重要成员。此举还将减少人才外流，使那些在海外生育的大马籍母亲不再需要担心子女在国内的公民地位，她们可以放心选择留在国内工作和养育孩子。最终，马来西亚将成为一个更加包容、进步且对妇女友善的国家。

公众必须声援所有大马籍的母亲——无论是过去、现在，还是未来的母亲们。虽然这项法律现在可能并不适用于每个人，但它可能会影响到你们的女儿、孙女，或者生活中的其他女性。因此，我呼吁大家以选民的身份向政府施压，要求其履行承诺，执行并落实有关母亲权益的公民权修正案，同时停止其它退步和负面的公民权修正案。

刊登于《東方日報》《群議良策》專欄2024年8月10日 

政府医院里设立“私营部”是个好主意？

 在卫生部经营的政府医院内设立“ 私营部”（Private Wings）是个好主意？上个月17日，卫生部长祖基菲里在瑞士日内瓦举行的“世界癌症大会”上宣布了这一政策倡议，并为这个私营部门命名为“卫生部之友”（RakanKKM）。先不谈这项政策将为国内的癌症病患者带来什么好处，单从表面来看，这一重新包装的政策似乎就是自2007年卫生部实施的“病人全额支付”（Full Paying Patient, FPP）计划的升级版，同时也借鉴了马来亚大学和国立大学医院已设立的“私营部”的运作模式。

FPP计划为公众提供了一个选择，即在特定政府医院内，可在正规执勤时间之外指定自己心仪的专科医生诊治，并入住一级护理病房。在这种情况下，患者需支付全额医疗费。通常，这笔费用要比一般私立医院的收费低廉。根据FPP政策协议，该计划的收入将由专科医生和政府共同分享。此举意味著参与计划的专科医生可以获得额外收入，同时政府也能受益。目前，参与FPP计划的政府医院有10家，其中5家位于巴生谷。政府提出FPP政策的一个初衷，是希望通过提高旗下专科医生的收入，来防止其流失至私立医院。

这次的“卫生部之友”与FPP究竟有什么显著的不同？祖基菲里大致说明，卫生部计划由官联投资公司主导，设立一个特殊目的公司来运营“卫生部之友”。然而，他在日内瓦并没有透露太多计划细节，只是卖了个关子，说将在即将到来的2025年财政预算案中由首相兼财政部长安华作出宣布。

增加收入和减少专科医生人才外流

已经运营了17年的FPP计划仍可提供一些参考。前卫生总监诺希山曾报告称，FPP在2018年为政府带来了约2200万令吉的收入，但相较于卫生部在医疗方面的支出（134亿令吉），这仅占0.02%，简直是杯水车薪。而在过去五年中，专科医生的流失问题并未停止，去年更是达到新高，有359名专科医生离开了卫生部。

祖基菲里表示，这项改革是他在卫生筹资方面推动的重要举措。他坦诚地指出，长期以来所维持的一令吉门诊费和五令吉专科医生诊疗费已经无法持续。他希望政府能够继续为B40群体提供服务，而让T20群体转向使用私人医疗服务，M40群体则可以选择更加负担得起的“卫生部之友”服务。

然而，卫生部长的这些设想在某种程度上是基于对现状的误解。首先，联邦政府的财政资源都必须集中在名为“综合基金”(Consolidated Fund)的统一账户中，这意味著所有政府收入都汇入这一基金。因此，即便卫生部能够“赚更多的钱”，这些资金也无法保留在卫生部里。虽然如此，部长确实可能有更强大的道德理由，来争取更多的财政拨款。

卫生医疗本应政府提供的基本服务

这样的想法并不完全正确，因为人民并不期望每个政府部门都必须有收入。试想，如果我们现在享有的基本政府服务和福利项目，如国家安全与社会秩序（军警）、国民登记和中小学教育，都要收费，这将意味著什么呢？同样的道理，为什么卫生部会有压力认为必须有收入才能合理地要求更多的拨款？为何政府不能将人民的健康视为一项重要投资，而把医疗服务视为国民的基本福利和权利呢？ 

部长可能想得很美，希望更多M40群体的病人愿意在政府医院自掏腰包付费，以便政府能够专注于为B40群体提供免费或低廉费用的服务。然而，随著M40群体的经济消费能力相对于医疗通胀已逐渐下降，他们是否能够负担自付全额费用也是一个值得关注的问题。

待遇因付费造成不平等

姑且先不论政府医院里的专科医生和医护人员是否能满足“卫生部之友”的需求，在政府医院内强调“有钱就能优先享受服务和获得优待”这一资本市场逻辑，势必会引发严重的道德问题，并加剧贫富差距带来的不平等待遇。这样的情况可能侵蚀社会团结和人民互助的精神，更可能动摇政府医院医护团队把人民健康和救命放在首位的态度和价值观。尤其在当前，政府医院的医护人员已经面临巨大的医疗需求压力，而人力资源和医疗设施有限。如果因为“卫生部之友”计划而产生利益冲突，专科医生选择优先为付费者提供服务，而不是为B40群体或免收费患者提供额外治疗时间，那些仍在排队等待诊断或治疗的患者不就变成了政府医院的“二等公民”吗？

要避免专科医生的人才流失，部长不应见树不见林，因为专科医生跳槽的原因不只局限于个人收入。其他重要因素包括：事业发展机会（如学术研究或其他专科深造机会）和升迁机会（如升职或担当领导角色）。医护和管理层的支持，以及更灵活的工作时间（如应对生产和育儿的家庭需求）也同样重要，这些因素都有助于留住大部分人力资源。毕竟，在政府医院工作的公务员身份本身就是一个优势。与其设立“私营部”，不如加强现有计划，例如允许专科医生在有限的时间内在私立机构行医，同时欢迎私立专科医生回到政府医院为病人提供服务。

关于医疗筹资问题，与其通过“私营部”来为卫生部的运营补贴，不如通过更有效的税收措施如消费税（GST）来解决？但最值得关注的是，即便增加和扩大了收入来源，政府是否愿意对等增加对人民健康和医疗的投资？

 刊登于《東方日報》《群議良策》專欄2024年10月16日 

東方臉書鏈接

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