卫生白皮书引领卫生改革的实质讨论

 自凯里被委任为卫生部长以来，他启动和努力打造的《卫生白皮书》终于在6月13日由接任的卫生部长扎丽哈发布并提呈给国会。经过与许多利益相关者多轮谘询和反馈，白皮书能在不同的部长和政府下继续生存面世，这绝非易事。

这份厚达57页的文件，目前只有马来文版本，是卫生部立下里程碑的重要策略性出版物，或可说是自10多年前卫生部提出1Care医疗改革倡议以来最大胆的系统和结构改革声明。能发布这白皮书也说明，卫生部及旗下公务员能批判性地体认这国家的卫生健康挑战和核心问题，而不需政府花费宝贵的纳税人钱，高价聘请国际谘询公司做研究或提供“建议”。

当年卫生部单方面宣传1Care卫生制度大改革是个大败笔，时任卫生部长廖中莱并没有很强的政治意愿。由于1Care倡议从目前的政府津贴和服务制度改去独立的健保制度，人民将会要因此额外付出保金。这个倡议不受公民社会欢迎，到了2013年大选，1Care就被搁置。卫生部显然已吸取了过去1Care的教训，它在过去一年制定《卫生白皮书》时与超过800个利益相关者以及超过7000参与者接触，并听取了他们的意见。现在卫生部决心在议会里为这个15年计划寻求和争取跨党派支持。

这份文件中提出了许多重大改革建议： 将卫生部作为服务提供单位和购买单位的角色分开；给予医院和初级卫生保健（PHC）团队自主权；为卫生基金创建一个专门的公共账户；创建一个新的策略购买单位；加强公共和私营领域以及非政府组织在提供健康医疗服务方面的合作和资源整合；通过建立社区的PHC团队，从“疾病护理”迈向促进和预防保健（promotive and preventive care）的模式转变；采用电子医疗记录和电子终身健康记录；等等。

有鉴于现有卫生系统和普遍政府运作的局限和挑战，再加上白皮书第一章概述的社会人口和健康趋势，卫生部清楚地认知维持现状是不可持续的，不再是一个良好选择。

他们所提倡的建议并非没有挑战：为了将公共卫生投资增加到国内生产总值的5%，白皮书建议不要仅依赖一个金钱来源（即联邦财政预算对卫生部的拨款），而是要实现财源多样化并汇集在一起： 官联公司、个人贡献、wakaf、基金会和私人捐赠。所谓的“国家卫生缴费计划”（skim caruman kesihatan negara）在白皮书里没有提及具体细节；它或会引起争议，因为白皮书已呼吁要调整《收费法》下的收费结构。这个计划让人想起了当年1Care的健保倡议，当时遭受多人的反对。

小心政客煽动情绪

原则上，我同意医疗支出应该有交叉补贴。有能力承担医疗费用的高收入家庭不应如低收入家庭成员那般获得高额补贴。但是，习惯了在政府医疗设施象征性付费，突然要求某一家庭收入阶层开始支付或缴纳费用给某项医疗基金，或不容易让受影响的民众明白其中的必要。我可以想像，更多的民粹主义政客会利用这个课题煽动情绪，把它描绘成受影响家庭的不公平损失。

然而，我不确定该计划是否会有如过去1Care提案中的健保强制付费机制。我不会为类似健康保险的计划背书，因为运行一个类似的系统的行政成本很高，一些社会人士很容易会被该系统排除在外并被边缘化。因此，我有兴趣知道的是，《卫生白皮书》中提及的所谓“健康福利配套”的实际好处和效果如何，它是否有如目前的PeKaB40计划，即人们不必为所提供的健康检查服务付费。

在规划和管理方面，卫生部有许多改革的承诺，以证据、价值和需求为决策根据。白皮书也非常强调公共和私营领域之间更好的整合、资源共享与合作。我有顾虑的是，若私人界将自己的既得利益置于公共利益之上，那么公私合营计划是否真的有利于人民？潜在的风险和成本会是什么？私人界会完全信任政府吗？政府会向私人界的要求让步、妥协多少？

即使是将服务提供单位和购买单位的角色分开，我很想知道到底卫生部如何才能有效地做到这一点，而不会增加更多的官僚行政，最终影响医疗服务的效率和素质。我理解卫生部声称要避免所谓的“利益冲突”说法——可能是在狭义下，卫生部旗下各部门在联邦预算底下有限的项目资源分配，各自划分争夺和圈定资源，尽管卫生部的这两个角色在很大程度上仍为公众利益和需求而服务。我担心角色分离后会导致把关者划地为王，“购买单位”或可限制或拒绝服务单位的更多真正需求。

尽管如此，我还是相当乐见卫生部为改革我国的卫生系统所付出的真诚努力，使其系统可持续为民众提供更好的服务和导向更良好的健康结果。卫生改革应该如何，《卫生白皮书》提供了基础让大家可实质讨论，这是改革的开始。

刊登于《東方日報》《群議良策》專欄2023年6月21日 

東方臉書鏈接

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.

 

 

Health white paper the first step to meaningful reform discourse

 

The health white paper, the initiative of former health minister Khairy Jamaluddin, was finally published and tabled in parliament on June 13.

The 57-page document, currently only available in Bahasa Malaysia, is a landmark publication by the Health Ministry. It is probably the boldest step for systemic and structural reform since the ministry proposed 1Care more than 10 years ago.

This document also shows that the Health Ministry can 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 learnt from the lessons of 1Care. It listened to the stakeholders while drafting the white paper, and it is now determined to build cross-party support in parliament for the 15-year plan.

The paper makes many big calls: separation of the ministry’s roles as service provider and purchaser; autonomy for hospitals and primary healthcare (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.

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 it is unsustainable to maintain the status quo.

The proposals it calls 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) but diversifying and pooling the resources of government-linked companies, individual contributions, wakaf, foundations, and donations.

The mechanism for the so-called National Health Contribution Scheme (“Skim Caruman Kesihatan Negara”) is not mentioned; it could be controversial, as the paper already calls for the adjustment of the fee structure under the Fee Act.

The scheme reminds some of the 1Care proposal, which 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 healthcare should not be subsidised as much as lower-income households.

But it might not be easy to get selected income groups to start contributing to a health fund.

I imagine the more populist politicians would seize the chance to portray the move as an unfair loss for the affected households.

But it is uncertain if 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 system. Some members could easily be left out.

It will 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 that do not require people to pay for the health screening services that they provide.

The paper holds many promises of reform to 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 should the private sector put its own interests ahead of public interest, would the public-private partnership deals really benefit the people? What are the potential risks and costs? Will the private sector fully trust the government? How much does the government have to give in to the demands of the private sector?

As to separating the Health Ministry’s roles as provider and purchaser, I would be interested to see how this could be done without adding layers of bureaucracy that would affect the efficiency of health service delivery. I understand the risk of so-called “conflict of interest 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 of separation can lead to gatekeeping where the “purchaser” can limit or deny more genuine demand for services.

Nevertheless, I welcome the paper as a serious and sincere effort by the Health Ministry to reform and transform our health system for better sustainability and to deliver better health outcomes for the population.

This should be the beginning of a substantive discussion on what the health reform should look like.

159th article for Agora@TMI column, published on The Malaysian Insight, 19 Jun 2023