Suaram Podcast: Edisi COVID-19: Episode #3 - Isu Kesihatan di Malaysia Semasa Pandemik (14.12.2021)

 

Podcast URL: https://open.spotify.com/episode/5t5M11ebF1jILC1Hch7CYC

Episode Description

Malaysia juga suatu ketika pernah diancam dengan kes-kes wabak seperti virus Nipah, virus Zika, Chikungunya, selesema burung dan beberapa lagi lain. Ini bermakna negara kita mempunyai pengalaman dalam menangani wabak yang pernah berlaku. Di dalam Episod #3 Podcast SUARAM - Edisi Covid-19, Amirah menemu bual Dr Lim Chee Han, seorang Penyelidik Kanan kepada Third World Network - sebuah organisasi antarabangsa. Episod kali ini akan membincangkan tentang isu-isu kesihatan yang berlaku di Malaysia antaranya dari segi fasiliti, kakitangan kesihatan, bajet kesihatan serta penerimaan vaksin sebagai satu hak atau kewajipan.

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1.       Dahulunya, Malaysia pernah diancam dengan kes-kes wabak seperti virus Nipah, virus Zika, Chikungunya, selesema burung dan beberapa lagi lain. Berdasarkan pemerhatian Dr, boleh Dr ceritakan pengalaman Malaysia dalam menangani wabak ini terdahulu?

 CH:

Memang benar bahawa Malaysia pernah menangani wabak-wabak yang membawa derita mahupun maut kepada masyarakat sejak kemerdekaan negara. Contoh-contoh wabak penyakit pada zaman dulu berleluasa seperti campak, tibi, batuk kokol, pertusis, polio dan lain-lain, semua ini kini telah dalam kawalan kerana wujudnya vaksin yang berkesan dan diberi kepada kanak-kanak sejak awal.

Benar juga bahawa wabak penyakit baru yang lebih kontemporari terutamanya Nipah dan SARS memberi cabaran yang besar kepada pihak pemerintah negara kita. Semuanya dikendalikan dengan agak baik, kerana ciri-ciri penyakit berbeza dengan COVID-19, orang yang dijangkiti lebih mudah dikesan dan dikuarantinkan.  Hanya 5 kes SARS dan 2 kes MERS dilaporkan kepada WHO yang telah dikendali oleh Malaysia, adalah dianggap penyakit telah dibendung kerana wujud unit aktif terhadap pemantauan penyakit dengan kerjasama antarabangsa dalam pengkongsian ilmu pengetahuan and informasi.

Susulan dan hasil daripada wabak SARS , Malaysia telah menetapkan satu dasar strategi yang komprehensif yang berjudul: Malaysia Strategic Workplan for Emerging Diseases (MySED Workplan) pada 2012. Versi kedua dikemaskini dan dikeluarkan pada 2017 susulan ancaman wabak Zika, dalam versi dasar strategi ini, Crisis Preparedness and Response Centre (ataupun lebih dikenali sebagai CPRC) telah ditubuhkan. Ini telah menyediakan Malaysia menangani COVID-19 pada peringkat awal dengan lebih bersistematik, dan Malaysia adalah di antara negara-negara pertama yang dapat mengesan virus SARS-CoV-2 dengan secara PCR dalam laboratori.

 

2.       Setahun yang lalu, negara China mengumumkan kematian Covid-19 yang pertama (Januari 2020). Kini wabak ini adalah antara 10 wabak yang membawa maut disenaraikan di dalam sejarah dunia. Pada pandangan anda, adakah Malaysia sebenarnya bersedia untuk menghadapi situasi pandemik sedemikian?

a)       Dari segi fasiliti (keperluan dan kemudahan kesihatan)

CH:

COVID-19 adalah antara wabak penyakit yang sukar ditangani. Ia jauh lebih mudah dijangkiti dan memberi risiko maut yang berkali ganda lebih tinggi daripada selsema influenza.

Oleh kerana konflik aktiviti manusia dengan alam semulajadi kerap berlaku dan komuniti masyarakat semakin berpeluang berinteraksi dengan haiwan liar , adalah dijangka wabak-wabak penyakit seperti COVID-19 akan berlaku dengan kekerapan yang lebih tinggi berbanding dengan zaman dulu.

Walau bagaimanapun, COVID-19 wujud atau tidak, fasiliti kesihatan di KKM haruslah dipertingkatkan, kerana kapasiti sekarang telah jadi sukar memuaskan  permintaan orang awam yang semakin tinggi. Sebelum pandemik, sesiapa yang kerap pergi melawat hospital pakar kerajaan ataupun hospital besar negeri, akan tahu bagaimana sesak dengan orang ramai dalam fasiliti tersebut. Bilangan katil juga tidak mencukupi di sesetengah hospital; banyak alat peralatan perubatan perlu diperbaiki ataupun dibeli yang baru bagi menaikkan taraf ataupun “upgrade”; lebih banyak hospital ataupun klinik dibangunkan terutama di kawasan bandaraya yang sering menghadapi kesesakan.

COVID-19 adalah lawan yang luar biasa. Dengan jangkitan yang berleluasa ataupun hilang kawalan pada peringkat komuniti tempatan, tiada negara boleh menampung permintaan rawatan penyakit kalau setiap hari ada kemasukan beribu-ribu pesakit baru harus dijaga. Jadi, dari pengurusan dan kawalan penyakit, fasiliti yang lebih penting dan diperlukan adalah seperti apa yang telah diumumkan oleh kerajaan dalam bajet baru-baru ini: Institut Penyakit Berjangkit di Bandar Enstek Negeri Sembilan.

Haruslah saya nyatakan juga, usaha menangani situasi pandemik dan rawatan bukan hanya tanggungjawab kerajaan sahaja, seolah-olah sektor kesihatan swasta boleh dikecualikan. Mereka juga diminta oleh orang awam untuk memikul beban bersama kerajaan juga, dan memberi kemudahan kepada pesakit yang dijangkiti ataupun dikuarantinkan. Dalam tempoh krisis kemanusiaan, usahlah mereka katakan menjaga keuntungan ataupun ‘bottom line’ mereka – pihak pengurus fasiliti perubatan haruslah diingatkan tentang Tanggungjawab bersama dan ‘People before profit’ – Kebajikan masyarakat didahulukan.

b)      Dari segi kakitangan kesihatan

CH:

Sudah pasti sekarang frontliners kita amat berpengalaman semasa menghadapi pandemik COVID-19, sama juga frontliners di seluruh dunia, tetapi wabak pada masa depan mungkin muncul dalam bentuk dan cara jangkitan yang jauh beza. Jadi, persiapan terhadap wabak akan datang adalah penting dari segi kawalan penyakit wabak.

Tidak dapat dinafikan bahawa lebih ramai kakitangan kesihatan terutamanya pengamal-pengamal perubatan ataupun ‘frontliners’ anggota-anggota barisan hadapan diperlukan untuk menjalankan tugas untuk menangani dan merawat jangkitan penyakit baru, tetapi lebih-lebihnya untuk memuaskan permintaan perkhidmatan kesihatan menjaga orang awam.

Untuk makluman anda, rancangan kerajaan untuk memperkembangkan tenaga kerja terutamanya untuk penjagaan kesihatan, telah ditetapkan dan sedang dijalankan. Langkah tersebut adalah untuk memenuhi permintaan servis penjagaan kesihatan atau perubatan yang semakin meningkat di Malaysia. Rancangan adalah mustahak dan munasabah, TETAPI masalahnya adalah pelaksanaan rancangan haruslah diberi kerjasama oleh pihak lain daripada kerajaan juga, seperti Jabatan Perkhidmatan Awam yang menentukan dan mewujudkan jawatan tetap rasmi kepada pengamal-pengamal perubatan yang menunggu. Situasi inilah adalah konundrum yang dihadapi oleh doktor kontrak.

 

3.       Berikutan keadaan pandemik ini, banyak kelemahan yang tidak dipedulikan mula timbul. Salah satu daripadanya adalah isu kontrak bagi kakitangan kesihatan. Seperti yang dapat kita lihat dalam laporan berita mengatakan bahawa adanya jurang yang besar antara kakitangan kesihatan kontrak dan kakitangan tetap. Dr boleh terangkan mengapa jurang ini berlaku dan apakah perbezaan antaranya? Dan mungkin Dr boleh kembangkan lagi bagaimana masalah ini berlaku? Apakah antara faktor disebalik isu ini?

 CH:

Status kakitangan kesihatan kontrak dan kakitangan tetap ada perbezaan dan jurang, ini sememangnya dapat dijangkakan. Manfaat dan kebajikan kepada kakitangan perkhidmatan awam sepatutnya hanya diberi layanan setimpal sekiranya anda adalah kakitangan tetap.

Tetapi, isu atau masalah kontrak ini timbul kerana dasar kerajaan yang tidak koheren, menyebabkan ramai yang berlayak diterima sebagai kakitangan tetap terpinggir kat luar sebagai kakitangan kontrak. Ini tidak adil pada titik permulaan, jadi, ini adalah tanggungjawab kerajaan untuk menjaga kebajikan doktor kontrak dan cuba memberi layanan yang hampir serupa kepada kedua-dua kumpulan, janganlah ada diskriminasi kerana status kerja yang di luar kawalan pengamal-pengamal kesihatan tersebut. Mereka bekerja sama panjang dan sama berat, sepatutnya diberi manfaat yang hampir sama.

Janganlah menyalahkan graduan perubatan yang ramai, ini semua adalah dalam jangkaan kerajaan  semasa buat unjuran jumlah permintaan jawatan dan jumlah graduan serta jumlah tenaga kerja yang diperlukan oleh sektor kesihatan. Kerajaan haruslah mengubahsuai dasar polisi bagi mengambil lebih ramai doktor kontrak ke dalam sistem perkhidmatan awam dan mengecualikan sesetengah bahagian dalam kementerian dalam rancangan optimisasi saiz kakitangan.

 

4.       Selain isu kakitangan kesihatan, berita seperti katil hospital tidak cukup, pesakit kongsi tangki oksigen juga turut dilaporkan. Adakah ini masalah yang turut dihadapi oleh negara–negara lain? Adakah fasiliti kesihatan di negara kita memang tidak mampu untuk menampung pesakit? Adakah ini masalah yang baru semasa pandemik atau masalah yang sedia ada sebelum pandemik berlaku?

 CH:

Ya, banyak negara mengalami masalah tersebut, ada yang menghadapi situasi jauh lebih teruk daripada Malaysia. Contohnya, India semasa dilanda dengan gelombang jangkitan Delta varian tahun ini. Bersyukurlah kerana Malaysia masih ada sistem kesihatan awam yang sempurna dan tidak bergantung banyak terhadap sektor swasta. Berfikirlah apa rupanya jika kerajaan haruslah sentiasa berunding dengan pihak swasta yang berbeza atas pelaksanaan program atau dasar memberi rawatan dan ujian COVID-19.

Memang benar bahawa pandemik COVID-19 kali ini, seperti apa yang berlaku pada bulan Julai dan Ogos tahun ini, telah memberi cabaran agak besar sampai melumpuhkan sesetengah sistem penjagaan di negeri-negeri dan hospital-hospital tertentu. Akibat daripadanya, ramai yang dijangkiti dan dikorban kerana tidak dapat rawatan dengan sempat.

Sebelum pandemik COVID-19, sudah diketahui bahawa bilangan katil di hospital KKM adalah agak penuh, sehingga semua hospital utama negeri sampai 70% dan ke atas.  Hospital Tengku Ampuan Rahimah di Klang telah pun mencapai hampir 90%. Tragedi kematian beratus-ratusan berlaku di Klang semasa bulan Julai-Ogos adalah sangat sedih dan mengecewakan. Jadi kerajaan haruslah mengutamakan isu kesihatan selepas apa yang telah berlaku di sektor kesihatan awam semasa pandemik. Malangnya, dari segi bajet 2021 dan 2022, saya tak nampak kemahuan politik yang kuat dan ketara berkenaan peningkatan pelaburan dalam sektor kesihatan awam.

 

5.       Dalam belanjawan yang baru, adakah Kerajaan memberikan lebih banyak bajet dalam meningkatkan fasiliti kesihatan dalam fasa pemulihan Covid-19?

 CH:

Dukacitanya saya maklumkan, Tidak, kerajaan gagal melabur secukupnya mahupun merentasi jangkaan minimum saya. Peningkatan peruntukan untuk KKM adalah terendah dalam 6 tahun, hanya sebanyak 1.5%, Ya, walaupun ada penambahan bajet bagi pengurusan ia hanya 3%, saya anggap jumlah ini hanya cukup bagi pelarasan seperti gaji kakitangan.

Apa yang sangat mengecewakan saya adalah peruntukan bagi bajet pembangunan. Sebanyak RM440 juta telah dipotong. Apa mesej yang hendak kerajaan hantarkan, sedangkan masyarakat, aktivis dan orang awam banyak menyatakan bahawa pelaburan serius haruslah dituju kepada sektor kesihatan awam, dan pembangunan serta naik-taraf fasiliti dan kemudahan KKM harus dirancang dan dilaksanakan. Mestilah anda tahu, jika nak bina satu hospital, ia akan ambil masa tempoh lebih kurang 5 tahun. Kalau lewat bermula projek, maka terlewatlah manfaatnya dibawa kepada masyarakat setempat. Kelewatan semua ini adalah berkaitan dengan peruntukan, dan ini bukan perkara yang remeh-temeh, tetapi melibatkan nyawa dan kesejahteraan orang ramai.

 

6.       Malaysia dijangka selesai memberi suntikan lengkap vaksin COVID-19 kepada sekurang-kurangnya 80 peratus populasi negara menjelang 3 Disember depan. Imuniti kelompok adalah harapan dalam memutuskan rantaian jangkitan wabak ini. Setakat 17 Nov lalu, tahap vaksinasi negara juga mencapai 76.2%. Walau bagaimanapun, ada sesetengah individu atau kelompok yang tidak mahu mengambil suntikan vaksinasi. Pada pandangan Dr, adakah seseorang mempunyai hak untuk menolak daripada divaksin atau ini merupakan kewajiban rakyat di setiap negara untuk ambil?

 CH:

Ya, seseorang ada hak untuk menentukan apa yang dimasukkan ke dalam badan sendiri. Tiada orang sepatutnya buat keputusan bagi seseorang, jika orang itu boleh berfikir dengan waras dan umurnya cukup matang. Konsen, ataupun ‘persetujuan’ individu adalah mustahak dalam pertimbangan etika perubatan. Sekiranya pembuatan seseorang tidak mengganggu ataupun menjejaskan hak orang lain, dialah yang harus bertanggungjawab atas keputusan dan tingkah laku sendiri. Dalam isu vaksin COVID-19, orang yang menolak vaksin mungkin berpeluang dijangkiti dan mengalami penyakit teruk sehingga risiko kematian, tapi mengikut pengetahuan sains terkini, orang yang divaksin ataupun tidak divaksin masing-masing ada peluang yang lebih kurang sama untuk menjangkiti orang lain. Jadi, orang yang tolak vaksin tidak harus dipersalahkan dan didiskriminasikan. Walaupun keputusan untuk tidak menerima vaksin, pada pendapat saya, saya tidak menggalakkan. Saya boleh memberi keterangan kenapa vaksin ada banyak manfaat, tetapi jika seseorang masih tegas atas pendirian itu, dialah yang akan menghadapi risiko dan mungkin akibat yang lebih besar. Saya tidak akan berasa simpati jika keputusan seseorang memudaratkan sendiri.

Akan tetapi, saya berasa kerajaan tidak wajar untuk menjadikan imunisasi COVID-19 sebagai wajib ataupun de-facto wajib. Seorang individu mesti ada hak untuk membuat keputusan terhadap apa yang dimasukkan ke dalamnya sendiri. Jika tidak, masyarakat ini adalah amat dahsyat jika seseorang boleh dipaksa.

TWN submission on the CBA 2.0 preliminary findings (6.12.2021)

Below are Third World Network’s initial issues and concerns regarding the CBA 2.0 preliminary findings. We strongly call for more details and information, especially with regard to the data and their sources, the CBA’s methodology and assumptions, the list of interviewees (categories if not actual individual names for personal privacy protection), and the interview questionnaires. We also put on record our concern that this CBA is conducted by a Ministry without the mandate nor competence, on a very important public interest issue that is the responsibility of other ministries, i.e. the Ministry of Health and the Ministry of Domestic Trade and Consumer Affairs. 

1) Identity of the Third Party Consultant: Who is it? What are the credentials for appointing this consultant? Who funded the study? Can the TPC make a declaration of conflict of interest, if any? (Update: the latest response from the UPC admin on 5.12.2021 still did not reveal the identity of the TPC, but admitted that the private industry has funded the study)

2) Conflict of Interest: The composition of the steering and technical committees both look very much driven by the pharmaceutical and private healthcare sector major players (PhAMA, MOPI, MMA, APHM and even US-based PhRMA) who have direct interest in stopping or reversing the Cabinet-approved Medicines Price Mechanism (MPM) policy. A Senior Industry Representative from PhAMA is even the co-chair for the technical committee. 

3) Need for a full study report with details and information: The preliminary findings are just results presented in numbers, without clear and specific methodology, assumptions, supporting data and calculation process for the public to validate and review each of the findings.

4) Misrepresentation of the MOH’s proposed Medicines Price Mechanism (Slide 8): The study used a two-tier margin system to calculate the mark-up margin (35% for < RM1,000 per unit drug; 10% for >RM1,000/unit), whereas the MOH has 4 tiers. Also, it is not correct to assume ALL other drugs in the market will have MPM mark-up control even in Phase 2 -- only prescription drugs will be covered. What are the 5000 medicines selected for the CBA2.0?

5) The first CBA was on Phase 1 of the proposed MPM, covering about 600 single-sourced prescription medicines available in the Malaysian market. Comparing that with 5000 (undisclosed list) medical products in CBA 2.0 is highly questionable.

6) Wrong assumption on the MPM model (Slide 10) : MPM policy is to regulate mark-up range at wholesale and retail levels, not ‘discount on cost of therapy’ as shown in the “Price-volume vs price scenarios” graph. In fact, in the CBA1.0, the study showed that 30% of medicines might even experience initial upward adjustments of prices; did the second study consider these gains for the wholesalers and retailers? 

7) The exclusion of consumer and patient advocacy groups for the interviews (Slide 11): The interviewees are industry-dominant, not taking account of the public health and well-being costs. In the Webinar-format ‘consultation’ conducted by MPC, we were told that the patients under the Patient Assistance Programme were interviewed instead of what it is written as ‘patient advocacy groups’ - the patients may not have medicine access issues because they are sponsored or subsidised by the pharmaceutical companies. Insufficient access to affordable cancer medicines is a major issue voiced by patient advocacy groups such as Together Against Cancer and this is absent in what was presented by MPC.

8) No counterfactual in the analysis: For example in Slide 15, the assertion made claiming that 33% or 2,600 clinics will shut down.  We do not know how the study arrived at that number. If it was based on interviews or a survey, we need to look at the questionnaire and response (sample size). The most damaging part of the assertion is that there is no counterfactual. We know that in recent years there were clinics shutting down, it was also the trend before the COVID-19 pandemic. If the study is serious, those clinics shut down in the counterfactual cannot all be attributed to the MPM policy.

9) Possible exaggerated claim in Slide 15: There is an assertion that the MPM policy will cause a 35-40% drop of total hospital revenue. According to the Malaysia National Health Accounts 2020 preliminary data, private hospitals contributed RM14.553 billion to the total health expenditure. 35% of total hospital revenue could mean a figure close to RM5 billion. Did private hospitals overcharge so much to the tune of RM5 billion a year, beyond the MPM proposed mark-up range? This admission of the difference is simply astonishing, we would like to understand how it is derived. 

Given that there are such good prospects in the projection in private healthcare industry stated in Slide 13 (ie. RM1 Trillion economic value, RM44 billion planned investments), it is baffling to understand why the CBA 2.0 result claimed that “hospital industry operates on tight margins” (Slide 15). The wordings claiming that the hospitals “consider shutting down outpatient wings” sounded unfortunately more like a public threat than what could be qualified or quantified in the study.

10) Baseline problem for the B40 households in Slide 16: It is wrong to assume an increase in private healthcare usage especially for the B40 households based on the current baseline -- this is because the current high price or unaffordable prices are probably keeping a significant number of the medicines out of reach for treatment. With the possible effect of the MPM policy resulting in more affordable pricing of medicines, more B40 households should be expected to get access. The analysis in Slide 16 seems to have the intention to pit T20 and M40 against B40 in a moral narrative. There is no need to do that, as we are talking about access to medicines for all, especially for B40 households. Furthermore, M40 and T20 households do not deserve to be overcharged or exploited for the industry’s higher profit margin. In any event, the B40 relies on the public health system while the price regulation mechanism seeks to particularly reduce out-of-pocket expenses of the rakyat.

The annual premium cost avoidance result in the same Slide 16 also suffers from similar prejudice, given that we know why not many B40 households are among the private health insurance purchasers, simply because they cannot afford it. And one of the major reasons why the premium could be prohibitively high for B40 households, is probably the medicine prices. Hence, there is no point in projecting the premium cost ‘avoidance’ based on the current scenario.

11) Doubtful Basis of the claim of fewer Innovative Medicine launches (Slide 21) : There is no counterfactual -- could it be due to the trend of the pharmaceutical industry having fewer new chemical entities? The MPM policy regulates the mark-up upper limit for wholesalers and retailers only, the medicines manufacturers should not feel deterred or discouraged to introduce their new medicines in the market. They can still declare and sell the products at their proposed prices. Given that these medicines would have certain healthcare demand in the country, would the companies really want to give up the Malaysian market entirely? So many other countries have some sort of Medicines Price Regulation policy, do they experience the same fate after the policy implementation?

12) Peculiar case of loss in medical tourism due to more affordable medicines pricing (Slide 19): The entire assumption seems based on loss of innovative medicine access (referring to the previous Point 11). If that is not logical, then it makes no sense to say that healthcare travellers would shun Malaysia as the destination if the medicine prices become lower. This MPM policy would instead increase the competitive edge of Malaysia against regional competitors such as Thailand for healthcare travellers.

Industry attempting to block medicine price regulation (7.12.2021)

MEDICINES are essential for the sick or injured, and can be a matter of life and death. It is not an ordinary commodity but a necessity for survival or recovery.

However, access to life-saving medicines can face the barrier of affordability because, unfortunately, medicine pricing in Malaysia is currently totally unregulated.

A 2019 study by University of Malaya revealed that 72% of cancer patients experienced financial catastrophe during the first year of treatment in private hospitals, while one-third of households became impoverished.

Cancer medicines are very well known to have exorbitant price tags, and mark-ups by the private hospitals on the originator drugs and generic drugs are also well-studied. Affordable medicines are a challenge if we leave it entirely to the market.

In April 2019, the cabinet approved the Medicines Price Mechanism policy proposal tabled by the Health Ministry (MOH) in collaboration with the Domestic Trade and Consumer Affairs Ministry. Under the first phase of the policy implementation, the government will impose an upper limit of mark-ups at the wholesale and retail levels in a regressive manner (higher priced items will have a smaller mark-up for the upper limit), for about 600 single-sourced prescription medicines. But almost three years later, the policy still has not yet been implemented.

Recently, I was shocked to discover that certain vested interests in the private healthcare and pharmaceutical sectors, who have strong objections to the policy, managed to persuade the International Trade and Industry Ministry (Miti) to have a go at conducting a cost-benefit assessment (CBA) on the medicines pricing policy’s impact on private healthcare.

On November 29, the preliminary findings of the study were uploaded to the UPC (Unified Public Consultation) website of the Malaysian Productivity Corporation (MPC). The presentation of the findings was conducted via Zoom using the Webinar format on December 1, in which participants were restricted to typing questions in the Q&A box without being able to see each other’s questions or find out who else was present in the meeting.

The so-called public consultation lasted about one hour, with many questions left unanswered or not adequately addressed. Some participants resorted to the Zoom Chat box to share their comments.

One of the most pertinent questions is the identity of the so-called Third Party Independent Consultant and the funder(s) behind the study. It was not revealed throughout the meeting nor in the document despite being repeatedly asked by a number of participants. What is the point of having public consultation then?

What I found most troubling was the direct involvement of the major private sector players in the steering committee and technical committee for this CBA study: the Pharmaceutical Association of Malaysia (Phama) comprising multinational companies, the Malaysian Organisation of Pharmaceutical Industries (Mopi), the Association of Private Hospitals of Malaysia (APHM), Malaysian Medical Association (MMA) and even the Pharmaceutical Research & Manufacturers of America (PHRMA) – they all have direct interest in stopping or reversing the new policy.

Should this not already raise the red flag of conflict of interest? Not surprisingly, the preliminary findings eventually produced questionable results, indicating the big negative impacts to the economy, especially to the private sector themselves.

However, the preliminary findings were just numbers presented without showing the supporting data and calculation processes. The methodology of the study was also sketchy in its details, and the interview questionnaire used by the consultant was not known.

Among the “expert interviews”, no one represents the consumer’s interests, and in response to which patient advocacy groups were interviewed, the answer was patients under patient-assisted programmes sponsored by pharmaceutical companies (meaning, they already have access to the medicines concerned at some reduced cost).

What is of concern is that the CBA might have misrepresented the Health Ministry’s original proposed mechanism, such as reducing the regressive mark-up (10-35% in four categories) to just two categories, hence exaggerating the price impact.

The study also showed the impact of “discount on cost of therapy” to B40-M40-T20 households. This is misleading because the proposed mechanism is a regulation of the mark-up upper limit, and not giving a “discount”. In fact, the medicine prices could also go up for some cases in the beginning, a possibility that the ministry presented in its own extensive consultations in 2019/2020.

There also seems to be an intent to divide the income groups, pit B40 households against M40 and T20 in order to show the benefits will go most to the T20. But even M40 and T20 households do not deserve to be overcharged or exploited for the industry’s greed.

The study might also miss the point that when medicine prices become more affordable and accessible to the B40, the utilisation volume will go up as well. In any event, the B40 relies on the public health system while the price regulation mechanism seeks to particularly reduce out-of-pocket expenses for the rakyat.

Probably the two most controversial and bold claims in the preliminary findings attributed to the Medicines Price Mechanism policy are: 1. It is said that there will be a 35-40% total drop in private hospital revenue. According to the Malaysia National Health Accounts 2020 preliminary data, private hospitals had contributed a total of RM14.55 billion in health expenditure in 2020. If the claim of a 35% hospital revenue drop was true, this means RM5 billion per year is forgone! Is this the admission of private hospitals that RM5 billion is the amount they have overcharged their patients following implementation of the new policy?

Secondly it was claimed that 33% or 2,600 private clinics will close. How does the study arrive at this number?

Hence, it is in the best interests of the public to examine the full study, especially to validate the numbers, methodology and the interview questionnaire involved.

The preliminary findings in the study also tells us that many healthcare travellers will not come to Malaysia, hence causing economic loss. This is contrary to our general expectation that the lowering of medicine prices would give Malaysia a competitive edge, vis-à-vis Thailand, in the region.

The basic assumption of the study is that Malaysia will lose 10-35% of new drug launch/access resulting in a drop of 54% in incoming healthcare travellers coming. Is the assumption plausible? Given the MOH’s new policy to regulate the mark-up for the upper limit only for the wholesalers and retailers, the fact remains that medicine manufacturers can still declare their preferred price for sale in Malaysia. So why wouldn’t they come to a market known for its demand?

Lastly, the Medicines Price Mechanism policy is a matter of public health and consumer price. Hence, under the policy purview and jurisdiction of MOH and the domestic trade and consumer affairs ministry. Miti should not overstep its own boundaries and competence and dictate the policy direction of other ministries. This industry-driven CBA study sets a dangerous trend, shows precedence to commercial interests, and subverts the decision already made by the cabinet.

Forget about the CBA’s self-claimed virtues of being “independent”, “data-driven”, “comprehensive” and “unbiased”. What was presented to the public is the opposite.

The Medicines Price Mechanism policy, in the long term, can ensure fair and transparent medicine pricing for patients in Malaysia. It is not true that the policy does not allow wholesalers and retailers to make profits.

Excessive profit at the cost of people’s health and lives is what the policy helps to safeguard against. Narrow, vested interests for profiteering should not trump public interest, let alone people’s health and lives.

Article URL:

https://www.themalaysianinsight.com/s/355176

Omicron是Delta后的剋星？ (群議論點-12月8日) （愛FM《名師早點》12月6日）

#群议论点 第32篇，社员林志翰撰文

# 林志翰：Omicron是Delta后的剋星？

11月24日，这个变种毒株由南非通报而首次面世；两天后就被世界卫生组织列为需密切关注的病毒变体（Variant of Concern, VOC）,并将之命名为Omicron。这是继5月的Delta后，最新的VOC。

Omicron为何会被视为一个极大潜在的威胁呢？根据基因排序报告，Omicron变种毒株的刺突蛋白被发现拥有32处基因突变，其中一半在受体结合域（Receptor binding domain）里，这其实是病毒侵入人体细胞的接触面。那意思是什麽？大部分我国人民接种的疫苗种类，除了科兴和国药，其他的疫苗只让我们的免疫系统辨识病毒的刺突蛋白而已。如此多的基因突变，除了有崭新的突变，还有过去被发现和证实可提升传播能力以及协助逃逸免疫反应的突变。因此各方有所顾虑和担忧，实属正常。

然而，Omicron已被证实危险了吗？坦白说，目前还言之过早，尤其是有关它的感染力和传播能力，以及它的伤害能力。由于这个变种毒株的发现还相当近期，一般上要在病患被证实感染的两周内才能知道它的实际威胁。现在我们已知道的事实是，截至12月4日，这Omicron已散播传开至全球的44个国家和地区，包括我国马来西亚，在12月3日发现第一宗病例。在南非，Omicron已成为主流传播的毒株，而该国自从发现了Omicron后，每日新增病例迅速飙升，诱发该国的第四波疫情。有科学家计算南非Gauteng省的病例增幅趋势，得出Omicron的传染力是Delta的3至6倍。

根据新闻报导，南非年轻人和小孩受感染的人数有所增加。由于南非是个人口相对年轻的国家，这不太让人惊讶，一般上这些年龄阶层的病患也比较健康能避免重病，所以新闻也报道目前Omicron受感染病患的症状轻微，还未出现死亡病例。但现在还是太早断定，因为卫生当局要担忧和提防的是高危且未疫苗接种的群体受感染。

不过，目前的数据显示不少曾冠病痊愈的病患也重新受感染，因此可推测疫苗接种者也相当有机会受感染。那么是否意味着疫苗已失效了呢？别慌，没有证据显示一般疫苗已失去了针对性免疫作用。预料抗体与Omicron毒株的结合度会减少，但不至于疫苗诱发的免疫细胞如T细胞无法辨识变种毒株。毕竟过去所有的变种毒株包括Delta，疫苗免疫反应还在，仍有一定成效保护疫苗接种者免于重病和死亡。无论如何，针对高危群体，若有机会，请你们赴约接受疫苗加强剂的保护。

大家也不应该太害怕太多基因突变的毒株，因为有些的基因突变对毒株来说未必有利或增强功能，反之有可能减弱。因此一下子突变太多，对病毒来说也未必是好事。

由于Omicron毒株与过去发现的毒株基因排序差别太大，科学界纷纷推测这毒株出现的源头以及变种进化演变过程，目前有三个解说：（一）出现在一个长期感染冠病未能痊愈的病患，（二）从一个与世隔绝的偏僻社区传开，（三）源自动物宿主。

无论如何，这次Omicron的发现，重新让全世界检视疫苗分配不公平不正义的问题，特别是非洲大陆国家的疫苗接种进展仍十分缓慢，面对货源短缺、疫苗採购价格高昂、或订单延迟交货等种种问题。发达国家若任由低收入国的疫苗接种问题延续将有可能再出现下一个威胁力更大的变种毒株，届时他们的经济也会继续受到全球疫情波及和影响。这次的Omicron出现就是一个严厉的警告。

(此分享同時出現在愛FM《名師早點》12月6日）

Medicines Price Regulation. “Nothing Without Us”. Failure to Consult Cancer Patient Groups in the CBA 2.0 Study. (13.12.2021)

Joint Statement by 16 cancer societies on 13 DEC 2021 in Kuala Lumpur

Medicines Price Regulation. “Nothing Without Us”.
Failure to Consult Cancer Patient Groups in the CBA 2.0 Study.

We, the undersigned 16 cancer societies led by Together Against Cancer (TAC) and the Prostate Cancer Society Malaysia (PCSM) raise doubt and express disapproval of the recently presented preliminary findings of the Cost-Benefit Assessment (CBA) 2.0 on the impact of the Medicines Price Regulation (MPR) policy.

Although the study summary stated that patient advocacy groups had been approached for 'expert views', none of our societies was invited.

Cancer medicines are among the most expensive in the market. Many of our members are experiencing financial hardship coping with the treatment costs, with medicine price as one significant determining factor. Under the 12th Malaysia Plan, Strategy B2, “Ensuring Financial Sustainability for Healthcare,” spells out explicitly: “a price control mechanism for medicines will be introduced to protect consumers from unfair pricing” (Page 4-22). The government clearly knows the issue and attempts to address the medicine pricing concern.

The Medicines Price Regulation policy is fundamentally a public health and consumer affairs policy first and foremost, hence rightfully spearheaded by the Ministry of Health (MOH) and Ministry of Domestic Trade and Consumer Affairs. Public consultation on the CBA 1.0 was held on 4 January 2021 for the patient and consumer groups and NGOs.

We are very disappointed with how the CBA 2.0 was conducted. The fact is that the CBA 2.0 primarily chose to overlook the impact on the most affected stakeholders (i.e. patients and their families) on the demand side but instead on the exaggerated claim of loss to the private industry on the supply side. Who plays victimhood here, who needs the medicines more? For whose interest and where is the objectivity of the study? The CBA 2.0 study is too biased towards the views of the private healthcare industry and even funded by them, suggesting a massive conflict of interest.

Confusion involving the private primary care sector, where the Phase 1 MPR policy likely will not affect, further confuses the picture. CBA 2.0 is framed as if the proposed policy will be taking away the narrow margin of the private primary care sector and threaten their survival. We want to focus on expensive, unaffordable cancer drugs that are not even free or subsidised in the government sector, which the MPR policy attempts to address.

According to the National Cancer Registry Report 2012-2016, males and females in this country have a lifetime risk of 1:10 and 1:9 respectively of cancer. In 2019, MOH and private hospitals treated 123,848 and 49,364 cancer patients and recorded 7,031 and 1,166 deaths, respectively (Health Indicators 2020).

A significant number of patients in the community need cancer drugs every day to stay alive. According to the Medicine Prices Monitoring Report 2017, cancer drugs stood out as one of the most expensive drug treatments by disease category. For example, Gefitinib and Trastuzumab, a Her2 type breast cancer drug, would require 190.8 and 551.7 days of wages (in the minimum wage category) for just one course of treatment.

Very interesting to note that the original Trastuzumab Herceptin came down in price by 50% from close to RM7,000 per month to RM3,000 per month in 2017 when biosimilars or generics came into the Malaysian market. Imagine if the average cost of Trastuzumab biosimilar cancer drug per treatment course is RM3,000. This would already cost the government and society about RM400 million per year just for one type of drug treating breast cancer patients in Malaysia; what more with higher markups at different distribution levels?

Ms Crystal Ng, a TAC Committee member, has shown that to continue to survive Stage 4 Her2 type breast cancer. She needed to spend RM8,870 every three weeks for Her2 drug TDM1 (Kadcyla) alone. The price does not include other costs such as Pirimat, Dexamethasone, Heparinised Saline, Chlorhexidine, doctor's consultation, nursing fee, etc. She has spent a total cost of RM168,503 of TDM1 (Kadcyla) alone for 19 cycles so far; how many Malaysian households could afford the treatment like this? Crystal chose to continue treatment in the private sector because the cost of the innovators is similar in the government hospital. It shows that even in the MOH hospital setting, many cancer drugs are not provided or listed in the MOH Medicines Formulary because they are too expensive.

We also found that some oncologists do not even inform the patients that they have a choice of expensive but efficacious drugs that could extend the lives of the cancer patients. Ms. Chang Chu San, a government teacher, was not given any option by a MOH hospital and a MOE hospital when her breast cancer recurred in her liver in 2014. When she consulted a private oncologist, she was informed of life-saving drugs (Herceptin and Kadcyla) that have kept her alive since then. She has spent close to RM177,200 (now 81 cycles) with the assistance of a compassionate programme, and after seven years, she continues to pay for lifelong treatment. She has since retired this year and leads a very active, fulfilling life. This is not acceptable for any contributing member of society to have lives cut short if not for these life-saving drugs.

In PCSM, some of their patient members have their lives unnecessarily shortened due to overpricing of medicines. Some medicines are so costly that only the wealthy could afford them, leaving the majority of the patients either facing financial catastrophe or opting out. PCSM recognise that the cost could be flexible among the drug manufacturers, as the cost price for the drug is just a fraction of the sale price, especially with drugs that have been in the market for a while but enjoy monopoly due to patents or only one or two generic suppliers. Also, there are equally efficacious generics elsewhere in the world in some cases, which could be obtained through limited supply personal imports.

Unfortunately, with wholesalers and retailers' current 'middleman' system, the markups at different levels would likely 'eat up' the supposed savings for the patients and families. Just to give one example, prostate cancer has an efficacious drug called Abiraterone acetate, priced at RM7,500 per month originally. PCSM fought hard for years to get accessibility of cheaper generics. Finally, a generic came to Malaysia two years ago, promising a lower price, but since it was a monopolised market, it was priced at RM4,000 (although it costs only RM800 in India). PCSM appealed to MOH to get a second generic. Before the generics arrived in Malaysia, PCSM had negotiated directly with the manufacturer as their members could only afford RM1,400. The manufacturer agreed and brought down the market price to the more affordable level exclusively for their members. But the other Malaysians are not so lucky. They have to go to the 'common market', either in the public or private hospital, where the costs range from RM2,400 to RM3,500. This shows the significant massive extent of the markup to the final price. PCSM has more than 50 members using the second generic, and the numbers are growing. From their experience in Malaysia with 350 prostate cancer survivors, some members managed to extend their lives and quality of living by an average of two years. How can anyone object to the regulation of markups that can prolong lives?

The lesson from the abovementioned stories is that patient advocacy organisations such as TAC and PCSM play a vital direct role in safeguarding the best interest of the demand side (the patients). Reducing the wholesalers and retailers' markups can achieve more affordable or favourable medicine pricing. Also, the Abiraterone acetate story told us, generic competition is the key to bringing affordable medicines to the patients.

For Phase 1 of MRP, only prescription drugs with a single registration holder in the Malaysian market (about 600 drugs) will be subjected to MRP, as single-sourced medications are usually most expensive due to market monopoly. Phase 1 will be monitored and reviewed before proceeding to the next phase. Transparency of the pricing that will be compared to external pricing of countries with similar GDP is good practice to ensure reasonable pricing for the patients in Malaysia. That is fair to the industry and private healthcare sector, which MOH always consults.

Therefore, we call for the government to implement the 1st phase of the MPR as soon as possible and urge the proponents of the CBA 2.0 to re-focus on implementing the 1st phase in line with the CBA 1.0. Stop using the victim card and stop exaggerating the numbers to include drugs outside Phase 1 in the CBA 2.0 study.  If they genuinely care for their patients, the private healthcare industry also shouldn't make excessive profits at the expense of the patients, forcing them to fall into financial catastrophe or impoverishment. Instead, they should comply and lower their markup margin for costly drugs while still making a reasonable profit while changing their strategy to provide access to all patients, hence earning more by increased sales volume. Furthermore, it is reassuring that Europe, Australia, New Zealand, Canada, Indonesia, Thailand, India and China practice medicine price control.

We, the cancer patients, are very hopeful that cancer drugs can be made more affordable. Hence, we hope with regulated price control, more people can access and, through the economy of scale, bring reasonable profits to all parties.

Endorsed by:

1) Together Against Cancer (TAC)
2) Prostate Cancer Society Malaysia (PCSM)
3) Academy of Medicine Malaysia (AMM)
4) Breast Cancer Welfare Association Malaysia (BCWA)
5) Cancer Survivors Malaysia (CSM)
6) Cancer Survivor Support Group (CSSG)
7) Colorectal Cancer Survivorship Society Malaysia (Corum)
8) Kanwork
9) Majlis Kanser Nasional (MAKNA)
10) Malaysian Society of Haematology
11) National Cancer Society Malaysia (NCSM)
12) Persatuan Sukarelawan Kanser Negeri Kedah
13) Pink Ribbon Wellness (L) Foundation (PRWF)
14) Society for Cancer Advocacy & Awareness Kuching (SCAN)
15) The Max Foundation
16) War on Cancer

* Together Against Cancer (TAC) is motivated to provide a unified voice for all cancer patients, to improve access to high quality healthcare in Malaysia through health policy and legislative reforms. Prostate Cancer Society Malaysia (PCSM) represents a Blue Ribbon Movement : Giving support to prostate cancer survivors through sharing & education; Educating public benefits of early detection & keeping them fit.

More information please visit: facebook.com/TACMalaysia ; facebook.com/NPCSG

Best harm reduction is quitting, not switching

The world turns its attention New Zealand for its innovative and bold policy to bar future generations from smoking by ensuring those who are currently aged 14 and below will never be legally able to buy any tobacco product.

The new legislation effective in four years to raise the legal smoking age every year means the population born after 2008 cannot legally smoke, hence creating a smoke-free generation of New Zealanders.

In 2019, 13.4% of New Zealand’s adult population were smokers. The Labour government which pledged a Smokefree 2025 as headline policy is determined to reduce the national smoking rate to 5% by 2025. 

Many doubt whether Malaysia can replicate the policy and effectively stop teenagers from getting cigarettes at the shops or on the black market.

Illicit trade of tobacco due to smuggling activities (sometimes even orchestrated by the industry themselves) is a common tactic used to undermine the government’s tobacco control policy.

Getting youngsters addicted first to tobacco and start picking up the smoking habit is always the industry’s hidden agenda and game plan for profit sustainability and bottom-line in future, no matter if it is in the form of cigarettes or vapes.

According to the National Health and Morbidity Survey (NHMS) 2019, Malaysia has a smoking prevalence of 21.3% among the adult population. It was estimated that 4.8 million Malaysians aged 15 years and above currently smoke, with men disproportionately at risk (30 times higher prevalence to women) and also higher prevalence found in rural areas (25.4%) compared to urban areas (20.1%).

What is more worrying, 12.3% of the 15-19 age group are already smokers. As more young people pick up up e-cigarettes or vapes, a bad health outcome is a certainty. 

Smoking is one of the world’s largest preventable causes of premature death, killing more than eight million people and costing the global economy US$1.4 trillion (RM6 trillion) each year.

Malaysia is no exception. A 2018 study found that smoking presented a 45% attributed risk of death in Malaysia for male smokers aged 15-64 while 23.5% of deaths among men is attributed to smoking.

Some 213,122 patients were treated and 12,167 patients died in MOH hospitals of diseases and cancers related to the respiratory system in 2020 (Health Indicators 2021, MOH).

Since the public healthcare cost is largely subsidised by government revenue, the negative health consequences of the smoking habit are eventually borne by the taxpayers. The excise tax collected by the government for cigarettes is unlikely to cover all expenses.

Besides health, loss of productivity, happiness and even lives are social costs associated with smoking habits. The people surrounding the smokers could also be affected by the second-hand smoke.

Thus, as much as the tobacco industry wants people to believe that it is their choice to smoke, once they are in it, they lose the freedom to choose because of addiction.

The intention is increasingly obvious. The tobacco industry is using “harm reduction” campaigns through third party or front groups for diversion, attempting to divide public health communities and influence the policymakers so that they can stay in the game.

There is no good information to suggest that switching to the so-called “next generation products” such as vapes and heated tobacco products will lead to harm reduction or facilitate quitting smoking altogether.

The appeal of vape to young “nicotine-naïve” people cannot be overstated. They can be lured with misleading information (e.g., vaping is better, safer and “cleaner” than conventional cigarettes) and enticing choices of vape flavours. It makes them look cool to their peers.  In fact, the most prevalent (14.7%) vapers are in the 20-24 age group (NHMS 2019).

Personally, I have not seen a single person successfully transition from cigarettes to vape and later quit smoking. Instead, more have become dual smokers and vapers.

Quitting is never easy; sometimes the smoker does not even wish to quit. Smokers need help and support from family and friends, not another product that perpetuates their addiction to nicotine.

Anti-tobacco activists are familiar with the tactics of the tobacco industry, therefore they push for “zero harm” for a quit-smoking approach. 

When the harm reduction concept is applied to drug users, they are usually supervised by medical personnel to help them stop drug-related harmful behaviours or the use of harmful products.

The concept may not be a bad idea for tobacco use but the problem is, there is little evidence  to show that the alternative products are actually less harmful, and merely “switching” does nothing much to encourage quitting.

Also, for the concept to work, one must switch completely to a genuinely less harmful product if he is not able to quit smoking. Continuing to smoke cigarettes alongside other tobacco or nicotine products will defeat the purpose.

We have to bear in mind that nicotine is classified as a Group C poison under the Poisons Act 1952. It is actually illegal to put nicotine in vape liquids but the products are not as strictly regulated as cigarettes.

This means anyone, including youngsters, can easily gain access to the products. The vape industry is also lobbying to remove the provision stating “nicotine as poison” so that nicotine-containing vape liquids can be sold freely.

In Malaysia, the tobacco product and e-cigarette draft bill will be presented to parliament in the first quarter of 2022.

It is likely that it will stay in line with the WHO recommendation stating that "electronic nicotine delivery system devices, such as e-cigarettes, should be strictly regulated for maximum protection of public health.”

More independent studies are needed to find out how to effectively achieve smoking cessation and study the public health claims of all sorts of nicotine-containing products.

We expect the tobacco industry to continue churning out new products and making unsubstantiated health benefit claims. These claims have to be vigorously and independently studied and assessed.

All in all, prevention is always better than treatment. Preventing non-smokers from becoming new smokers should be the endgame policy for our government.

New Zealand has sent out a bold statement with its policies and actions.

Will Malaysia accept the challenge to follow suit to reach the target of 5% smoking prevalence by 2045? 

81st article for Agora@TMI column, published on The Malaysian Insight, 14 Dec 2021 

Industry-driven attempt to block medicines price regulation

Industry-driven attempt to block medicines price regulation

Medicines are essential for the sick or injured, and can be a matter of  life and death. It is not an ordinary commodity but a necessity for survival or recovery.  

However, access to life-saving medicines can face the barrier of affordability because unfortunately medicine pricing in Malaysia is currently totally unregulated. A 2019 study by University of Malaya revealed that 72% of cancer patients experienced financial catastrophe during the first year of treatment in private hospitals, while one-third of households became impoverished. Cancer medicines are very well known to have exorbitant price tags, and mark-ups by the private hospitals on the originator drugs (median=51%) and generic drugs (median=166.9%) are also well-studied. Affordable medicines are challenging if we leave it entirely to the market.

In April 2019, the Cabinet of the Government of the day approved the Medicines Price Mechanism policy proposal tabled by the Ministry of Health (MOH) in collaboration with the Ministry of Domestic Trade and Consumer Affairs. Under the first phase of the policy implementation, the government will impose an upper limit of mark-ups at the wholesale and retail levels in a regressive manner (ie. higher priced items will have a smaller mark-up upper limit), for about 600 single-sourced prescription medicines. But almost 3 years later, the policy is still not yet implemented.

Recently, I was shocked to discover that certain vested interests in the private healthcare and pharmaceutical sectors who have strong objections to the policy, managed to persuade the Ministry of International Trade and Industry (MITI) to have a go at conducting a Cost-Benefit Assessment (CBA) on the medicines pricing policy impacts on the private healthcare sector. 

On 29th November, the preliminary findings of the study were uploaded to the UPC (Unified Public Consultation) website of the Malaysian Productivity Corporation (MPC). The presentation of the findings was conducted via Zoom using the Webinar format on 1st December, where the participants were merely restricted to typing questions in the Q&A box without being able to see each other’s questions or find out who were present in the meeting. The so-called public consultation lasted about 1 hour, with many questions left unanswered or not adequately addressed. Some participants resorted to the Zoom Chat box to share their comments.

One of the most pertinent questions is the identity of the so-called ‘Third Party Independent Consultant” and the funder(s) behind the study. It was not revealed throughout the meeting and in the document despite being repeatedly asked by a number of participants. What is the point of having public consultation then?

What I found most troubling is the direct involvement of the major private sector players in the steering committee and technical committee for this CBA study: Pharmaceutical Association of Malaysia (PhAMA) comprising multinational companies, the Malaysian Organisation of Pharmaceutical Industries (MOPI), the Association of Private Hospitals of Malaysia (APHM), Malaysian Medical Association (MMA) and even the Pharmaceutical Research & Manufacturers of America (PhRMA) -- they all have direct interest in stopping or reversing the new policy. Should this not already present the red flag of conflict of interest? Not surprisingly, eventually the preliminary findings produced questionable results indicating the big negative impacts to the economy, especially to the private sectors themselves.

However, the preliminary findings are just numbers presented without showing the supporting data and calculation processes. The methodology of the study is also sketchy in its details, and the interview questionnaire used by the consultant is not known. Among the ‘expert interviews’ groups, no one represents the consumer interest, and in response to which ‘patient advocacy groups’ were interviewed, the answer was patients under patient-assisted programmes sponsored by pharmaceutical companies (ie. they already have access to the medicines concerned at some reduced cost).

What is of concern is that the CBA might have misrepresented the MOH’s original proposed mechanism, such as reducing the regressive mark-up (10-35% in 4 categories) to just two categories, hence exaggerating the price impact. The study also showed the impact of ‘discount on cost of therapy’ to B40-M40-T20 households – this is misleading because the proposed mechanism is a regulation of the mark-up upper limit, not giving a ‘discount’. In fact, the medicine prices could also go up for some cases in the beginning, a possibility that the MOH presented in its own extensive consultations in 2019/2020. 

There also seems to be an intent to divide the income groups, pit B40 households against M40 and T20 in order to show the benefits will go most to the T20. But even M40 and T20 households do not deserve to be overcharged or exploited for the industry’s greed. The study might also miss the point that when the medicine prices become more affordable and accessible to the B40, the utilization volume will go up as well. In any event, the B40 relies on the public health system while the price regulation mechanism seeks to particularly reduce out-of-pocket expenses of the rakyat.

Probably the two most controversial and bold claims in the preliminary findings attributed to the Medicines Price Mechanism policy. First it is said that there will be a 35-40% total drop in private hospital revenue. According to the Malaysia National Health Accounts 2020 preliminary data, private hospitals had contributed a total of RM14.553 billion in health expenditure in 2020. If the claim of 35% of hospital revenue drop was true, this means RM5 billion per year is forgone! Is this the admission of private hospitals that RM5 billion is the amount they have overcharged their patients following implementation of the MOH new policy? 

Secondly it is claimed that 33% or 2600 private clinics will close. How does the study arrive at this number? Hence it is in the best interest for the public to examine the full study, especially to validate the numbers, methodology and the interview questionnaire involved.

The preliminary findings in the study also tells us that many healthcare travelers will not come to Malaysia hence causing economic loss. This is contrary to our general expectation that the lowering of medicine prices should give Malaysia an even more competitive edge vis-à-vis Thailand in the region. The basic assumption of the study is that Malaysia will lose 10-35% of new drug launch/access resulting in 54% healthcare travelers who will stop coming. Is the assumption plausible? Given the MOH new policy is to regulate the mark-up upper limit only for the wholesalers and retailers, the fact remains that medicines manufacturers can still declare their preferred price for sale in Malaysia, so why wouldn’t they come to a market known for its demand?

Lastly, the Medicines Price Mechanism policy is a matter of public health and consumer price, hence under the policy purview and jurisdiction of the MOH and the Ministry of Domestic Trade and Consumer Affairs. MITI should not overstep its own boundaries and competence, and dictate the policy direction of other ministries. This industry-driven CBA study sets a dangerous trend and precedence shown to interfere in, and subvert the decision already made by the Cabinet. 

Forget about the CBA’s self acclaimed virtues of being ‘independent’, ‘data-driven’, ‘comprehensive’ and ‘unbiased’.  What was presented in the public now is the opposite. The Medicines Price Mechanism policy in the long term can ensure fair and transparent medicine pricing for patients in Malaysia. It is not true that the policy does not allow wholesalers and retailers to make profits.  Excessive profits at the cost of people’s health and lives is what the policy helps to safeguard against. Narrow vested interest for profiteering should not trump public interest, let alone people’s health and lives.

 

Lim Chee Han

6.12.2021