Healthcare of the rakyat should not be compromised for monetary benefits

The Consumer's Association of Penang (CAP) views with deep concern the government's proposal to implement its full-paying patient (FPP) scheme via commercial private wings (CPWs), which in its pilot project at the Hospital Selayang has failed to benefit both doctors and patients. Such a scheme is fundamentally flawed and will only serve to deprive the low income and poor rakyat of their right to specialist care as is their basic human right as citizens.

By right, there should be a very clear separation between the public and private sector when it comes to healthcare. This is because the government is responsible for regulating the private healthcare sector and carrying out enforcement duties. 

In fact, private healthcare is, in principle, is supposed to complement public healthcare and not assume the role of the public healthcare sector as the principle guardian of the rakyat's health. This abrogation of duty by the government towards the rakyat is now being manifested by its various exercises in corporatisation and the outright albeit gradual and systematic privatisation.

As far back as 2004, CAP had objected to this proposed scheme. Now the government seems insistent on reintroducing this unjust programme despite the public outcry. If the proposal is implemented, it will mean that public hospitals will have a private wing purely for commercial purposes; the idea being to increase remuneration for government doctors and other medical staff. 

At the outset, the idea seems novel and attractive to those working in the public sector. However, there are serious implications for consumers especially the poorer ones. There is also the possibility of discrimination which might pit one set of professionals against the other.

A look at our private health sector and how it operates profitably should be able to give us an insight into the repercussions of a move to encourage privatisation in parts of the public healthcare sector.

For example, the general practitioner operates in a way that he profits from his consultation charges and for the procedures that he does outside of the routine ones like urine tests, blood tests, etc. He also makes money from dispensing medications, where prices are marked up.

The private hospital makes its money from a whole list of services that it provides. The list is exhaustive and includes the charges for the following: medicines, board and lodging, procedures (surgical), nursing, use of equipment and also administrative costs – all of which can be exorbitant and beyond the means of many. The above is likely to be duplicated if public hospitals set up private wings. 

As it is, some public hospital settings in the country already have a public-private mix. The Universit Malaya Medical Centre (UH) is one such setting while the other is the Institut Jantung Negara (IJN). What have been the consequences of such changes?

So far, they can be said to be discouraging, to say the least. The costs of medicines, procedures, and laboratory charges at UH have shot up many times. The IJN is probably the costliest place for heart surgery. Also, the waiting time for heart patients who are unable to afford surgery could be up to two years or more.

There are other implications if the ill-planned scheme goes through. Among them are:

Manpower shortage - there has been a perennial shortage of medical manpower in the country. In the year 2000, there were 6,429 medical vacancies in the public sector. In 2004, there were at least 3,000 critical vacancies. In 2008, the doctor to patient ratio in the country was 1 to 1,105 patients.

As a result of this shortage, medical officers are very much overworked in the public sector. For instance, a medical officer in the Outpatient Department in the major government hospitals could see up to 150 patients a day or more (the ideal number recommended by the health ministry is a maximum of 50).

How is this shortage to be addressed with the commencement of CPWs? If there is an overall manpower shortage, why is there a need to deploy staff to the CPW and while facing ever increasing number of patients?

Inadequate infrastructure - there is a shortage of better-class wards even in the general hospitals so how do we accommodate the influx of CPW patients into the general hospitals? This could lead to depriving the poorer patient and the converting of beds for the use in the privatised wings.

In addition, there are already some big hospitals with insufficient medical equipment, for example, MRI machines. The patients who come in will have to be sent to another hospital to obtain these services, thus inconveniencing these patients.

Discrimination - upgrading of some hospitals to CPW status and not others will create discrimination in terms of remuneration for staff and this might cause an exodus of staff to greener pastures.

The lure of the ringgit can also be a temptation for corrupt practices - there could be corrupt doctors who would see patients in the CPW and admit them to the public side for procedures. He could then pocket fees illegally by offering a concession to the patient. This practice is rampant in places like India and Egypt where there is a public-private mix.

Equity and accessibility - to remain competitive, charges over the years will escalate. The net benefit for the poor will be less access and a further erosion of equity.

Sustainability - CPWs found not to be profitable might face a predicament unlike private hospitals. The latter can be closed down if seen to be unprofitable, but can the same thing be done for CPWs?

If the aim is to increase remunerations for medical staff, then there are some means whereby additional income for the government could be generated. Among these are:

Part payment by patients at government hospitals - Third-class patients should continue to be charged nominal rates for specialist and in-patient treatment. These charges can be raised slightly, where appropriate, to bring in more revenue. Those who cannot afford to pay full rates should be given discounts or, in the poorest cases, free treatment. Patients in the second-class and those in first-class should pay a greater percentage of the costs of treatment.

Increase the charges for outpatient treatment - the current charge of RM1 for outpatient treatment at government facilities could be raised. Based on the 1998 total outpatient attendances at government health facilities, raising the outpatient rate to RM5 could bring in at least another RM100 million which could go towards financing the healthcare system further. The figure would be much higher with the present day number of patients.

Extend Socso's services to include medical care in general - in other words, its services should not be restricted to only treatment for industrial accidents and occupational diseases. The annual 'profits' of Socso (which actually represents a significant subsidy to the state by workers) could thus be transferred to the Health Ministry through hospital payments.

Since Socso covers all employees earning below RM2,000 per month, the poor and lower-income wage-earners would be able to draw on their contributions to finance their medical bills in government clinics and hospitals, thus easing the financial strain on the Health Ministry.

If the existing Socso contributions are still insufficient, the rates for Socso contributions could be raised marginally. An increase of only RM1 a month by employees plus another RM1 by employers would yield a substantial overall increase in the government's healthcare spending capacity.

At the same time, the manpower shortage should be addressed. As a short-term solution, a fixed number of foreign doctors should be encouraged to take up permanent employment here. This measure could be halted once there is enough local staff to cater for our medical needs, especially in the rural areas.

CAP reiterates its objection to the government's proposal to create private wings in public hospitals for the purpose of increasing doctors' remuneration or for any other reason. The primary role of public hospitals is to ensure equitable and accessible healthcare especially for the middle and lower-income groups and the poor. There will be a conflict of interest if the already- overburdened public healthcare resources are further diluted to cater for private wings.

The initiation of a two-queue system within public sector hospitals will be disadvantageous to the very population they are aiming to serve, ie, the patients who need the service most. There is great potential for abuse of the system as was shown in previous attempts in the late 1960s.

If the intention of these private wings is to help retain public specialists, this has yet to be proven as there will inevitably be a tendency for specialists to use the private wing as a 'testing ground' before they leave completely for the private sector.

Introducing private practice in government hospitals is decidedly unacceptable as it will drastically change the face of the present healthcare system to the acute disadvantage of the rakyat. CAP calls on the health ministry to scrap the proposal for introducing the FPP scheme. 

The healthcare of the rakyat should not be compromised for monetary benefits.

The writer is president, Consumers Association of Penang - Malaysiakini, 9/3/2010, Private wings will cripple public healthcare

Star : Diabetes and blindness

KUALA LUMPUR: One in four patients with severe diabetic-related retina damage end up blind because they come in too late.

The national Diabetic Eye Registry principal investigator Dr Nor Fariza Ngah said that out of 13,973 patients with diabetic retinopathy, 3,311 suffered severe retinal damage and of them, 774 could no longer get their blindness reversed.

The statistics were derived from 36,952 diabetic patients screened for diabetic retinopathy from January 2007 to December 2009.

Dr Nor Fariza told The Star that the symptoms were often missed because it was asymptomatic, with some seeing floaters or having blurred vision.

For this reason, she said all diabetic patients must get their eyes examined at least once a year.

Retinal damage occurs when the thin layer of the retina is detached from the eye-wall and patients could suffer bleeding in the eye-ball as well. Blockage in the eyes’ blood vessels results in new blood vessels growing into the eye cavity to compensate the blockage and pull the retina away from the back wall of the eye.

It also occurs when protein leaks from the vessel into the surrounding retina and causes swelling.

Universiti Malaya Medical Centre retinal surgeon Dr Angela Loo said some patients ended up blind despite a well-done surgery because they came in too late.

“Often, they expect us to perform miracles, but even if we managed to do a good job re-attaching the retina, their sight cannot be restored.”

Dr Loo, who trained in Britain for seven years and practised in Hong Kong for four, said severe retina damage numbers were low in both countries.

She said the lack of awareness and complacency among Malaysians, were the main reasons for many diabetes cases being undiagnosed and poorly controlled, adding that some patients also did not return for follow-up laser treatment and their condition deteriorated.

She said teamwork was needed in detecting the symptoms, adding that the high-risk groups included those with diabetes for a long time, poorly controlled blood sugar and blood pressure, presence of other diabetic complications such as kidney impairment and foot ulcer/gangrene, high blood cholesterol, smoking habit, anaemia and diabetes in pregnancy. - Star, 10/3/2010, Diabetes and blindness