Why Malaysia Lacks Universal Health Care For Cancer

By Boo Su-Lyn | 16 December 2019

Dr Murallitharan highlights problems with cancer diagnosis, treatment, survivorship, and palliative care in the public and private sectors.

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KUALA LUMPUR, Dec 16 — Like other countries, Malaysia has yet to achieve the ideal of providing universal health care in cancer, where people can get screened and treated with innovative drugs for free, a cancer advocate said.

National Cancer Society of Malaysia (NCSM) medical director Dr M. Murallitharan said this was an ideal goal for every health system in the world.

“But it’s not something we’ll achieve today or tomorrow, and it’s not something the NHS or Singapore or US or Thailand will achieve,” Dr Murallitharan told a recent forum organised by the Galen Centre for Health & Social Policy here titled “One Year After The World Cancer Congress”.

Universal health care, he said, comprised four dimensions: how much of the population is covered, which services are covered, who pays for these services, and quality of the services.

Dr Murallitharan said many people did not want to bring universal health care into the cancer context because of the high cost of oncology treatment.

“That’s perhaps one of the big mistakes we’re doing,” the public health specialist said.

“We have a lot of new drugs. The drugs may be lifesaving, they may be life changing, but a lot of them are just ridiculously expensive. Patients, when they do come onto them, if they have access to them, are often crippled financially as an end result. This is a huge problem.”

Dr Murallitharan highlighted Malaysia’s biggest problem in cancer as the late presentation of the disease, which leads to more expensive treatment and poorer outcomes.

No Uptake Despite Free Government Services

Dr Murallitharan noted that the Malaysian government practices “opportunistic screening”, where patients who visit government health clinics for other ailments are also offered breast exams or pap smears.

“But don’t forget the problem with this is there’s a whole lot of people who never go to Klinik Kesihatan. These are your Stage 4 cancer patients who present in terminal stage. These fellows are not presenting in the health system. Because they’re not presenting at all, we can’t capture them,” he said, adding that Malaysia doesn’t have a population-level screening registry.

He said there is little uptake of cancer screenings at government clinics even though these are free, but told clinicians not to blame patients’ attitudes.

“In a health system, how stubborn the fellow is or how resistant he is, the problem still lies if he doesn’t come, the problem is with the health system.”

Dr M. Murallitharan, medical director of National Cancer Society of Malaysia (NCSM)

Dr Murallitharan also highlighted perceived poorer quality of care in the public sector, even among low-income people, despite published data showing no difference in the quality of care between the government and private sectors.

“It’s irrelevant what the data means in this new pseudoscience age. Because people think care in the public sector is poorer, people don’t want to use,” he said.

“Even low socio-economic groups have the same perception – they feel care in the government sector is so poor, ‘even though I’m poor, I still want to go private sector’.”

But screenings in private centres are often paid by people themselves out-of-pocket, unless these are covered by insurance, which leads to poor utilisation of tests like mammograms for breast cancer, cervical cancer screenings, or faecal occult blood tests (FOBT) to check stool samples for hidden blood that may indicate colon cancer.

“When you need to self-pay, you’ll pay for pasta, but you won’t spend money on FOBT – people don’t pay because they don’t see the value.”

Tumour markers gave a false sense of security, while genetic risk tests were often unnecessary, according to Dr Murallitharan.

Problems With Diagnosis In Public And Private Sectors

Although cancer diagnosis is practically free in Ministry of Health (MOH) facilities, with patients paying a subsidised fee, there are system delays from the primary to secondary departments, as biopsy results take nine months to cross over. Human errors also result in lost documents.

Quality of procedures in the public sector is also an issue, Dr Murallitharan said, as district hospitals may have far fewer facilities than tertiary ones. Waiting periods, according to qualitative data, were long for specific procedures in smaller hospitals.

Many patients who get diagnosed in the government sector want a second opinion, which then leads to a delay in starting treatment. Getting medical reports in the public sector “stretches quite a bit” beyond the stated 14-day waiting time, said Dr Murallitharan. And private physicians can’t give a second opinion without getting the medical report first.

In the private sector, meanwhile, although there’s no real delay in getting a cancer diagnosis, uninsured patients who pay out-of-pocket may delay for six months to get a colonoscopy if their FOBT turns up positive, for example, since this costs a few thousand ringgit.

Discontinuity of care among patients seeking multiple opinions from different physicians can also happen in the private health sector because of the misperception that private doctors are out to make money, even though their fees are regulated by law.

“When a private physician tells you you need surgery, ‘this doctor wants to get money by operating on me’. It’s a ridiculous perception, but it exists,” said Dr Murallitharan.

The private health sector also has differences in diagnostic strategy among facilities in various locations, which leads to a disparity in the standard of care, he said.

Problems With Treatment In Public And Private Sectors

When it comes to cancer treatment in public hospitals, Dr Murallitharan said targeted therapies are only available, in limited amounts, at certain facilities. Hospital Kuala Kubu Baru in Selangor, for example, doesn’t provide cancer patients targeted therapy.

“What a lot of people don’t understand is, it’s not about the drug itself, it’s about delivery mechanism and infrastructure that needs to support the delivery of drug. Those are costs outside the cost of the drug,” he said.

The cancer advocate questioned if innovative cancer medicines should be restricted in government facilities based on one’s disease stage.

“There’s a delay as well — the delay in rolling in innovators due to high prices and the complicated process of bringing them into the national formulary,” Dr Murallitharan said, expressing hope that the government’s proposed pool purchasing would bring more original medicines into public facilities at cheaper prices.

For cancer treatment in the private sector, Dr Murallitharan said patients paying out-of-pocket risked encountering financial catastrophe. When cancer patients exhaust their health insurance, they switch treatment from the private to public sector, but get charged higher rates by the government when they do so.

“I don’t think that there are that many patients crossing over from private to public which will make such a big difference to the revenue the government collects. Our Ministry of Health (MOH) and Ministry of Education (MOE) budgets are derived from general tax, not so much revenue from seeing patients; it’s less than 4 per cent if I’m not mistaken,” said the cancer advocate.

Besides private and employer health insurance, cancer patients can opt for patient assistance programmes in some private hospitals, or access programmes for certain targeted therapies.

“There’s also non-profit hospitals like [Mount] Miriam [Cancer Hospital], which provide subsidised care,” said Dr Murallitharan.

Problems With Survivorship In Public And Private Sectors

Dr Murallitharan said public sector cancer patients may discontinue treatment either because they get “lost within the system”, such as nurse changes or staff forgetting to call long-term patients for follow-up, or because of patient-related factors, such as patients choosing to discontinue maintenance treatment after undergoing chemotherapy.

“Psychosocial support within MOH and MOE structure is largely NGO-run. Sustainability in programmes where there are certain hospital-based champions, if there’s a consultant or head of department who believes in psychosocial support, they’ll pull a hospital psychologist and say you must work here two days a week. But if they don’t do that, it doesn’t happen,” the cancer advocate added.

As for survivorship for cancer patients in the private sector, their health insurance usually runs out during maintenance treatment, especially those taking innovative drugs.

“People drop out from surveillance because they think they’re so much better. If insurance runs out, they won’t see their oncologist so often,” Dr Murallitharan said.

Although psychologists and therapists are available in private facilities, cancer patients usually have to pay out-of-pocket for psychological treatment because health insurance typically only covers hospitalisation.

“If you have to pick and choose between seeing your oncologist and psychologist, I have no answer.”

Non-government organisations (NGOs), on the other hand, dislike working in private hospitals because of the perception of “rich” patients, according to Dr Murallitharan.

Problems With End-Of-Life Care In Public And Private Sectors

Palliative care is available in few government hospitals, but beds are highly limited due to the long-term nature of care for patients on the death bed.

Hospice organisations, on the other hand, don’t get public funding, said Dr Murallitharan.

Sustainable palliative care is difficult to run in the private sector because it’s not covered by insurance, according to the cancer advocate.

“You start off in Ferrari level hospice, then downgrade, downgrade, downgrade,” said Dr Murallitharan. “Patients no longer receive palliative care they deserve, they just receive very basic care.”

He stressed that cancer patients cannot keep relying on the government for funding, noting that private hospitals are increasingly running corporate social responsibility (CSR) programmes, while Cancer Research Malaysia has done a patient navigation programme in Hospital Tengku Ampuan Rahimah Klang to prevent patients from getting lost in the system.

“The idea is not to let these pilot projects lie in isolation, but to scale them up,” said Dr Murallitharan.

“There’s money for health care as well, but it has to be shared across different sectors of health care. Cannot keep relying on the government to throw money at cancer.”

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