Stop Promising Free Health Care, Ex-Health Minister Subra Tells MPs

Ex-Health Minister Dr S. Subramaniam wants MPs to stop telling their constituents that health care will always be “free”, as a political tool. MPs should prime Malaysians to be ready to pay for care; otherwise, health care financing reform will be hard.

KUALA LUMPUR, Feb 15 – Dr S. Subramaniam has urged Members of Parliament to quit touting free health care for political support, amid difficulty in pushing through health financing reform.

The former health minister revealed that during his time in office, Prime Minister Najib Razak’s administration wanted to raise the RM1 outpatient fee at public hospitals under the Ministry of Health (MOH).

“But just one week before implementation, we were forced to stop it because we were scared, politically, that this issue cannot be taken forward,” Dr Subramaniam said at a BFM podcast with Bukit Gasing state assemblyman Rajiv Rishyakaran aired last February 2.

Dr Subramaniam was health minister from 2013 to 2018, before Barisan Nasional (BN) lost the 2018 general election for its first time in history – not over health care, but issues of corruption with the 1MDB scandal and the goods and services tax (GST).

“So it all depends whether we’re politically strong enough to make this very bold decision, to transform health care financing, so that we’ll have more money to spend for health and address all these issues – human resources issues, building issues, machine issues, all the issues. The central core is money; how are we going to get this extra money?”

BFM’s Health & Living episode – co-hosted by producer Tan Shiao Eek and consultant urologist Dr George Lee with Dr Subramaniam and Rajiv – was discussing Rajiv’s call for the construction of a general hospital under the MOH in Petaling Jaya, Selangor, as the city’s only public hospital is university hospital, Universiti Malaya Medical Centre (UMMC).

Dr Subramaniam – who is co-chair of the advisory council for the Health White Paper (HWP) that was passed in Parliament last year – advised Rajiv to fight for extra funding for UMMC to enable lower charges for patients instead, saying this proposal had a higher chance of success than trying to build a new hospital in Petaling Jaya.

“When we were explaining the Health White Paper to Members of Parliament, I told them one thing – that MPs must be more realistic and more responsible,” added the former health minister.

“Do not sell this idea that health care will always be free to your constituents as a political tool. I think they actually have to prime their mind to say that this free thing might not last for long and that, sooner or later, we should be ready to pay something.

“If they can do that politically, then at the point of implementation, it will be easier. But the problem is, politicians always go and say, ‘I’ll get this thing free, I’ll get that thing free’. Once you give that discourse, to change this discourse to a more realistic thing is very, very difficult.”

During his tenure as health minister, Dr Subramaniam tried unsuccessfully to push for a voluntary social health insurance scheme, after the government’s failure to push through the 1Care social health insurance programme with mandatory contributions from employees and employers during Najib’s first term in office.

The HWP – passed in Parliament last June under then-Health Minister Dr Zaliha Mustafa’s tenure in the Madani government – refrained from proposing a national health insurance scheme with employer-employee contributions, describing plans for a “progressive” insurance scheme in vague terms instead.

Dr Zaliha’s successor Dzulkefly Ahmad, in his maiden address at the MOH’s monthly staff gathering last December 14, said he would focus on digitalisation of the health care system and health care financing, but has yet to announce substantive plans on reforming health care financing.

More than seven months since passage of the HWP, neither Dr Zaliha during her tenure nor current Health Minister Dzulkefly have announced any updates, including the formation of working committees on the 15-year plan for health care reform.

On the BFM podcast, Dr Subramaniam said the 12th Malaysia Plan targets 2.06 hospital beds per 1,000 people, equivalent to more than 80,000 total beds in the country. In 2021, as Malaysia reached 2.01 beds per 1,000 population, with currently about 70,000 beds, Dr Subramaniam expressed confidence that the target would be reached.

However, he questioned if the target was too low, noting that countries like Singapore, the United States, and the United Kingdom target 2.5 beds per 1,000 people. Japan has 13 beds per 1,000 population.

A target of 2.5 beds per 1,000 people means adding another 17,000 to 18,000 beds.

“I think that 2.5 beds per 1,000 people is a reasonable number, taking into account the changing demographics of illnesses which are happening,” Dr Subramaniam said, noting a large population of retirees in Petaling Jaya, for instance.

However, the former health minister noted that the average cost of building a public hospital is nearly RM1.3 million to RM1.5 million per bed, slightly more expensive than private sector costs of RM1 million per bed.

Hence, to reach 2.5 beds per 1,000 people, at the cost of RM1.3 million to RM1.5 million per bed, Dr Subramaniam estimated a cost of between RM25 billion and RM30 billion.

“The real question of the day is – is the government able to afford this amount of money purely for the purpose of building hospitals?” he said.

Dr Subramaniam pointed out that the MOH’s 2024 allocation of RM41.2 billion comprised more than 10 per cent of the federal government’s total RM393.8 billion budget.

“Now the question is – can the government give more than 10 per cent, to 12 per cent to 30 per cent of the budget towards health cost to meet this requirement and expectation? It’s a very difficult question.

“In Malaysia, we are stuck because from the start, we have allowed people to develop this idea that health care will be delivered in the public sector, free of charge at point of delivery; we’ve given this perception.

“That’s a very deep ingrained feeling and mindset of Malaysians, even among those who can afford and those who cannot afford. Because of this thing which we have done, to reverse it into alternative forms of financing, which would generate more income towards capital expenditure – it’s a very big challenge.”

Rajiv expressed doubts that “drastic reform” in health care financing would happen anytime soon, saying it probably would have been easier during Dr Subramaniam’s time in office than the Madani government today with 19 political parties.

“Any new model puts financial pressure on the people. People will have to pay – one way or another – either to the system indirectly through social health insurance or pay more in actual fees when they walk into a hospital, or pay more in general taxation,” Rajiv told the BFM discussion.

“But one way or another, if more money is to go into the public health care system, more money needs to come out from our individual pockets, and that’s a more difficult decision.

“We’ve seen the government tread very slowly on petrol subsidies. If they finally pull the plug and do it, that might be enough pain for one term.” 

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