I was holding back about the state of our national health service under the Ministry of Health (MOH) because so many individuals have articulated opinions about it. But the limited solutions currently offered by the government require that we speak up.
In the past 15 to 20 years, when we discussed our national health service, and when people asked about my opinion, I would say that it is dying.
Many of us have spoken to senior management in the MOH to tell them about the crisis on the ground. Sadly, no one has been listening, and no meaningful, concerted action has been taken to rectify the situation.
Therefore, we are now in the present situation where our national health service is in real crisis. Those of us who have served for decades in the public health service feel heartbroken about its current state and the lack of adequate care for the public.
What is most distressing is that the solution presented by the government is a fee-for-service model, which is detrimental to the B40 and M40.
I do not agree with private practice being a model for health care. Not only is it expensive, it is also unsupervised by doctors but by large corporations, who have a profit motive as their primary goal.
Private health care only serves those who have the money to pay. I have friends and colleagues in the private sector who are doing much good work, but they do not control the fee structure, which is set by private hospitals and corporations.
Hence my comments here will be about how we can resurrect our national health service. The recent Rakan KKM “Express Lane” service, as announced by the health minister, is another attempt at a fee-for-service model.
Past fee-for-service-models include enabling MOH specialists to work in private practice (part-time private practice), full paying patients, private wings, etc.
All these take away experience and expertise from patients who really need them. They worsen the inequality of care within the national health service.
It has been suggested that specialists somehow have extra time to operate within the Rakan KKM scheme, but most of us who have served in the MOH have 10 to 12-hour working days, which does not include calls.
The MOH seems to be unaware of the fact that its own health care professionals are demoralised and exhausted. Health care professionals in the public health service currently see no future for themselves.
I am unsure who is advising our health minister, but surely the advice is poorly given. We do not pay taxes so that the national health service is transitioned into a fee-for-service model or corporatised.
Private Health Insurance (PHI) and Social Health Insurance (SHI) are not good solutions. for an analysis on this, read the excellent commentary and insightful discussion by Jomo Sundaram and Nazihah Noor.
There are no easy solutions to resurrect the national health service, which has been in critical condition for decades. But perhaps it is important to crystallise what plagues it.
Why have we come to the point where many specialists want to leave the service? Why do new graduates and young doctors prefer working in other countries or in the private sector rather than in the MOH?
Why do we have such a poor complement of nursing personnel and allied health care professionals? Why are our hospitals and health infrastructure so run down?
One answer has been that the government has been neglecting the national health service for decades. We have spent too little on the public health service.
But successive governments have spent lavishly on other mega projects. Preterm babies and sick children and adults have died due to the lack of intensive care services.
The failure to rectify overcrowded emergency, outpatient, and primary care services for decades is testament to the government’s long-standing failure.
The Harapan government promised to “rebuild Malaysia from the rubble of devastation brought about by overlapping crises across multiple sectors such as health care.” But they have not lived up to such promises made in their manifesto.
Other key issues are the elephants in the room that we are reluctant to face. We have institutionalised corruption in our country. Corrupt practices impact the public health care system in terms of spending and development.
Meritocracy is lacking in the civil service and this damages the development of the public health service, with a resulting brain drain of many good health professionals to the private sector and other countries.
In addition, we have failed to address the quality of training of medical undergraduates, with medical errors and incompetency rising over the years.
The MOH has also encouraged for decades a misguided focus on specialisation and sub-specialisation, which take up 60 to 70 per cent of health resources.
This has resulted in a huge lack of general practitioners, with primary care services by and large being neglected. This model that the MOH has been promoting has resulted in the public being addicted to curative services.
This has resulted in a public demand for more hospitals nearer their homes, more specialists, and more quick fixes for their medical problems. We have failed to promote health and wellness with a focus on community care as the primary model for our health services.
We have not addressed the worsening social determinants of health, where the poor, disadvantaged, and marginalised have the worst access to and quality of health care.
These are the ones whose children have the highest rates of mortality and morbidity. Data has suggested that the under-five-years mortality rate for the B40 community is at least 10 times that of the T20 community.
How do we “rebuild Malaysia from the rubble of devastation”? How do we move forward?
Firstly, we must admit that we are in a very bad state, and we have failed. It is not possible to move forward without an honest assessment and public admission of our dire public health service crisis.
Secondly let’s take some ideas from the October 2022 Harapan manifesto, in other words, their promises to us at the last election. Many suggestions are meaningful:
- “Health care reform must be done immediately before it is too late.”
- “Increasing the public health care expenditure to 5 per cent of Gross Domestic Product (GDP) in five years in order to keep up with the national population growth, increase in lifespan, and current needs.”
- “Shifting from sick care to health care and wellness, including addressing social determinants for health such as poverty and preparing health education and equal access to health care for all.”
- “Giving special attention to overcoming the rise of non-communicable diseases (NCDs) by focusing on primary care.”
- “Tabulate and monitor the execution of the National Health Reform Plan.“
- “The national health service delivery reform will cover reduction of waiting periods for procuring health services, modernising health facilities.”
- “To solve the contract doctors conundrum, set up a National Health Services Commission to reinforce the management of human resources, staffing, training, and career growth of health care staff.”
While the Harapan government has failed to live up to most of these promises over the past two years, these ideas are still valid, and we should use them.
We need increased spending for the public health service, with an increased focus on preventive health efforts. And we will need to develop workable solutions to fund this.
I ask the current government to return to their health care promises and look back at what they were fighting for just five years ago. Any meaningful National Health Reform Plan must be fully accessible to the public and involve all Malaysians in its development.
For far too long we have allowed the national health service to decay. There are no easy fixes or solutions. But I do believe that we can resurrect our public health services and keep health care professionals serving in the public sector.
Basic health is a human right and not something where citizens should have to pay to receive. It is time we work concertedly to end the inequality in health care and not exacerbate it any further.
I leave you with a quote from Martin Luther King Jr: “Of all the forms of inequality, injustice in health is the most shocking and inhumane.”
Dr Amar-Singh HSS is a consultant paediatrician and child disability activist.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
