Part 1: 1-CARE : Scouting in the dark
- In the current setting, MOH provides healthcare services to everyone at with a starting cost of RM1.00. In terms of value per unit cost, I would say that the MOH in general provide good services as it is able to provide the services at nationwide. In the rural setting MOH has eradicated Malaria in many areas, reduce the infant mortality rates, increased health delivery for mother and child and many others. However the shortcomings of MOH today is that it appears to be a giant monster that walks too slowly. This is a malady that affects many successful organizations that do very little decentralization. The bureaucratic process is slowing it down and MOH is not able to grow and provide services in tandem with population growth and to meet healthcare demand.
- This funding for MOH has always been from the Federal Budget, which is derive partially from the employed taxpayers. Not everyone in the country gets his or her healthcare needs at government hospital. Therefore the total healthcare budget does not reflect the cost of managing 100% of the population. Based on the study by MNHA in 2007, the government expenditure on healthcare is equivalent to 81% of those provided by the private sector. The cost that is compared here is not on apple-to-apple basis as the government provided many other health services other than curative program. The private sector is mainly into the investigative and treatment sector. If comparison were done in the same sector, we would expect that the actual percentage of MOH expenditure against the private sector would be much lower. I estimate it to about 30%-40%. What MOH does is that it provides the system. Its available and up to the people to use it.
- If the government intent to do the NHS, the central funding from Treasury must continue. It must not reduce its contribution. From what I read this appears to be reduced. The reduction in contribution will be top up when NHA sells the Social Health Insurance (SHI) on compulsory basis. Based on the materials that I have read, the government will pay the premium for government servants and retirees and their immediate family. The foreign workers will pay for their own insurance cover. Those in private sector will be pay jointly by the employer and employee. Nothing has been mentioned about the unemployed and those retired from the private sector.
- At this point, the cost and the actual insurance benefit of SHI are unclear. What is critically missing is how much the people have to pay. What about those who are covered by their employer with private health insurance or those who buys private health insurance on their own. Are they expected to pay for the SHI as well? There are many unanswered questions that need to be address. The best people to address this are the people in MOH and they need to do it fast. In my next post I will write on how I feel it should be run.
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Dear doc,
Nice write. Based on how all other NHS being developed my thinking is that we should develop from what we have. Unlike the US, we have already put in place a universal health system. It’s affordable and accessible. I think two tier health system works too. Some people who wants fast service can go to private hospitals.
The model that has worked for us which is examplary to me is IJN. It provides relatively cheap and highly respected quality. It has a new commercial wing to deal with private demands.
Dr R- IJN don’t have a new wing to serve private patient. The old part of IJN has become crowded. Dato Radzif who was the CEO decided to expand the hospital. It raised money via sukuk. On financial, IJN lose money heavily every year. Radzif had a vision but IJN doctors thinks that no one no better than them. There was a fallout between the two and the Radzif left and became the chairman of SME bank
One option is thus to expand this model. The private wing cross subsidizes the public side while profitable enough to ensure sufficiently reasonable rewards for good quality doctors to reside. We also have UM and hukm model to look at. I don’t have detailed analysis of their operation but hope you can explore this.
DR R- I disagree with the private wing concept practices at HUKM and UHKL. Recently it was introduced at several MOH hospitals.With private wing, the doctors time is spread between his public wing. To keep doctors, we need to pay them reasonably. No need to force them to work elsewhere to supplement their income
Essentially if possible I want to avoid insurance. Note all developing countries have resorted to health insurance. But it has it’s own moral hazard. Because of insurance our medical cost escalates.
DR R- I agree that when Health Insurance is in place, the cost of healthcare goes up. The root cause of the problem is not due to insurance rather the private hospitals who took advantage of the presence of insurance. Read my first post on the same subject. In Thailand, there is a strong control on health care cost and there is system that link the hospital and the insurance company. Medisave singapore has the same
Since payment is by a third party we’re willing to go to clinics even for normal fever and that hasn’t include the wide use for antibiotics for many cases.
You have demonstrated the abuse by patients.In reality doctors will push for antibiotics even when they are not needed
If we pay we become more discerning and picky about prescription. Doctors too will consider the affordability of patient. Thought these are moral hazards of insurance. To me on a bigger world scheme I’m also incline to follow the argument that drug producer charge a high price for their medicine coz there’ll be insurance coverage elsewhere who will pay this. A wild conspicary theory but the price of drugs and costs has been high and we must go low. Right now drug makers make tons of money. Think balance not right.
Dr R- We can always depend on generic as the manufacturer has 7 years monopoly on every new drug that they introduce.
Wow. Youre way ahead on me on this. I’m still bogged down on the healthcare system.
Thanks for correcting me then on IJN. Last time when I went to IJN to visit an acquaintance the wing look plush and asked him on the new wings operation and admission. Perhaps I got the wrong info and perception. I’ll check again.
Also I’ll look up on the canadian model below.
Could you elaborate of the link between how the health costs is kept lower with the insurance scheme in Thailand? I assume they pay on time and based on standard fees? Who pays for the insurance say for farmers then?
P.s doc on this subject I tell you upfront that I don’t have a fix view. I’m probing to know the permutations. it’s been a good write by you and am trying to close the gap I have. From my angle i just need to understand why we need NHS and how the proposed NHS provide a reasonable universal health care without costing too much.
Ellese
(1) Healthcare cost is not kept lower in Thailand but the it is kept at reasonable rates. The hospitals has an IT system link with insurance administrator and the private health care cost is regulated. The population is covered either by private insurance or social security organization or a national health coverage known as the 30 Bhat cover.
(2) In 2001, the Thai Government introduced the 30Bhat system. For a flat user fee of 30 Baht per consultation, or for free for those falling into exemption categories, every scheme participant may access registered health services. The exemption categories include children under 12 years of age, senior citizens aged 60 years and over, the very poor, and volunteer health workers. The functioning of these exemption mechanisms and the effect of the scheme on health service utilisation among the poor is controversial. This is similar to MOH RM1 scheme.
Something for you to ponder upon
The more I delved the more complicated the issue. But before I need to clarify one basic misconception. NHS exist in various forms and various names in developed countries. Not only Singapore. Only in UK they call it NHS.
Dr R-NHS is a generic term.In Singapore it is known as medisave
Each country has developed differently. And to this the new Yorker article is illustrative. I enclosed the reference. http://m.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande?currentPage=all
France is still regarded as one of the best. I quote from new Yorker how they’ve developed.
“In France, in the winter of 1945, President de Gaulle was likewise weighing how to insure that his nation’s population had decent health care after the devastation of war. But the system that he inherited upon liberation had no significant public insurance or hospital sector. Seventy-five per cent of the population paid cash for private medical care, and many people had become too destitute to afford heat, let alone medications or hospital visits.
Long before the war, large manufacturers and unions had organized collective insurance funds for their employees, financed through a self-imposed payroll tax, rather than a set premium. This was virtually the only insurance system in place, and it became the scaffolding for French health care. With an almost impossible range of crises on its hands—food shortages, destroyed power plants, a quarter of the population living as refugees—the de Gaulle government had neither the time nor the capacity to create an entirely new health-care system. So it built on what it had, expanding the existing payroll-tax-funded, private insurance system to cover all wage earners, their families, and retirees. The self-employed were added in the nineteen-sixties. And the remainder of uninsured residents were finally included in 2000.
Dr R- This is what Singapore Medisave did. What is meant here with collective insurance funds do not refer to insurance practices per say but rather, employer-employee contribute to a central fund much similar to the practices of EPF. Each individual can only use the money in his account to pay for his medical expenses.
Today, Sécurité Sociale provides payroll-tax-financed insurance to all French residents, primarily through a hundred and forty-four independent, not-for-profit, local insurance funds. The French health-care system has among the highest public-satisfaction levels of any major Western country; and, compared with Americans, the French have a higher life expectancy, lower infant mortality, more physicians, and lower costs. In 2000, the World Health Organization ranked it the best health-care system in the world. (The United States was ranked thirty-seventh.)”
Dr R- I believe the canadians also has a good system in place
It also explained how the NHS was developed in UK, Switzerland and the US.
What is striking is there is no
Underpinning theoretical principle on the structure of healthcare system but more of a gradual development from existing structure. The major drive is still to afford health care to many which I understand embodied in the concept universal health care system.
Tuan Doktor,
Isu cukai tidak layak digunakan sebagai modal untuk menjustifikasikan 1Care nih.. sebab … kalau pun Orang Asal atau orang kampung yang kerja sendiri tidak membayar cukai pendapatan.. tetapi mereka tetap juga membayar cukai… iaitu dari cukai harga barangan dan cukai perkhidmatan… tolong jangan pulak gunakan isu GST sebab sebelum GST ujud pon memang ader cukai dikenakan kepada harga barangan dan perkhidmatan….
Jadi… point cukai tidak layak digunakan sebagai justifikasi….
Isunya sekarang ini… kos perkhidmatan kesihatan yang dialami oleh Kementerian Kesihatan aderlah lebih kepada ketirisan dan kos monopoli yang dibuat oleh pembekal ubatan kepada Kementerian iaitu Pharmaniaga….
Bayangkan bila harga ubat generik yang dibekalkan hampir sama dengan harga ubat yang masih berpaten… dan inilah yang berlaku sekarang ini.
“Isunya sekarang ini… kos perkhidmatan kesihatan yang dialami oleh Kementerian Kesihatan aderlah lebih kepada ketirisan dan kos monopoli yang dibuat oleh pembekal ubatan kepada Kementerian iaitu Pharmaniaga….”
Saya berpendapat ada kebenaran di dalam kenyataan C++ tersebut. Adakah Pharmaniaga masih lagi anak syarikat UEM Group?
Dan siapakah itu Idaman Pharma?
Ramai yang akan menyokong sesuatu polisi yang memanfaatkan rakyat sekiranya pentadbirannya telus. Malangnya, UMNO/BN tidak…
,
,
,adakah idaman pharma si dia yang telah
whisper whisper whisper kat telinga pm?
Inilah homepage-nya.
mengikut homepage mereka, mereka adalah
peniaga ubat seperti ms ally di bandar.
alamat mereka menunjukkan mereka tidak
terletak di kawasan kilang.
,
,
inilah homepage-nya.
http://www.idamanpharma.com/main.html
.
sila check dengan roc siapakah shareholders di dalam
syarikat
C++
I agree with you. In reality if the government manage its finances well enough than there isn’t a need to change the present system. However the present system has to be changed because (1) Government finances are not properly managed (2) MOH is too big and too bureaucratic. It need to restructured so that it can run fast enough in tandem with the population needs.
Having said that, a rich country like singapore also practice NHS. Why is that? They have money and yet they ask the people to buy health insurance.Why?
Tuan Doktor,
Saya setuju dengan pandangan tuan bahawa KK adalah terlalu besar dan banyak kerenah birokrasi…. dan ianya perlu diperkemaskan dan diperbetulkan…. Pengurusan dan pentadbiran kewangan pun masih lagi cacamarba…
Pandangan saya.. daripada diujudkan 1Care … aderlah lebih baik diperkemaskan sistem sedia ada dan ujudkan satu sayap komersial pada setiap hospital kerajaan. Dengan cara ini, pilihan masih ada kepada yang tidak mampu. Khazanah negara amat besar dan jika mengikut apa yang saya kaji.. mampu untuk menampung kos perubatan biasa kepada 50 juta rakyat jika ditadbir sebaiknya.
Berkenaan Singapura… saya berpandangan… mereka mengalakkan implementasi NHS kerana mereka tiada Orang Asal dalam negara mereka. Dan satu lagi.. pihak kerajaan Singapura tidak mengawal pasaran perubatan negara tersebut…
Dear tuan c++
NHS is implemented worldwide in developed country with different names. Only in UK they call it NHS. They also have problems with dealing with costs of foreigner.
Raffick,
The reason why Singapore practises this is because they are afraid if not, it would be vicious black hole where all the money would be sucked in if they continue with the old policy. Frankly speaking, it’s not really perfect whereby instances of singaporeans can’t afford to pay all medical bills
It’s not exactly medical insurance. Basically, citizens & PRs forced to set aside money for medical use. Government still provide subsidies. Furthermore, there is medishield that further protects the citizens & PRs. They call it the 3M. Medisave, Medishield & Medicare. But yet with all these, singaporeans & PRs still need to pay medical insurances for better coverage
Dear doc,
Admittedly my involvement in health care sector is not much. At most involved in dealings establishing private hospitals. During the course of this work, I was told that we have quite respectable health system. IJN seems to lead in the region for example.
So far we’ved had a parallel of public and private healthcare. Were already providing universal health care system. the cost has been reasonable. According to wHO measurement of efficientcy in terms of infant mortality rate were comparable with developed countries.
My personal encounter is I’ve had very good experience with the doctors and facilities at our public hospitals. Even better than private as some top end hospital don’t even have certain machines on the excuse of not economical (were talking about life and death here man !!!). The main problem is the queue ie we need more hospitals. (public hospitals even have private wings).
My point is this. I am fairly okay with the current health care structure of private and public. Government just need to continue more in what they’re doing now in adding a slew of new hospitals, facilities and doctors. The cost has been reasonable. Those who want less queue and hassle has the private option.
So I’m uncertain what is the purpose of this NHS. Are we to provide to all free medicals. If so who is to pay for this?
Main concern is medical cost to the public which makes healthcare not accessible and too expensive. I haven’t done proper research but I blame this as a function of the availability of insurance and of course the human character called greed. I was appalled by statistics in US. I quote from Wikipedia:
“the USA has the third highest public healthcare expenditure per capita, because of the high cost of medical care in the country…A 2001 study in five states found that medical debt contributed to 46.2% of all personal bankruptcies and in 2007, 62.1% of filers for bankruptcies claimed high medical expenses.”
This we must totally avoid.
Had kins who were on medical utilizing our public hospitals. Think our health system is still accessible and reasonably affordable. From my layman perspective i think our system needs more of tinkering than revolutionizing into an NHS which I assume moving towards UK model.
I hope you can along the way write what is this NHS? How does it differ from our system? Why do we need to change? How does this affect cost? How is this financed?
Sorry doc with the many questions. I need a more firmer grasp of our health care system n industry.
Never never let any government to privatise or push health cost to public. This is a very basic and important part of service must be taken care of by any government.
We see many privatisation and it result huge financial burden to public.
Look at toll charges for an example, either you let PLUS to up the toll charges or government have to bear the costs. Now many people need to think twice whether to travel home to visit family members because of ridiculous high toll charges!
Once privatisation happen, you will have to pay …and pay….and pay more!!! No point to complain after the privatisation. Just like toll charges, you can make lot of noise and complants now but at the end the government and PLUS will not listen to you. You just have to pay!
We just want any goverment to keep the current healthcare but with improvement in service. That’s it!
It is corporatization and not privatization. Its two different thing. I agree healthcare is a basic need just as water. The way I see it the government is not able to contain the healthcare cost with its current taxation system because the revenue collected is not properly managed. The government is wasting too much money elsewhere and unable to manage the rising healthcare cost. On another side, even the most well managed government like singapore has push for NHS because they see that in future they are not able to maintain the healthcare cost. Not to forget the personal income tax is much lower.
Soon will turn into Privatisation!
The problem in this country is we have so much looting and deliberate mismanagement and wastful spending going on therefore it will soon run out of money.
Singapore run the country just like a corporate entity. Nothing is free in Singapore. But they are very effective and efficient and very focus to build a better Singapore. And they have world class healthcare system. Even Royal family members choose to go to Singapore for surgery operation.
Malaysian Care,
I agree to a certain extend. That means the priority of the new government (Sorry, Raffick, BN must go) is to plug all the leaks. Once all the leaks have been plugged, then we talk about restructuring provided the current system may run into overcost.
Raffick,
Not all privatisation is good for nation. Especially when it ended up with certain groups of people. I am not sure healthcare cost under current taxation system really in deep trouble. It’s just your assumption. By the way, Malaysia has huge natural resources that complement healt care cost.
The idea is to have manageable health cost…..Not the spiraling one. This is exactly the objective of singapore government. People would tend to abuse the system if not properly take care of.
Come to think, is the tax low? What about the rate of GST? Why Jib gor wanna introduce GST? Hahahaha
Raffick,
All this can only happen only if BN-UMNO be gone. Hence, ABU first! Just like in WWII, make sure Adolf Hitler dead first. Then, hantam Japan.