Payments to providers to be based on global budgets and case-mix

In his reply to the Coalition on 25 May 2005, Health Ministry Director General Ismail Merican attached a five-page response to the seven questions raised by the Coalition on 4 May.

The following is a summarised translation of the text followed by a copy of the five-page document in Malay:

1. How much will a worker earning RM1,000 have to pay in monthly contributions?

Although mandatory contributions have been proposed, they will only be levied on those who can afford it. The government will finance the contributions of the poor, the elderly and the disabled. The services of consultants are being sought to determine the income threshold above which contributions will be mandatory so that the people will not be burdened. Thus, the quantum of contribution for a worker earning RM1,000 has not yet been finalised.

2. What will be the cut-off point (in monthly income) below which workers will be exempted from making contributions to the health fund?

See above

3. Will workers who are given full government subsidies be entitled to the same treatment package as those (earning higher salaries) who make full contributions to the health fund? Will they have equal access to treatment?

The essential health care packages will be the same irrespective of the rate/mode of contribution. The level of access will be the same. Those who can afford it can take up additional private health insurance that would entitle them to additional services such as accommodation in a higher-class ward.

4. Will those given full subsidies be entitled to go to private hospitals?

Yes.

5. Will this new financing scheme reduce the income disparities between doctors in the private sector and those in state-run hospitals? How? (If income disparities are not reduced - and the market for the private sector is broadened by this new scheme - more government doctors will quit and the general hospitals will be further weakened!)

The implementation of the mechanism will be carried out in stages. It is proposed that government hospitals and clinics be restructured to improve efficiency and quality. Through this restructuring, government doctors will enjoy better salaries and working conditions, and it is hoped that this will stem the brain drain to the private sector.

The concept of “full-paying patients” will be introduced as an incentive for doctors to remain in government service. The Private Health Care Facilities and Services Act 1998 will be enforced so that the construction of private hospitals will be controlled and not concentrated in certain areas.

6. Will the system of payments to doctors be based on the procedures and surgeries that they carry out?

Several health financing models have been studied, and we find that the "provider payment mechanism" is suitable. What you are suggesting in your question is the “fee-for-service” model, which is not encouraged because it leads to excessive and unnecessary procedures and higher costs.

Among the proposals put forward is for annual global budgets based on a hospital’s case-mix and on the local population (“capitation”) seeking treatment at clinics. This system is better than one based only on surgeries and procedures carried out by doctors.

7. What kind of safeguards will there be to ensure that the fund is not abused to procure certain services from private firms at prices that are detrimental to the people (and profitable for those select firms)?

The fund will be administered by the National Health Care Financing Authority under the Health Ministry. This Authority will function as a non-profit organisation and will not be privatised. Apart from its collection and payment functions, the Authority will also be involved in planning, research, evaluation and monitoring to ensure there is no abuse.

The Health Ministry will constantly monitor the Authority and, under the Ninth Malaysia Plan, the Ministry will set up a National Health Advisory Council. This Council will comprise members from both the public and private sectors and seek their feedback/views on various aspects including the health financing mechanism.

8. The Ministry is ready to discuss the health care financing mechanism with you, and you will be informed about this soon.

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Mechanism won't be privatised, reiterates Ministry

Health Ministry Director General Ismail Merican responded on 25 May 2005 to the Coalition’s letter of 4 May, reiterating the points he had made earlier:

The aim of the national health financing mechanism is to improve accessibility to high quality, efficient and comprehensive health care services and to ensure equity for the people.

This would be based on the concept of sharing costs among the various healthcare “stake-holders” and optimising the contribution and commitment of the government with the overall aim of raising the quality of health care services.

The mechanism would also integrate the public and private sectors and assist the government in monitoring health care providers more effectively. It would also strengthen social solidarity and promote a caring society.

This mechanism would be managed by a National Health Care Financing Authority, which would come under the supervision of the Health Ministry. It would be a not-for-profit entity, which would not be privatised.

The Health Ministry and the Economic Planning Unit are obtaining the services of healthcare specialist consultants to work out the details of the implementation of this mechanism. The Ministry welcomes feedback from all parties.

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Consultants need to hear our views first, says Coalition

Nearly three weeks passed without a response after the Coalition wrote to the Health Ministry on 4 May 2005. The Coalition followed up with another letter on 24 May, stressing that the issue was urgent and discussions had to be held pronto, so that the consultants formulating the scheme - whoever they are - could consider civil society’s views right from the start.

Since there was no response to the earlier request for an appointment (for a discussion), the Coalition said it would be sending 20 representatives to the Ministry on 2 June to meet the Minister and/or the Director General to discuss the issues listed in the Coalition’s letter of 4 May.

The following is the Coalition's letter sent out on 24 May 2005:

Gabungan Membantah Pengswastaan Perkhidmatan Kesihatan
D/a 2A Jln Sitiawan, Lim Gardens
30100 Ipoh, Perak DR.

24 Mei 2005

DENGAN TANGAN

Kepada
Datuk Dr Hj Mohd Ismail Merican
Ketua Pengarah Kesihatan
Kementerian Kesihatan Malaysia.

dan

YB Datuk Chua Soi Lek
Menteri Kesihatan Malaysia.


Permohonan Tarikh Berbincang Dengan YB Menteri Kesihatan

Surat kami bertarikh 4 Mei 2005 yang dihantar dengan tangan pada 6 Mei ke pejabat Datuk dirujuk.

Malangnya kami belum terima sebarang maklumbalas sampai sekarang.

Memandangkan isu perubahan pada Sistem Kesihatan Negara adalah suatu isu yang amat penting yang akan membawa kesan kepada hampir kesemua rakyat Malaysia, kami rasa adalah patut perbincangan yang dipohon kami diadakan secepat mungkin dan sebelum konsultant terbaru bermula tinjauan beliau supaya isu-isu yang kami mengemukakan boleh diambilkira oleh konsultant tersebut dalam tinjauan/analisa beliau.

Oleh itu serombongan kami seramai 20 orang, yang mewakili 81 NGO, Kesatuan Pengguna, Kesatuan Pekerja dan Parti Politik akan datang ke Kementerian Kesihatan pada 10.30 pagi Khamis 2 Jun 2005 dengan harapan kami dapat berjumpa dengan Menteri Kesihatan dan/atau Ketua Pengarah Kesihatan untuk membincang perkara-perkara yang disenaraikan dalam surat kami betarikh 4 Mei 2005.

Kerjasama pihak Datuk diharapkan.

Terima kasih.

Yang Benar,


Jeyakumar Devaraj
Setiausaha Gabungan

SK:
Dato Seri Abdullah Badawi, Perdana Menteri Malaysia
81 NGO, Kesatuan dan Parti.

Devil is in the details, Health Ministry told

In response to Health Ministry Director-General Ismail Merican’s letter dated 30 March 2005, the Coalition sought further clarification from the Ministry on 4 May 2005.

The Coalition said it was pleased to hear that the new financing scheme was aimed at improving the accessibility and equitability of high quality, efficient health services for the people. But it said the Ministry's track record - especially in the the privatisation of health care in the country over the last 20 years - does not exactly inspire confidence. The introduction of private hospitals in the 1980s sparked an exodus of doctors and specialists from the public sector while the ill-conceived privatisation of certain sectors of the public health care system in the 1990s led to spiralling costs. The public is now being asked to share these higher costs through the introduction of the new health care financing scheme.

In particular, the Coalition posed the following questions to the Ministry:

How much will a worker earning RM1,000 have to pay in monthly contributions?

What will be the cut-off point (in monthly income) below which workers will be exempted from making contributions to the health fund?

Will workers who are given full government subsidies be entitled to the same treatment package as those (earning higher salaries) who make full contributions to the health fund? Will they have equal access to treatment?

Will those given full subsidies be entitled to go to private hospitals?

Will this new financing scheme reduce the income disparities between doctors in the private sector and those in state-run hospitals? How? (If income disparities are not reduced - and the market for the private sector is broadened by this new scheme - more government doctors will quit and the general hospitals will be further weakened!)

Will the system of payments to doctors be based on the procedures and surgeries that they carry out?

What kind of safeguards will there be to ensure that the fund is not abused to procure certain services from private firms at prices that are detrimental to the people (and profitable for those select firms)?

The Coalition said it understood that the Health Ministry had produced a comprehensive working paper on the National Health Insurance Scheme and requested a copy. It ended the letter by requesting an appointment (for a discussion) within two weeks.

The following is the actual letter sent to the Ministry:

Gabungan Membantah Pengswastaan Perkhidmatan Kesihatan
d/a 2A Jln Sitiawan, Lim Gardens
30100 Ipoh, Perak DR.

4 Mei 2005

DENGAN TANGAN

Kepada
Datuk Dr Hj Mohd Ismail Merican
Ketua Pengarah Kesihatan
Kementerian Kesihatan Malaysia.

dan

YB Datuk Chua Soi Lek
Menteri Kesihatan Malaysia.


Permohonan tarikh berbincang dengan YB Menteri Kesihatan

Kami ingin mengucap terimakasih pada Datuk Dr Ismail Merican kerana membalas surat kami bertarikh 8 Mac 2005. Kami gembira membaca dalam surat Datuk bertarikh 30 Mac 2005 bahawa objektif Tabung Pembiayaan Penjagaan Kesihatan adalah “untuk memperbaiki aksesibiliti dan ekuiti rakyat terhadap perkhidmatan penjagaan kesihatan yang menyeluruh, bermutu tinggi efisyen dan bersepadu”.

Perkara yang masih membimbangkan kami ialah dalam sejarah perkembangan sistem kesihatan di Malaysia, beberapa keputusan yang melemahkan sistem kesihatan umum serta merugikan dan menyusahkan rakyat telah pun dilaksanakan. Tetapi tiap keputusan ini yang merugikan rakyat telah dikemukakan pada negara sebagai suatu cadangan yang akan memperkukuhkan sistem kesihatan dan menguntungkan rakyat.

Satu contoh adalah keputusan dalam tahun 1980an untuk membenarkan syarikat swasta bersifat komercial untuk membuka hospital swasta. Sampai itu hanya badan-badan kebajikan (non-profit organizations) yang dibenarkan menjalankan Hospital Swasta. Pada takat itu, kami, rakyat Malaysia diberitahu oleh kerajaan bahawa keputusan ini akan membantu lapisan sederhana dan miskin kerana jika orang kaya pergi ke hospital swasta, pakar-pakar di hospital awam dapat lebih masa untuk jaga lapisan-lapisan sederhana dan miskin.

Sekarang, selepas 25 tahun, kita semua sedar bahawa keputusan membenarkan hospital swasta telah melemahkan hospital awam kerana pendapatan yang jauh lebih tinggi di sektor swasta telah menyebabkan “brain drain” hingga sekarang hanya 25 peratus daripada pakar di negara ini masih berkhidmat di hospital awam (yang masih merawat 75 peratus daripada semua pesakit dalam). Inilah punca utama untuk beberpa kelemahan dalam hospital-hospital awam.

Suatu lagi contoh adalah keputusan untuk mengswastakan beberapa bahagian sistem kesihatan awam – termasuk Bahagian Membeli Ubat (1993) dan lima Perkhidmatan Sokongan (1997). Bila ide ini dikemukakan pada negara, alasannya adalah syarikat swasta adalah lebih efisyen dan akan menyelamatkan wang kerajaan yang boleh diguna untuk membantu rakyat dalam cara-cara lain. Tetapi sebaliknya, perbelanjaan hospital-hospital awam telah berlipat ganda manakala syarikat yang menerima kontrak pengswastaan mencatitkan keuntungan lumayan. Sekarang kerajaan ingin berkongsi kos tinggi ini dengan rakyat melalui tabung kesihatan baru.

Mungkin pihak Kementerian tidak berjangka kesan-kesan buruk yang telah menimbul daripada kedua-dua keputusan di atas. Tetapi ini hanya menggariskan betapa pentingnya untuk Kementerian memberitahu rakyat secara terpirinci apakah perubahan baru yang dicadangkan oleh kerajaan dalam sistem pembiayaan kesihatan, termasuk “operational details” dan memberi masa dan ruang yang mencukupi untuk mendapat maklumbalas dan input daripada rakyat.

Antara perkara yang kami ingin tahu adalah –

1. Berapakah kuantum bayaran sebulan untuk seorang pekerja dengan gaji
RM1,000?

2. Apakah “cut-off point” (gaji bulanan) di bawah mana pekerja berkenaan tidak dikenakan bayaran kepada tabung kesihatan?

3. Adakah pekerja yang diberi subsidi penuh oleh kerajaan dapat pakej rawatan yang sama dengan seorang pekerja bergaji tinggi yang menyumbang secara penuh pada tabung kesihatan ini? Adakah akses seorang yang menerima subsidi penuh ke pakar sama dengan mereka yang bayar penuh?

4. Dapatkah orang yang diberi susidi penuh berhak pergi ke Hospital swasta?

5. Adakah sistem pembiayaan baru ini mengurangkan perbezaan pendapatan antara doktor di sektor swasta dan doktor di hospital awam? Bagaimana? (Jika tidak, dan pasaran untuk sektor swasta diperluaskan oleh skim ini, lebih ramai doktor kerajaan akan meletak jawatan, dan hospital awam akan dilemahkan lebih lagi!)

6. Adakah sistem bayaran pada doktor diasaskan atas prosedur dan pembedahan yang dibekal oleh doktor itu?

7. Apakah “safeguard”nya untuk memastikan tabung ini tidak disalahguna untuk membeli perkhidmatan tertentu daripada syarikat-syarikat swasta dengan harga yang merugikan rakyat (dan menguntungkan syarikat terlibat)?

Kami percaya perkara-perkara yang dikemukakan di atas adalah amat penting. Kami mahu suatu sessi dialog dengan Datuk Ketua Pengarah dan YB Menteri Kesihatan untuk membincang isu-isu ini.

Kami juga difahamkan bahawa Kementerian Kesihatan telah menyediakan satu kertas kerja lengkap mengenai Skim Insurans Kesihatan Kebangsaan. Kami memohon suatu salinannya supaya dapat memaham skim insurans ini dengan lebih dalam dan dapat memberikan maklumbalas terhadapnya.

Oleh kerana kerangka waktu untuk melaksanakan tabung ini adalah beberapa bulan sahaja, kami memohon supaya tarikh perbincangan dengan kami yang terdiri daripada 81 buah NGO, Kesatuan dan Parti ditetapkan dalam lingkungan dua minggu dari tarikh surat ini.

Terimakasih.

Yang benar

Jeyakumar Devaraj
Setiausaha Gabungan


SK:
Dato Seri Abdullah Badawi, Perdana Menteri Malaysia
81 NGO, Kesatuan dan Parti