Sorry, we can't tell you, it's confidential, says EPU

It's a secret, says the government's Economic Planning Unit.

The Coalition has received a reply from the EPU on 27 January 2006 to its letter dated 14 December 2006 (see below).

Basically, they are saying that they will take into consideration the Coalition's suggestions and proposals in appointing the consultants who will be tasked with formulating the national health financing mechanism. The consultants are expected to start work in February 2006. But, sorry, the EPU can't release the Terms of Reference because it is... why, "sulit" (confidential) of course.

If the government is going to be so opaque re the TOR, then can we expect transparent behaviour when it comes to administering the fund, outsourcing services etc?

Here is the letter from the EPU:
EPU Letterhead


24 Januari 2006

Jeyakumar Devaraj
Secretary,
Gabungan Membantah Penswastaan Sistem Kesihatan

Tuan,

TERMS OF REFERENCE FOR THE CONSULTANT FOR THE PROPOSED HEALTH FINANCING SCHEME

Adalah dengan segala hormatnya saya merujuk kepada surat tuan bertarikh 14 Disember 2005 mengenai perkara di atas.

Unit Peranchang Ekonomi (UPE) mengucap terima kasih di atas cadangan dan saranan yang dikemukakan oleh pihak tuan. Sehubungan ini, cadangan dan saranan tersebut akan diambil kira dalam pelantikan juruperunding dan pelaksanaan Skim Pembiayaan Kesihatan Kebangsaan (National Health Financing Scheme) di negara ini. Merujuk kepada permohonan untuk mendapatkan salinan Term of Reference (TOR), UPE tidak dapat mengedarkan TOR tersebut kerana ia adalah dokumen sulit. Untuk makluman pihak tuan juga, juruperunding dijangka akan memulakan kajian pada Februari 2006.

Sekian, terima kasih.

BERKHIDMAT UNTUK NEGARA

Saya yang menurut perintah,

Signed

(Datin Shamsiah Haji Dahaban)
b.p Ketua Pengarah
Unit Perancang Ekonomi. 

These were the Coalition's letters to the EPU and the UNDP asking for the consultants' terms of reference.

Gabungan Membantah Penswastaan Sistem Kesihatan
2A Jln Sitiawan
Lim Gardens
30100 Ipoh

14 December 2005

The Principal Assistant Director
Economic & Planning Unit
Prime Minister’s Department
Putra Jaya

Dear Ms Daisy Rajoo

Terms of Reference for the Consultant for the Proposed Health Financing Scheme

The Forum on Health Financing Reform organized by the Health Coalition on 11th December 2005, went well with about 130 people from a large variety of civil society groups participating. I am enclosing a set of the documents that were given out to the participants that day.

One of the suggestions from the floor was that we should ask for a copy of the Terms of Reference for the Consultant who is supposed to give suggestions as to how the new Health Financing Scheme should be implemented.

Would you be able to let us have a copy of the Terms of Reference? Do let us know.

When do you expect the Consultant to start work?

Please let us know.

With sincere regards

Jeyakumar Devaraj
Secretary
Coalition Against Health Care Privatisation
H/P 019 5616807

---------------------

Gabungan Membantah Penswastaan Sistem Kesihatan
2A Jln Sitiawan,
Lim Gardens
30100 Ipoh

14 December 2005

The Coordinator
UNDP
Kuala Lumpur

Dear Dr Richard Leete

Terms of Reference for the Consultant for the Proposed Health Financing Scheme

The Forum on Health Financing Reform organized by the Health Coalition on 11th December 2005, went well with about 130 people from a large variety of civil society groups participating. I am enclosing a set of the documents that were given out to the participants that day.

One of the suggestions from the floor was that we should ask for a copy of the Terms of Reference for the Consultant who is supposed to give suggestions as to how the new Health Financing Scheme should be implemented.

Would you be able to let us have a copy of the Terms of Reference? Do let us know.

When do you expect the Consultant to start work?

Please let us know.

With sincere regards


Jeyakumar Devaraj.
Coalition Against Health Privatisation
H/P 019 5616807

Better treatment for full-paying patients; inferior service to the poor

In Ismail Merican's response to P Ramakrishnan's criticism of moves to allow government specialists to provide "private treatment" after working hours, the Health Ministry Director General said that the Aliran president had based his comments on an erroneous inference. Ismail said:

...the inference that the Government will extend the working hours of specialists — requiring them to provide "private treatment" after working hours — is erroneous.

But look what the NST had to say on 8 January 2006, in particular the first paragraph of its report. It clearly says that specialists will be allowed to provide "private treatment" after working hours.


Ismail also said:

At present, the Government is subsidising 98 per cent of health services provided by the ministry. In no way will this new scheme jeopardise the provision of patient care for non-full-paying patients.

To say that the government is subsidising 98 per cent of health services paints a distorted picture. The money is not coming out of the Cabinet's pockets. It is not charity from the government. Rather, the funds are from hard-earned taxpayers' money and it is only right that this money should be used for essential services for the people such as health care. The whole idea of taxation is to provide an element of cross subsidy so that nobody is denied such essential services because they cannot afford to pay.

Right now, the government is only spending a paltry 2 per cent of GDP on health care - well short of the 5 per cent recommended by the World Health Organisation. If the government were to spend more of public funds on such a critical area as health care, it wouldn't need to come up with fanciful ideas and ill-thought-out schemes to raise money to pay its specialists, doctors and other medical personnel. It would have enough funds to pay specialists and doctors higher salaries without taxing patients a second time through higher fees. (Remember, the public have already paid for public health care services the first time through taxation.)

Finally, Ismail may give us all kinds of arguments and assurances that his proposal for "full-paying patients" (to allow specialists to earn more) will not affect the poor. But the fact remains: once government specialists discover which side their bread is buttered, they can be expected to gravitate to the full-paying patients and spend more of their time and energy with them. Gradually, the non-"full-paying patients" will be subjected to second-class service, longer queues, and crowded wards.

This will result in two classes of patients and two types of services. In effect, better treatment from the best specialists will be provided to the rich (full-paying patients) while inferior service will be dished out to poor patients. Specialists will quite naturally devote more of their time and attention and energy to patients who will contribute more to their take-home income and less to those who cannot afford to pay. In the end, it will be the poor who suffer. So how can Ismail say that the poor will not be affected?

Poor will not be affected, says Health Ministry DG

Ismail Merican (pic right), the Health Ministry's Director General, has responded to P Ramakrishnan's statement, which criticised the move to allow government specialists to provide "private treatment" after working hours. Ismail argues that the poor will not be affected by the move.

The Coalition will be rebutting his remarks in the next couple of days.

For now, here is Ismail's response, published as a letter in the NST today. See whether you agree with it or if it makes sense:

Provision of patient care not affected

By DATUK DR MOHD ISMAIL MERICAN Director-General of Health

IN response to the concerns raised by P. Ramakrishnan of Aliran ("Extra hours not the best solution"; NST, Jan 17), I must point out that the inference that the Government will extend the working hours of specialists — requiring them to provide "private treatment" after working hours — is erroneous. What the Health Ministry intends to do is to carry out the strategy that the Prime Minister, who is also Finance Minister, announced during the 2005 Budget pertaining to private practice in ministry hospitals.

The ministry, after much deliberation, decided to implement the full-paying patient scheme to support this decision by the Government as we realise that a significant number of well-to-do patients seek treatment from ministry specialists but are unable to pay for the services simply because there is no mechanism for them to do so.

Most of them are willing to pay for services obtained.

The full-paying patient scheme is one way of addressing this inadequacy. In addition, it will help provide better incentives and remuneration for our specialists and encourage them to continue working in government hospitals.

The full-paying patient service will provide patients the option of being treated by specialists of their own choice in an executive/ first-class facility and be charged accordingly.

To check abuse and ensure professionalism and accountability, access by all patients (full-paying or otherwise) to diagnostic and treatment facilities, after admission, will be governed by clinical considerations and not affordability. The full-paying patients will be attended to during normal hospital operational hours as other patients or extended hours if needed, as decided by the hospitals.

This scheme will relieve the Government’s share of the healthcare budget by letting patients who can afford to pay their hospital bills to do so.

At present, the Government is subsidising 98 per cent of health services provided by the ministry. In no way will this new scheme jeopardise the provision of patient care for non-full-paying patients.

The scheme will be implemented as a pilot project in Putrajaya and Selayang hospitals this year. After one year, the scheme will be evaluated before being considered for implementation in other government hospitals.

I wish to emphasise that poor patients will continue to enjoy the same privileges and be treated by our best healthcare providers.

Let's debate and discuss the scheme before you finalise it

Make public the operational details of the scheme and allow civil society adequate time to meet the consultants and debate their proposals before finalising the health care financing scheme. These are among the Coalition's main demands to the Health Ministry in a letter dated 12 October 2005.

In its letter, the Coalition thanked the Ministry for arranging the dialogue session on 27 September 2005. It said it was pleased to note that the main objective of the scheme is to improve accessibility and equity for all the people.

But it also reiterated the following concerns raised at the session:

• The operational details are going to be very important as it would determine whether the main objective of the scheme would be realised.
• The private health care market would be expanded under the scheme, and this would worsen the brain drain and undermine the public sector.
• The term "stakeholders" gives the impression that private hospitals, private doctors and insurance companies have the same status as the people. The Coalition, however, believes that any health care system should give top priority to the interests of the peoplet.
• It would be naive to think that a "win-win" situation can be achieved. If the people are to "win", then the greed and interests of other parties must be curbed and controlled.
• The Coalition is not opposing for the sake of opposing. If the scheme truly benefits the people, the Coalition would support it and cooperate in its implementation.

Although the Coalition is able to support the principles of the scheme, it cannot support the actual scheme until the operational details are made known.

The Coalition wants to meet the consultants BEFORE they carry out their work so that they can consider public concerns and doubts when they commence their work.

The public must be informed of the proposal, with all the operational details, before it is finalised. Adequate time must be given for various civil society groups to discuss the scheme and provide further input before the scheme can be finalised.

The Coalition wants to be invited to dialogue sessions with the Ministry and the consultants so that it can provide constructive proposals and suggestions for the benefit of the people.

The full letter to the Ministry is shown below followed by the Ministry's assurance that the Coalition would be involved in future consultation sessions.

Coalition's letter: Page 1

Coalition's letter: Page 2

Health Ministry's reply

Don't allow govt specialists to provide "private treatment"

Groups have come out in protest against the government's plan to allow government specialists to provide "private treatment" after working hours as a means of boosting their income.

Aliran asks the pointed question: Does the Health Ministry truly care for the poor?

Exhausted specialists cannot be expected to be efficient and remain true to their calling. We are not told how many hours per day and how many days per week these specialists would be permitted to work outside their working hours to earn extra money. Wouldn't this arrangement require these specialists to work well beyond the already very long working hours? And if so, would it be healthy for them or beneficial to the profession?

In the end, the people who would suffer from this arrangement are the poor. It is the poor who would be sacrificed and marginalised; health care would be out of reach for this majority of Malaysians. This is not the solution or remedy for the legitimate grievances of the specialists.

Parti Sosialis Malaysia, on the other hand, wants civil society to stop the BN from killing our public health system.

We appreciate that government doctors work hard, and in difficult conditions – we want them to be paid better. The pay-scale in IJN is much better than that in the Health Ministry, but this is not due to supplementary income derived from private practice after office hours but by a better salary structure. The PSM would like the Ministry of Health to set up a separate Service Commission for Health Care Workers and offer them a better salary structure – something similar to the IJN scale. The BN government spends only 1.9% of GDP on health care provision, whereas the WHO has advised an outlay of 5% of GDP for developing countries. (UK spends 9.8% of GDP on health!) An outlay on health is an investment in our people – and as the government itself often says our human resources are the nation’s most precious resources.