Who is calling the shots in health care?

The Coalition met Health Ministry Director General Dr Ismail Merican in Putrajaya on 14 March 2006. The meeting started with Ismail citing time constraints to the "star-studded" cast from the Coalition, giving them just one hour to cover all the issues.

There were around 40 people in the room - 30 from the Coalition and 10 from the Health Ministry and department. With the clock ticking away, it appeared from the start time was going to be a major constraint.

The Coalition members were led by some doctors - medical as well as PhDs. Among them were Datuk Devaraj (former MMA president), Dato Kumarasingam (former director of the Health Ministry's Pharmaceutical Division), Dr Chan Chee Khoon (Citizens' Health Initiative), Dr Xavier Jayakumar, Dr Mariam, Dr Nasir Hashim (PSM Chairperson), Dr Subramaniam Pillay (Coalition chairperson and Aliran exco member) and Dr Jeyakumar Devaraj (Coalition secretary). Also high profile were NGOs representatives led by the MTUC president himself, Syed Shahir. Other organisatons present included the Oppresed People's Network (JERIT), WDC, Suaram and the Nurses Union. Most of the major opposition parties' representatives were also present - from PSM, PKR, PAS and PRM.

DG defends full-paying patients' scheme

The Health DG had his own team of experts. Ismail Merican started with an attack on the media for not writing the facts. He started by explaining that there was no privatisation plan but just “full paying patients” and that they are undertaking a pilot project to determine the feasibility of the proposal. A pilot project is a pilot project, he said, and there is nothing to worry about. He said specialists won’t be tired; they cannot impose their own charges; they have to follow rules and conditions. He said that his Ministry is a caring Ministry - but then he imposed a strict time constraint on the discussions that followed.

Coalition raises its concerns

The floor was then open to the Coalition partners who spoke one after another starting with Xavier. Xavier stressed that health efficiency would be compromised with the new practice; he asked why there was a need to double-tax paying patients; why not just spend more money on funding the existing system?

Syed Shahir from the MTUC and Joachim Xavier from the Penang Office of Human Development (POHD) raised the issue of migrant workers having to pay much higher fees. Syed said that, internationally, it is an embarrassment the way we treat our migrant workers. Joachim added that the country was actually profiting from migrant workers - but his contribution was stopped short by the Ismail, who said, "Next?"

S Arutchelvan from PSM said that it appears that the government is washing their hands off its responsibility and is more interested in health tourism. The DG was definitely irritated with this remark. Koh Swee Yong from PRM and Maria from WDC also shared personal experience on how patients are suffering in government hospitals.

Other very straightforward questions were put forward: Have you done a study on the University Hospital? have the consultants been appointed? who are they? how are you going to segregate patients between paying and non-paying patients?

Ducking the issues

Then the Health Ministry officers responded. They said that their first-class rates had not been raised since 1982, to which Subramaniam, the coalition chairperson responded, "Who is stopping you from raising those?" The Coalition is more interested in the well being of the lower- and middle-income group, he said.

The Ministry officials continued to brief the meeting about disciplinary action that had been taken against doctors. But when pressed, they conceded that so far no government doctors had been dismissed. They also said that if a private doctor refers any patient, irrespective of the patient’s socio-economic status, they would be immediately told to pay first-class rates. If they are unable, then they can apply to the Fund. At this point, the participants were quite resigned as everyone knows how 'efficient' these Funds are.

But when more pressing questions were put up, the DG kept saying that these are cabinet decisions especially the proposal for private wings. He said no study has been done on the current private wings concept in UM and UKM.

On the migrant workers issue, he also ducked the question by saying that it is a policy matter but he would raise the issue again.

On the health financing scheme, he said, it would take a long time and would not be implemented in the 9th Malaysian Plan. He added very hesitantly that the health consultants are in the process of being appointed.

The DG also kept saying how efficient and excellent our health system is - comparable to any country in the world.

Coalition wants improved public health care system

Coalition chairperson Subramaniam said that we would need another date but said that the Coalition's position is not to run down the public health system but to support it. We want an improved public health care system.

The Coalition members were treated to a lunch. The DG left for another meeting, and the coalition members pondered if perhaps they should be meeting the Minister or the Prime Minister, as it looks decisions are not made here but higher up. It is time to take the struggle to a higher level.

Ismail Merican was efficient. He started and ended on time. But it is obvious that he does not call the shots. He is put there to defend the position of the State, which seems quite intent on turning the public health care system into yet another money-making machine.

Coalition raises host of questions at dialogue with Health Ministry

We need some answers now. The Coalition raised three main areas of concern during its dialogue session with the Ministry on 14 March 2006: the "full-paying" patients proposal, the secrecy over the identity of the consultants hired to design the blueprint for the proposed national health care financing mechanism, and the proposal to get migrant workers to pay much higher private sector medical fees for treatment in government hospitals.

Dialogue session between the Coalition (GMPPK) and Health Ministry director general Dr Ismail Merican

14 March 2006

Terlebih dahulu, kami, Gabungan Membantah Penswastaan Perkhidmatan Kesihatan (GMPPK) ingin mengucap terima kasih atas kesudian Yg Bahagia Datuk meluangkan masa berjumpa dengan kami untuk membincang beberapa perkara penting berkaitan dengan perkhidmatan kesihatan awam.

Antara perkara yang kami ingin membawa ke sessi dialog ini adalah

1. Cadangan ‘Full Paying Patients”.

2. Pakar Perunding untuk Skim Pembiayaan Kesihatan Baru.

3. Caj mengikut kadar swasta untuk pekerja asing.

Cadangan Full Paying Patients

Surat khabar NST 8 Januari 2006 melaporkan bahawa KP Kesihatan telah mengumumkan bahawa “specialists will provide private treatment after working hours at the Putrajaya and Selayang Hospitals by March “ dan “the scheme will be extended to all hospitals with specialists based on the outcome of a six-month trial period”

Pengumuman lanjutan oleh Yg Bahagia Dato yang dilapor dalam NST 23 Januari 2006 berbunyi “it will help provide better incentives and remuneration for our specialists …” dan “the full-paying patients will be attended to during normal hospital operational hours or extended hours if needed . ..”

Keratan akhbar berkaitan adalah disertakan sebagai Appendix I.

Kami, GMPPK, khuatir cadangan “Full Paying Patients “ ini akan menjejaskan kualiti rawatan untuk pesakit biasa. Rationale kami untuk mengatakan ini adalah seperti

berikut–

1. Pada masa ini hanya 30% daripada doktor pakar di Malaysia berkhidmat di hospital-hospital kerajaan, dan beban kerja mereka adalah terlalu berat kerana 70% in-patient di Malaysia masih dirawat di Hospital-Hospital Kerajaan. Selain daripada beban klinikal ini, doktor pakar kerajaan ditugaskan membimbing dan melatih doktor siswazah dan juga doktor yang sedang berlatih menjadi pakar, selain daripada kerja-kerja pemantauan lain. Pada takat ini mereka tidak ada cukup masa untuk menjaga semua pesakit dengan baik.

2. Perlaksanaan skim wad swasta di Hospital Universiti dan UKM Cheras sejak tahun 1998 telah menjejaskan kualiti rawatan pesakit biasa dan juga pengajaran pelajar perubatan.

3. Wujudnya kemungkinan penyelewengan seperti meminta pesakit menjadi “full-paying” jika mahu dapat awatan segera dll akan berlaku

Kami, GMPPK, beranggap sistem kesihatan awam negara kita adalah suatu asset yang amat penting pada rakyat dan harus dipelihara dan dikekalkan. GMPPK setuju pendapatan doctor kerajaan harus ditingkatkan, tetapi cadangan mewujudkan rawatan swasta di bawah nama “Full-Paying Patient” bukan kaedah yang baik.

Syor GMPPK:

• batalkan cadangan “Full-Paying Patient”

• menubuhkan Komisyen Perkhidmatan (Service Commission) berasingan untuk kakitangan kesihatan supaya gaji dan elaun doctor dan kakitangan kesihatan lain boleh ditingkatkan.

Pakar Perunding untuk Skim Pembiayaan Kesihatan Baru

Pihak GMPPK telah mengemukakan beberapa soalan pada Menteri Kesihatan terhadap bentuknya Skim Pembiayaan Kesihatan Baru melalui surat-surat kami bertarikh 4 Mei 2005 dan 21 Jun 2006. (Sila rujuk Appendix II) Antara soalan yang dikemukakan adalah

1. Apakah kuantum bayaran untuk seorang yang berpendapatan RM 1000 sebulan?

2. Apakah “cut-off point” di bawah mana pekerja berkenaan tidak dikenakan bayaran pada tabung kesihatan?

3. Adakah rawatan seperti pembedahan cataract, coronary angiogram, hemodialysis dan rawatan untuk leukaemia diliputi oleh “essential health package”?

4. Adakah ahli untuk”National Health Advisory Council” dipilih oleh orang ramai atau dilantik sahja oleh Menteri?

Jawapan yang diberi untuk soalan-soalan ini adalah kerajaan sedang menunggu kajian dan nasihat Pakar Perunding. YB Menteri Kesihatan telah mengumumkan di surat khabar (The Star, 26 April 2005) bahawa kerajaan akan menetapkan pakar perunding terhadap Skim Pembiayaan Kesihatan Baru ini. Surat pihak EPU bertarikh 24 Januari 2006 menyatakan Pakar Perunding telahpun dikenalpasti dan akan memulakan kerja beliau pada bulan Februari 2006. (Appendix II) Dr Chua telah memberitahu para wartawan pada 14 Disember 2005 bahawa “The details are being determined by the expert, who will study all the implications.”

Kami ingin tahu

1. Siapakah pakar perunding yang dilantik? Sudahkah beliau mula tinjauan beliau?

2. Adakah terma rujukan beliau mewajipkan beliau berjumpa dan mendapat ide dan maklumbalas kumpulan NGO, dll kumpulan masyarakat supaya dapat mengambilkira pandangan kami sebelum memberi keputusan beliau? Bolehkah GMPPK dapat tarikh berjumpa dengannya?

3. Adakah cadangan untuk memberitahu keputusan pakar perunding ini supaya orang ramai dapat memberi maklumbalas sebelum kerajaan buat keputusan muktamad terhadap bentuk skim pembiayaan baru?

Pada kami, GMPPK, adalah amat penting untuk memperkukuhkan sistem kesihatan awam, dan segala aspek Skim Pembiayaan Baru harus memelihara sistem kesihatan awam. Pandangan GMPPK mengenai sistem pembiayaan kesihatan adalah terkandung dalam laporan bertajuk “The People’s Alternative” dan sesalinannya adalah disertakan sebagai Appendix III. Kami harap dapat sempatan membincang aspek-aspek Alternatif ini dengan Pakar Perunding dan juga dengan pihak Kementerian Kesihatan.

Caj mengikut kadar swasta untuk pekerja asing.

Menteri Kesihatan, YB Dr Chua Soi Lek telah membuat pengumuman akhbar pada 22 Oktober 2005 bahawa semua pesakit asing, termasuk pekerja asing, akan dikenakan caj mengikut kadar yang diamalkan di sektor swasta (Rujuk Appendix IV). Pekerja asing pada masa ini dikenakan kadar kelas pertama. Jika cadangan Menteri Kesihatan dilaksanakan, caj terhadap mereka akan meningkat tiga kali ganda!

Dalam sessi perbincangan yang diadakan oleh GMPPK pada bulan Disember 2005 di Universiti Malaya, beberapa peserta telah membantah cadangan meningkatkan caj rawatan terhadap pekerja asing. Antara sebab yang dikemukakan adalah:

i. Pekerja asing sedang menyumbang ke pembangunan ekonomi negara kita. Oleh itu adalah adil mereka juga dapat menikmati sedikit daripada kekayaan negara ini.

ii. Pekerja asing merupakan satu lapisan masyarakat berpendapatan rendah yang tidak berkuasa dan mudah ditekan. Suatu masyarakat yang penyayang harus memberi perlindungan yang sempurna pada lapisan seperti ini.

iii. Jika caj rawatan adalah tinggi, pekerja asing akan cuba mengelak daripada datang mendapat rawatan, kerana mahu cuba rawat diri sendiri untuk mengelak daripada membayar. Kelambatan dalam mendapat rawatan akanmenjejaskan kesihatan rakyat Malaysia sekiranya pekerja asing itu
mengidap penyakit berjangkit seperti TB, malaria atau typhoid.

iv. Ikut kenyataan Datuk Abdul Rahman Bakar, Timbalan Menteri Sumber Manusia, di Parlimen, negara kita sedang mengutip levy sebanyak RM1.8 bilion setahun daripada kaum pekerja asing (Sila rujuk Appendix IV)

Syor GMPPK

Membatalkan cadangan meningkatkan lagi caj terhadap pekerja asing di hospital kerajaan. Kerajaan harus memakai sebahagian daripada duit levy yang dikutip untuk mensubsidikan kos rawatan pekerja asing di hospital kerajaan.

Sekali lagi pihak GMPPK ingin mengucap terima kasih pada Ketua Pengarah Kesihatan atas kesudian beliau berjumpa dan berdialog dengan kami. Kami harap proses berdialog akan diteruskan dan segala pemindahan ke sistem kesihatan awam akan diberitahu pada masyarakat awam dan dibincang sebelum diputuskan.

Dr Subramaniam Pillay
Pengerusi GMPPK

Syed Sharir
Presiden MTUC

----------------
Appendix I

Keratan akhbar 8/1/06 dan 23/1/06

Appendix II

Surat GMPPK bertarikh 4/5/05 & 21/6/05

Jawapan KKM bertarikh 25/5/05

Keratan Akhbar 26/4/05 & The Star 14/12/05

Surat EPU bertarikh 24/1/06

Appendix III

The Peoples Proposal.

Appendix IV

Keratan akhbar 23/10/05

Keratan akhbar Star 28/10/05.

After sustained pressure, TOR finally revealed

It's finally out. After sustained pressure from the Coalition, the Health Ministry has revealed the terms of reference (TOR) for the consultants it is engaging to design a detailed blueprint for the implementation of the national health care financing mechanism. The terms were revealed in a letter to the coalition dated 22 February 2006 from Dr Rosnah Hadis, director of the Ministry's planning and development division.

The terms of reference cover the following areas:

1. Reporting issues, challenges, gaps, and strengths in the existing health care and financing mechanism.
2. Determining the sources of finance, including the shape of the National Health Insurance scheme, which will cover aspects such as the rate and level of contribution and the exempted groups.
3. Determining and recommending the appropriate provider payment mechanism such as case-mix.
4. Determining the health care benefit packages.
5. Studying, proposing and determining the organisation and function of the authority or body under the Health Ministry that would manage and implement the health care financing mechanism.
6. Analysing the implications of the proposed mechanism from the legal, economic, and quality standpoints and evaluating its affordability to the people.
7. Coming up with a detailed action plan for implementation.
8. Discussing and clarifying with the public and carrying out social marketing to promote the mechanism.
9. Developing the human capital and information management systems necessary for the creation and implementation of the mechanism.

Unfortunately, the identity of the consultant remains a secret. The following is the letter received from the Ministry:

Page 1

Page 2

Lampiran

Meanwhile, the Health Ministry says the Coalition is "confused" about the proposed "full paying patients" scheme and it is therefore inviting the Coalition for a dialogue on 14 March at Putrajaya.