The change in the Government in May 2018 has led to expectations of improvements in healthcare delivery.
The significant announcements in Budget 2019 were the establishment of the B40 Health Protection Fund and a nationwide health screening programme, Skim Perlindungan Kesihatan (Peka); introduction of a soda tax; and about RM29bil in allocation for the Health Ministry, which is a 7.8% increase compared with 2018 (RM27bil).
The demand for healthcare is rising and continues unabated with opportunities for improved diagnoses and treatment.
However, economic uncertainties and budgetary constraints continue to put significant financial pressures on healthcare provision.
The net impact of these contradictory pressures is uncertain. What will Malaysian healthcare be like in 2019?
The incidence of non-communicable diseases (NCDs) will continue to rise with increasing undiagnosed and uncontrolled numbers, and increasing demands on total healthcare expenditure.
Peka will probably increase the diagnosis rate, but does not guarantee increased compliance to treatment.
The soda tax is unlikely to decrease the incidence of NCDs. This is because no comprehensive programme with several interventions to control NCDs was announced.
The statement of the Unicef (United Nation’s International Children’s Emergency Fund) representative to Malaysia that “The combination of obesity, stunting and anaemia in Malaysia is a growing public health emergency and needs to be treated as such”, is a timely reminder that the ingredients of the perfect healthcare storm are already here.
Needless to say, it will damage the country economically and socially.
Patients’ voices and actions will become louder in 2019 as they become increasingly more informed, particularly from the electronic media – notwithstanding its variable quality of health information.
There has been a deafening silence on the Malaysian Health Data Warehouse (MyHDW), which was launched in April 2017 with the objective of using big data for analysis and decision-making with the potential of reducing cost, reducing waste and optimising the use of limited resources.
The unavoidable collection of personally identifiable data, which raised questions about data security, its deidentification when released to users, and public oversight of MyHDW have not been clarified.
With the global leaks of personal data, patients need assurance that their health information is always kept confidential. Interestingly, the Personal Data Protection Act does not apply to the public sector.
Public trust in allopathic healthcare delivery systems continue to wane.
Healthcare will be entrusted by many to the non-health sectors with technology providing them the tools to do so, e.g. vaccination refusal, home deliveries by unregistered personnel and internet purchases of unlicensed medicines.
The demand for better patient experiences, patient safety and better quality of care will continue to pressure regulators and payers to ensure the provision of safe and quality healthcare services.
The increased budgetary allocation to the Health Ministry will not assure improved safety and quality of care unless wastages, inefficiencies and the role of middlemen are reduced markedly.
When middlemen take a share of the healthcare ringgit, compromises are inevitable, with consequent impacts on safety and quality of care.
Rising healthcare expenditure
Healthcare expenditure will continue to rise because of the ageing population, the double whammy of non-communicable and infectious diseases, new technologies, increasing patient demands and the unrestrained role of middlemen in healthcare.
It is iniquitous that a few are permitted to profit from the illnesses of the vast majority.
The need for long-term care and NCD management will increase for the senior population and an increasing number of young adults as large segments of the population are unhealthy with diabetes, hypertension, overweight and obese.
Infectious diseases like dengue and malaria will continue to afflict Malaysia with no cure for the former and increasing drug resistance in the latter.
Some previously eradicated diseases like rabies have already made a comeback.
There will be increasing out-of-pocket expenditure in the private and public sectors, particularly with increasingly expensive medications and procedures.
An increasing number of families will face financial ruin if they or their relatives get catastrophic diseases like cancer and heart attack.
Medical inflation will continue to rise.
Cost containment in private hospitals has failed. Charges in private clinics, and even in private hospitals, are increasingly capped by managed care companies and third-party administrators.
More general practitioner clinics will close, primarily because of financial unsustainability, and rarely because of retirement.
Whether the B40 will benefit from the Health Protection Fund is a moot question when they already have access to virtually free healthcare at public healthcare facilities.
When the RM8,000 limit is reached, transfer to a public hospital will almost always be inevitable.
The current practice of the imposition of the First Class treatment charges under the Fees (Medical) (Amendment) Order 2017 on all patients referred from private hospitals will have to be changed and other measures taken so that those in the B40 Health Protection Fund do not end up with hefty bills from both private and public hospitals, particularly when there is a chronic condition.
Private practice for public sector specialists may or may not stem the outflow to the private sector as the outflow is often due to service conditions and not just financial compensation.
Would the safety and quality of care of public sector patients be affected by such private practice?
Only time will tell.
There are too many medical schools, too many graduates, and too few house and medical officer posts.
Over-production of the medical workforce continues although the public are wiser with decreasing applications to private medical schools, which will lead to mergers, acquisitions and closures of some.
The crunch will come in 2020 when the four-year contracts of the initial cohort of junior doctors in the Health Ministry ends.
Some will continue to be employed, but the rest will have to find their way in the saturated private sector or seek alternative employment.
Delays in the appointment of housemen after graduation has led to some of our best and brightest doing their housemanship training in regional countries which provide certainty of appointments.
Training doctors at taxpayers’ expense for other countries is, to say the least, illogical.
Healthcare has lagged behind others like telecommunications, transportation, retail, etc, in utilising new technologies like artificial intelligence (AI) and virtual reality.
The smartphone, portable diagnostics, smart drug delivery mechanisms, digital therapeutics, genome sequencing, machine learning, blockchains and the connected community will begin to impact on multiple aspects of healthcare delivery, e.g. operations, workforce management, business models, patients’ confidentiality and security.
Whilst the potential of AI for healthcare IT application is the focus of attention of a select few, the basics of healthcare are paramount to all recipients of healthcare.
Technology cannot be permitted to depersonalise healthcare. New technologies are just new tools. Whether it adds to or detracts from humane healthcare has to do with how and why it is used.
Staying healthy avoids the need for healthcare.
A healthy diet, maintaining an appropriate weight, regular exercise, sufficient rest, safe sexual practices, avoiding smoking, mode-rate alcohol consumption and keeping vaccinations current are some of the measures to stay healthy.
This requires some work, smart lifestyle choices and the occasional medical check-up. Wishing all readers good health in 2019!
Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
(Editor’s note: The Doctor Says will be available online every alternate Tuesday starting from the next column on Jan 22, 2019)