By: Choo Sing Chye
This article appeared in MalaysiaKini and Malaysia Today
The study to privatise public heath care services and hospitals by the government began in the late 80’s and it came into the open when the 7th Malaysia plan was unveiled. There were 12 major entities/projects earmarked for privatisation and 8 for corporatisation. One of the eight were Hospitals.
Apparently the government had studied many health care systems in the world but could not find any system that fit what the government is looking for until today. This is because no where in the world that we can find a system that completely divorce the government from the responsibility to provide health care coverage to all its citizens.
Even in Britain where privatisation was the main political trust during the heydays of Margaret Thatcher’s administration, health care surprisingly still remains within the realm of socialised medicine. Many hospitals are still own and operated by the government.
In Canada, although most of the hospitals are private own, provincial governments get block grants from the federal government to cover every patient with the same package of benefits to ensure universal and comprehensive coverage. Thus what Canada is practising is socialised insurance and Britain, socialised medicine. 1
After all the studies made by the government in the 80’s to privatise hospitals, the only solution that it is able to come out is, instead of privatisation, it opts for corporatisation. Even then, the issue of corporatisation is yet to be debated and many still do not know its form and function let alone answer the nagging question whether sufficient long term safeguards to protect the poor are built into it.
The haste to corporatise stands as a hallmark of the government to renegade from the responsibility to provide universal health care for the people. The crux of the question is not whether corporatisation in its initial form has sufficient safeguards, but will these safeguards be sustained indefinitely without falling prey to the ‘slippery slope’ principle which would begin to operate when cost escalates.
According to this principle, the involvement of the government in the corporatised health care system would surely and slowly shrink and in the end slips into a state where the government is totally divorced from it. Inevitably corporatised health care would transformed into privatised entities. This had unshamefully happened to INSTITUT JANTUNG NEGARA
Sad to say, the slippery slope principle has already begun even before corporatisation. According to the then Director-General of Health Tan Sri Dr Abu Bakar Suleiman, the cost of health services would inevitably rise once government hospitals were corporatised and the government which spent RM4 billion a year on health care could “not afford to subsidise fees as is being practised now.” 2
We do not need to corporatise or privatise our hospitals on the account that it is too expensive to maintain. The policy makers must be enlightened to the fact that Malaysia is not burdened with the kind of social security (e.g., unemployment security, old age pension and etc) or with a comprehensive health care safety net that we see exist in Western Countries.
Western Countries spent around 10 percent of their GDP for their health care services, Malaysia only spent 2.30 percent of its GDP on health care services. According to Dr. Chan Chee Khoon, “the health care expenditures has been declining, from 3.53 percent of GDP in 1980 to 2.30 percent in 1995, well below the WHO recommended norm of 5 percent.” 3
The policy makers are fond of arguing, in fact, too liberally that the government had allocated too large a sum on health care services and could not continue doing so. To dominate societal thinking with this argument is morally wrong. Must we devalue public health care on the account of this or let ringgit and sen to dictate the accessibility to health care?
Conspicuously if one supports the issue of privatisation of government hospitals in Malaysia, one must be prepared to face the immoral issue of having thousands of poor common people excluded from proper medical care. Needless to say that it is like withholding medicine to those who cannot afford and it is likened to the practise of Passive Euthanasia.
The government had privatised a few of its services namely, hospital equipment and facilities maintenance, laundry and clinical waste disposal but instead of decreasing operational cost, it increases to five times as much. (Sun 20-6-1999)
The American example offers the best indicator of a privatised health care merits and demerits.
In the first instance, private health care in the United States is more expensive to maintain then that of the government, for an example:
Americans paid the 1.500 private insurance companies $241.5 billion for premiums during 1991. Those companies paid out $209.2 billion in benefits. The remaining $32.3 billion, more than 13 percent of every premium dollar, went for overhead - claims processing, marketing, building and furnishing insurance company offices, executive’s salaries, and, of course, perks and profits. In contrast, Medicare spent about 2 percent on administration , and Canada’s public insurance system pays less than 1 cent of each premium dollar to insurance overhead. 4
Furthermore, according to the Rand study which concluded that “free care would avert 106,00 deaths per year.” 5 In 1987, the National Medical Expenditure Survey found “that a million Americans who needed emergency attention never got it.” 6 An increasing proportion of Americans are “avoiding care because of cost - up from 27 percent in 1981 to 36 percent in 1987.” 7
According to the National Health Interview Survey, about one-third of all Americans are either uninsured or underinsured. “Many of them face grave difficulties getting needed care, and they are sicker and die younger because of this poor access.” 8
In his paper, Privatisation and the heath care sector - Re-negotiating the Social Contract, Dr. Chan Chee Koon, brought the question of inaccessibility of the poor to reasonable good health care: one is reminded that the Longwood Medical Area in Boston, home to some of the most sophisticated medical technologies at the Harvard Medical school and its affiliated hospitals, exists cheek by jowl with the Roxbury neighbourhood, a deplorable urban ghetto reputedly having one of the highest infant mortality rates in the North Eastern United States.
During the early 70’s when the American health care policy shifted to cutting costs:
private insurers raised deductibles and co-payments, expanded exclusions from coverage (e.g., refusing to pay for “pre-existing” conditions), and intensified efforts to avoid insuring people with high risk of illness. State governments threw people off Medicaid rolls and reduced coverage.
While these policies have not contained costs, their toll has been high in terms of restrictions on care and inequalities in health. Decades of improvement in health standards have been halted, and in many instances, reversed. 9
Thus when the government dabbles with the idea of privatising or corporatising public hospitals, it must first prepare to discard the very universal principle which is part and parcel of our moral values that if a person should die from an illness, it is because there is no cure rather than the fact that he or she has no money.
If somehow this universal principle applies, then privatisation and corporatisation of health care services and public hospitals should not have any place in our society.
Morally the government had spent an enormous sum of public fund through the years to build these hospitals and health facilities. How can the government now, without consulting the people, contemplate in corporatising all these health facilities?
The Ministry of Health or the Cabinet should not have the final say on the issue of corporatisation. What should rightly happen now is to have a referendum so that the people can have a direct say on whether they want corporatisation or not.
We must remind the government that the institutions of health care must rest on the foundation of a caring society and not in the clutches of the profit driven companies.
The whole idea of the need to have a caring non-profit health care can be summed up eloquently by the Massachusetts physicians and nurses.
We are Massachusetts physicians and nurses from across the spectrum of our professions. We serve patients rich and poor…Mounting shadows darken our calling and threaten to transform healing from a covenant into a business contract. Canons of commerce are displacing dictates of healing, trampling our professions’ most sacred values. Market medicine treats patients as profit center. …Public resources of enormous worth - non-profit hospitals, visiting nurse agencies, even hospices - built over decades by taxes, charity, and devoted volunteers are being taken over by companies responsive to Wall Street…10
1. John Canham-Clyne. “A Rational Option”
2. Utusan Melayu. ”Government To Ensure Healthcare Remains Affordable.” (July 4 1999 Press Report)
3. Chan Chee Khoon. “Rrivatisation and the Healthcare Sector.” (Sept 1996)
4. John Canham-Clyne. “A Rational Option”
10. “For Our Patients, Not for Profits.” Dec 1997 (Internet)