How does one take a position on one “wrong” within a larger system of “wrongs”?

The “mother” of all these “wrongs” is the concept that health care is just another commodity that can be traded in the marketplace. This concept should be rejected in civilized society because, not only is access to health care a basic human right, it is also a transaction where there huge asymmetry in knowledge between the provider of the service (the doctor) and the recipient of that service (the patient). More importantly, a decent health care system based on solidarity of all citizens, and independent of the patient’s capacity to pay, does something undefinable to our sense of ourselves as a nation. It makes us feel that we are a people, enhances a sense of belonging, and contributes to building a more harmonious society.

However, mistakes were made. Private practice was allowed in Malaya even before Independence and general practitioners (GPs) set up clinics all over the country. They did provide a very useful service to the community by making health care more accessible. They also earned handsomely, and the GPs were among the wealthiest 10% of the population then.

That began to change in the 1980s after Dr Mahathir encouraged the setting up of private, for-profit hospitals. These hospitals also provided out-patient care for any patient who decided to walk in. The Primary Care system that was the practice in Malaysia before 1980, where a patient had to see a GP or a doctor in the government out-patient department before getting referred to the specialist (at that time almost entirely in government service) was supplanted by direct self-referral to private specialists. This trend is accelerating with the proliferation of private hospitals, and the income of the 8000 odd GP clinics in the country has taken a hit.

GPs also used to have contracts with factories, banks and government agencies to be listed as one of the doctors on the medical panel of these institutions which would pay the doctor a pre-negotiated rate for each patient seen by them. The invasion of “Third Party Administrators” (TPAs) into this space witnessed many employers switching to TPAs as they offered lower rates. The TPAs, which are large corporations with financial heft, now have the market power to force GPs to accept very low rates on a “take it or leave it basis”.

As a result of these changes, GPs now make low 5 figure monthly incomes or even only high 4 figure ones, about 5 to 10 fold less than the specialists in the private hospitals. They now rank in the second, or even third decile from the top, of the country’s income pyramid when they were in the top decile before. And they feel “short-changed”!
But really, how much should professionals earn / be paid? Sure, they had to work hard to acquire their knowledge and skills, but that knowledge was built up of the contribution of many generations of men and women. That knowledge was not developed de-novo by these professionals themselves. They have equipped themselves with collective intellectual and scientific inheritance of mankind to provide us their medical expertise.

The PSM is proposing that the top income in a society should not be more than 10 times the living wage, which in Malaysia today is set at about RM 3200 per month. Anything above 10 times that, should be seen as misuse of the skills and knowledge entrusted to the professional to administer the collective wisdom / knowledge of mankind.

Coming back to the GP’s march in Putrajaya, the “straw that broke the camel’s back” is the impending enforcement of the requirement to display the prices of medicines. As the medical fee schedule has not been revised for the past 33 years, many GP augment their income by hiking up the prices of the medicines they prescribe. I believe that there would also be quite a number of GPs who subsidise medicines for their poorer patients, but charge their affluent patients more, for the same medicines. The enforcement of price display of medicines would make this cross-subsidization difficult, and also impede income augmentation.

Also, many GPs only label medicines by writing the symptom they are meant for – “fever”, “cough”, “headache” or “antibiotic”- without specifying the pharmacological name of the medicines supplied. This is purely a business strategy to prevent patients from buying further doses of the same medicines from the pharmacists (many of whom sell prescription items without a prescription). It is difficult to blame any party here. For we, as a society, have encouraged practitioners (doctors and pharmacists) to treat health care as a commodity. It would be hypocritical of us now to take the high moral ground and criticize them when they act as businessmen.

But doctors should bear in mind that their stature in society is diminishing. Doctors are still respected, but an increasing number of people are starting to see doctors as selfish profiteers. This is reflected in the increasing number of litigations involving doctors. Apart from fighting for better remuneration for doctors, the medical profession should speak up for the ordinary Malaysian who is experiencing crowded government facilities, long waiting times, soaring medical costs in the private sector and financial distress because of the malfunctioning health care system. Doctors should support the demands of the Peoples’ Health Coalition which are

• a 10 year moratorium on new private hospitals. This is to stem the massive out-migration of specialists from government hospitals to the private sector.
• initiation of a capitation scheme that allocates GPs diabetic and hypertensive patients to follow-up on, but at government expense – medicines and investigations being borne by the Ministry of Health and the doctors’ professional fee covered by the capitation payment.
• increase of the MOH budget to 5% of GDP over the next 5 years. That would enable the MOH to finance the above initiatives – the first requires funds to employ more specialists in government and expansion of hospital facilities so that the specialists can treat more patients. The support of pro-people proposals for health care reform would help rehabilitate the image of doctors in the public’s eye.

We sympathise with the Madani government, as they have inherited a difficult situation arising from wrong policy decisions in the past. But it is sad to see that the Madani government is still intent on promoting the Rakan KKM scheme and launching a new voluntary insurance policy. These are steps that further commodify health care and legitimize profiteering from it. As we mentioned at the outset, treating health care provision as just another commodity to be traded is the root of many of the problems we are now facing. Resolution of these problems will have to be phased, and will take time. The genie, once out of the bottle, is difficult to be enticed back into it! But further commodifying health care is definitely a step in the wrong direction!

The Madani government should step back and take a hard look at the distribution of income in Malaysia at present. Only 29% of total national income goes to 97% of the working population, while 55% accrues to the corporations and the richest individuals (who make up only 3% of the working population). The government should seriously study how a portion of the 55% currently being appropriated by the economic elite can be channeled to government coffers as taxes, and used to improve the health care system.

Dr. Jeyakumar Devaraj
Chairperson
Parti Sosialis Malaysia