The Proposed 1Care – Does It Really Care?

By Toh Kin Woon

Introduction

Aneurin Bevan (1897-1960), who was the Minister of Health in the United Kingdom immediately after the 2nd World War, once stressed that where medical needs exist, medical care should be provided and budgets should be of secondary importance. Based on this progressive and compassionate principle, he went on to establish Great Britain’s National Health System (NHS), which was then one of the most inclusive, comprehensive and equitable healthcare systems in the world. Unfortunately, Bevan’s stand is not much supported by many policy-makers today, especially after the widespread dissemination of neo-liberalism. The consequences are concern over costs rather than adequate healthcare coverage for the people, especially the poor and marginalized and priority on profits for healthcare providers over good health for the general population, achieved largely through rationing of heath care resources via the ability to pay rather than need. 

That health is a social good with large positive externalities is increasingly being forgotten. Similarly neglected is the recognition that access to adequate healthcare is a basic human right. Hence, that the state should play a fundamental role in its provision in order to obviate under-consumption by the poor and sick, while at the same time preventing over-consumption by the rich and healthy, is increasingly being ignored. This has led to continuous moves by the state to outsource the many aspects of healthcare provision, such as treatment, drug supply, non-medical services and financing, to the private sector providers such as private hospitals and clinics, pharmacies, large contractors and insurance companies.

Like many other countries, Malaysia has not been spared the onslaught of neo-liberal thinking. The effect is the outsourcing to the private sector of several services related to healthcare management such as hospital cleaning and laundry, the management of clinical wastes, facility engineering and bio-medical engineering, as well as the procurement of drugs. Such privatization has sharply increased the costs of servicing the healthcare system. Alongside these measures, the state has introduced the system of co-payments by patients and private practice by doctors in publicly funded hospitals after working hours. Under the former, patients are now required to pay high collateral payments for the treatment of several conditions such as orthopedic procedures which require plates and nails, lens for cataracts, clips for surgical procedures, drug-coated stents for angioplasties and certain anti-cancer drugs, while under the latter, patients would be required to pay much more if they wish to seek earlier and speedier treatment. The financial burden borne by poor patients has gone up consequent upon the introduction of co-payments. At the same time, they are being increasingly excluded from the much needed after office hours for-profit services. Added to these worrying trends is the planned introduction by the Ministry of Health of a new healthcare system that, according to sources familiar with the scheme, are likely to bring even greater burden to the poor and sick.

1Care –Salient Points

Called 1Care, this new healthcare scheme, whose details have as yet to be officially announced, has the following broad features.

* 1Care will be funded by a national health insurance system, which requires every household to contribute close to 10% of its gross household income to it. This amount is, however, to be shared among 3 parties viz the individual, the employer and the government, though the proportions have as yet to be worked out. How the government plans to collect such premiums from the self-employed and the amount to be collected have not been worked out. The government is, however, likely to pay for the premiums of civil servants, pensioners and up to 5 of their dependents.

* Contribution by every household is compulsory and payment has to be done upfront. The current practice of fee for service will be replaced by fee before service.

* It will be managed by a National Healthcare Financing Authority (NHFA), which is likely to be a government-linked company (GLC).

* The new 1Care healthcare system does not provide for all your medical expenses. It does so for only a prescribed basic list. The costs of seeking treatment for anything beyond this basic list will have to be borne by the patients themselves out of their own pockets.

* Patients are not allowed to see doctors of their choice, but will have to see one allotted to them. Private practitioners will have to join the 1Care system if they wish to see patients covered under this scheme.

* Patients can see specialists only after first being screened by general practitioners who will decide when they can do so. This is a practice called gate keeping. Such rationing of specialist care applies to healthcare by general practitioners as well under the proposed 1Care scheme. This means that patients cannot visit their doctors as and when they please, though how this is going to be regulated is as yet unclear. For those wishing to seek specialist care without the requisite recommendation by their doctors, they will have to pay out of their own pockets as these visits will not be covered by national health insurance.

* The proposed fee for seeing a general practitioner under the 1Care system is RM60, which is only for consultation and does not include medication. Compared to the present charge for treating common illnesses, including medication, these proposed fees work out to be three to four times more for patients. Although these charges may be covered by national health insurance, patients may still be asked to make certain co-payments.

* Medicines prescribed will have to be from a standardized list of not the original medicines in line with the World Health Organization’s list of essential medicines. The idea is to save costs for 1Care and maximize profits for the insurance companies, which will have a big say in deciding on this list and the prices of medicines. Needless to say, these companies are likely to approve the cheapest medicines.

Why Worry?

Based on what we know thus far, Malaysians have much to be concerned over the proposed 1Care healthcare system. Why?

* For a start, everyone, irrespective of his or her socio-economic status, will have to pay for healthcare. They will have to contribute to the national health insurance scheme. Presumably, anyone who is unable to contribute because of financial difficulties will not be covered and will hence not be treated even in public hospitals, which currently provide almost free medical treatment to all who cannot afford to seek treatment in private hospitals and clinics. This gives rise to the possibility that the poor and sick may not get access to healthcare, a basic human right.

* The introduction of a national health insurance scheme adds on to the financial burden of the poor, who are already stressed by rising costs and hence declining real wages. The government can well counter by insisting that it will pay for the premiums of the poor, but only after they have passed a means test. We all know though that such tests are more often than not exclusionist in nature. It is not easy for the poor to prove that they are indeed poor.

* The new practice of having to get medicine from a pharmacist will mean placing a great deal of inconvenience on rural and semi-urban residents who will have to travel a considerable distance to the nearest pharmacy.

* Placing the entire healthcare system under the NHFA will mean that erstwhile public healthcare providers will have to change their entire orientation from being social service providers to corporatized entities out to cut costs and seek profits. Being a GLC, this is what the NHFA will set out to do, leaving the poor and sick vulnerable to being excluded from basic healthcare. The ideal that where medical needs exist, medical care should be provided and budgets should be of secondary importance will not be realized under this framework of operation.

* The introduction of 1Care opens up more profit opportunities for financial services providers, in particular insurance companies and pharmaceutical companies. Given the propensity of the present Federal Government to use state power to nurture crony capitalism, more crony capitalists are likely to emerge to exploit these opportunities for profits. Indeed, with declining opportunities in manufacturing, plantations and construction, services such as healthcare are fast emerging as new profit centers. This clearly has not escaped the attention of power holders and their business allies. When 1Care is implemented, the divide between the rich and poor, already yawning wide, will yawn even wider, thereby worsening a wealth and income distribution pattern that is skewed in favor of the rich.

Conclusion

Our analysis of 1Care and its social implications seem to suggest that the over-riding concerns of the government are controlling costs and availing more opportunities for appropriating profits to private healthcare-related service providers under the new healthcare system to be managed by a GLC called the NHFA. Malaysians must rightly wonder why greater priority is placed on curbing costs over meeting healthcare needs, especially to the poor and needy in a resource rich country such as theirs, that until recently only spent roughly 2% of GDP on healthcare, way below the minimum 5% as stipulated by the World Bank. While controlling costs is not undesirable in itself, using the need to curb costs as an excuse to deny access of the poor to basic healthcare or to introduce a new financing scheme that works against them is, however, clearly unacceptable and socially undesirable. In seeking additional finances to meet rising costs, most Malaysians will agree that in the Malaysian context, rather than introducing additional payments to be borne by the poor, it is a case of re-arranging priorities. Wasteful spending can be curbed, if not eliminated, thereby freeing resources that could then be productively mobilized for spending on basic healthcare. Spending on healthcare should also be further increased. 

Our current public health system, thus far funded by general taxation, has provided decent healthcare for the general public, including the poor and has thus helped play a key role in nation building and social solidarity. We see no reason why the system, especially its financing, needs to be overhauled. This is not to suggest that the healthcare system, as it is, is bereft of problems. But these should be tackled without the necessity of requiring every Malaysian to contribute to a national health insurance scheme. We, therefore, reiterate that illnesses and health care should not be viewed as commodities to be allocated through the market. 

This is because such outsourcing to markets invariably leads to over-consumption by those with financial resources and under-consumption by those who are indigent, at the same time as it yields huge profits to healthcare-related service providers. Rather, healthcare should be seen as a social good, whose provision, including its financing, should be largely, if not exclusively, the responsibility of the government. Further, it bears repeating that healthcare services must be regulated and administered such that it benefits all members of the Malaysian society who are in need. The regulation of the national risk pool is a fundamental role of the government, as it is this facility which allows the social solidarity principles to function – the principles that the rich support the poor; the healthy support the sick and the young support the aged.