We rarely discuss healthcare, does it mean we don’t care? We aim to be a developed country by 2020 but will our healthcare system keep up? Congestion, preventative care, quality doctors, and research. Topics we rarely discuss but are critical to ensuring a quality healthcare system for the growing population in coming years.
Join us as Umapagan Ampikaipakan speaks to the Deputy Director General of Healthcare, Dr Abdullah Noor Hisham, his sister Dr Sundari Ampikaipakan who works at Pantai Medical Center, Dean Dr Charles Weiner of Perdana University and Ron Sabapathy a patient who has been in and out of public and private hospitals for the couple of years.
Produced by Handy Jobs (Hear & Now in Malaysia) in collaboration with the Economic Transformation Programme and brought to you by BFM.
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Kam Raslan: BFM 89.9 This is Hear and Now in Malaysia, I am Kam Raslan. On this week’s episode, our correspondent, Umapagan Ampikaipakan, takes an in depth look at the Malaysian healthcare system. What are some of the problems facing Malaysian healthcare system, how can it be improved, and who should pay for it.
Umapagan Ampikaipakan :There is a reason they call it a heart attack. A sudden and aggressive action by your body against itself, a fatal occurrence of coronary thrombosis. Flatline. You’re dead.
50 years ago, heart disease was a death sentence. But no more. Bypass surgery and angiograms and stent technology and statins have done more than just help manage the disease, they are the closest thing we have today to cures. And boy do they work.
There is good reason why a baby girl born in Japan, or Australia, or Singapore is likely to live to 85 years of age while the same girl born in Sierra Leone would likely have a life expectancy of about 36 years old. And it is this. An effective and efficient healthcare. But where can we find this in Malaysia – in private or public?
What should a WORLD CLASS healthcare system look like? How do all the players – the government, the healthcare professionals, the private corporations, the academics, the insurance companies – come together in a way where society wins?
Ron Sabapathy: In the beginning, I went to private and they went through the elimination process, they did a lot of test on the arms and the legs, blood tests, and these drag on for about a year because…
Umapagan Ampikaipakan :Meet Ron Sabapathy. His is the story of how a quirk of fate would force him to face down a frightening medical condition.
Ron Sabapathy: And at the end of it, they charged quite a bit, and there was no diagnosis. The doctors did not know what was wrong with me.
Umapagan Ampikaipakan : Having spent more than 8 months in a public hospital, Ronnie experienced both the best and the worst that the Malaysian healthcare system has to offer.
Ron Sabapathy: Then, I was referred to a government hospital, and the same thing happened. They were going through a lot of their elimination processes, and I was referred to a specialist and they went through a lot of tests again. They had their own elimination process and finally, they found the tumor. When they found the tumor, they scheduled the operation right away, two weeks later. And, the operation was 10 hours long and they had to go through the back of my neck to reach the spine. They actually had to cut through the bones to get to the tumor.
Umapagan Ampikaipakan :Close to two years after his operation Ronnie continues to receive rehabilitative treatment from a public hospital.
Healthcare is something very few Malaysians talk about. What are our options? What does the Malaysian healthcare system have to offer us?
Dr Hisham Abdullah: I am Dr Hisham Abdullah. I am actually trained as a surgeon but I am also the Deputy Director General of Health in the medical site. So we start off with the system that we have. In our country, from 1957 until now, you can see our system was relevant in the past because it was a very simple healthcare, we’re looking only into communicable diseases only at that time. And we evolve over a period of time.
Umapagan Ampikaipakan :I spoke to him with the purpose of discovering just what was going on with the healthcare system here in Malaysia. I wanted to know where we are.
Dr Hisham Abdullah : When we evolve over a period of time, what we have today now is two systems, the private system and the public sector right? The system that we have, benefits the most to those that can afford, the rich and the famous, because the rich and the famous can afford to go abroad like Singapore, go overseas and have treatment there obviously because they have the money, and they can also afford to go to the private hospital in this country. And, they can also come to the public hospital, because they are the one that pay income tax. They are the tax payers. So, the rich have the best healthcare in this country, right? But, the poor does not have any alternatives even though the private hospital is right infront of their house, or the private clinic is infront of their house, they still need to go to the public clinic or the public hospital for treatment.
Umapagan Ampikaipakan : Our total expenditure on healthcare is 35.15 billion ringgit, with the government’s share at around 15.35 billion ringgit. But is this enough? What does this expenditure mean to someone who is experiencing the system?
Ron Sabapathy : The care was reasonable because in a ward, each nurse has 8 patient to look after. And there are about 58 patients in a ward. The thing I really noticed was how they are overwhelmed, there were a lot of patients but not enough doctors or nurses. And a lot of time, you have to wait for things, like a scan, or to do any medical procedure, you have to wait because there were just too many patients.
Umapagan Ampikaipakan :Our population currently stands at 28.85 million. We have a total of 32,979 doctors. Our doctor to population ratio is a woeful 1:859. The WHO recommends it to be at 1:600.We are struggling to craft a healthcare system that best suits the needs of our population. And hospitals, both public and private, are unable to cope.
I spoke to my sister, Dr Sundari Ampikaipakan, who is a consultant chest physician at Pantai Medical. She recently returned after having practiced medicine in the UK for 11 years.
Dr Sundari Ampikaipakan : Now I think our government healthcare system gets a bad rep and I think partly, they are oversubscribed, you know, they are trying their best. They are a group of doctors trying in very difficult healthcare circumstances ie: they are in clinic of 40/50 patients, working with constraint healthcare resources, so I think its no fair to say one is better than the other. I think they have their pros and con, and the question is, how can the two work together? And, how can we achieve better outcomes for our patients?
Dr Charles Wiener : In Malaysia, I found that they can do a much better job in the country in providing continuity care, what I call primary continuing care, where one person has one person who manages their care. There is a deficiency of specialist in this country, we need to train more specialists.
Umapagan Ampikaipakan :That was Dr Charles Wiener is Dean of Perdana University Graduate School of Medicine set up in collaboration with John Hopkins University School of Medicine in the United States.
Dr Charles Weiner : They shouldn’t ask if I’ll be in the private healthcare system. They should be integrated between public and private. I think that, preventive care, much of which is already institutionally allowed by the Malaysian government has not been as widely implemented to prevent disease. So, I think the ideal healthcare system takes advantage of the US system which is complex, state of the art care and state of the art research, and combines that with continuity care and medical homes, places where people will get preventive care, risk assessments, and pre emptive care rather than reactive care.
Umapagan Ampikaipakan : Congestion. Congestion. Congestion. It is foremost on everyone’s minds.
Dr Hisham Abdullah : So when we look into congestions, what are we doing? How are we going to de-congest? How are we going to have this decongestion program? Well, decongestion programs start with our processes of work. So we do a lot of day care, and now we increase our day care cases, that means you come in, you have your surgery done and you go home. Day care, so you don’t need to stay overnight in the hospital and all that. That cut costs. Do with with early admission. If you are doing surgery, you admit in the morning. Not admit two or three days earlier and stay in the hospital and obviously, parking will be crowded, visitors will come and visit you and with all that, there will be problem. Community based medicine, that means, after surgery, you discharge them early to the GPs and the doctors close to home. Home at hospital, they call it. Move towards community based. This is a concept that we have and we are doing. Increasing more day care cases, more day surgery admission, early discharge community based medicine. We are trying to implement this as well.
Umapagan Ampikaipakan : What then about our doctors? How do they measure up with regards to education and training?
Dr Charles Weiner : The quality of the students is exceptional, nothing short of exceptional. They are training in their background. I personally believe it is excellent within the context that they have studied but lacking in the broadness of the education, the diversity of the education, and “the liberalness of the education”. For example, bio medical science students who have done a great job in our curriculum, its very possible that they went through their first degree three years and did not take any course in history, arts, economics, or any of the things that I think are necessary to be a broad based outstanding physician or an ideal physician. So, I can give atleast 2 or more reasons on why they should. One, at the very level, they are going to be communicating with other people, patients, other people and being unidimensional is never a good way to be a good communicator. Two, if you’re going to be an educator, and you’re going to be an investigator, then, you’ll need to know how to tackle problems from a non scientific standpoint, and there are a lot of great knowledge outside the rigid sciences that help you become a better investigator, a better educator, and a better communicator.
Umapagan Ampikaipakan : Dean Wiener of Perdana University knows what he’s talking about. He is after all board certified in internal medicine, pulmonary medicine, critical care medicine. And he has spent the last decade of his life involved with education, training, and mentoring.
Dr Charles Weiner : So, I think there are many ideal doctors. The ideal doctor always keeps human health well care at the forefront. In the tripartite mission of medical care which inter-digitates and gives equal weight to clinical care, resurgent education, so the ideal physician somehow understands that there is an equilateral triangle and in some context in that triangle, focuses on improving human health.
Umapagan Ampikaipakan : Such quality needs to be maintained. It needs to be developed and allowed to grow.
Dr Hisham Abdullah : It’s the satisfaction. The patient must be happy with your service, happy with your communication, happy with you and your total because you’re in the service industry. And perception, assessment is coming not from your boss but coming from the people behind you. All around, 360 degrees, your PA, your staff nurse, they can asses you so that they can know whether you’re good anot. The best person to asses a surgeon is not a surgeon or the head department but its people working with him in the OT. So, these are the things.
Umapagan Ampikaipakan : Today we’re looking at healthcare in Malaysia. The system is overwhelmed and quality is at stake. Now we have an idea of what an ideal doctor is. Coming up shortly how important is the environment in which they function and how can the system be funded? BFM 89.9 You’re listening to Hear & Now in Malaysia.
Umapagan Ampikaipakan : BFM 89.9 You’re listening to hear & now in Malaysia. Today we’re taking a deeper look at the Malaysian healthcare system and what will push it to become a health system suitable for a developed nation. We also ask that all important question of just who is going to pay for it all.
Umapagan Ampikaipakan :The medical profession is constantly changing, it is absolutely crucial for our doctors to be continuously learning. But how often do we even consider such things when picking our doctors.
For Ron Sabapathy, his experience as a patient in the Malaysian healthcare system gave him greater insight.
Ron Sabapathy : Like in public, the doctors, eventhough they are overwhelmed and they take a long time to see the patient and to finally diagnose what is wrong with the patient, but, they are more experienced because they have seen so many cases.
Umapagan Ampikaipakan : How often do we demand our doctors to invest their time and effort in more research?
Ron Sabapathy : The doctors there, they are constantly improving themselves by doing their Masters, their PhD and their profession ship. So, in this sense, they are quite knowledgeable and very experienced. He started off as an associate professor and I was his final thesis, and after my operation, he submitted his thesis and now he is a fully fledged professor.
Umapagan Ampikaipakan : I wanted to know what role does research play in a world class healthcare system? I asked Dr. Sundari Ampikaipakan who used to practice in the UK.
Do you think there should be more research done in private hospital?
Dr Sundari Ampikaipakan : Absolutely, without a doubt. I don’t think you need to be doing scientific based research but I think every hospital should start off at some point where we should atleast be publishing our outcomes. So, if you have a unit that does breast surgery, we should be publishing our breast surgery outcomes or I’m a chest physician, I should be able to publish my bronchoscopy outcome, for example. We should start there. We should start at almost an audit level where you know, somebody coming to use our service can go “Oh, look! This is a hospital that does a hundred coronary artery bypass graph a year, or they do a thousand coronary artery bypass graphs a year. So, we need to start somewhere because we need to be accountable for what we are doing as healthcare professional and people should be able to make an informed choice as to whether they are coming to the best place for their treatment. I think, the one thing that I would like to see, is definitely, more data, availability of data and both the public and private healthcare system where we have a better understanding of our diseases and disease profiles in this country, and really, a better working relationship between the private and the public sector. I think we have a lot to offer each other. And, I think there are some outstanding doctors in both areas and I think, if you work together, you definitely can do nothing but the best for your patient.
Umapagan Ampikaipakan : Because data is crucial. In being able to treat a population effectively. We need to know just how many of us are sick, we need to know what it is that is making us sick. Dean Dr Charles Weiner of Perdana University
Dr Charles Weiner : When you say research, that goes anywhere from identifying new genes to identifying better strategies for preventing diseases and vaccination. So it is essential and I think for Malaysia, specifically, if Malaysia wants to be seen as a world player in the intellectual environment, then research is essential. And where that research fits in anywhere from this what I call gene society spectrum, it can be anywhere as long as its work that improve knowledge and advances human health.
Umapagan Ampikaipakan : What’s more, research and data is only of any use if it’s localized.
Dr Charles Weiner : If you’re simply passive in adopting the research going on elsewhere in the world to Malaysia, you’re probably going to miss signals and do harm. There is no doubt that we are learning about individuality that Malaysians, Southeast Asians are different from Europeans, Caucasians and Africans in terms of the diseases they are susceptible to, their responses to medication, a whole host of factors and if Malaysia simply passively absorb research done by other population, it is likely to not fully benefit the Malaysian people. So, we have to be a centre for research here too.
Umapagan Ampikaipakan : Comprehensive healthcare should involve a combination of efficient public health measures, world class doctors, and cutting edge research. The endgame should be for all citizens to have sufficient health in order to lead a dignified and productive life. How do we achieve this?
The Deputy Director General of Health Datuk Noor Hashim seems to have a better idea than most on how it should be done.
Dr Hisham Abdullah : Its actually, we want the hospital to be autonomous so that the hospital can actually perform better. It is not based on limited by funds, so if they do well, they have more corporate social responsibility, and their surgeries are good and more patients come to them, then they should have more money, more funding by the government of course. The system we now have is actually all by the government. The funding comes in to reward the performance. This is what should be done, otherwise they will resign right? If they are happy with the system then they can do more research. Research is not very much available in the private sector, but in the public sector, there is a lot of research due to the volume of patient. So, each hospital will compete for quality. More quality so more patient will come to you.
Umapagan Ampikaipakan : The thing is we know how healthcare works or rather how we want it to work. Doctors and administrators and politicians can all agree on what they want and what makes for an ideal situation. The bigger question is who is going to pay for it?
Dr Charles Weiner: A nationalized system. I do believe that healthcare is a right and therefore every citizen should have access to adequate healthcare. I think that what has become a bad trend is thinking that that means everybody should be allowed to get any healthcare. So, I think the ideal healthcare system, if people are willing to take the best part of say, the US system where there is no doubt that the most complex healthcare system can be given the best possible care comprehensively. And, people will take the best part of say, the Scandinavian healthcare system where there is no doubt that the average person gets excellent care at a minimum and blend those two, then, you will have a system that provides phenomenal health care for everyone in the country. And you will actually do it at less cost.
Dr SundariAmpikaipakan : Health care is always going to be expensive. It is going to be expensive to the government, and it is going to be expensive for private healthcare providers. And, the NHS is not perfect. It is probably one of the world’s greatest example of national healthcare system and it is not perfect. And, frankly at the moment, it is also struggling because of the cost of healthcare and because of the fact that people are getting older and surviving longer. And I think, what we need to ask ourselves is, how do we retune this? How do we retune the way we deliver healthcare. What should be our priorities? There are more and more now and people are asking , why aren’t we thinking of prevention, about education, about educating the public, about educating the people about healthcare, about how to look after themselves.
Dr Hisham Abdullah : So, you look into our model of payment system and in Singapore, we have a ‘saving scheme’ system which means like you save, like EPF, and you use that money for payment. But, if you have cancer for example, you save 50,000 and cancer costs you 100,000 , you go bankrupt because you used up all your money. Worst still is that you still owe 50, 000 and your children’s savings will also be drained out. The pooling of risk is within the family, and we want the pooling of risk to be within the whole community. That’s what. You look into the German system, it is actually employer-employee, the Bismarck system. Employer pays some amount and employee pays some amount. We also practice here, panel doctors and all that. Then, the NHS system, that is based on general taxation. Everything is taxed by the government. I mean, everything is paid by the government. That is the system that NHS has. But, we are looking into a modern hybrid model, that is the government, the employer and the employee pay. At the end of the day, when the cost is taken care of by the national healthcare financing, then the person will ask himself, if the cost is being taken care of, when you go for hospital, what you go for? You will go for, quality. Cost is no longer an issue, you can go to any hospital now, but it is a quality hospital that you want to go.
Umapagan Ampikaipakan : How are we going to pay for it? This will be the new discourse. What makes for a developed country? There was a time when you would have said infrastructure. Roads. Logistics. Communication. But the era of hardware development is over. These days it’s all about the software. It’s about knowledge. It’s about people. What makes for a first class healthcare system?
It requires doctors that are all rounded. It requires comprehensive research and data collection. It requires public policy that is fair, that is balanced, that is inclusive.
Crafting an exceptional healthcare system is crucial in achieving any developmental goal. Which is why it is so very crucial that we have a healthy and productive population that can live up to their every potential. Because quality of life is paramount.
Kam Raslan : U has been looking out the Malaysian healthcare system that appears to be not broken but certainly overwhelmed. It is a system that many countries in the developing world would love to have. But, is it moving fast enough and fairly enough for a country that aspires to be a fully developed nation. If you have any comments or feedbacks, then please get in touch with us on our twitterfeed or join us on our Hear and Now in Malaysia Facebook page.
Hear and Now is made in collaboration with the Economic Transformation Program. This is BFM 89.9, I am Kam Raslan, and thank you for listening to Hear and Now in Malaysia.