Doctors are urging for a national health insurance system, dissolving the distinction between private and public hospitals, allowing all Malaysians to have easy access to healthcare.

They suggest that the scheme will alleviate the burden at government hospitals that are facing overcrowding problems due to their low fees, while private hospitals are unused - due to the higher prices - but are more accessible.

They also argue that it could lead to better overall healthcare services for Malaysians, lower out-of-pocket spending, reduced waiting times and advancements in modern medicines and technology. It would also give patients greater rights to demand a level of service that government hospitals are not offering due to cutbacks.

The proposal comprises a single-payer, multiple-provider arrangement where public and private hospitals would offer equal facilities and functions to a patient.

How much is enough?

"Moving to a national system of health insurance provides greater stability in health financing, with coverage for all citizens. It is community-rated, not risk rated, and excludes no one; contributions are decided based on ability to pay. There is pooling of risk and pooling of funding," said Tan Sri Dr. Abu Bakar Suleiman, former Ministry of Health (MOH) director-general and chairman of IHH Healthcare Berhad.

However, the rate contributed by Malaysian citizens is the delicate part. When the MOH proposed a similar system in 2012, the 1Care - which included set limits on doctor visits and assigned GPs - it was strongly resisted as it required 10% of gross income.

"More contribution, more benefits. 8% will be argued to be too much, 5% may provide inadequate benefits. Difficult and the politicians have to persuade voters to accept. What will you be willing to contribute?" Dr. Abu Bakar poses.

The current healthcare system is on a multiple-payer, multiple-provider basis. The public sector has payers such as the MOH, the Higher Education Ministry, the Social Security Organisation (SOCSO), other federal agencies, local authorities, state agencies, state governments, the Ministry of Defence and the Employees Provident Fund (EPF).

To add on, an extensive private hospital network exists and is funded by households' out-of-pocket spending, private insurance companies, corporations, private managed care organisations, and non-profits. Recently, a bundling system has been implemented to reduce costs.

A single-payer, multiple-provider arrangement is better

National Kidney Foundation (NKF) chairman Datuk Dr. Zaki Morad Mohd Zaher agrees that Malaysia's fragmented healthcare system should evolve into a single-payer, multiple-provider system.

"The payer can set certain standards and insist of certain outcomes of care and this will promote competition amongst providers," said Dr. Zaki.

He adds that value-based competition is now the major theme for healthcare providers current funding agencies do not focus on healthcare, making them unable to dictate the level of care or results that are expected. The existing system is also open to abuse if patients make duplicate claims to different agencies.

"There may be wastages if there is no central database to monitor payment. A single payer with multiple providers will improve outcomes as it can invest in activities monitoring quality," he said.

Can the government manage such a system?

Malaysia Medical Council member Dr. Milton Lum said there is a general consensus that the current public healthcare system is unsustainable in the long-term, as even now, government hospitals are overcrowded and have run out of certain medications and tests.

However, one of the problems with a social health insurance is that less than 10% of the Malaysian population pays income tax.

"You cannot ask the fellow who's paying income tax to carry a lot of the burden for others," Dr. Lum said. "So MOH has to decide - what are we going to cover? And the MOH is in a very difficult position. On one hand it is a provider, on the other, it is a regulator. There is a lot of conflict of interest there."

There is also concern whether the government can run a national health insurance fund well. Citing their previous proposal of 1Care, the Malaysian Medical Association (MMA) president Dr. John Chew said it "floundered due to a trust deficit in the system."

Therefore policy researcher Dr. Lim Teck Onn says that there is still risk that the social health insurance model is an "incompetent, dishonest, unaccountable bureaucracy created to manage the fund."

"Can we trust a healthcare 'EPF', basically?" Dr. Lim asked. "Can we trust them with so much money?"

Previously, Health Minister Datuk Seri Dr. S. Subramaniam announced that the MOH was considering a national health insurance scheme, but it would be voluntary. MIMS

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