Health reform starts with governance, not money

 

Health minister Khairy Jamaluddin turned to literature to demand more money for the Malaysian public health system. Paraphrasing George Orwell’s 1945 novel Animal Farm, he proclaimed something like, “all ministries are equal but some are more equal than others”.

This is an extraordinary reference to an allegory in which animals commandeer a farm through violent revolution and a herd of swine take power to expropriate the resources for themselves, changing the rules nefariously to make it look like nothing is wrong.

Some might say this is a strange way for the minister in charge to describe the Malaysian healthcare system, especially when demanding an extra RM30 billion.

Others might consider it an appropriate metaphor, considering a string of scandals from the mutilation of a patient in a botched circumcision to allegations in the international media, which have not been denied, of egregious malpractice at the heart of the Malaysian medical profession.

Reform of Malaysia’s health system is necessary but the idea that money is the solution is wrong. In fact, throwing money at a system that many, including the health ministry itself, consider dysfunctional, will make things worse. Reform must begin with root-and-branch restructuring of management, leadership, governance and above all ethics.

Systemic risk of patient abuse makes good governance a prerequisite. Patients are often uninformed about what treatment options are best. Financial rewards incentivise mistreatment.

Power relations and “doctor knows best” denude patients of choice in healthcare options. Pushing more money into the system without governance reform will make this worse.

Management failure leads to arbitrary denial of access to healthcare, a focus on expensive medicines, equipment and procedures, under-provision of unprofitable treatments, lower service quality and a lack of universal, comprehensive medical options.

A root-cause of this failure is the management and leadership itself. Clinicians with no formal management training control the senior manager positions. The nexus between insurance companies, pharmaceutical companies and clinician-managers, especially when there is a slew of money, incentivises mismanagement.

Systemic management dysfunction creates “accidental managers” and “group think” that resist innovation and growth. Key functions are captured by special interest groups and of course the “grumpy old men” who block diversity across age, gender, specialism and aptitude in management and leadership functions.

Stakeholder exclusion is endemic, even the current reform agenda excludes patients and non-medical experts from management and scrutiny positions.

The absence of credible, accountable and transparent governance makes things worse and leads to sclerotic management, poor resource decisions and above all, demotivated stakeholders and mass exit of key talent.

The biggest failure is the hopelessly ineffective regulatory system which is controlled by the very people it is supposed to be regulating. Statutory regulation is not fit-for-purpose. Enforcement departments in the ministry of health are under the control of the medical fraternity that patients are complaining about.

The courts offer little hope. In 2017, the Federal Court ruled that private hospitals are not generally liable for medical negligence. In other words, you have no protection. The botched circumcision case took 12 years to bring to court and the government is fighting to deny the compensation given to the patient.

The Malaysian Medical Council (MMC) can hear complaints of professional misconduct but according to reports alleging malpractice in their own procedures, which they have not denied, the chances of a remedy from MMC are vanishingly small.

To place additional money into the Malaysian health system when failures of leadership, management, governance and ethics are ignored is throwing good money after bad.

There can be no proper reform of the Malaysian health system unless the fundamental governance and ethical issues are resolved from the outset.- FMT

The views expressed are those of the writer and do not necessarily reflect those of MMKtT.