Consider This: Is Rakan KKM the Right Diagnosis? (Part 2)

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On one hand, long queues at public hospitals, on the other, astronomical bills at private ones. For many Malaysians, there’s no good option. That’s the gap Rakan KKM claims to fill: offering fee-based, expedited care for non-emergency procedures inside public hospitals. Is this a pragmatic ‘third lane’ between the extremes of unaffordable private care and overstretched public hospitals? or does it risk deepening inequality by allowing those who can pay to skip the queue? On this episode of #ConsiderThis Melisa Idris speaks with Dr Mark Cheong, a Public Health & Palliative Care Researcher and Deputy Head of School (Education), School of Pharmacy at Monash University Malaysia.

Transcript

00:00Hi, welcome back to Consider This. I'm Melissa Idris. Let's continue our discussion about Rakan

00:16KKM, which is a new initiative said to be public hospitals offering fee-based services to skip the

00:24queue for some elective procedures but at below private care prices. Joining me now is Dr. Mark

00:30Cheong, a public health and palliative care researcher. He's the deputy head of the School

00:35of Pharmacy in charge of education at Monash University, Malaysia. Mark, thank you so much

00:41for being on the show with me today. Rakan KKM really has sparked some strong opinions and I'm

00:47curious to know what your take is. What do you think Malaysia is really grappling with

00:54through this reform of Rakan KKM? Thanks very much, Melissa. Again, thanks very much for having

01:01me on this conversation. I think it's a topic that all of us are really interested in. Many

01:08of us Malaysians, I dare say all of us Malaysians, are very much invested in the health of our

01:14national health service and millions of Malaysians use it every day. So it's no surprise when there

01:22is talk of a scheme that might potentially privatise or potentially charge more for services, provides

01:31an avenue for people with more money to cut the queue, so to say. So it's not unsurprising to see

01:39people all up in arms about it. And I think one of the reasons why it's also generated perhaps a lot of

01:46controversy and a lot of buzz is that we know so little officially about it. A lot of it has been

01:54spoken about in social media. There are some media platforms that have published reports from sources

02:00who must remain anonymous and so on and so forth. But I think to actually get concrete facts and

02:07details about Rakan KKM, it's actually quite scarce, this information. In fact, the Ministry of Health's

02:15own website for Rakan KKM has, says a lot of very high level things about it. And these are things in

02:23which I think most of us are familiar with, you know, what it's supposed to be and what it's supposed to do.

02:28But I think the devil is always in the details and sadly that's the part that's missing and

02:33and it's generating a lot of anxiety among many Malaysians. Okay, but overall, Mark, just in terms of

02:40what we do know, do you see any ethical issues with the fact that there will be an option for patients to

02:51to essentially cut the queue or to pay for the privilege of immediate or almost immediate service?

03:03There are absolutely a lot of ethical issues in play and I think what we are most concerned about

03:10for those of us who are interested in this is really the inequalities that Rakan KKM threatens to create

03:17simply by allowing the option for people with more means to be able to get healthcare services

03:26quicker, presumably, you know, get more specialist care at a time that's more convenient to them,

03:34really, really does start to create a difference between the haves and the have-nots. Now,

03:41people who are supportive of Rakan KKM have tried to assure us that, you know, the scope of Rakan KKM is

03:49really just limited to shorter waiting times and it's limited to elective procedures. But even that,

03:56even if that were true, that itself is not completely harmless. I think when we think about shorter waiting

04:04times, it's perhaps tempting to just think about, well, it's the difference between a half an hour wait

04:09versus a two-hour wait. But if you consider, especially for those Malaysians who are from,

04:19let's say, poorer backgrounds, ironically, they are the ones who are most time poor themselves,

04:25and for them, additional waiting time, a longer queue may mean another day of lost income,

04:33may mean additional child caring costs, and it may very well lead them to decide it's really

04:39not worth me waiting longer. And so I'm going to then skip my appointment. And likewise,

04:46when we say that it's only really going to affect elective procedures or elective surgeries,

04:55what's missing really is what do you consider elective? Is an outpatient consultation with a

05:01cardiologist elective? Well, if you're really waiting in queue to check whether or not you have some

05:09serious heart conditions, a simple outpatient appointment like that may not actually be elective,

05:15it may actually have an impact on your health. Another example that was thrown about was,

05:21you know, it might be a procedure for trigger finger. But if you're a manual worker,

05:27you know, and you work using your hands, a trigger finger isn't something that's inconsequential to

05:33your livelihood. So can you actually afford to wait longer for that?

05:38So part of Rakan KKM is also not just from the patient's perspective, but also from healthcare,

05:46professional healthcare workers. The argument is that this initiative, Rakan KKM, will allow them to

05:53earn more. So, you know, this much needed incentive structure that the private sector allows for,

06:01but without the, without leaving the public healthcare system. Do you think that that's an

06:07argument that holds water, there's merits in the argument? So I think that there is a fundamental

06:13assumption that the powers that be are making when they, when they float that, essentially the

06:19assumption that's being made is that people, healthcare workers are leaving KKM mainly because

06:26of low remuneration. But I think we would argue that it's, it's more complicated than that there.

06:33We've heard from healthcare workers on the ground, colleagues of mine, even that it's a mixture of

06:40culture, bureaucracy, issues with autonomy, the lack of career progression, and welfare. And to imagine that

06:49some additional remuneration on top of that will shift minds in a, in a large scale, I'm wondering

06:58whether that assumption holds true. And I think, you know, that assumption was also tested with the

07:04full paying patient scheme that was introduced in the Ministry of Health in 2007, whereby the idea was

07:13then to allow specialists and consultants to be able to actually, you know, work on full paying patients

07:22to earn that extra bit of income in order to retain them in the service. Now, there have been a couple

07:28of studies done and the evidence is incredibly unclear as to whether or not it's actually helped retain more

07:36specialists than before. Oh, okay. That's, that's interesting. So, so how do we think about this?

07:42Because at the end of the day, this is an initiative meant to ensure the sustainability of the public

07:50healthcare sector, because MOH says they can't keep going back to MOF and asking for more money every year,

07:57despite the chronic underinvestment Malaysia is already making in healthcare below the accepted 5% GDP.

08:05What, what do you think then of this trade-off? Is this something that Malaysia should continue

08:13working on, given how many concerns there are? Or should we be looking elsewhere? Rakan KKM may not

08:20be the silver bullet that we need for the accessibility of our public health.

08:25It's, it's hard to imagine that Rakan KKM will actually be able to solve this huge problem that we

08:33have with regards to the underinvestment of our healthcare system. Now, think about some of the

08:40things that we've heard about Rakan KKM, that it will only perhaps work, operate after office hours,

08:48it will only work on weekends, it will only provide a narrow scope of elective services. And when you hear

08:57these things, you start to think that, well, this is going to be a service that's going to be relatively

09:02low volume. And if that is the case, you know, presumably then revenues aren't going to be that high,

09:10nowhere near the amount of money we need to actually make up for the underinvestment in our healthcare

09:18system. So even if everything goes right for Rakan KKM, it's hard to see it as the silver bullet that

09:25will solve our national healthcare problems. Ironically, if it were then to try to achieve

09:32that aim, we would have to massively scale up its scope and operations, which would then really do away

09:40with the national health service system that we have right now. And then in that case, our worst nightmare

09:46will come to, we will truly have privatisation of our healthcare system.

09:51Okay. Medical inflation, might it help address the runaway medical inflation that we're seeing, Mark?

09:58Again, I don't think so. I think these are very large macro market forces that are in play. And again,

10:05it's very hard to imagine that a sort of like a part-time side gig healthcare service that provided

10:13in whatever little free time that our healthcare staff have, if at all, will actually help to solve

10:19this problem. My sense is that we would be better served spending our attention and our efforts on

10:27larger scale reforms of how we finance our healthcare, how we attract and retain our health workforce,

10:35and how we improve our population's health through preventive measures, through health promotion in

10:42order to reduce the burden on our national health system. Mark, thank you so much for being on the

10:48show with me today. I appreciate your time. Dr. Mark Cheong there from Monash University, Malaysia,

10:53wrapping up this episode of Consider This. I'm Melissa Idris, signing off for the evening. Thank you so much for watching. Good night.

11:00I'm Melissa Idris, signing off for the evening.

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