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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