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One of the few similarities between the healthcare systems in place in Malaysia and Singapore is that they are both facing considerable challenges. Both might be advised to take a similar approach to these challenges as they try to meet the health needs of their people today and provide for future care.

Editorial

If a Singapore resident develops a severe disability and needs help with daily activities, such as a nurse or a maid, the government’s ElderShield health coverage provides cash pay-outs of at least SGD 300 (US$ 208) a month for up to 60 months. But those living just across the water in Malaysia suffer a much more difficult fate. Many people today fear not death, but falling seriously ill – it is a luxury they cannot afford.

Their stories are sad and difficult to listen to. One patient’s sister explained her brother was admitted to the public hospital in Malaysia with concussion and, “would have died if only we didn’t transfer him to a private hospital”. He was in a coma and as there was no space in the intensive care unit, medical staff placed him in the oncology ward with chronic cancer patients. It was only by paying themselves they felt they could save his life. But this is a privilege not all can afford.

Facilities are being upgraded in Malaysia, but progress is slow

Malaysia, unlike Singapore, which has most infrastructures in place, is currently working towards upgrades for its existing facilities and construction of more advanced healthcare complexes with projected completion by 2020. Malaysia’s universal healthcare system is undergoing a structural reform to improve problems such as long waiting times, over consumption and high price differences between the public and private healthcare sectors.

In Malaysia’s budget for 2017, MYR 536 million (US$ 119.8 million) is set aside for upgrading medical facilities and MYR 4.5 billion (US$ 1 billion) allocated to the operation of 340 1Malaysia Clinics, 11 1Malaysia Mobile Clinics, 959 health clinics and more than 1,800 rural clinics.

The standard of care in Malaysia is slowly improving

In Malaysia, a minimum fee of MYR 1 ($US 0.22) is enough to guarantee complex treatments such as cancer operations. This system provides universal coverage and affordable care as a form of social protection. Meanwhile, the public health sector has been plagued by long waiting times, overcrowding at public hospitals and the evolution of patient demands. However, in recent years, the Malaysian government has actively worked on structural reforms and facilities upgrades.

As results in the 10th Malaysia plan from 2010 to 2015 show, measurable improvements in Malaysia’s healthcare have been made. According to data from the Ministry of Health, there has been a steady decrease in the doctor to population ratio from 1:791 in December 2012 to 1:671 in 2015 and there was also an increase in the numbers of government clinics in rural areas. At some government clinics waiting times have decreased by 50%. Although some improvements have been made, more work is needed to increase the number of hospital beds available, reduce the price difference between public and private health and improve technical aspects of treatment such as infection control and personnel quality.

The government is preparing to work with other organizations to meet demand

To help reduce overcrowding in public hospitals, the government will cooperate with the private sector or non-governmental organizations (NGOs) to operate non-profit charitable hospitals. A total of MYR 20 million (US$ 4.47 million) will fund loans for hospital equipment.

In July 2016, Malaysian Health Minister Datuk Seri Dr. S. Subramaniam discussed the idea of introducing a voluntary government insurance scheme. He indicated that the scheme will be dynamic and evolve in line with the changing needs of the population. However, he reiterated that it will not phase out the current health system but will serve as an alternative to the public health sector.

He explained, “There will be no private player and no profit motive. The government health insurance scheme will evolve according to time. It is too early for me to give details such as the structure the scheme and so on. I am just throwing it as a concept and let the relevant party discuss it.” The details of this policy are yet to be publicised and more information is expected to be announced in the coming year.

Singapore’s healthcare system has very different priorities

Meanwhile in Singapore, healthcare policies for 2017 are focused on three general points: seamless care, review of the Eldershield scheme and stepping up efforts against preventable chronic diseases such as diabetes. In line with the Smart Nation masterplan, future plans are geared towards helping patients access or move through different care service disciplines of care services.

For example, a patient who needs care in two different disciplines of care (such as cardiology and physiotherapy) could have his appointments coordinated at a time best suited to the best treatment outcome. His records and history would also be accessible to all doctors caring for him to prevent overtreatment. All the facilities he needs can be in the same location or close to home now his information and treatment notes are now accessible online by the care provider.

The Singaporean government has been pro-active in developing healthcare in the country

Since the introduction of the 3Ms policy (Medicare, Medishield, and Medifund) the government has taken on the role of co-payer in Singapore’s healthcare, stressing the importance of self-reliance and individual responsibility. However, the government has created a series of social safety nets to help lower or middle-income groups mitigate the financial impact of falling ill.

A review of the Eldershield scheme aims to provide greater protection for every Singaporean against massive bills in the event of severe disability and provides coverage for an extended time period. The Ministry of Health has also been actively seeking feedback and engaging the population for suggestions and comments on the scheme.

Combating diabetes is one of the chief targets for Singapore’s government

One of the main chronic diseases targeted is diabetes. Diabetes is highly preventable yet it is highly prevalent. Among developed countries, Singapore has the second highest proportion of diabetics and one out of eight adults aged between 20 and 79 has some form of the disease. As a contributing factor to many other diseases such as strokes and hypertension, it costs SGD 1 billion (US$ 696 million) annually, with that figure projected to rise to SGD 2.5 billion ($US 1.74 billion) by 2050 if nothing is done.

During parliamentary budget debates in April 2016, Health Minister Gan Kim Yong declared a “war on diabetes” and now aims to step up efforts to prevent diabetes through health promotion programmes and education.

In Singapore, problems are being anticipated but are they doing enough for their ageing population?

Comparing the two systems is difficult as they are fundamentally different. Singapore’s policy, which has always emphasised self-reliance and individual responsibility, has resulted in high insurance coverage rates. This makes the system highly cost-efficient, reduces the demand on public health and gives Singaporeans more healthcare options although it does mean there are sectors of the population that are left out because they cannot afford the premiums – even with subsidies.

The Singaporean government would do well to prepare for the challenges of rising healthcare costs, but everything it has done so far seems to be anticipating the problem. There is still much that can be done to improve the situation by, for example, expanding the list of subsidized drugs and funding home-care services provided by hospitals.

A development that seems to have been overlooked is the increased demand for home care due to the ageing population. Currently, home-care services are mainly covered by the private sector and NGOs with limited subsidies. Home-care services remain expensive and out of the reach of most Singaporeans, so the government should consider expanding Medisave to cover home care and increase subsidies to patients who need it. In turn, this can reduce the systematic cost of managing more hospital beds and deliver more responsive care.

Malaysia’s healthcare system can be compared to a struggling caretaker

Meanwhile in Malaysia, the healthcare system is seen as a caretaker, providing ‘public good’ to the population. However, this has led to overconsumption of the service, resulting in deteriorating standards of care and long waiting times in public hospitals.

The idea of healthcare being all but free means there is little chance of privatising healthcare in Malaysia. And even though privatisation of healthcare would greatly help, the government has to stress individual responsibility to its people to prevent overconsumption, abuse of the system and a mindset that health is their personal asset. Resistance to privatisation over the years has made it difficult for health officials to make any fundamental changes to the system.

Changes to both healthcare systems will require a holistic approach

To achieve any major healthcare progress, the Malaysian government is charged with the task of first changing the way its people think about health. A possible path is for the government to deregulate laws to make it easier to open a clinic or private hospital. This will help create competition in the private health sector and bring private healthcare prices down. In the long-term, it will provide Malaysians with an affordable alternative to public hospitals and clinics.

Both countries have their own unique problems which will require unique solutions. However, when it comes to healthcare, their leaders should adopt a more holistic approach and create solutions that are far-reaching and forward-looking. Instead of focusing only on achieving short-term goals, it is time for them to anticipate possible changes in the future and create policies that are sustainable.