Death is a process, not an instantaneous event for many. Indeed for some it can be a long goodbye for friends and loved ones. How do we fare as a nation, caring for the dying?
The way a nation cares for its weakest and most vulnerable is the mark of its soul. How it cares for the dying is a measure of the society’s advancement and enlightenment.
~ Lee Poh Wah, CEO, Lien Foundation

Sian sent in this link to Life Before Death which can be played via a Flash compatible browser. This is a summary of the The Quality of Death report from the Economist Intelligence Unit commissioned by the Lien Foundation, a Singaporean philanthropic organisation. Ranking end-of-life care across the world, the report shows that the UK leads the world in quality of death, in view of its excellent hospice care network and statutory involvement in end-of-life care. Malaysia stands at 33/40 in overall ranking in the Quality of Death Index, which contains four categories: Basic End-of-Life Healthcare Environment; Availability of End-of-Life Care; Cost of End-of-Life Care; and Quality of End-of-Life Care. So it seems we have a long long way to go when it comes to caring for our dying. We have a Hospis “Malaysia” which is so resource strapped it can’t even serve all of the Klang Valley, let alone Malaysia. I suppose we are too busy fighting over sand and water, who pays who in corruption scandals, to worry about the soul of the nation?

Shan has emailed to let us know that Malaysia’s TeleHealth initiative is very much alive. They have a website which explains about the TeleConsultation project. In principle, technology such as this, can help reach out to under-served areas for example rural-based doctors can consult specialists in bigger cities. In practice though there are enormous hurdles in implementing projects such as this, not only considering the infrastructure but also availability of human resources who are capable of carrying this out.
In our doctors’ forums, GPs quipped they are already carrying out TeleConsultation – using the good old telephone! I for one would be glad for simple things like people checking and replying their emails promptly, let alone real-time video conferencing and teleconsultation. When it comes to broadband, I think we have a long way to go, and perhaps we are even lagging behind our Asian neighbours. I remain somewhat skeptical how well Teleconsultation will perform given these constraints but I sincerely wish the project success, lest it turns out to be another waste of taxpayers’ money like the previous TeleMedicine debacle.

According to the Star, the Health Minister was quoted as saying Suspected dengue patients shouldn’t be sent home

Health Minister Datuk Seri Liow Tiong Lai, expressing concern over the management of dengue cases in hospitals, said he had received complaints that some suspected dengue patients were sent home while waiting for the test results, instead of being placed under observation.
“I see a number of cases where the dengue patient died in the hospital just after one, two or three days of being warded. I want them (doctors) to look into the cases of death, how to minimise death.

I hope the Minister checked with his medical advisors since he is not a medically trained doctor. Dengue patients have varying degrees of severity as far as the illness is concerned. Patients with milder forms of dengue and who are not so ill need not be admitted. Indeed if doctors were to follow the Health Minister’s advice and admit every “suspected dengue patient” then I can tell you his MOH hospital wards will be overflowing with unnecessary admissions. The MOH already has guidelines for Outpatient monitoring of dengue as well as Criteria for Admission (you can read these in the 2nd Edition of the Guidelines in PDF format) and I am sure the Minister is not suggesting we ignore the guidelines to follow his advice.
No one wants to see anyone die from dengue. In an endemic, there will be some very severe cases and despite all that can be medically done, there still will be some deaths. Perhaps the Minister should look into why public health measures are still sorely lacking that the breeding grounds for Aedes are still rampant in our urban areas. That is where the solution lies, not indiscriminate admission of all suspected dengue patients.

Related MMR posts

The NST has this article which claims Healthcare will be “for FREE”

To ensure all Malaysians get adequate healthcare, wage earners will have to make scheduled monthly contributions to the proposed National Health Financing Scheme. The self-employed, those who have an independent income as well as employers would also have to contribute, Health Minister Datuk Seri Liow Tiong Lai told the New Sunday Times.
The government proposes to set up a health financing scheme that will give all Malaysians access to primary healthcare at any public or private clinic for free.
The scheme will also look at secondary healthcare coverage and the illnesses and treatments it might be able to cover, said Health Minister Datuk Seri Liow Tiong Lai.
Although much of the scheme has yet to be finalised, the rate of contributions
is expected to be based on wage scales, in which the rich will pay more. The poor will not have to contribute to the scheme but will still be covered.
“It works on the principle of the rich helping the poor, the able helping
the disabled, the young helping the old, and the healthy helping the unhealthy. All kinds of illnesses will be covered under this scheme so that everyone will have access to good adequate healthcare,” Liow said.
The funds will be administered by the proposed National Health Financing Authority, a statutory body under the ministry. New legislation may have to be passed and existing ones amended to make way for this scheme.
Regardless of how much one contributed, everyone would enjoy the same standard of care, said Liow.
Only workers aged 18 and above with an income that has reached a certain threshold, need to contribute.
Children will be financed by their parents. The poor and disabled who have no income or whose income does not reach the threshold need not contribute.
For those who wish to stay in a suite rather than a standard room, they will have to pay the difference.

So while the headlines tries to put a positive “spin” on things, in reality consumers will be “forced” to contribute to the National Healthcare Financing Scheme, something we have blogged about for a long time, but has not materialised. It seems it will not happen just yet, but in stages and the whole process could take “about 10 years or more” according to the Health Minister. He is upbeat about it and believes the whole thing can be done in “four phases”

The first phase is strengthening the healthcare system like governance and standards of care; the second is to grant more autonomy to primary healthcare providers in areas like human resource and management; the third is to integrate all public and private clinics so that they are all linked under a common network so that people can access either one; and the fourth phase will be the introduction of the national health insurance under the national health
financing scheme.

The integration of public and private clinics may begin sooner than you think and GPs may now be faced with a financing system based on Capitation whereby they are paid not as “fee for service” but according to a fixed number of patients allocated to them, irrespective of how many visits patients make to their GPs (which in turn has its upsides and downsides if you read the Wikipedia link). From the discussion in the MMR doctors forums, there is some concern that this may spell the end of 24 hour clinics and that instead of “walk-in” visits to your GPs, capitation based patients might be seen only by appointments. Solo GP practices are less likely to survive under a Capitation scheme and ultimately the winner will be large group practices.
Not everyone is enthusiastic about the proposed Healthcare scheme and some say it is “frightening” and prefer the status quo.

“What frightens us is that nothing is ready, nobody knows about the scheme,” said Selangor state executive councillor Dr Xavier Jayakumar today.
Under the country’s current health care system, Malaysians can seek medical treatment at a public hospital with just RM 2 for registration.
Consultations and medications are provided for free.
Under the new scheme, Xavier said that an uninsured person would have to pay consultation fees and for medications at market rate.
Pointing out that 70 per cent of the population had household incomes of less than RM 3,000, he said most would not be able to afford medical treatment.
“You have to have a very clear scheme on how the poor, the unemployed, the lower income population is going to benefit from the new scheme,” he said.

There is an Internet acronym – TANSTAAFL – which stands for There Ain’t No Such Thing As A Free Lunch. In healthcare nothing could be further from the truth. Healthcare is not free. It is expensive business and at the end of the day someone has to foot the bill. What the Government is trying to do is to shift the payment responsibility directly on the consumer rather than indirectly via public funding which is paid for mainly by taxes and other Government revenue. We are at a cross-roads as far as healthcare financing goes. Whatever the outcome I hope a sensible balance is reached and the poor are not burdened.

In the Nutgraph today : Private healthcare: Too expensive?

Universiti Malaya political economist Associate Professor Dr Terence Gomez says declining standards in government sectors have led the middle class to look for ways to bypass the public system.
“The promotion of medical insurance has led to private healthcare being more affordable for the middle class,” he tells The Nut Graph in a phone interview. Rising private healthcare costs, however, have led to higher insurance premiums, coupled with lower coverage.
Gomez says escalating private healthcare costs is therefore a political issue as well as an economic one. “The government faces a potential backlash from the middle class who don’t want to pay huge insurance premiums and yet are not willing to return to the public health system,” he says.
“This is an issue of concern for the [Barisan Nasional] government, which is already facing declining middle-class support.”

It is interesting that there is little talk of capping hospital charges which are distinct from doctors’ professional fees. Will capping charges (as opposed to leaving it to market forces) in any case be counter-productive for all concerned? I doubt it will ever happen if you read between the lines.

To complicate matters further, Dr Quek says the government, in fact, owns some of the large corporations that have entered the private healthcare business. “Khazanah Nasional owns 60% of the Pantai-Gleneagles group, while KPJ is wholly owned by the Johor state government. Since they’ve entered the market, they’ve been aggressively pushing profit margins higher and higher,” he says.

It will be a never ending problem until there is a comprehensive National healthcare financing system, perhaps something like the Australian Medicare system. This will take a lot of effort and political will power. People’s health and indeed lives are at stake the longer politicians dilly dally on this extremely important matter.

I spotted this sad tale A Tragic Incident at Standard Chartered KL Marathon 2010 (via Retna Vijayan)
In this incident, a young runner collapsed during the marathon. While CPR was instituted by fellow marathon runners, and eventually (after 15-20 minutes) a St. John’s Ambulance arrived, this was the situation:

…after we performed CPR procedures on Lim for the the third time, finally a St. John ambulance came after around 15 – 20 minutes after Lim collapsed…
…we let the EMS officers to take over the CPR and First Aid… Dr. Visva asked whether do they have the AED(Automated External Defibrillator)… one of the person from the EMS said that they do not have it.. then I asked whether do they have a face mask with pump.. they also did not have it there… THEY PRACTICALLY HAVE NOTHING IN THE AMBULANCE!!!!!!!! -.-”

This is a doubly tragic tale.
1) Did the marathon organisers think of providing standby EMS?
2) It’s now the 21st century and why are our ambulances still so poorly equipped (possibly only with an Ambu bag and Oxygen if you are lucky)?
- No defibrillators or AED?
- No equipment for intubation?
- No equipment for IV fluids and IV administration of emergency/resuscitation drugs?
- and most importantly no EMTs trained to do all of the above safely?
This, IMO, should be high on the priority of Emergency medical care. This is where the focus should be – Emergency services at the point of care where it is needed first (not GP clinics as the PHFSA would have you believe).
The story had a sad ending as the young (20+ year old) marathon runner died.
Kudos to the runners who tried to help but I am sorry that Malaysian EMS scored a big FAIL.

An interesting article in Aliran which caught my eye and the example of one of the problems faced by even civil servants who are supposed to have healthcare provided by the Government

Puan Rozita then gave a first-hand witness account of how she lost her husband, Encik Ahmad Nazri Ibrahim, as a result of the privatisation of the Prosthesis Procurement Services of the public hospitals and the bureaucratic procedures involved.

Her husband Encik Ahmad Nazri Ibrahim, 48, suffered from shortness of breath one day and was rushed to a public hospital, where he was informed that he needed to have three stents inserted in his heart vessels to relieve the blockages. The cost: RM19,000, to be paid in cash or by a bank draft.
The family did not have ready cash but had funds in the EPF. The EPF, however, refused to issue a letter of guarantee, citing the reason that this was not the usual procedure. The family then appealed to the DAP to solicit for donations from the public.
However, the funds came in too late as during the waiting period her husband suffered a massive heart attack, lapsed into a coma and succumbed to heart failure.
This is a tragic example of how the pay-first policy as a result of the privatisation of the prosthesis procurement department of the public hospital led to a delay in the treatment of a patient, resulting in his untimely death.

There is something to be said for socialist medicine but at the same time purely socialist healthcare systems are not without problems. Whatever the case, ultimately there is the price to pay as demand of increasingly sophisticated and expensive medical care in this country increases. Society has to decide how the bill is to be paid. It is easy enough to say “the Government” but ultimately it is the public which will have to pay one way or another, in the form of increased taxes or the ever elusive National Healthcare Financing Scheme. The doctors who work in specialized areas like oncology, transplantation, interventional cardiology etc. will despair at how ultimately it boils down to money – and bucket loads of it – which will decide whether or not patients get the treatment they require.
Clearly our current system is not working as well as it should. It failed Encik Ahmad Nazri. How many more Ahmad Nazris have there been in the past (I can tell you his case is not unique) and will continue to be in the future? It’s depressing.

Whistle-blowing doctor should be protected: MMA

I reproduce the MMA press release :

Dr Selvaa Vathany & JHEOA
MMA Press Release 4 June 2010

The MMA views with grave concern that Dr Selvaa Vathany continues to be facing more personal inquiries/investigations, with the latest being a show-cause letter from the JHEOA.

We recognise the right of Dr Selvaa Vathany to act as a responsible and caring doctor. She has shown great personal conviction and concern about her role as a doctor to a group of often marginalised minority in our country, the Orang Asli.

That she should place herself in possible jeopardy with regards her position and work in the Ministry of Health is to say the least, humanitarian and selfless.

Her whistle-blowing regarding possible mismanagement and procedural opacities in the JHEOA hospital where she had previously been working, must be seen in the light of her noble intentions and empathy to help improve the plight and healthcare of the Orang Asli. This is particularly ironic because just in January this year, we have passed the Whistleblower Protection Act in Parliament.

As Dr Selvaa has rightfully obtained statutory declarations (SDs) to add weight to her convictions of possible wrongdoings of the many issues raised, this should not be used as a pretext to find fault with her noble actions.

Instead, this should spur the JHEOA and the MOH to fully investigate her complaints and quickly resolve whichever problems that have been long-ingrained in the system, which had caused such a systemic failure for the Orang Asli community (as fully documented by SUHAKAM previously).

By quickly resolving such possible problems, the various departments involved would be helping to dispel serious misgivings as to the inefficiency and possible corruption of the ground-level practices.

Such transparency would enhance the image of the government especially in this era of wanting to transform the economy and the country, as so strongly propounded by the Prime Minister, YAB Dato’ Sri Najib Razak. The MMA fully supports the GTP (government transformation plans) initiatives, which must be seen to be more of a paradigm shift in practice rather than mere sloganeering.

Therefore, the MMA is seriously concerned that Dr Selvaa has been possibly victimised and punished unfairly, by
1) being swiftly transferred off to another state by the MOH; and
2) the show-cause demand letter to explain her actions by the JHEOA;
just because she had taken the trouble and had staked her personal courage of conviction to pursue some causes which have raised concerns for some of the possibly errant authorities/officers.

Instead, we urge the Minister of Health and the government, to help resolve this issue quickly, by instituting a full inquiry and investigations into these allegations. We also urge the authorities not to use the general orders of civil service to possibly intimidate officers who mean well by their humanitarian and caring actions.

This is important because, such perceived actions would thwart potential whistle-blowers and well-wishers from doing the right and ethical thing when practising their medical professionalism vis-a-vis their charges, i.e. their patients.

Doctors are exhorted to be the patients’ most ardent advocate, and we continue to believe that Dr Selvaa Vathany has shown just such an example.

Dr David KL Quek
MMA President

See also the Sun2Surf

Quek said that both the show-cause letter and transfer order is a sign that Dr Selvaa has possibly been “victimised and punished unfairly” for her actions.
“Her whistle-blowing regarding possible mismanagement and procedural opacities in the JHEOA hospital must be seen in the light of her noble intentions and empathy to help improve the plight and healthcare of the orang asli,” he said.
Quek said that Selvaa’s allegations should spur JHEOA and Health Ministry to initiate a full investigation and find a solution for problems.
He said by resolving such problems, the various departments involved would dispel misgivings related to the inefficiency and possible corruption in the healthcare system.
“Such transparency would enhance the image of the government, especially in this era of wanting to transform the economy and the country,” he said.

What will happen now? Will everything be swept under the carpet and in the meantime the whistle-blower continues to be persecuted?

Once again the report in the papers on the issue of private hospital fees emerges and the DG was quoted to say Private hospital fees exorbitant; to be revised

The government will revise the fees charged by private sector hospitals and clinics, Health Director-general Tan Sri Dr Mohd Ismail Merican said.
“The exorbitant fees now charged by private hospitals has been brought to my attention many times and the current schedule drawn by the Malaysian Medical Association (MMA) was not as comprehensive as it should be.
“As such I have made it a point to call for a meeting soon with MMA to develop a comprehensive fee schedule that was acceptable to all,” he said in a special interview published in the latest issue of the MMA newsletter.
He reminded doctors that the main reason for them to choose the profession was not merely to make money and profits, although there was nothing wrong with it, but to help the sick.

I don’t know why the DG is again harping on private doctors fees. After all, it was the Government which came up with the PHFSA and in fact private doctors’ fees are now regulated by law according to the PHFSA, and doctors consultation fees and procedures are spelt out clearly in the PHFSA. So is the DG saying the law needs to be changed now?

The point the report fails to make is that there is an important distinction in your hospital bill – the hospital charges versus the doctors fees. The private hospital charges, contrary to the doctors fees, ARE NOT regulated by law. So in fact, there is nothing to stop a private hospital from charging RM10 for a toilet paper roll or sanitary napkin. The main thing which governs the charges are “market forces”. Private hospitals are not in the business to run charities and they are in the business to make profit, and this is understandable since the vast majority of private hospitals today are owned by businessmen, big corporate entities, SEDCs and the like.
So perhaps we should be asking the DG is should there instead be regulations on the hospital charges which form the bulk of the hospital bill anyway? Perhaps too the Government should be focusing efforts on implementing a proper national healthcare financing scheme instead of the hodge podge mess of health insurance schemes we have.

Related posts:
Hospital charges and fee splitting

Indeed it is not science fiction but fact as the Malaysian Medical Association sees a drastic change, as just a tiny fraction of members who attended the 50th AGM, succeeded in amending the Constitution and in doing so, have done away with postal votes which has been a long standing tradition in the MMA (a necessary point as many doctors practicing in all parts of the country often can’t participate in the AGM directly). David Quek says The wants of a few triumph over the needs of many

It was said in the last 2 AGM’s that only those that care for the association attend the AGM. The arrogance displayed by those in attendance was astounding and I was ashamed to have brought my friends in attendance to see grown man attack each other without regard for the professional image we strive to uphold daily. Our feelings and thoughts from 4 different states at least were brushed aside just because we were of a small number in the AGM…. and therein lies the fault of the association and the constitution we try so valiantly to follow.
A mere 2% of the membership wield the power to change the constitution at their whims and fancy. As shown in this AGM, all that is needed is the will to bring a few dozen members who are sympathetic to your fight and you can win any resolution put up. Perhaps we did not learn from last year where it was the timely intervention of the Opthalmo society which staved off the inevitable. There are many who attend the AGM year in and year out and perhaps by seeing the same faces yearly have become, if I may call it arrogant in their thoughts that they are the only stalwarts of the Association. Perhaps this year we lacked the calming force of Dr Roy McCoy, and the feel good feeling after Dr Abdul Hamid’s rousing speech last year. The lack of respect for the smaller members were evident and finger pointing the letter of the day.
I concur with Dr John, we have to make a stand. Even now I see, that perhaps having Dr Hooi as a dissenting voice on the council was not that bad an idea, rather than having another lackey to the group. I feel for Dr Mary and she will need us to be her staunchest supporter in the year or 2 to come. Next year, for sure one of the mentioned will stand to be elected, now its up to us to decide, are we going to stand by and let the handful control the association that I am sure many of us hold dear, or will we answer in force telling them that the earthquake this year will lead to a tsunami from the others next year.
We have to stand and put a stop to this trend of changing the constitution at the whim and fancy of a few. Perhaps moving with the times, we need to implement a more tech savvy mechanism for voting and dissemination of information. The archaic manner of snail mail should be reevaluated. I would suggest that we put forth a multibranch constitutional amendment to state that any constitutional change should be done by referendum. The argument that only 20% of members vote for any due cause, it is still more than the 2% attending the AGM. This fact was repeated many times to the group sponsoring the amendment but fell on deaf ears and I find this amusing to say the least, as even a child could tell you that 20% is much better than 2% of any group

You may ask why the poor attendance in the AGM? Don’t Malaysian doctors care about the MMA? One wonders if the MMA faces the spectre of becoming an irrelevant organisation for the Malaysian medical community. Membership is not compulsory. How many Malaysian doctors today are not MMA members? There may be a feeling amongst some that the MMA may not be standing up for the needs of doctors in various sectors e.g. GPs and those in private practice. How many prefer to joining for instance other Professional Societies/Associations like the Federation of Private Medical Practitioners’ Associations Malaysia (e.g. the active PMPASKL branch)?

Yesterday was World No Tobacco Day and the theme this year is to combat the rising prevalence of cigarette smoking amongst adolescents and women in particular. One way to dissuade cigarette smoking is to ban sales of small cigarette packs (and hence presumably youngsters who are more inclined to buy the cheaper smaller packs). This was supposed to be enforced on June 1, 2010 but for some strange reason, the Government has decided to defer the ban. I can’t fathom the reason for this flip-flop decision since even the Tobacco companies are caught unaware by the deferment of the ban and they seemed all set to comply with the new regulation. Firms like JTI in fact are calling on the authorities to rescind the delay decision since they have already made preparations to comply.
The ball is on the Government’s court. What on earth could have made them defer the ban at the last minute? I can’t see any good coming out of the delay.

Update 4/6/10: the ban is on again

The Health Ministry is working with the MMA to implement 1Care, a scheme whereby we should see “the government and private clinics working together to provide better healthcare for the people”. The Star reports:

Minister Datuk Seri Liow Tiong Lai said the scheme, once approved, would have an immediate impact on improving the country’s healthcare system while also addressing the scarce distribution of government clinics in Sabah and Sarawak.
At present, there are 800 government health clinics nationwide with 6,500 general practitioners.
“If we work together with the private clinics, we will be able to increase this number to more than 7,000 doctors nationwide,” Liow said at the MMA’s 50th annual general meeting on Friday night.
Liow said the ministry was in discussion with MMA to iron out details of the tie-up.

If it works out, I think a lot of good could come out of it. It all depends on how it will be implemented and the details aren’t known at this point in time. Let’s hope it succeeds. The problem about clinics, like doctors, in Malaysia is not so much a shortage but a mal-distribution. The main concentration of private clinics is in the urban areas. How this scheme will help those in the rural areas remains to be seen.
Bernama also carried the story and also a bit more on the problem about the mushrooming of medical schools in this country.

He also said that the government was studying the possibility of imposing a moratorium on the setting up of private medical colleges following concerns raised by the MMA of possible glut of doctors over the next few years.
“We agreed with the MMA to put a stop on this so that we can concentrate on producing quality doctors,” he said.
MMA president Dr David Quek, in his speech, pointed out that the number of doctors in the country would swell to between 45,000 and 50,000 by 2015 and 75,000 to 80,000 by 2020.
Quek said that as of May this year, there were 28 approved private institutions offering 37 medical courses and produced between 2,000 and 3,000 doctors annually, excluding the estimated 2,000 graduate doctors returning from abroad.

If there are genuine concerns about the quality of medical graduates, then I think the moratorium on new medical schools in this country should start immediately. As “poor doctor” in the shoutbox pointed out, already Housemen are not getting adequate training