The World Health Organization’s (WHO) member states recently adopted a watered down resolution on improving drug price transparency that leading medical charity Doctors Without Borders (also known by its French acronym MSF) criticised as insufficient.
An initial draft of the resolution first introduced by Italy at WHO’s main annual meeting on May 20-28, 2019, called for near absolute transparency in the pharmaceutical sector, including requirements that companies make all data from clinical trials publicly available.
The Italian text presented to the World Health Assembly also demanded full disclosure from pharmaceutical firms on net revenue, once research and development, tax breaks and other subsidies are factored in.
Several countries – notably those that host large pharmaceutical industries like the United States, United Kingdom, Germany and Switzerland – expressed reservations about the Italian draft.
The final version includes several modifications.
For example, an earlier draft called on governments to “require the dissemination of results and costs from human subject clinical trials regardless of outcome”.
But the approved text urged states to “take the necessary steps, as appropriate” to make data from clinical trials public “regardless of outcomes or whether the results will support an application for marketing approval, while ensuring patient confidentiality”.
The language was similarly softened with respect to the production costs incurred by drugmakers and patent notification.
Campaigners say some drugs are highly overpriced although they are often developed with public funding and that governments at times negotiate prices without any idea of how much the drugs cost.
MSF in a statement called the resolution “a welcome first step”, but said it did not go far enough.
“While earlier drafts of the resolution included clear language to bring more transparency to this opaque area, unfortunately a small group of countries … obstructed more concrete advances,” it added.
It singled out the UK, Germany, Japan and the US as countries that “chose to place the interests of a handful of corporations above the interests of people”.
“We need to know the mark-ups corporations charge, production costs, the cost of clinical trials, how much investment is really covered by companies, and how much is underwritten by taxpayers and non-profit groups,” MSF said.
The only way to guarantee fair drug pricing is to have fair negotiations, which “are impossible without transparency”, it added.
WHO has for years supported calls for drug pricing transparency, arguing that a more open, balanced market would improve access to life-saving drugs, notably in lower income countries. – AFP Relaxnews
If you were to compare Malaysia’s healthcare scorecard with that of other countries’, how do you think we’d do? I got answers to that question when I came across a World Health Organisation (WHO) report, World Health Statistics 2017. It lists data on key health-related development goals for all countries.
On many issues, we’re not doing too badly. But one figure caught me by surprise: the amount of money that Malaysia spends on healthcare, as a percentage of total government expenditure. It is a mere 6%.
When I compared that with what our neighbours were spending, I was even more surprised. Thailand allocates more than double the amount, at 13%, and Singapore and Vietnam even more, at 14%. Even many low-income countries, from Afghanistan to Zambia, earmark relatively more funds to healthcare than we do!
Globally, most countries apportion about twice as much as we do to healthcare. This is shocking.
This issue has in fact been raised by politicians and healthcare leaders. Last year, Klang MP Charles Santiago filed an (unsuccessful) parliamentary motion to reallocate RM20bil to the Health Ministry from the Prime Minister’s Department and the Defence Ministry.
He said lower government subsidies in the last few years has resulted in costs being passed onto patients. And more private sector patients are now migrating to public hospitals due to higher medical costs, he added.
The trauma centre at Tan Tock Seng Hospital, the busiest emergency department in Singapore. The island state allocates 14% of total government expenditure on healthcare while Malaysia spends a mere 6%. Photo: SPH
He also questioned why defence spending was being raised. “To my knowledge, we are not going to war anytime soon,” he said. “But we are certainly witnessing the predicament of thousands of people struggling with the prices of medicines and the staggering hidden costs of treatment.”
Malaysian Medical Association President Dr Ravi Naidu described current government healthcare expenditure as “too little”. “Almost 50% of spending is from private insurance and out-of-pocket payments,” he pointed out.
(“Out-of-pocket payments” are direct costs made by the patient to healthcare providers – as opposed to, say, insurance coverage – that can make healthcare very inequitable, as the high costs may deter people from seeking care, or exhaust their savings, pushing them into poverty and debt.)
“At the same time,” he added, “non-communicable diseases and obesity are spiralling upwards.” The increase of these diseases has been dramatic in the last decade or so; diabetes, for example, has jumped more than 50% among adults.
“The government needs to work with the profession to come up with a workable solution,” he said.
Prof Datuk Dr Adeeba Kamarulzaman, dean of Universiti Malaya’s School of Medicine, also concurred that current healthcare spending is not enough to prepare us for the challenges of non-communicable diseases and an ageing population; additionally, it cannot overcome the chronic shortage of healthcare workers in the public sector.
“We have not even begun to build the allied health sector – specialist nurses, physios, occupational therapists, medical social workers – all of whom are crucial in dealing with the expansion of chronic diseases and the ageing population,” she said.
“How are we going to be able to access newer, better drugs and technology on that budget when it is not enough to cover basic healthcare?”
She also questioned how the country would achieve universal health coverage. “How is that budget going to cater for those in rural areas?”
Universal health coverage is a global development goal to provide health services to all people, without causing them to suffer financial hardship. Every year, 100 million people are pushed into extreme poverty due to those “out-of-pocket” payments for healthcare.
Malaysia’s healthcare system does provide wide coverage, but there are signs that not everyone is served equitably, particularly the poor and rural folk. One sign is stunting among children – a key survey in 2016 found this affects one in five toddlers.
Another sign is the death of women in childbirth and pregnancy. Let me tell you: in rich countries, women rarely die giving birth. But in poor settings, it can be a fact of life – a fact that reflects inequities.
For decades, Malaysia made excellent progress on maternal mortality, but in recent years, the numbers have stagnated. Countries like Thailand and Sri Lanka have now overtaken us, according to WHO’s report. In Johor, Sabah and Sarawak, maternal mortality actually increased at one point in the previous decade.
This all shows the work the needs to be done in providing basic, essential services to all citizens in all states.
Healthcare has been a national priority and our healthcare system was long considered a model. The rise of the Asian “tiger” nations has even been partly ascribed to investments made in healthcare and education.
The challenges ahead are enormous, including mammoth chronic diseases that are cripplingly costly to treat, but these can be prevented or lessened, with early action. If there was ever a time to invest more in healthcare, this is it. After all, this is an investment in our own people.
Mangai Balasegaram writes mostly on health, but also delves into anything on being human in the fortnightly Human Writes column. She has worked with international public health bodies and has a Masters in public health. Write to her at firstname.lastname@example.org.
The demand for healthcare is rising and continues unabated, with opportunities for improvement and innovation in diagnoses and treatment.
However, economic uncertainties and budgetary constraints continue to put significant financial pressures on the provision of healthcare services.
The net impact of these contradictory pressures is uncertain.
What will Malaysian healthcare be like in 2018?
Impact on patients
The Federal Court reaffirmed in Kok Choong Seng & Sunway Medical Centre v Soo Cheng Lin in 2017 that the legal standard for the provision of information to patients is the Rogers v Whitaker principle, i.e. doctors have a duty of care to disclose material risks.
A risk is material, if “in the circumstances of the particular case, a reasonable person in the patient’s position, if warned of the risk, would be likely to attach significance to it, or if the medical practitioner is, or should reasonably be aware that the particular patient, if warned of the risk, would be likely to attach significance to it”.
Although this patient-centred standard has been around since 2006, many healthcare providers still do not understand their legal duties, with some of them having been held liable by the courts for their failure to inform.
Patients’ voices will become louder in 2018 as they are increasingly more informed, particularly from the electronic media – although the quality of health information on the internet is variable.
The Malaysian Health Data Warehouse (MyHDW) was launched in April 2017 with the objective of using Big Data for analysis and decision-making, with the potential for reducing cost, reducing waste and optimising the use of limited resources.
The collection of personally-identifiable data is unavoidable. Questions about data security, its de-identification when released to users, and oversight of MyHDW have not been clarified.
With the reported leaks of the personal data of mobile phone subscribers, organ donors and members of medical organisations, patients need assurance that their health information is always kept confidential.
Interestingly, the Personal Data Protection Act does not apply to the public sector.
Public trust in allopathic healthcare delivery systems continue to wane.
Many people willingly entrust their healthcare to the non-health sectors with technology providing them the tools to do so, e.g. refusal to vaccinate, home deliveries by unregistered personnel and purchase of unlicensed medicines unavailable locally through the internet.
The public will increasingly demand to be treated as human beings with better patient experiences enhanced by providers, and not as entries in medical records.
The demand for patient safety and quality of care will continue to pressure regulators and payers to ensure that the healthcare services provided are safe and of high quality.
Increasing healthcare expenditure
Healthcare expenditure will continue to rise because of the ageing population, the double whammy of non-communicable and infectious diseases, new technologies and increasing patient demands.
The need for long-term care and non-communicable disease management will increase for the senior population and an increasing number of young adults.
This is inevitable as large segments of the population are unhealthy with diabetes, hypertension, overweight and obese.
Concomitantly, infectious diseases, especially dengue, will continue to plague the public.
Despite vector control measures, dengue and malaria prevail with no cure for the former and increasing drug resistance in the latter.
Some previously-eradicated diseases like rabies are also making a comeback.
There will be increasing out-of-pocket expenditure in the private sector, and even in the public sector, particularly with increasingly expensive medications and procedures.
An increasing number of people will face financial ruin if they or their relatives get catastrophic diseases like cancer and heart attack.
Medical inflation will continue to exceed the increase in GDP (gross domestic product).
Healthcare expenditure will continue to rise because of the ageing population, as seen in this filepic, the double whammy of non-communicable and infectious diseases, new technologies and increasing patient demands.
Cost containment in private hospitals has not succeeded.
The Private Healthcare Facilities and Services Act regulates doctors’ professional fees, which comprise not more than 20%-30% of the private hospital bill, but hospital charges continue unregulated.
A RM100,000 private hospital bill, which was uncommon at the beginning of this decade, is now common.
Concomitantly, charges in private clinics, and even in private hospitals, are increasingly being capped by managed care companies and third-party administrators.
More general practitioner clinics will close, primarily because of financial unsustainability, and rarely because of retirement.
When middlemen take a share of the healthcare ringgit, compromises are inevitable, with consequent impacts on safety and quality of care.
Studies about a national health financing scheme have been on-going since the 1980s. Although voluntary health insurance was announced in October 2017, details are yet to be disclosed.
Private practice for public sector specialists may or may not stem the outflow to the private sector, as the outflow is often due to service conditions and not just financial compensations.
Would the care of public sector patients be affected by such private practice?
Only time will tell.
There are too many medical schools, too many graduates, and too few house and medical officer posts.
Over-production of the medical workforce continues although the public is wiser, with decreasing applications to private medical schools, which will lead to mergers, acquisitions and closures of some.
The crunch will come in 2021 when the four-year contracts of the initial cohort of junior doctors in the Health Ministry will end.
Some will continue to be employed, but the rest will have to find their way in the saturated private sector or seek alternative employment.
Delays in the appointment of housemen after graduation from medical schools has led to some of our best and brightest doing their housemanship training in regional countries that provide certainty of appointments.
Training doctors at taxpayers’ expense for other countries is, to say the least, illogical.
Healthcare has lagged behind others like telecommunications, transportation, retail etc, in utilising new technologies like artificial intelligence and virtual reality.
The smartphone, portable or at-home diagnostics, smart drug delivery mechanisms, digital therapeutics, genome sequencing, machine learning, blockchains (decentralised databases) and the connected community will begin to impact on multiple aspects of healthcare delivery, e.g. operations, workforce management, business models, patients’ confidentiality and security.
Staying healthy is critical to avoid receiving healthcare.
A healthy diet, maintaining an appropriate weight, regular exercise, sufficient rest, safe sexual practices, avoiding smoking, moderate alcohol consumption and keeping vaccinations current are some of the measures to stay healthy.
This requires some work, smart lifestyle choices and the occasional medical check-up.
Wishing all readers good health in the Year of the Dog!
Dr Milton Lum is a past president of the Federation of Private Medical Associations and the Malaysian Medical Association. The views expressed do not represent that of any organisation the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.