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Title: Globalisation and Healthcare in Malaysia Dr David KL Quek


1
Globalisation and Healthcare in Malaysia
  • Dr David KL Quek, KMN
  • MBBS (Mal), MRCP (UK), FRCP (London), FAMM
    (Malaysia), FASCC (ASEAN), FAPSC (Asia-Pacific),
    FCCP (USA), FACC (USA)
  • MMA Selangor Symposium
  • FUTURE CHALLENGES FOR HEALTHCARE FOR MALAYSIA,
    Sunway Resort Hotel Spa
  • Jan 18, 2009

2
Globalisation UNDP 1997
  • Descriptive concept used to describe the global
    proliferation of cross-border flows of trade,
    finance, information also refers to the
    emergence of a single, increasingly integrated
    global economy.
  • As prescription, usually calls for liberalization
    or deregulation of national markets in the belief
    that the unrestricted or free flow of trade,
    investments, and profits across national
    boundaries will facilitate global integration and
    produce the best economic, social, and political
    outcomes for humanity.
  • Outcomes or effects of globalization usually
    equated with economic growth, increased personal
    incomes, improved living conditions and liberal
    democracy.
  • Globalization in these terms often prescribed
    with air of inevitability, moral superiority,
    overwhelming conviction (UNDP 1997).

UNITED NATIONS DEVELOPMENT PROGRAM (UNDP) 1997
GlobalizationPoor Nations, Poor People. Pp.
82-93 in Human Development Report 1997. New
York Oxford University Press.
3
Free Market Capitalism
  • Key concepts free market and free trade,
  • Advocates of this ideology use these concepts
    like a mantra.
  • Since 1989, belief in the triumph of capitalism
    over communism and the end to the Cold War are
    due to the victory of the market over the state
    (Korten 199937).
  • Belief that the more you let market forces rule
    and the more you open your economy to free trade
    and competition, the more efficient and
    flourishing your economy will be (Friedman
    1999).
  • In this ideology, globalization spread of free
    market capitalism to virtually every corner of
    the world.
  • Proponents believe they have discovered the
    universal formula for economic prosperity.

4
The Rise of Free Market Capitalism The Demise
of Socialism
  • Globalism 1st introduced since 1970s
  • Free market capitalism expanded during the Reagan
    and Thatcher years, into the 1980s
  • Culminated with the fall of the Berlin Wall and
    the crumbling of the Soviet Union from 1989
  • Usually touted as Capitalisms triumph over
    Communism/Socialism

5
  • TURBO-CAPITALISM
  • Luttwak (1999) this capitalist formula is good
    for every country, rich or poor.
  • Formula PRIVATIZATION DEREGULATION
    GLOBALIZATION TURBO-CAPITALISM PROSPERITY.
  • In applying this ideology, the IMF, the World
    Bank, the regional development banks, and the
    international development agencies of the major
    donor countries (led by the United States) have
    insisted that the governments receiving their
    loans, credits, and development assistance adopt
    a series of so-called structural adjustments and
    economic reforms.

LUTTWAK, EDWARD 1999 Turbo-Capitalism Winners
and Losers in the Global Economy. New York
Harper-Collins
6
Globalisation
Globalisation a definition The intensification
of global flows of capital, goods, ideas and
people across borders and the institutions and
rules established to regulate these flows.
7
Globalism and Unfettered Trade
  • Globalism taken as the ultimate and inevitable
    pathway for economic theoryFree Trade supervenes
    every other consideration
  • Borderless world (Keynes Without passport or
    other formality), no barriers to investment,
    money flows, services, goods
  • National barriers such as regulations and
    cultural sensitivities, some deemed
    protectionist are downgraded or removed
    entirely
  • Crucifixion economics advocated, no pain, no
    gain top-down approach with capital reining
    supreme, corporations given widest berth to
    flourish with least restrictions, hardly any
    oversight let the moral right of the consumer
    take flight
  • Is it an experiment doomed to cyclical failure?

8
The power to become habituated to his
surroundings is a marked characteristic of
mankind. Very few of us realise with conviction
the intensely unusual, unstable, complicated,
unreliable, temporary nature of the economic
organisation by which western Europe has lived
for the last century. We assume some of the
most peculiar and temporary of our late
advantages as natural, permanent and to be
depended on, and we lay our plans accordingly.
John Maynard Keynes, 1919
9
The Promise of Globalisation
  • Power of nationstate waning, maybe even dying
  • In future power lies with global markets
  • Economics, not politics or armies, will shape
    global markets
  • Global markets, freed from narrow nationals
    interests/ regulations, will establish
    international economic balances
  • Eternal boom-and-bust cycles will be outgrown
  • Markets unleash trade waves, tides of growth
  • Rising tide of growth will raise all prosperity
    for all, converting dictatorships into
    democracies
  • But new democracies will have no absolute
    powersirresponsible nationalism, racism,
    political violence will shrivel away

10
The Promise of Globalisation
  • New market sizes, larger corporationsraise
    beyond bankruptcy risks, hence market stability
  • Transnationals will be market leaders of
    civilisationlike virtual states, their
    aggressive dominance will make them impervious to
    local political prejudices
  • Thus conditions for healthy governance, emergence
    of debt-free governments
  • Stable public accounting in turn will stabilise
    societies
  • Theory freed from wilful men, following
    individual self-interests will lead to life of
    prosperity, general happiness
  • Cycles of history will be broken history will be
    dead!
  • But are all these true and inevitable?
  • Can individual self-interest lead to prosperity
    and general happiness for all, or only for some?
  • If so, what has history taught us so far?
  • Can Man be trusted to be ethical and follow a
    moral path, or will the path of greed for
    unquenchable money/wealth and overpowering
    self-interests, supersede all other concerns?

11
Recent Banking and Financial Crises put paid that
globalism unfettered free-market capitalism is
anything but benign and self-regulatory
12
Money, gentlemen, money! The virus That infects
mankind with every sickness We have a name for no
greater scourge Than that! Sophocles
UNITED NATIONS DEVELOPMENT PROGRAM (UNDP) 1997
GlobalizationPoor Nations, Poor People. Pp.
82-93 in Human Development Report 1997. New York
Oxford University Press. 1999 Human Development
Report 1999 Globalization with a Human Face. New
York Oxford University Press. Retrieved March 9,
2003 (http//hdr.undp.org/reports/global/1999/en/d
efault.cfm).
13
Health Globalisation
  • Global risks for health
  • Exclusion from global markets, e.g. North Korea,
    Zimbabwe, Cuba (converse results)
  • Private ownership of knowledge TRIPS, drug
    patent laws, HIV drugs,
  • Migration of health professionals mainly to
    wealthier nations, OECD, Australiasia, e.g. in
    one town in Canada, 2/3 doctors migrant from one
    small area of South Africa
  • Cross border transmission of disease SARS, bird
    flu, NIPAH, MDR-TB
  • Environmental degradation rise in dengue, Nipah,
    SARS, West Nile disease, Chikungunya floods,
    tsunami, forest fires, tropical storms
  • Conflict War, refugees, famine e.g. cholera

14
Health Globalisation
  • Health in globalising world
  • Domestic action alone insufficient
  • Health achievements critical to international
    development goals

15
Health Globalisation
  • Global opportunities for health
  • Inclusion/ connection
  • New market incentives for RD
  • New resources for effective interventions
  • Knowledge dissemination
  • New rules to control cross border risks

16
Public health Globalisation
  • WHOs response
  • Strategic directions
  • Priority for diseases of the poor, tobacco
    control/elimination
  • Support for national health systems
  • New Partnerships and relationships
  • Resources
  • Rules
  • Optimism.

17
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18
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19
Health Globalisation
  • Globalisation, trade and healthA policy,
    research and training programme
  • Develop knowledge and skills
  • Promote policy coherence
  • Contribute to global public goods for health,
    global health funds,
    international rules for health

20
Globalisation and health
Openness
Cross border
flows technology
National Policies
Regional/global rules
and institutions
Level and
Education
Health
Health
distribution
Water
risks
systems
of
Energy
household
Transport
Other sectors
income
GCP/HSD June 2000
Health
Outcomes
21
Health Globalisation
  • WTO (1995) Agreements and health
  • GATT
  • Technical barriers to trade
  • Intellectual property and trade TRIPS
  • Services GATS
  • AFTA ASEAN Free Trade Zone 2013

22
Health Globalisation
  • Globalisation and health
  • policy measures
  • Equitable and sustainable growth
  • Openness gradual, sequenced and paced
  • Produce global public goods, control the
    bad/illegal/unexpected
  • Increase transfer of financial and technical
    resources
  • Strong national health policies, institutions,
    regulations and programmes
  • Engage across sectors and borders

23
Structural Reforms Adjustments for Globalisation
  • These adjustments and reforms
  • make the private sector the primary engine of
    these countries development efforts,
  • give priority to servicing their foreign debts,
  • deregulate their commercial and financial
    markets,
  • reduce the size of their government budgets and
    bureaucracies,
  • eliminate all barriers to foreign investments and
    imports,
  • sell off their state enterprises and public
    utilities to private corporations, e.g. attempts
    to sell off IJN to Sime Darby
  • privatize as many of their public services as
    possible, and
  • terminate all government subsidies and most
    welfare programs (Balasubramaniam2000).

BALASUBRAMANIAM, K. 2000 Globalization and
Liberalization of Healthcare Services WTO and
the General Agreement on Trade in Services.
Paper prepared for The Peoples Health Assembly,
December 4-8, Savar, Bangladesh. Retrieved
December 9, 2002 (http//phmovement.org/pubs/issue
papers/bala2.html).
24
STIGLITZ, JOSEPH2002 Globalization and its
Discontents. New York W.W. Norton.
  • Joseph Stiglitz (2002), (2001 Nobel Prize in
    Economics and former Chief Economist and Senior
    Vice President of the World Bank) in his recent
    book on globalization, provides a harsh
    indictment on the disastrous effects on the
    structural adjustment programs and neoliberal
    development strategies of the IMF, the World
    Bank, and the WTO.
  • Stiglitz claims that what he learned while he was
    at the World Bank radically changed his views
    of both globalization and development, because
    he saw firsthand the devastating effect that
    globalization can have on developing countries
    and especially the poor within these countries
  • The neoliberal policies that the IMF and the
    other international financial and trade agencies
    have imposed on these countries have been an
    almost certain recipe for job destruction and
    unemployment creation at the expense of the
    poor, and they have contributed to the
    instability of their economies

25
HILARY, JOHN2001 The World Banks Private
Sector Review Does the Private Sector
DevelopmentStrategy Threaten Childrens Right to
Health? Save the ChildrenPosition Paper.
Retrieved on March 15, 2003(http//www.challengeg
lobalization.org/html/tools/WB_private_sector.pdf)
.
  • The introduction of cost recovery programs in the
    health sector is now widely accepted to have been
    disastrous, forcing many families and their
    children into a medical poverty trap
    characterized by untreated illness and long term
    impoverishment.
  • Even the World Bank, while it continues to
    support user fees for health in national Poverty
    Reduction Strategy Papers, has acknowledged that
    they are responsible for denying poor families
    access to health care. (Hilary 2001)

26
Negative Consequences of Globalisation Hilary,
2001
  • Many countries that have followed the World
    Banks private sector development strategy have
    experienced negative consequences
  • (1) commercialization has led to increased
    inequality in access to health care
  • (2) private investment tends to be concentrated
    in the more affluent areas and in
    profit-maximizing activities
  • (3) health maintenance organizations and health
    insurance companies favor the healthy and
    wealthy
  • (4) the private sector draws health personnel
    away from the public health system (causing a
    brain drain) and worsens the shortage of
    trained personnel in public health

27
Negative Consequences of Globalisation Hilary,
2001
  • (5) many conflicts of interest between the
    pursuit of commercial interests and public health
    goals have arisen
  • (6) profit-motivated health care gives excessive
    focus to curative rather than preventive health
    measures
  • (7) limited funds are often diverted toward
    nonpriority areas
  • (8) privatization schemes have restricted the
    access of poor families to not only health but to
    water and sanitation and
  • (9) rising prices in the health care system are
    often accompanied by a decline in the quality of
    service.

28
The United Nations Development Program (UNDP
2001) has offered the following observations on
this situation
  • The technology divide does not have to follow
    the income divide throughout history, technology
    has been a powerful tool for human development
    and poverty reduction.
  • Markets are powerful engines of technological
    progress, but they are not powerful enough to
    create and diffuse the technologies needed to
    eradicate poverty.
  • Developing countries may gain especially high
    rewards from new technologies, but they also face
    especially severe challenges in managing the
    risks.

29
The United Nations Development Program (UNDP
2001) has offered the following observations on
this situation
  • National policiesimportant though they bewill
    not be sufficient to compensate for global market
    failures.
  • New international initiatives and the fair use
    of global rules are needed to channel new
    technologies towards the most urgent needs of the
    worlds poor people.
  • The challenge is for the international community
    to act on these propositions, and to organize and
    finance more effectively than in the past the
    development and distribution of the new
    health-related technologies that are needed by
    the populations of the developing world in the
    face of the growing pressures of globalization

30
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31
Driving forces, facilitating factors and
constraints Technology political influences
economy ideas global concerns
GLOBALISATION
World Markets
National Economy, Politics Society
Health Related Sectors
Population Level Health Influences
Individual Health Risks
Household Economy
Health Care System
HEALTH
32
GLOBALISATION
Openness
Rules Institutions
Cross-border flows
World Markets
Health Care System
Population-level Health Influences
Health-related Factors
33
Health Care System
Regulation
Inputs/costs
organisation
financing
delivery
Health service access
Health service quality
Health service price
34
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35
Why the Need for a Common (ASEAN) Market?
  • It is the creation of an economic association of
    sovereign states into a single trading market
    having little or no restriction of movement of
    individuals, capital, goods, and services among
    the partner states.
  • A Common Market further facilitates trade by
    lowering regulatory and tariff barriers.

36
Common Market Advantages
  • The advantages gained from a Common Market
    association are many
  • It increases division of labour and productivity.
  • It allows and encourages freedom of movement for
    all the factors of production.
  • The factors of production will be more
    efficiently allocated.
  • It creates a greater competitive environment.
  • It generates economies of scale making goods
    cheaper.
  • There is greater availability and choice of
    products.
  • A larger market also encourages creation of new
    products

37
  • Medicine has evolved into a service industry
    catering to the medical needs of the community.
  • With new practices in the economic and labour
    market, and improved lifestyle and expectations
    of patients, the practice of medicine has seen
    two major changes in the medical care arena.
  • First, the privatization of health-care and
    second the role of third party players acting
    between patients and health-care providers.
  • Medical care and service is now regarded as a yet
    another commodity to be bought and sold in the
    market place.

38
Market-Orientated Health Care
  • In market-orientated medical care, the patient is
    the customer and the medical care and service
    rendered by the doctor and hospital is the
    commodity and service traded in a demand and
    supply chain.
  • As a user and client, the patients main desire
    is to secure the best doctor, the best medicine,
    the best hospital facilities and the best
    attended and related personal care services.
  • And the patient hopes to purchase all these at
    the lowest possible medical cost.
  • 3 Players
  • the Patient/Citizen,
  • the Health Care Provider, and
  • the Health Care Purchaser.
  • 3 Markets
  • the Service,
  • the Expert, and
  • the Purchaser Markets.

39
Free market strives on competition
  • Benefits of market-orientated medicine.
  • For example
  • 1) Being consumer orientated, it is
    patient-centred. The result is better health
    service where patients receive good value for
    money.
  • 2) There will be shorter waiting time and the
    patient better informed. The end result is a
    satisfied customer.
  • 3) Competition will encourage medical practice to
    be more vigilant, transparent and accountable.
  • 4) Doctors are bound to practise evidence based
    medicine and hospitals strive to ensure and
    maintain recognised standard of care.
  • (An example of a recognised standard of care is
    for hospitals to be accredited to the Joint
    Commission International (JCI).

40
Anton Petter Gudrun Eder. European Health
Management Association (EHMA) Annual Conference
in 2007, Lyon
  • In practice, medicine does not behave like other
    kinds of commodity in market trading.
  • Some problems associated with market-orientated
    medicine that can cause market failure or less
    than perfect results/outcomes, in some instances
  • 1) There is asymmetry of information. The Patient
    may not necessarily be able to make the best
    decisions on the varied products and treatments
    that are available to them. Often, expert
    knowledge is required to make decisions on
    complex issues such as the type of treatment most
    appropriate to the illness, the standard of
    safety, the level of comfort and the health cost
    involved.
  • 2) Market barriers created by Health Care
    Purchasers not only dictate the price but limit
    the types of product available to the Patients.
  • 3) Principal-Agent problems surfaced as a result
    of the introduction of third party agents who act
    between the Health Care Provider and the Patient.
  • 4) Moral hazard is always present when a decision
    has to be made between best available treatment
    and the balance sheet of the Health Care
    Provider.
  • 5) Transaction cost involving additional
    marketing and administrative expenses has made
    health care less efficient.
  • 6) Risk selection by choosing less complicated
    cases can ensure greater returns to the Health
    Care Provider.

41
AFTA ASEAN Free Trade Area
  • Malaysias trade policy is to pursue trade
    liberalisation through rule-based multilateral
    trading system under WTO
  • One important WTO principle is to eliminate
    duties and tariffs for all parties
  • Common Effective Tariff Scheme (CEPT) adopted by
    ASEAN-6 (Brunei, Indonesia, Malaysia,
    Philippines, Singapore, Thailand)
  • Reduced duties on 98.9 of all their products
  • 99.6 of these products are at tariff rates 0 to
    5

42
In 1995, the ASEAN Economic Ministers agreed to
the establishment of an ASEAN Common Market
(AEC).
  • Aim to allow continued growth and prosperity in
    the region, enabling the region to withstand
    global competition.
  • A framework of an ASEAN Common Market was set up
    to substantially eliminate barriers to trade and
    services in Bali 2003, this AEC was targetted to
    be established by 2020
  • In 2007, the Economic Ministers met in Cebu,
    Philippines and agreed to the following plan -
  • 1) Develop Asean into a single market
  • 2) Eliminate tariffs and non-tariffs barriers
  • 3) Free movement of professionals
  • 4) Encourage private participation
  • 5) Harmonise custom procedures

43
AFTA Mutual Recognition Arrangements 2015
  • A common market will no doubt benefit the
    health-care services as it facilitates the
    movement of talents, capital, goods, and services
    across the region.
  • Steps were taken in 2004 in Vientiane, Laos
    during the ASEAN Summit to harmonise standards
    and regulations for health services.
  • The Economic Ministers further met in Bangkok
    early this year for further co-operation on trade
    in health services. A roadmap was drawn up for
    the integration of the health care sector by
    2010.
  • In August 2008, the Ministers met again in
    Singapore to help the ASEAN partners move closer
    towards economic integration.
  • Three Mutual Recognition Arrangements (MRAs) in
    the accounting, medical and dental fields were
    signed by the ASEAN members as part of a bigger
    goal of realising a liberalised and integrated
    ASEAN economic community by 2015.

44
10th ASEAN Summit (20-24 Nov 2004) Ventiane
Priority Sectors for fast-tracking realisation of
AEC
  • Health Services
  • Healthcare service Hospital, medical, dental
    services
  • Social work services nursing homes
  • Human helath activities
  • Veterinary services
  • Ancillary Healthcare services cover
  • Manufacture of pharmaceutical products
  • Medical equipment and devices
  • Health insurance
  • RD
  • Education and training of medical personnel

45
AFTA Aims
  • Health without frontiers
  • Access to affordable healthcare, (?)
  • impact of trade liberalization on health sector
  • Access to wider healthcare choices,
    opportunities, greater flow of trade and services
    exchange, overall economic growth stimulatedGDP
    increasefunction of global prosperity?
  • Formulate ASEAN food safety policy
  • Harmonisation of maximum residue limits for
    pesticides

Sarjeet SS. Implications of AFTA for medical
associations and the medical profession. MMA
News, Dec 2008, Vol.38 (11) pgs 13-14.
46
The European Union (the EU) is the best example
of a long established Common Market model.
  • In the EU, the practice of a common market in
    health services has resulted in the following -
  • 1) Greater mobility of people from one member
    country to another to seek better and faster
    health care service.
  • 2) Also greater mobility of doctors from one
    member country to another for training and
    practices. Little difficulty was encountered in
    the standardization of educational curriculum and
    training among the educational bodies. But there
    was much resistance from the professional
    licensing bodies of the various member countries.
  • 3) Another feature was increased migration of
    doctors from member countries with lesser
    remuneration to member countries with higher
    remuneration.
  • 4) The EU countries saw an increase in the number
    of private hospitals in member countries with
    lower labour cost.
  • 5) The EU had encouraged more innovations of
    medical products, one of which was the invention
    and production of the Cypher Stents.
  • 6) In the United Kingdom, there was an increase
    in complaints of long waiting lists and the poor
    service of the National Health Service when
    compared to some of the other EU countries.

47
Market-Orientated Health Care
  • 3 Players
  • the Patient/Citizen,
  • the Health Care Provider, and
  • the Health Care Purchaser.
  • 3 Markets
  • the Service,
  • the Expert, and
  • the Purchaser Markets.

48
First Player of the Health Market - The
Patients/Citizens
  • a) The ASEAN population size and economics, a
    huge market potential consisting of 589 million
    people with GDP of 2.6 trillion US dollars.
  • However the economic characteristics vary
    greatly among the ASEAN member countries, ranging
    from a GDP of 710 US dollars per capita to 51,000
    US dollars per capita.
  • b) Expect greater mobility of people among the
    ASEAN countries
  • follows from waiver of visa among the ASEAN
    govts,
  • introduction of budget air fares
  • migration of workers among ASEAN member
    countries for better employment opportunities and
    greater remunerations.

49
First Player of the Health Market - The
Patients/Citizens
  • c) With improved living standards and exposure to
    different lifestyles in the various ASEAN
    countries, healthcare expectation of patients is
    expected to rise.
  • Patients now have better knowledge and
    understanding on diseases, and the treatments
    available.
  • More importantly, patients are now presented
    with a wider range of treatment options available
    to them.
  • These options differ not just in terms of
    therapy offered, but in quality of care, and
    cost. At the same time, they have greater
    expectations of the service provided.
  • d) With improved living and educational standards
    of the people in ASEAN, the pattern of diseases
    also changes, more heart or chronic ailments.

50
Second Player of the Health Market The Health
Care Providers
  • a) Physicians GPs and Specialists
  • In an ASEAN Common Market setup, we expect a
    greater mobility of doctors among the ASEAN
    countries. Doctors move from one country to
    another for training, consultation and better
    remuneration and job opportunities.
  • Government health authorities will/should meet to
    standardize the education curriculum and training
    of the medical practitioners, including that of
    specialists and surgeons, the various
    subspecialty bodies would have to help in giving
    relevant inputs and recommendations to the
    Government authorities.
  • There is a large variation in density of
    specialists in relation to population. Patients
    from areas with low density of specialists will
    seek treatment in places where the specialists
    are more accessible.

51
Second Player of the Health Market The Health
Care Providers
  • b) The Hospitals.
  • 1) Privatization over public ownership will be
    more common in market-orientated medicine. We
    expect increase in the number of private
    hospitals in the ASEAN countries. Presently with
    the exception of Cambodia and Laos, highly
    specialised care/surgery services are available
    in many of the private hospitals in the ASEAN
    countries. With greater mobility of health
    workers there may be a shift of private hospitals
    to countries with lower labour cost.
  • 2) Private expected to bring in foreign exchange
    to member ASEAN. Medical tourism is greatly
    encouraged by the Governments of the Philippines,
    Thailand, Malaysia and Singapore. In the
    Philippines incentives such as tax relief are
    offered to encourage the development an
    construction of private hospitals. Indonesia too
    is building new, well equipped private hospitals
    for its well-to-do patients.
  • 3) Another good outcome that can be expected will
    be hospitals striving to attain recognised
    standard of health care as a result of keen
    competition among the private hospitals. Many
    hospitals now seek accreditation from the Joint
    Commission International for quality management
    and health-care service. To-date, there are 21
    private hospitals in the ASEAN member countries
    with JCI certification.

52
Second Player of the Health Market The Health
Care Providers
  • b) The Hospitals.
  • 4) Large growing market for health care will lead
    to segmentation of various kinds of private
    hospital catering to the different needs/sectors
    of patients.
  • Some private hospitals thrive on offering
    top-class quality medical care to patients who
    are able and willing to pay higher cost. E.g.
    Parkway Group Healthcare Pte Ltd is building a US
    1.5 billion-dollar luxurious state-of-the-art
    hospital in Singapore.
  • 5) With more private hospitals being set up,
    there will be an increase in job opportunities
    for the doctors and health-care workers, in the
    region with no border restraints.
  • 6) A large market base will also enable some
    hospitals to go into more specialized disciplines
    and services for example, neonatal surgery and
    robotic surgery.
  • 7) The market will also encourage greater
    innovations and use of new devices, for example,
    new biotech/genomic and stem cell therapy.

53
Third Player of the Health Market The Health
Care Purchaser
  • 1. Patients in public hospitals of all ASEAN
    countries are now receiving free or heavily
    subsidized medical treatments. Vietnam and
    Singapore have co-insurance payment by employers
    and employees so that more citizens can seek
    treatment in private hospitals.
  • 2. Private health insurance coverage among ASEAN
    countries at present is still very low, ranging
    from 0 to 20.
  • There is great opportunity for private
    investors to invest in this area but would
    for-profit motives drive up health care costs?
  • The insurance planners can design and provide
    different health packages and market them
    according to the needs of the patient.
  • Insurance agencies can tailor and organise
    different kinds of health/medical packages for
    their clients. They range from budget to an
    exquisite care, from mass to private luxuries,
    etc.
  • Problem what about the uninsured or those
    unable to insure?
  • 3. Can emergence of insurance planners
    international referring agencies help lower the
    cost of medical treatment?
  • May be tendency to dictate and limit the
    types of treatment available case and risk
    selection worries are real

54
ASEAN Common Market on Health Services Benefit
  • The most immediate benefits would likely be
  • 1. An ASEAN Common Market on Health Services will
    mean greater access to better quality healthcare
    to the people of ASEAN.
  • 2. An ASEAN Common Market on Health Services
    encourages the setting up of specialised medical
    centres that focus on the use of sophisticated
    medical equipment and advance state of the art
    treatment but cost is likely to escalate
  • 3. As the healthcare expectations of people
    increase, public hospitals will be motivated to
    improve, thereby further raising the general
    standard of health care in ASEAN.
  • 4. Richer, more developed nations such as
    Singapore may benefit more than poorer countries
    such as Laos and Cambodia, as freer movement of
    its specialists or large physician or hospital
    groups (more established and experienced) can tap
    into the larger population of the wealthier
    citizens of other ASEAN nations.

55
ASEAN Common Market on Health Services
Challenges
  • 1. Inequity/disparity of healthcare access is a
    real threat The care treatment extended to the
    rich and the poor will vary the very poor or
    uninsured/uninsurable will very likely be left
    out.
  • 2. Outward migration of already short-staffed
    expertise Easy mobility enhanced by attractive
    job opportunity and prospect may result in
    shortage of doctors in the outlying areas and
    poorer regions where patients desperately need
    specialised care.
  • 3. Market forces may encourage popularisation of
    specialist treatments, interventional rather than
    simpler treatment strategies that are more
    profitable to the Health Care Providers.
  • 4. Information Asymmetry and Difficult Patient
    Choices Patients face difficulty in making
    informed choices in treatment arising from
    unequal relationship between the Patient and the
    Health Care Provider.

56
AFTA/WTO Current status of Liberalisation
  • Legal Profession only Malaysian citizens or
    permanent residents admitted to the Bar. Foreign
    lawyers can appear before Malaysian court with
    sepcial Admission certificates from AGs office.
    Admission regulated under Legal Profession Act,
    slightly dfferent for Sabah/Sarawak
  • Medical Services
  • Right now, only recognised medical colleges and
    their graduates who must be citizens/permanent
    residents, allowed to practice in the country.
  • Foreigners allowed on temporary licenses
    depending on application from employing or
    contracting institutions usually for medical
    post-graduate training/research, but still must
    be registered with MMC and given temporary or
    limited registrations
  • Such registrations are not available for family
    or general practitioners, great difficulties even
    with foreign spouses of Malaysian citizens

57
AFTA 2013/GATS/WTO
  • What does this mean for Malaysia?
  • Beginning with ASEAN countries, there will be
    free exchange of good and services in the health
    care sector by 2013, and extended to WTO
    signatory members latest by 2015
  • Hospital groups can set up in any ASEAN country,
    from any country, as long as they are set up
    based on local laws and regulations, as for any
    local/national groupno discriminatory
    regulations allowed (this includes no language
    discrimination)
  • It also includes multinational insurers, large GP
    groups, Physician Provider Organisations, other
    health maintenance organisations/MCOs
  • No specialist group will be exempted, and medical
    and specialist degrees will be recognised
    automatically as long as these degrees and
    training have been granted by the local medical
    boards/councils as acceptable for their own
    nationals. National licensing rules should be
    uniform for locals as for foreigners from ASEAN
  • Not sure if this means automatic recognition of
    every national medical degree in ASEANMMC is
    looking into this to see if this contravenes the
    AFTA charter vis-à-vis our Medical Act.

58
Will there be Flood of Migrant Medical
Professionals into Malaysia?
  • Possibly. 2 sources
  • one from many of our less developed (lower GDP)
    neighbouring countries who oversupply their
    medical professionals and whose income is still
    relatively low (economic professional migrants)
  • Another even from Singapore with their small
    population and more advanced systematic approach
    to healthcare, large number of highly skilled and
    trained experts
  • Richer and large group practices may invade our
    shores with not just specialist hospitals, but
    possibly general practice consortia
  • Solo GP practices may become swallowed by these
    larger group practices, e.g. as already seen with
    the Qualitas group.
  • Health maintenance organisations and insurers
    from abroad may also make entry into our shores
    to tap the growing number of middle class
    citizens who are more health-conscious as well as
    more informed for choices
  • What about our public health sector? Will these
    be corporatised? Privatised? Who will look after
    primary care practices and public health issues
  • What about the NHIS or National Health Insurance
    Scheme (SIKK)? Will this be permanently put on
    the back-burner, and if so, how can we improve
    our health care economics and plans?

59
Will AEC go the way of EU?
  • ASEAN Secretary-General One Keng Meng
  • The EU has a common currency. They have free
    movement of people. We dont think SEA countries
    are ready to do this.
  • What we care seeing in ASEAN is more the
    movement of professional people, skilled people.
    We cannot be like the EU which allows free
    movement of people.
  • Many of our countries are still relatively
    insecure, and if you have complete free movement
    of people, you can see thousands more coming into
    a small country or thousands more going where the
    market is good.
  • The local population may not be ready to welcome
    the competition from the guy next door.
  • Will Malaysians be so ready to welcome our ASEAN
    brethren?
  • Will our doctors be prepared for the challenges
    and competition?

Source http//english.vietnamnet.vn/2006/10/62558
0/
60
  • Malaysia scored above world average in 8 of the
    10 economic freedoms
  • fiscal freedom (83.0),
  • government size (81.4),
  • monetary freedom (79.9),
  • trade freedom (78.2),
  • labour freedom (71.5),
  • business freedom (70.8),
  • freedom from corruption (51.0), and
  • property rights (50.0)
  • 2 economic freedoms that Malaysia fared below
    world average
  • investment freedom (40.0)
  • financial freedom (40.0)

Heritage Foundation ranking Hong Kong,
Singapore, Australia, Ireland, New Zealand,
United States, Canada, Denmark, Switzerland
United Kingdom
61
  • There is a canker corroding the soul of
    society. Economic rationalism the all-pervasive
    nature of competition anti-social behaviour in
    many aspects of life and across all levels of
    society the unrestrained consumerism of a
    surging global population, together with the
    consequent deterioration of our natural
    environment and the dizzying rate of escalating
    social and technological change are, for many
    people, signs of cultural disengagement
    illuminating industrialisms final convulsions.
    These convulsions are reflected in increasing
    corruption, crime rates and levels of stress,
    soaring public investment costs, disenchantment
    with our institutions and a growing mistrust of
    authority.

Richard David Hames. Burying the 20th Century,
1997, Business and Professional Publishing,
Australia
62
Peoples Health Movement
63
Peoples Charter for Health
64
Health as a Human Right Is a Human Right?
65
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Health worker density Global Discrepancy /
Inequity
71
Health workers migrate toward richer countries
loss from poorer lower-income country esp. public
sector
72
Migrant health workers from poorer nations
usually drift toward richer nations
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So, what do I feel about globalisation, AFTA, and
health?
  • Im cautiously optimistic
  • I dont favour unrestrained free trade which can
    impact significantly on weaker institutions and
    societies, often creating more pain and hardship
  • Globalisation is not inevitable or unstoppable,
    there are viable alternative models (not TINA
    i.e. there is no alternative) where
    trade/capital is not the centre of civilisational
    or human progress
  • Cultural, traditional and humane activities,
    local meaningful betterment of individuals or
    groups are perhaps a more desired goal
  • There might still be time enough to modify or
    help reshape the not invariable postures of free
    trade and globalisation excesses.
  • Do we all have a collective will to think and act
    differently?

75
Myths of Globalisation and the Free-trade
Paradigm Graham Dunkley (Free TradeMyth,
reality and alternatives, 2004, Zed Books
  • 3 false assumptions
  • Globalisation is now well advanced
  • It is inevitable and unstoppable
  • It is overwhelmingly good for virtually everybody
  • Adverse impacts include
  • Integrative effects (homogenisation of legal or
    administrative practices)
  • Displacement effects (destruction of one culture
    by another)
  • Disruption effects (social or other dislocation)

76
Myths of the Free-trade Paradigm Graham
Dunkley (Free TradeMyth, reality and
alternatives, 2004, Zed Books
  • 5 false assumptions
  • Trading is anciently integral to human nature
  • Free trade, free markets and private initiative
    are best for most exchange
  • comparative advantage is the best basis for all
    goods and services
  • Trading and free trade have, on balance,
    overwhelmingly net positive benefits for all
    concerned
  • Amount of trading has gradually increased over
    time, indicating inevitable globalism

77
4 Alternative Models
  • Free Market Economic Rationalist (Smith/Ricardo)
    approach
  • Market Interventionist (Keynes/Kaldor) approach
  • Human Development (Marx/Sen) approach
  • Community Sovereignty (Gandhi/Schumacher) approach

78
Human Development (Marx/Sen) approach
  • Amartya Sen (Nobel laureate) accepts general
    market principles, current forms of
    globalisation, reasonably free trade and
    longer-term growth-oriented goods
  • But believe in human capacity development i.e.
    capacity expansion which implies collective
    benefit provisions such as infrastructure,
    health, education, literacy, training, female
    employment, general social development also
    people sustenances through collective security
    and market-derived income some public
    redistribution which leads to social justice.

79
Gandhian Principles
  • Ahimsa (Non-violence)
  • Satyagraha (non-violent recitification of wrongs,
    restrained political action)
  • Sarvodarya (respect and justice for all)
  • Swadeshi (sovereignty and self-reliance for
    communities and nations)
  • Gandhi regarded opposed rampant economic growth
    as morally corrupting, free trade as socially
    destructive and copying of the west as
    degrading...
  • He advocated national self-reliance and
    self-restraints to consumption (Satya Sai Babas
    ceiling on desires), simple technologies and
    lifestyles

80
Schumacher (1973)
  • Heavily influenced by Gandhi, Buddhist precept of
    right livelihood
  • Individuals should do what is morally right and
    environmentally requisite
  • Economic policies should be ethical, ecological,
    people-centred and spiritual
  • Appropriate and intermediate technology and
    development, without creating too much
    unnecessary mobility, structural instability,
    community decay and general footlooseness
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