theSun | MONDAY APRIL 20 2009
speak up!
Merits of devolving
health care
comment
by Dr Helmy Haja Mydin
IN 1970, Sabah was ranked as
one of the richest states in the
federation, with a per capita GDP
second only to Selangor (which
then included Kuala Lumpur).
However, despite its vast natural
resources, it is now the poor-
est state in Malaysia, with the
largest number of people living
below the poverty line and a
poverty rate that is higher than
that of the Indonesian national
poverty rate.
Over the past few months,
various news agencies have pro-
vided an insight into the lamenta-
ble state of health care in Sabah.
News of the predicament facing
both health-care professionals
and their patients is making the
rounds in cyberspace. The crisis
is said to have been exacerbated
by poor building planning, the
lack of infrastructure as well as
inadequate medical facilities.
Would the situation be dif-
ferent if the rakyat of Sabah had
a greater say in the running of
their economy, and by exten-
sion, their health-care
service? Would decen-
tralisation improve In essence, the
things for the benefit
of the rakyat?
federal government
Decentralisation should direct policies
is the devolution of
decision-making from and steer clear from the
a central government
to a regional govern-
temptation of micro-
ing body. Its concept managing from afar.
is complex and mul-
tifaceted, as it covers
a variety of factors involving
politics, administration, fiscal
policies and market forces. It is
these factors that play a role in
the provision of a comprehen-
sive health-care service, and it
can be argued that administra-
tive and fiscal decentralisation
are of particular importance.
The decentralisation of health
care is not a novel idea, having
been proven to bring positive
results in countries such as
Canada. The Spanish system is
not dissimilar, with regions such
as Catalonia being a benefici-
ary of decentralisation, with a
system that allows operational
flexibility in hiring practices,
compensation and managerial
freedom.
The concept of decentralisa-
tion has also been increasingly
gaining credence in the United
Kingdom with the introduction
of foundation trusts. A founda-
tion trust is a not-for-profit
administrative entity with the
freedom to borrow capital, sell
assets, retain financial surpluses
and to develop their own system
of management. It is subject to
national standards, but has the
freedom to determine the meth-
od by which these standards will
be achieved.
A report by the British Health-
care Commission, an independ-
ent watchdog for health care in
the UK, found that managers of
foundation trusts responded to
their new-found freedom enthu-
siastically, reporting improve-
ments that included the ability
to flexibly plan ahead and set
priorities for investment, more
confidence in financial manage-
ment and faster decision-making
and funding for developments in
services.
13
The main advantage of
decentralisation is the fact that
necessary reforms and creative
initiatives would be easier to
implement, allowing for greater
health equity. It does not take
that great a leap of imagination
to see how the advantages of
decentralisation can be applied
to the Malaysian health-care
service generally, and the state
of Sabah specifically.
The federal government
should start the ball rolling by
providing state health-care au-
thorities with greater autonomy
when dealing with the alloca-
tion of resources for building
maintenance, public health and
provision of medical services,
including decisions on staffing
and the purchase of medication
and equipment.
By providing a greater level
of discretion over the application
of resources, state authorities
will be able to provide a service
that caters to their particular
demographic, as well as the
health-care issues that are more
prevalent within their geo-
graphical region. For example,
a state with frequent epidemics
of dengue fever would be able
to choose to invest more in the
area of public health, as opposed
to another state that might prefer
to provide a greater number of
clinics due to a burgeoning
population with diabetes.
Current level of bureaucracy,
including constraints imposed
by the federal administration,
deters dynamic changes.
The federal government
should limit their remit to
financial support, the establish-
ment of guidelines based on
nationally agreed standards, the
establishment of tertiary health-
care and research centres as
well as having overall control
of the training programmes of
health-care professionals.
In essence, the federal gov-
ernment should direct policies
and steer clear from the tempta-
tion of micro-managing from
afar.
Naturally, such a paradigm
shift will not be easy to imple-
ment given the decades-long
policy of excessive, top-heavy
managerial style.
The new Najib administra-
tion should provide the impetus
for such a change to halt the
inexcusable decline of our once
internationally respected health-
care service. This shift of focus
in providing more autonomy
to regional centres will allow
them to prosper as autonomous
entities that would primarily be
answerable to their main stake-
holder, ie the rakyat.
Dr Helmy Haja Mydin is Health-
care Policy Fellow at the Malaysia
Think Tank (www.WauBebas.
org)