KUALA LUMPUR, March 4 — The unexpected termination of an online dispensary system earlier this week caused alarm among hundreds of thousands of federal government pensioners who had been using it since 2012 to collect their free medicines and medical supplies from private hospitals.

The government responded quickly to assuage their fears that they can now get their prescriptions filled out at medical facilities managed by the Ministry of Health (MOH). But one question arose: why couldn’t they have got them all from public hospitals in the first place?

The answer is not as simple as one would expect, as we found out after speaking to several doctors familiar with the issue.

The Blue Book

"Generally speaking, public hospitals abide by the Blue Book,” Dr Helmy Haja Mydin, an associate with libertarian think tank Institute for Democracy and Economic Affairs, told Malay Mail Online.

The Blue Book refers to a formulary — an official list giving details of medicines which can be prescribed by public facilities, available in one form or another in each country.

It is updated periodically, most recently last month with a total listing of 1,694 types of medicines, complete with information of each one from its generic name to dosage.

All medicines listed in it are provided free at MOH facilities. Patients only have to pay a fee for treatment.

According to Dr Helmy, what goes inside the formulary depends on a combination of a medicine’s clinical and cost-effectiveness.

"Basically, you can’t give everything to everyone — you’ll go bankrupt pretty soon,” said the former academic at the University of Malaya Medical Centre.

It was this document that Health Director-General Datuk Dr Noor Hisham Abdullah had referred to when he clarified that new cancer treatments, including targeted therapies and immunotherapy, are mostly available at MOH tertiary hospitals.

"For a medicine to be listed in the Blue Book, it must first be registered in the country. The company responsible for marketing the product shall apply for it to be listed in the formulary,” Dr Noor Hisham said in a statement.

"It will then be evaluated based on criteria such as proof of superior effectiveness compared to standard therapy, a positive cost benefit ratio and an acceptable safety profile. However, not all medicines get listed into the formulary if there is a very high budget impact, especially the newer targeted cancer therapies.”

Some medicines may also not be available because it is not in stock, either in the midst of being replenishing, or for strategic reasons.

"Not all medicines are fully stocked… So we have to pick and choose which patients we can offer them to,” said a medical officer working in a Selangor tertiary care centre who asked not to be named as he is not authorised to speak to the media.

This does not mean patients are denied treatment completely but they have restricted access to costly treatments due to the limited supply, he said.

"And different hospitals have different allocations for medicines. It depends on the patient demographic. No point for a non-renal specialised hospital to stock up renal transplant medicines when there are no such patients,” he added.

Dr Helmy Haja Mydin said all countries with a public healthcare system will inevitably have to make hard choices about where funding flows to. — Picture courtesy of Dr Helmy Haja Mydin

Have money, will travel

It is a different situation with private hospitals, where money is no concern, or as Dr Helmy said: "Pretty much anything approved is available as long as the individual or insurance company pays for it.”

There are many reasons why patients choose to seek treatment at private hospitals despite the dirt cheap public healthcare system, and not just because of the availability of certain medicines and treatments.

"Most people seek help in the private sector because of convenience — less waiting time, less crowds, more comfortable facilities,” said Dr Helmy, who now serves as a respiratory consultant at Pantai Hospital Kuala Lumpur.

"Then there are those who seek particular doctors because they want a specialist opinion, or a second opinion.”

Those who had previously sought treatment in private hospitals, but then switched to public hospitals — usually due to dwindling funds — would make up a bulk of those who would later usually face disappointment over the lack of some treatments in public facilities.

For example, a survey in 2015 showed that nearly half of Malaysian cancer patients suffer from "financial catastrophe”, where their medical costs exceed 30 per cent of household income, a mere 12 months after they were diagnosed.

According to the Asean Costs in Oncology study by Sydney-based George Institute for Global Health, around 51 per cent of those studied were pushed into "economic hardship” after a year from diagnosis, with 49 per cent of them already having already used up all their personal savings, while 39 per cent of all respondents could not pay for their medication.

"We encounter many patients who go to private hospitals, and their doctors had started highly specialised medication. When they couldn’t afford anymore, then they turn to us.

"But we can’t be absorbing all the potential cost when the initial treatment was not started by us, or if we simply don’t have it,” our medical officer source said.

Where is the money?

In Budget 2017 tabled in October last year, Prime Minister Datuk Seri Najib Razak announced RM24.8 billion for MOH, a 7.8 per cent increase over the previous budget.

The increase came after Deputy Health Minister Datuk Seri Dr Hilmi Yahya warned that the ministry could not take any more cuts, even after it had started moving from branded drugs to cheaper generic medicine to cut costs.

However Kampar MP Dr Ko Chung Sen pointed out that even with the increased budget, the allocation for medical supplies and medicine had instead fallen.

"The money to buy medical supplies and medicines has been reduced by RM300 million in this year’s budget. From RM1.5 billion to RM1.2 billion when the number of patients has increased by five million.

"That shows the government has less than RM20 to pay for each prescription, let alone they are able to afford operations,” said the DAP MP who is also a heart surgeon in Ipoh’s KPJ Specialist Hospital.

What this means, according to our anonymous medical officer, is that both public doctors and patients suffer as they try to cope with tighter budget but an increasingly demanding clientele.

"I think one important point is that governments have to be judicious in their use of medication, because of the ever escalating costs of new drugs and the increasing elderly demographic.

"So all countries with a public healthcare system will inevitably have to make hard choices about where funding flows to,” Dr Helmy explained.

The end of e-MASS

On January 27, the Public Service Department (PSD) terminated the service of OratisRx Sdn Bhd, which was appointed through an open tender in 2012 to operate the Electronic Medical Automation Supply System (e-MASS). Its service was extended by one month and ended on February 27.

The e-MASS enabled federal government pensioners and military veterans to get their medicines or medical equipment at private hospitals, clinics or pharmacies registered with OratisRx without making any payment.

Pensioners only needed to go directly to those places, call the e-MASS call centre or make orders through the e-MASS portal and have OratisRx deliver the item to them or to the respective private hospital most convenient to them.

Doctors told Malay Mail Online they suspected the service was likely another casualty of dwindling federal funds.

"I guess PSD has been affected by the general pressures on funding that the government is facing. This however is a serious issue for patients that are affected,” said Tan Sri Dr Abu Bakar Suleiman, who served as Health D-G between 1991 and 2001.

The Federal Expenditure Estimate for 2017 released by the Finance Ministry showed the damning proof: the estimated spending of PSD’s Post-Service Department that handled e-MASS was slashed from RM371.5 million in 2016 to just RM220.7 million in 2017 — a cut of over 40 per cent.

"This has been expected. It is sad and unfortunate though for civil servants. People who rely heavily on daily medications would probably feel the impact the most. If they do not have the right medicines, they might suffer in the long term.

"They also may be required to go for less suited medicines or not have the medicine at all. In the long term, this is not ideal for our country’s healthcare,” said Dr Ko.

Health director-general Datuk Dr Noor Hisham Abdullah said that affected pensioners will receive "highly subsidised” medical treatment, like other Malaysians who seek treatment at MOH. — Reuters pic

What now for pensioners?

Dr Abu Bakar said the PSD needs to pick up the slack from the situation that is affecting an estimated total of 750,000 pensioners, although he insisted the main responsibility still lies with the MOH.

"The responsibility for delivery of health care is with the MOH, not PSD who appears to have additional funds to support pensioners even on health matters,” said the chairman of IHH Healthcare, Asia’s largest private healthcare group.

"Even so they should only do so with the assistance and collaboration of MOH who has the capacity and expertise to do this, if PSD wishes to exercise control of this additional funds.

"It is the responsibility of PSD to assist the pensioners who are affected by this, by informing MOH who the affected pensioners are and the type of assistance needed,” he added.

The PSD has since told federal government retirees and pensioned military veterans that they can get their supply of medicine and medical equipment from the MOH facilities directly.

Dr Noor Hisham also said that affected pensioners will receive "highly subsidised” medical treatment, like other Malaysians who seek treatment at MOH.

Dr Abu Bakar supported this, explaining that the MOH has a system of prioritising the medicines, and pensioners affected can be given alternate medicines from the list that is just  as effective.

Referring to the Blue Book, Dr Abu Bakar said while branded proprietary medicines may only be available in private hospitals, their generic alternatives would be available.

"I would think that all critical medicines as you put it, that is available in private is also available in public hospitals, but may be in generic form.

"There may be very new medicines that is not yet included in MOH list of medicines, but this would be very few,” said the National Kidney Foundation president.