medical globalization by dr david quek

Globalisation and Globalisation and Healthcare in MalaysiaHealthcare in Malaysia

Dr David KL Quek, Dr David KL Quek, KMNKMNMBBS (Mal), MRCP (UK), FRCP (London), FAMM (Malaysia), FASCC MBBS (Mal), MRCP (UK), FRCP (London), FAMM (Malaysia), FASCC

(ASEAN), FAPSC (Asia-Pacific), FCCP (USA), FACC (USA)(ASEAN), FAPSC (Asia-Pacific), FCCP (USA), FACC (USA)

MMA Selangor SymposiumMMA Selangor SymposiumFUTURE CHALLENGES FOR HEALTHCARE FOR FUTURE CHALLENGES FOR HEALTHCARE FOR

MALAYSIA, Sunway Resort Hotel & SpaMALAYSIA, Sunway Resort Hotel & SpaJan 18, 2009Jan 18, 2009

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

UNITED NATIONS DEVELOPMENT PROGRAM (UNDP) 1997 “Globalization—Poor Nations, Poor People.” Pp. 82-93

in Human Development Report 1997. New York: Oxford University Press.

Free Market Capitalism…Free Market Capitalism…Key concepts: “free market” and “free trade,” Key concepts: “free market” and “free trade,”

Advocates of this ideology use these concepts like a Advocates of this ideology use these concepts like a mantra. mantra. Since 1989, belief in the triumph of capitalism over Since 1989, belief in the triumph of capitalism over communism and the end to the Cold War are due to the communism and the end to the Cold War are due to the victory of the market over the state victory of the market over the state (Korten 1999:37). (Korten 1999:37).

Belief that Belief that “the more you let market forces rule and the “the more you let market forces rule and the more you open your economy to free trade and more you open your economy to free trade and competition, the more efficient and flourishing your competition, the more efficient and flourishing your economy will be”economy will be” (Friedman 1999). (Friedman 1999).

In this ideology, globalization = “spread of free market In this ideology, globalization = “spread of free market capitalism to virtually every corner of the world.”capitalism to virtually every corner of the world.”

Proponents believe they have discovered the universal Proponents believe they have discovered the universal formula for economic prosperity.formula for economic prosperity.

The Rise of Free Market Capitalism; The Rise of Free Market Capitalism; The Demise of SocialismThe Demise of Socialism

Globalism: 1Globalism: 1stst introduced since 1970s introduced since 1970s

Free market capitalism expanded Free market capitalism expanded during the Reagan and Thatcher during the Reagan and Thatcher years, into the 1980syears, into the 1980s

Culminated with the fall of the Berlin Culminated with the fall of the Berlin Wall and the crumbling of the Soviet Wall and the crumbling of the Soviet Union from 1989Union from 1989

Usually touted as Capitalism’s triumph Usually touted as Capitalism’s triumph over Communism/Socialismover Communism/Socialism

TURBO-CAPITALISMTURBO-CAPITALISM Luttwak (1999): this capitalist formula is “good for every Luttwak (1999): this capitalist formula is “good for every country, rich or poor.” country, rich or poor.”

Formula: Formula: “PRIVATIZATION + DEREGULATION + “PRIVATIZATION + DEREGULATION + GLOBALIZATION = TURBO-CAPITALISM = GLOBALIZATION = TURBO-CAPITALISM = PROSPERITY”.PROSPERITY”.

In applying this ideology, the IMF, the World Bank, the In applying this ideology, the IMF, the World Bank, the regional development banks, and the international regional development banks, and the international development agencies of the major donor countries (led development agencies of the major donor countries (led by the United States) have insisted that the governments by the United States) have insisted that the governments receiving their loans, credits, and development assistance receiving their loans, credits, and development assistance adopt a series of so-called adopt a series of so-called structural adjustments and structural adjustments and economic reforms.economic reforms.

LUTTWAK, EDWARD 1999 LUTTWAK, EDWARD 1999 Turbo-Capitalism: Winners and Losers in the Global Economy. Turbo-Capitalism: Winners and Losers in the Global Economy.

New York: Harper-New York: Harper-CollinsCollins

GlobalisationGlobalisation

Globalisation Globalisation –– a a definitiondefinition

The intensification of The intensification of global flows global flows of capital, goods, ideas of capital, goods, ideas and people across and people across borders and the borders and the institutions and rules institutions and rules established to regulate established to regulate these flows.these flows.

Globalism and Unfettered TradeGlobalism and Unfettered TradeGlobalism taken as the ultimate and inevitable pathway for Globalism taken as the ultimate and inevitable pathway for economic theory—Free Trade supervenes every other economic theory—Free Trade supervenes every other consideration…consideration…

Borderless world Borderless world (Keynes’ “Without passport or other formality”)(Keynes’ “Without passport or other formality”), no barriers to , no barriers to investment, money flows, services, goodsinvestment, money flows, services, goods

National barriers such as regulations and cultural sensitivities, National barriers such as regulations and cultural sensitivities, some deemed ‘protectionist’ are downgraded or removed some deemed ‘protectionist’ are downgraded or removed entirelyentirely

““Crucifixion economics” advocated, “no pain, no gain” top-Crucifixion economics” advocated, “no pain, no gain” top-down approach with capital reining supreme, corporations down approach with capital reining supreme, corporations given widest berth to flourish with least restrictions, hardly any given widest berth to flourish with least restrictions, hardly any oversight; let the ‘moral right’ of the consumer take flight… oversight; let the ‘moral right’ of the consumer take flight…

Is it an ‘experiment’ doomed to cyclical failure?Is it an ‘experiment’ doomed to cyclical failure?

““The power to become The power to become habituated to his habituated to his surroundings is a marked surroundings is a marked characteristic of mankind.characteristic of mankind.

Very few of us realise with Very few of us realise with conviction the intensely conviction the intensely unusual, unstable, unusual, unstable, complicated, unreliable, complicated, unreliable, temporary nature of the temporary nature of the economic organisation by economic organisation by which western Europe has which western Europe has lived for the last century. lived for the last century.

We assume some of the most We assume some of the most peculiar and temporary of our peculiar and temporary of our late advantages as natural, late advantages as natural, permanent and to be permanent and to be depended on, and we lay our depended on, and we lay our plans accordingly.”plans accordingly.” ~ John Maynard Keynes, 1919

The Promise of GlobalisationThe Promise of GlobalisationPower of nation–state waning, maybe even dyingPower of nation–state waning, maybe even dyingIn future power lies with global marketsIn future power lies with global marketsEconomics, not politics or armies, will shape global Economics, not politics or armies, will shape global marketsmarketsGlobal markets, freed from narrow nationals interests/ Global markets, freed from narrow nationals interests/ regulations, will establish international economic balancesregulations, will establish international economic balancesEternal boom-and-bust cycles will be outgrownEternal boom-and-bust cycles will be outgrownMarkets unleash trade waves, tides of growthMarkets unleash trade waves, tides of growthRising tide of growth will raise all prosperity for all, Rising tide of growth will raise all prosperity for all, converting dictatorships into democraciesconverting dictatorships into democraciesBut new democracies will have no absolute powers—But new democracies will have no absolute powers—irresponsible nationalism, racism, political violence will irresponsible nationalism, racism, political violence will shrivel awayshrivel away

Power of nation–state waning, maybe even dyingPower of nation–state waning, maybe even dyingIn future power lies with global marketsIn future power lies with global marketsEconomics, not politics or armies, will shape global Economics, not politics or armies, will shape global marketsmarketsGlobal markets, freed from narrow nationals interests/ Global markets, freed from narrow nationals interests/ regulations, will establish international economic balancesregulations, will establish international economic balancesEternal boom-and-bust cycles will be outgrownEternal boom-and-bust cycles will be outgrownMarkets unleash trade waves, tides of growthMarkets unleash trade waves, tides of growthRising tide of growth will raise all prosperity for all, Rising tide of growth will raise all prosperity for all, converting dictatorships into democraciesconverting dictatorships into democraciesBut new democracies will have no absolute powers—But new democracies will have no absolute powers—irresponsible nationalism, racism, political violence will irresponsible nationalism, racism, political violence will shrivel awayshrivel away

The Promise of GlobalisationThe Promise of GlobalisationNew market sizes, larger corporations—raise beyond New market sizes, larger corporations—raise beyond bankruptcy risks, hence market stabilitybankruptcy risks, hence market stabilityTransnationals will be market leaders of civilisation—Transnationals will be market leaders of civilisation—like virtual states, their aggressive dominance will like virtual states, their aggressive dominance will make them impervious to local political prejudicesmake them impervious to local political prejudicesThus conditions for healthy governance, emergence Thus conditions for healthy governance, emergence of debt-free governmentsof debt-free governmentsStable public accounting in turn will stabilise societiesStable public accounting in turn will stabilise societiesTheory: freed from wilful men, following individual Theory: freed from wilful men, following individual self-interests will lead to life of prosperity, general self-interests will lead to life of prosperity, general happinesshappinessCycles of history will be broken; history will be dead!Cycles of history will be broken; history will be dead!

New market sizes, larger corporations—raise beyond New market sizes, larger corporations—raise beyond bankruptcy risks, hence market stabilitybankruptcy risks, hence market stabilityTransnationals will be market leaders of civilisation—Transnationals will be market leaders of civilisation—like virtual states, their aggressive dominance will like virtual states, their aggressive dominance will make them impervious to local political prejudicesmake them impervious to local political prejudicesThus conditions for healthy governance, emergence Thus conditions for healthy governance, emergence of debt-free governmentsof debt-free governmentsStable public accounting in turn will stabilise societiesStable public accounting in turn will stabilise societiesTheory: freed from wilful men, following individual Theory: freed from wilful men, following individual self-interests will lead to life of prosperity, general self-interests will lead to life of prosperity, general happinesshappinessCycles of history will be broken; history will be dead!Cycles of history will be broken; history will be dead!

o But are all these true and inevitable?

o Can individual self-interest lead to

prosperity and general happiness for all,

or only for some?

o If so, what has history taught us so far?

o 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?

Recent Banking and Financial Crises put paid that Recent Banking and Financial Crises put paid that globalism & unfettered free-market capitalism is globalism & unfettered free-market capitalism is

anything but benign and self-regulatory…anything but benign and self-regulatory…

UNITED NATIONS DEVELOPMENT PROGRAM (UNDP)UNITED NATIONS DEVELOPMENT PROGRAM (UNDP)1997 “Globalization—Poor Nations, Poor People.” Pp. 82-93 in 1997 “Globalization—Poor Nations, Poor People.” Pp. 82-93 in Human Human Development Report 1997. New York: Oxford University Press.Development Report 1997. New York: Oxford University Press.1999 1999 Human Development Report 1999: Globalization with a Human Face. Human Development Report 1999: Globalization with a Human Face. New York: New York: Oxford University Press. Retrieved March 9, 2003Oxford University Press. Retrieved March 9, 2003(http://hdr.undp.org/reports/global/1999/en/default.cfm).(http://hdr.undp.org/reports/global/1999/en/default.cfm).

“Money, gentlemen, money! The virusThat infects mankind with every sicknessWe have a name for no greater scourgeThan that!” ~ Sophocles

“Money, gentlemen, money! The virusThat infects mankind with every sicknessWe have a name for no greater scourgeThan that!” ~ Sophocles

Health & GlobalisationHealth & GlobalisationGlobal risks for healthGlobal risks for health

Exclusion from global markets, Exclusion from global markets, e.g. e.g. North Korea, Zimbabwe, Cuba (converse results)North Korea, Zimbabwe, Cuba (converse results)

Private ownership of knowledge: Private ownership of knowledge: TRIPS, drug patent laws, HIV drugs,TRIPS, drug patent laws, HIV drugs,

Migration of health professionals: Migration of health professionals: mainly to wealthier nations, OECD, Australiasia, e.g. in mainly to wealthier nations, OECD, Australiasia, e.g. in one town in Canada, 2/3 doctors migrant from one one town in Canada, 2/3 doctors migrant from one small area of South Africasmall area of South Africa

Cross border transmission of Cross border transmission of disease: disease: SARS, bird flu, NIPAH, MDR-TBSARS, bird flu, NIPAH, MDR-TB

Environmental degradation: Environmental degradation: rise in rise in dengue, Nipah, SARS, West Nile disease, Chikungunya; dengue, Nipah, SARS, West Nile disease, Chikungunya; floods, tsunami, forest fires, tropical stormsfloods, tsunami, forest fires, tropical storms

Conflict: Conflict: War, refugees, famine e.g. choleraWar, refugees, famine e.g. cholera

Health & GlobalisationHealth & Globalisation

Health in globalising worldHealth in globalising world

Domestic action alone Domestic action alone insufficientinsufficient

Health achievements critical to Health achievements critical to international development goalsinternational development goals


Global opportunities for healthGlobal opportunities for healthInclusion/ connectionInclusion/ connectionNew New market market incentives for R&Dincentives for R&DNew resources for effective New resources for effective interventionsinterventionsKnowledge dissemination Knowledge dissemination New rules to control cross border New rules to control cross border risks risks

Public health & GlobalisationPublic health & Globalisation

WHO’s responseWHO’s responseStrategic directions;Strategic directions;Priority for: diseases of the poor, Priority for: diseases of the poor, tobacco control/elimination;tobacco control/elimination;Support for national health systems; Support for national health systems; New: Partnerships and relationships;New: Partnerships and relationships;

Resources; Resources; Rules;Rules; Optimism.Optimism.


Globalisation, trade and healthGlobalisation, trade and healthA policy, research and training A policy, research and training programmeprogramme

Develop knowledge and skillsDevelop knowledge and skills

Promote policy coherence Promote policy coherence

Contribute to: global public goods Contribute to: global public goods for health, global health funds, for health, global health funds, international rules for international rules for healthhealth

Globalisation and healthGlobalisation and health

OpennessOpenness Cross borderCross borderflows technologyflows technology

Regional/global rulesRegional/global rulesand institutionsand institutions

National PoliciesNational Policies

GCP/HSDJune 2000

HealthHealthrisksrisks

HealthHealthsystemssystems

Level andLevel anddistributiondistribution

ofofhouseholdhousehold

incomeincome

EducationEducationWaterWaterEnergyEnergy

TransportTransportOther sectorsOther sectors

HealthHealthOutcomesOutcomes

Health & GlobalisationHealth & GlobalisationWTO (1995) Agreements and WTO (1995) Agreements and

healthhealthGATTGATTTechnical barriers to tradeTechnical barriers to tradeIntellectual property and trade : Intellectual property and trade : TRIPSTRIPSServices : GATSServices : GATS

AFTA ASEAN Free Trade Zone:AFTA ASEAN Free Trade Zone: 20132013


Globalisation and health: Globalisation and health: policy measurespolicy measures

Equitable and sustainable growthEquitable and sustainable growthOpenness: gradual, sequenced and pacedOpenness: gradual, sequenced and pacedProduce global public goods, control the Produce global public goods, control the bad/illegal/unexpected bad/illegal/unexpected Increase transfer of financial and technical resources Increase transfer of financial and technical resources Strong national health policies, institutions, Strong national health policies, institutions, regulations and programmesregulations and programmesEngage across sectors and bordersEngage across sectors and borders

Structural Reforms & Structural Reforms & Adjustments for GlobalisationAdjustments for GlobalisationThese adjustments and reforms These adjustments and reforms – make the private sector the primary engine of these make the private sector the primary engine of these

countries’ development effortscountries’ development efforts, , – give priority to servicing their foreign debts, give priority to servicing their foreign debts, – deregulate their commercial and financial markets, deregulate their commercial and financial markets, – reduce the size of their government budgets and reduce the size of their government budgets and

bureaucracies, bureaucracies, – eliminate all barriers to foreign investments and importseliminate all barriers to foreign investments and imports, , – sell off their state enterprises and public utilities to private sell off their state enterprises and public utilities to private

corporations,corporations, e.g. attempts to sell off IJN to Sime Darby e.g. attempts to sell off IJN to Sime Darby– privatize as many of their public services as possible, and privatize as many of their public services as possible, and – terminate all government subsidies and most welfare terminate all government subsidies and most welfare

programsprograms (Balasubramaniam2000). (Balasubramaniam2000).

BALASUBRAMANIAM, K. 2000 “Globalization and Liberalization of Healthcare Services: WTO and theBALASUBRAMANIAM, K. 2000 “Globalization and Liberalization of Healthcare Services: WTO and theGeneral Agreement on Trade in Services.” Paper prepared for The People’s Health Assembly, General Agreement on Trade in Services.” Paper prepared for The People’s Health Assembly,

December 4-8, Savar, Bangladesh. Retrieved December 9, 2002 (December 4-8, Savar, Bangladesh. Retrieved December 9, 2002 (http://phmovement.org/pubs/issuepapers/bala2.html).).

STIGLITZ, JOSEPHSTIGLITZ, JOSEPH2002 2002 Globalization and its Discontents. New York: W.W. Norton.Globalization and its Discontents. New York: W.W. Norton.

Joseph Stiglitz (2002), (2001 Nobel Prize in Economics and Joseph Stiglitz (2002), (2001 Nobel Prize in Economics and former Chief Economist and Senior Vice President of the World former Chief Economist and Senior Vice President of the World Bank) in his recent book on globalization, provides a harsh Bank) in his recent book on globalization, provides a harsh indictment on the disastrous effects on the structural adjustment indictment on the disastrous effects on the structural adjustment programs and neoliberal development strategies of the IMF, the programs and neoliberal development strategies of the IMF, the World Bank, and the WTO. World Bank, and the WTO.

Stiglitz claims that what he learned while he was at the World Stiglitz claims that what he learned while he was at the World Bank Bank “radically changed [his] views of both globalization and “radically changed [his] views of both globalization and development,”development,” because he “ because he “saw firsthand the devastating effect saw firsthand the devastating effect that globalization can have on developing countries and that globalization can have on developing countries and especially the poor within these countries”especially the poor within these countries”

The neoliberal policies that the IMF and the other international The neoliberal policies that the IMF and the other international financial and trade agencies have imposed on these countries financial and trade agencies have imposed on these countries have been “have been “an almost certain recipe for job destruction and an almost certain recipe for job destruction and unemployment creation at the expense of the poor,”unemployment creation at the expense of the poor,” and they and they have contributed to the instability of their economieshave contributed to the instability of their economies

HILARY, JOHNHILARY, JOHN2001 “The World Bank’s Private Sector Review:2001 “The World Bank’s Private Sector Review: Does the Private Sector Development Does the Private Sector Development

Strategy Threaten Children’s Right to Health?” Save the ChildrenStrategy Threaten Children’s Right to Health?” Save the ChildrenPosition Paper. Retrieved on March 15, 2003Position Paper. Retrieved on March 15, 2003

(http://www.challengeglobalization.org/html/tools/WB_private_sector.pdf).(http://www.challengeglobalization.org/html/tools/WB_private_sector.pdf).

The introduction of cost recovery programs in The introduction of cost recovery programs in the health sector is now widely accepted to the health sector is now widely accepted to have been disastrous, forcing many families have been disastrous, forcing many families and their children into a and their children into a “medical poverty trap”“medical poverty trap” characterized by untreated illness and long characterized by untreated illness and long term impoverishment. term impoverishment.

Even the World Bank, while it continues to Even the World Bank, while it continues to support user fees for health in national support user fees for health in national Poverty Poverty Reduction Strategy PapersReduction Strategy Papers, has acknowledged , has acknowledged that they are responsible for denying poor that they are responsible for denying poor families access to health care. (Hilary 2001)families access to health care. (Hilary 2001)

Negative Consequences of Negative Consequences of GlobalisationGlobalisation… … Hilary, 2001Hilary, 2001

Many countries that have followed the World Bank’s Many countries that have followed the World Bank’s private sector development strategy have experienced private sector development strategy have experienced negative consequences:negative consequences:

(1) commercialization has led to increased inequality in (1) commercialization has led to increased inequality in access to health care;access to health care;

(2) private investment tends to be concentrated in the (2) private investment tends to be concentrated in the more affluent areas and in profit-maximizing activities;more affluent areas and in profit-maximizing activities;

(3) health maintenance organizations and health (3) health maintenance organizations and health insurance companies favor the healthy and wealthy;insurance companies favor the healthy and wealthy;

(4) the private sector draws health personnel away from (4) the private sector draws health personnel away from the public health system (causing a “brain drain”) and the public health system (causing a “brain drain”) and worsens the shortage of trained personnel in public worsens the shortage of trained personnel in public health;health;

Negative Consequences of Negative Consequences of GlobalisationGlobalisation… … Hilary, 2001Hilary, 2001

(5) many conflicts of interest between the pursuit of (5) many conflicts of interest between the pursuit of commercial interests and public health goals have commercial interests and public health goals have arisen;arisen;

(6) profit-motivated health care gives excessive focus to (6) profit-motivated health care gives excessive focus to curative rather than preventive health measures;curative rather than preventive health measures;

(7) limited funds are often diverted toward nonpriority (7) limited funds are often diverted toward nonpriority areas; areas;

(8) privatization schemes have restricted the access of (8) privatization schemes have restricted the access of poor families to not only health but to water and poor families to not only health but to water and sanitation; andsanitation; and

(9) rising prices in the health care system are often (9) rising prices in the health care system are often accompanied by a decline in the quality of service.accompanied by a decline in the quality of service.

The The United Nations Development Program (UNDP 2001)United Nations Development Program (UNDP 2001) has offered the following observations on this situation:has offered the following observations on this situation:

• • The technology divide does not have to follow the The technology divide does not have to follow the income divide; throughout history, technology has income divide; throughout history, technology has been a powerful tool for human development and been a powerful tool for human development and poverty reduction.poverty reduction.

• • Markets are powerful engines of technological Markets are powerful engines of technological progress, but they are not powerful enough to progress, but they are not powerful enough to create and diffuse the technologies needed to create and diffuse the technologies needed to eradicate poverty.eradicate poverty.

• • Developing countries may gain especially high Developing countries may gain especially high rewards from new technologies, but they also face rewards from new technologies, but they also face especially severe challenges in managing the especially severe challenges in managing the risks.risks.

The The United Nations Development Program (UNDP 2001)United Nations Development Program (UNDP 2001) has offered the following observations on this situation:has offered the following observations on this situation:

National policies—important though they be—will not National policies—important though they be—will not be sufficient to compensate for global market failures. be sufficient to compensate for global market failures.

New international initiatives and the fair use of global New international initiatives and the fair use of global rules are needed to channel new technologies towards rules are needed to channel new technologies towards the most urgent needs of the world’s poor people.the most urgent needs of the world’s poor people.

The challenge is for the international community to act The challenge is for the international community to act on these propositions, and to organize and finance on these propositions, and to organize and finance more effectively than in the past the development and more effectively than in the past the development and distribution of the new health-related technologies that distribution of the new health-related technologies that are needed by the populations of the developing world are needed by the populations of the developing world “in the face of the growing pressures of globalization”“in the face of the growing pressures of globalization”

Driving forces, facilitating factors and constraintsDriving forces, facilitating factors and constraintsTechnology political influences economy ideas global concernsTechnology political influences economy ideas global concerns

GLOBALISATIONGLOBALISATION

World World MarketsMarkets

National National Economy, Economy, Politics & Politics & SocietySociety

Health Health Related Related SectorsSectors

Population Population Level Health Level Health InfluencesInfluences

Individual Individual Health RisksHealth Risks

Household Household EconomyEconomy

Health Care Health Care SystemSystem

HEALTHHEALTH

GLOBALISATIONGLOBALISATIONOpennessOpenness

Cross-border Cross-border flowsflows

Rules & Rules & InstitutionsInstitutions

Population-level Population-level Health InfluencesHealth Influences

Health-related Health-related FactorsFactors

World World MarketsMarkets

Health Care Health Care SystemSystem

Health Care SystemHealth Care System

RegulationRegulation Inputs/costsInputs/costs

financingfinancingorganisationorganisation

deliverydelivery

Health Health service service accessaccess

Health Health service service qualityquality

Health Health service service priceprice

Why the Need for a Common Why the Need for a Common (ASEAN) Market?(ASEAN) Market?

It is the creation of an economic It is the creation of an economic association of sovereign states into a association of sovereign states into a single trading market having little or single trading market having little or no restriction of movement of no restriction of movement of individuals, capital, goods, and individuals, capital, goods, and services among the partner states. services among the partner states.

A Common Market further facilitates A Common Market further facilitates trade by lowering regulatory and trade by lowering regulatory and tariff barriers.tariff barriers.

Common Market: AdvantagesCommon Market: AdvantagesThe advantages gained from a Common Market The advantages gained from a Common Market association are many:association are many:

1.1. It increases division of labour and productivity.It increases division of labour and productivity.

2.2. It allows and encourages freedom of movement for all It allows and encourages freedom of movement for all the factors of production.the factors of production.

3.3. The factors of production will be more efficiently The factors of production will be more efficiently allocated.allocated.

4.4. It creates a greater competitive environment.It creates a greater competitive environment.

5.5. It generates economies of scale making goods It generates economies of scale making goods cheaper.cheaper.

6.6. There is greater availability and choice of products.There is greater availability and choice of products.

7.7. A larger market also encourages creation of new A larger market also encourages creation of new productsproducts

Medicine has evolved into a service industry catering to Medicine has evolved into a service industry catering to the medical needs of the community.the medical needs of the community.

With new practices in the economic and labour market, With new practices in the economic and labour market, and improved lifestyle and expectations of patients, the and improved lifestyle and expectations of patients, the practice of medicine has seen practice of medicine has seen two major changes two major changes in the in the medical care arena. medical care arena.

First, the First, the privatization of health-care privatization of health-care and second the and second the role role of third party players of third party players acting between patients and health-acting between patients and health-care providers. care providers.

Medical care and service is now regarded as a yet another Medical care and service is now regarded as a yet another commodity to be bought and sold in the market place.commodity to be bought and sold in the market place.

Market-Orientated Health CareMarket-Orientated Health CareIn market-orientated medical care, the patient is In market-orientated medical care, the patient is the customer and the medical care and service the customer and the medical care and service rendered by the doctor and hospital is the rendered by the doctor and hospital is the commodity and service traded in a demand and commodity and service traded in a demand and supply chain. supply chain.

As a user and client, the As a user and client, the patient’s main desirepatient’s main desire is is to secure the to secure the bestbest doctor, the best medicine, the doctor, the best medicine, the best hospital facilities and the best attended and best hospital facilities and the best attended and related personal care services. related personal care services.

And the patient hopes to purchase all these at the And the patient hopes to purchase all these at the lowest possible medical costlowest 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.

Free market strives on competitionFree market strives on competition

Benefits of market-orientated medicine. Benefits of market-orientated medicine. For example:For example:

1) 1) Being consumer orientated, it is patient-centred.Being consumer orientated, it is patient-centred. The result The result is better health service where patients receive good value is better health service where patients receive good value for money. for money.

2) There will be shorter waiting time and the patient better 2) There will be shorter waiting time and the patient better informed. The end result is a informed. The end result is a satisfied customersatisfied customer..

3) 3) CompetitionCompetition will encourage medical practice to be more will encourage medical practice to be more vigilant, transparent and accountable.vigilant, transparent and accountable.

4) Doctors are bound to practise 4) Doctors are bound to practise evidence based medicineevidence based medicine and and hospitals strive to hospitals strive to ensure and maintain recognised standardensure and maintain recognised standard of care. of care.

(An example of a recognised standard of care is for hospitals (An example of a recognised standard of care is for hospitals to be accredited to the Joint Commission International (JCI).to be accredited to the Joint Commission International (JCI).

Anton Petter & Gudrun Eder. European Health Management Anton Petter & Gudrun Eder. European Health Management Association (EHMA) Annual Conference in 2007, Lyon Association (EHMA) Annual Conference in 2007, Lyon

In practice, medicine does not behave like other kinds of commodity In practice, medicine does not behave like other kinds of commodity in market trading.in market trading.

Some problems associated with market-orientated medicine that can cause market Some problems associated with market-orientated medicine that can cause market failure or less than perfect results/outcomes, in some instances:failure or less than perfect results/outcomes, in some instances:

1) There is 1) There is asymmetry of informationasymmetry of information. The Patient may not necessarily be able to . The Patient may not necessarily be able to make the best decisions on the varied products and treatments that are make the best decisions on the varied products and treatments that are available to them. Often, expert knowledge is required to make decisions on 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, 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.the standard of safety, the level of comfort and the health cost involved.

2) 2) Market barriersMarket barriers created by Health Care Purchasers not only dictate the price but created by Health Care Purchasers not only dictate the price but limit the types of product available to the Patients.limit the types of product available to the Patients.

3) 3) Principal-Agent problemsPrincipal-Agent problems surfaced as a result of the introduction of third party surfaced as a result of the introduction of third party agents who act between the Health Care Provider and the Patient.agents who act between the Health Care Provider and the Patient.

4) 4) Moral hazardMoral hazard is always present when a decision has to be made between best is always present when a decision has to be made between best available treatment and the balance sheet of the Health Care Provider.available treatment and the balance sheet of the Health Care Provider.

5) 5) Transaction costTransaction cost involving additional marketing and administrative expenses has involving additional marketing and administrative expenses has made health care made health care less efficientless efficient..

6) 6) Risk selectionRisk selection by choosing less complicated cases can by choosing less complicated cases can ensure greater returnsensure greater returns to to the Health Care Provider.the Health Care Provider.

AFTA: ASEAN Free Trade AreaAFTA: ASEAN Free Trade Area

Malaysia’s trade policy is to pursue trade liberalisation through rule-based multilateral trading system under WTOOne important WTO principle is to eliminate duties and tariffs for all partiesCommon Effective Tariff Scheme (CEPT) adopted by ASEAN-6 (Brunei, Indonesia, Malaysia, Philippines, Singapore, Thailand):Reduced duties on 98.9% of all their products99.6% of these products are at tariff rates 0 to 5%

In 1995, the ASEAN Economic Ministers agreed to the In 1995, the ASEAN Economic Ministers agreed to the establishment of an ASEAN Common Market (AEC). establishment of an ASEAN Common Market (AEC). Aim to allow continued growth and prosperity in the region, Aim to allow continued growth and prosperity in the region, enabling the region to withstand global competition. enabling the region to withstand global competition.

A framework of an ASEAN Common Market was set up to A framework of an ASEAN Common Market was set up to substantially eliminate barriers to trade and services; in Bali substantially eliminate barriers to trade and services; in Bali 2003, this AEC was targetted to be established by 20202003, this AEC was targetted to be established by 2020

In 2007, the Economic Ministers met in Cebu, Philippines and In 2007, the Economic Ministers met in Cebu, Philippines and agreed to the following plan: -agreed to the following plan: -

1) Develop Asean into a single market1) Develop Asean into a single market

2) Eliminate tariffs and non-tariffs barriers2) Eliminate tariffs and non-tariffs barriers

3) Free movement of professionals3) Free movement of professionals

4) Encourage private participation4) Encourage private participation

5) Harmonise custom procedures5) Harmonise custom procedures

AFTA Mutual Recognition AFTA Mutual Recognition Arrangements: 2015Arrangements: 2015

A common market will no doubt benefit the health-care services as it A common market will no doubt benefit the health-care services as it facilitates the movement of talents, capital, goods, and services across facilitates the movement of talents, capital, goods, and services across the region. the region.

Steps were taken in 2004 in Vientiane, Laos during the ASEAN Summit Steps were taken in 2004 in Vientiane, Laos during the ASEAN Summit to harmonise standards and regulations for health services. to harmonise standards and regulations for health services.

The Economic Ministers further met in Bangkok early this year for The Economic Ministers further met in Bangkok early this year for further co-operation on trade in health services. A roadmap was drawn further co-operation on trade in health services. A roadmap was drawn up for the integration of the health care sector by 2010.up for the integration of the health care sector by 2010.

In August 2008, the Ministers met again in Singapore to help the In August 2008, the Ministers met again in Singapore to help the ASEAN partners move closer towards economic integration. ASEAN partners move closer towards economic integration.

Three Mutual Recognition Arrangements (MRAs) in Three Mutual Recognition Arrangements (MRAs) in the accounting, medical and dental fields were the accounting, medical and dental fields were signed by the ASEAN members as part of a bigger signed by the ASEAN members as part of a bigger goal of realising a liberalised and integrated ASEAN goal of realising a liberalised and integrated ASEAN economic community by 2015.economic community by 2015.

10th ASEAN Summit (20-24 Nov 2004) Ventiane: Priority Sectors for fast-tracking realisation of AEC

Health Services:Health Services:Healthcare service: Hospital, medical, dental Healthcare service: Hospital, medical, dental servicesservicesSocial work services: nursing homesSocial work services: nursing homesHuman helath activitiesHuman helath activitiesVeterinary servicesVeterinary services

Ancillary Healthcare services cover:Ancillary Healthcare services cover:Manufacture of pharmaceutical productsManufacture of pharmaceutical productsMedical equipment and devicesMedical equipment and devicesHealth insuranceHealth insuranceR&DR&DEducation and training of medical personnelEducation and training of medical personnel

AFTA: AimsAFTA: AimsHealth 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 stimulated—GDP increase—function of global prosperity?

Formulate ASEAN food safety policyHarmonisation 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.

The European Union (the EU) is the best example of a The European Union (the EU) is the best example of a long established Common Market model. long established Common Market model.

In the EU, the practice of a common market in health services has In the EU, the practice of a common market in health services has resulted in the following: -resulted in the following: -

1) Greater mobility of people from one member country to another to seek 1) Greater mobility of people from one member country to another to seek better and faster health care service.better and faster health care service.

2) Also greater mobility of doctors from one member country to another for 2) Also greater mobility of doctors from one member country to another for training and practices. training and practices. Little difficulty was encountered in the Little difficulty was encountered in the standardization of educational curriculum and training among the standardization of educational curriculum and training among the educational bodies. But there was much resistance from the professional educational bodies. But there was much resistance from the professional licensing bodies of the various member countries.licensing bodies of the various member countries.

3) Another feature was increased migration of doctors from member 3) Another feature was increased migration of doctors from member countries with lesser remuneration to member countries with higher countries with lesser remuneration to member countries with higher remuneration.remuneration.

4) The EU countries saw an increase in the number of private hospitals in 4) The EU countries saw an increase in the number of private hospitals in member countries with lower labour cost.member countries with lower labour cost.

5) The EU had encouraged more innovations of medical products, one of 5) The EU had encouraged more innovations of medical products, one of which was the invention and production of the Cypher Stents.which was the invention and production of the Cypher Stents.

6) In the United Kingdom, there was an increase in complaints of long waiting 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 lists and the poor service of the National Health Service when compared to some of the other EU countries.some of the other EU countries.

3 Players:3 Players: • the Patient/Citizen, the Patient/Citizen, • the Health Care Provider, andthe Health Care Provider, and• the Health Care Purchaser. the Health Care Purchaser.

3 Markets:3 Markets: • the Service, the Service, • the Expert, and the Expert, and • the Purchaser Markets.the Purchaser Markets.

Market-Orientated Health CareMarket-Orientated Health Care

First Player of the Health Market - First Player of the Health Market - The Patients/CitizensThe Patients/Citizens

a) The ASEAN population a) The ASEAN population sizesize and and economicseconomics, a huge , a huge

market potential consisting of market potential consisting of 589 million 589 million people with people with

GDPGDP of of 2.6 trillion US dollars.2.6 trillion US dollars.However the economic characteristics vary greatly among the However the economic characteristics vary greatly among the ASEAN member countries, ranging from a ASEAN member countries, ranging from a GDP of 710 US GDP of 710 US dollars per capita to 51,000 US dollars per capita.dollars per capita to 51,000 US dollars per capita.

b) Expect greater mobility of people among the ASEAN countriesb) Expect greater mobility of people among the ASEAN countries

——follows from waiver of visa among the ASEAN govts,follows from waiver of visa among the ASEAN govts,

— —introduction of budget air fares introduction of budget air fares

— —migration of workers among ASEAN member countries for migration of workers among ASEAN member countries for better employment opportunities and greater remunerations.better employment opportunities and greater remunerations.

c) With improved living standards and exposure to different c) With improved living standards and exposure to different lifestyles in the various ASEAN countries, lifestyles in the various ASEAN countries, healthcare healthcare expectation of patients is expected to riseexpectation of patients is expected to rise. .

Patients now have Patients now have better knowledge and understandingbetter knowledge and understanding on on diseases, and the treatments available. diseases, and the treatments available.

More importantly, patients are now presented with a More importantly, patients are now presented with a wider wider range of treatment optionsrange of treatment options available to them. available to them.

These options differ not just in terms of therapy offered, but These options differ not just in terms of therapy offered, but in in quality of care, and costquality of care, and cost. At the same time, they have . At the same time, they have greater expectations of the service provided.greater expectations of the service provided.

d) With improved living and educational standards of the d) With improved living and educational standards of the people in ASEAN, people in ASEAN, the pattern of diseases also changes,the pattern of diseases also changes, more heart or chronic ailments.more heart or chronic ailments.

First Player of the Health Market - First Player of the Health Market - The Patients/CitizensThe Patients/Citizens

Second Player of the Health Market – Second Player of the Health Market – The Health Care ProvidersThe Health Care Providers

a) Physicians: GPs and Specialistsa) Physicians: GPs and Specialists In an ASEAN Common Market setup, we In an ASEAN Common Market setup, we expect a greater expect a greater

mobility of doctors among the ASEAN countriesmobility of doctors among the ASEAN countries. Doctors . Doctors move from one country to another for move from one country to another for training, consultation and training, consultation and better remuneration and job opportunitiesbetter remuneration and job opportunities. .

Government health authorities will/should meet to Government health authorities will/should meet to standardize standardize the education curriculum and trainingthe education curriculum and training of the medical of the medical practitioners, including that of specialists and surgeons, the practitioners, including that of specialists and surgeons, the various various subspecialty bodiessubspecialty bodies would have to help in giving would have to help in giving relevant inputs and recommendations to the Government relevant inputs and recommendations to the Government authorities.authorities.

There is a There is a large variation in density of specialists in relation to large variation in density of specialists in relation to populationpopulation. Patients from areas with low density of specialists . Patients from areas with low density of specialists will seek treatment in places where the specialists are more will seek treatment in places where the specialists are more accessible.accessible.


b) The Hospitals.b) The Hospitals.

1) 1) Privatization over public ownershipPrivatization over public ownership will be more common in market- will be more common in market-orientated medicine. We expect increase in the number of private orientated medicine. We expect increase in the number of private hospitals in the ASEAN countries. Presently with the exception of hospitals in the ASEAN countries. Presently with the exception of Cambodia and Laos, highly specialised care/surgery services are Cambodia and Laos, highly specialised care/surgery services are available in many of the private hospitals in the ASEAN countries. available in many of the private hospitals in the ASEAN countries. With With greater mobility of health workers there may be a shift of private greater mobility of health workers there may be a shift of private hospitals to countries with lower labour cost.hospitals to countries with lower labour cost.

2) Private expected to bring in foreign exchange to member ASEAN. 2) Private expected to bring in foreign exchange to member ASEAN. Medical tourismMedical tourism is greatly encouraged by the Governments of the is greatly encouraged by the Governments of the Philippines, Thailand, Malaysia and Singapore. In the Philippines Philippines, Thailand, Malaysia and Singapore. In the Philippines incentives such as tax relief are offered to encourage the development incentives such as tax relief are offered to encourage the development an construction of private hospitals. Indonesia too is building new, well an construction of private hospitals. Indonesia too is building new, well equipped private hospitals for its well-to-do patients.equipped private hospitals for its well-to-do patients.

3) Another good outcome that can be expected will be 3) Another good outcome that can be expected will be hospitals striving to hospitals striving to attain recognised standard of health care as a result of keen competition attain recognised standard of health care as a result of keen competition among the private hospitals.among the private hospitals. Many hospitals now seek accreditation Many hospitals now seek accreditation from the Joint Commission International for quality management and from the Joint Commission International for quality management and health-care service. To-date, there are 21 private hospitals in the ASEAN health-care service. To-date, there are 21 private hospitals in the ASEAN member countries with JCI certification.member countries with JCI certification.


b) The Hospitals.b) The Hospitals.

4) 4) Large growing market for health care will lead to segmentation of Large growing market for health care will lead to segmentation of various kinds of private hospital catering to the different needs/sectors various kinds of private hospital catering to the different needs/sectors of patients. of patients.

Some private hospitals thrive on offering top-class quality medical care 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 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 Group Healthcare Pte Ltd is building a US 1.5 billion-dollar luxurious state-of-the-art hospital in Singapore.state-of-the-art hospital in Singapore.

5) With more private hospitals being set up, there will be an 5) With more private hospitals being set up, there will be an increase in job increase in job opportunities for the doctors and health-care workersopportunities for the doctors and health-care workers, in the region with , in the region with no border restraints.no border restraints.

6) A large market base will also enable some hospitals to go into 6) A large market base will also enable some hospitals to go into more more specialized disciplines and servicesspecialized disciplines and services for example, neonatal surgery and for example, neonatal surgery and robotic surgery.robotic surgery.

7) The market will also 7) The market will also encourage greater innovationsencourage greater innovations and use of new and use of new devices, for example, new biotech/genomic and stem cell therapy.devices, for example, new biotech/genomic and stem cell therapy.

Third Player of the Health Market – Third Player of the Health Market – The Health Care PurchaserThe Health Care Purchaser

1. 1. Patients in public hospitals of all ASEAN countries are now receiving free Patients in public hospitals of all ASEAN countries are now receiving free or heavily subsidized medical treatments.or heavily subsidized medical treatments. Vietnam and Singapore have Vietnam and Singapore have co-insurance payment by employers and employees so that more citizens co-insurance payment by employers and employees so that more citizens can seek treatment in private hospitals.can seek treatment in private hospitals.

2. 2. Private health insurance coverage among ASEAN countries at present is Private health insurance coverage among ASEAN countries at present is still very low, ranging from 0 to 20%.still very low, ranging from 0 to 20%.

There is great opportunity for private investors to invest in this area; but There is great opportunity for private investors to invest in this area; but would for-profit motives drive up health care costs?would for-profit motives drive up health care costs?

The insurance planners can design and provide different health The insurance planners can design and provide different health packages and market them according to the needs of the patient. packages and market them according to the needs of the patient.

Insurance agencies can tailor and organise different kinds of Insurance agencies can tailor and organise different kinds of health/medical packages for their clients. They range from budget to an health/medical packages for their clients. They range from budget to an exquisite care, from mass to private luxuries, etc.exquisite care, from mass to private luxuries, etc.

Problem: what about the uninsured or those unable to insure?Problem: what about the uninsured or those unable to insure?

3. 3. Can emergence of insurance planners & international referring agencies Can emergence of insurance planners & international referring agencies help lower the cost of medical treatment? help lower the cost of medical treatment?

May be tendency to dictate and limit the types of treatment available; May be tendency to dictate and limit the types of treatment available; case and risk selection worries are real…case and risk selection worries are real…

ASEAN Common Market on ASEAN Common Market on Health Services: Benefit Health Services: Benefit

The most immediate benefits would likely be:The most immediate benefits would likely be:

1. An ASEAN Common Market on Health Services will mean 1. An ASEAN Common Market on Health Services will mean greater greater access to better quality healthcareaccess to better quality healthcare to the people of ASEAN. to the people of ASEAN.

2. An ASEAN Common Market on Health Services encourages the 2. An ASEAN Common Market on Health Services encourages the setting up of setting up of specialised medical centresspecialised medical centres that focus on the use of that focus on the use of sophisticated medical equipmentsophisticated medical equipment and advance state of the art and advance state of the art treatment; but treatment; but cost is likely to escalate…cost is likely to escalate…

3. As the healthcare expectations of people increase, 3. As the healthcare expectations of people increase, public hospitals public hospitals will be motivated to improvewill be motivated to improve, thereby further raising the general , thereby further raising the general standard of health care in ASEAN.standard of health care in ASEAN.

4. Richer, 4. Richer, more developed nations such as Singapore may benefit more more developed nations such as Singapore may benefit more than poorerthan poorer countries such as Laos and Cambodia, as freer countries such as Laos and Cambodia, as freer movement of its specialists or large physician or hospital groups movement of its specialists or large physician or hospital groups (more established and experienced) can tap into the larger (more established and experienced) can tap into the larger population of the wealthier citizens of other ASEAN nations.population of the wealthier citizens of other ASEAN nations.

1. 1. Inequity/disparity of healthcare access is a real threat:Inequity/disparity of healthcare access is a real threat: The care The care treatment extended to the rich and the poor will vary; the very treatment extended to the rich and the poor will vary; the very poor or uninsured/uninsurable will very likely be left out.poor or uninsured/uninsurable will very likely be left out.

2. 2. Outward migration of already short-staffed expertise:Outward migration of already short-staffed expertise: Easy Easy mobility enhanced by attractive job opportunity and prospect mobility enhanced by attractive job opportunity and prospect may result in shortage of doctors in the outlying areas and may result in shortage of doctors in the outlying areas and poorer regions where patients desperately need specialised care.poorer regions where patients desperately need specialised care.

3. 3. Market forces may encourage popularisation of specialist Market forces may encourage popularisation of specialist treatmentstreatments, interventional rather than simpler treatment , interventional rather than simpler treatment strategies that are more profitable to the Health Care Providers.strategies that are more profitable to the Health Care Providers.

4. 4. Information Asymmetry and Difficult Patient Choices:Information Asymmetry and Difficult Patient Choices: Patients Patients face difficulty in making informed choices in treatment arising face difficulty in making informed choices in treatment arising from unequal relationship between the Patient and the Health from unequal relationship between the Patient and the Health Care Provider.Care Provider.

ASEAN Common Market on ASEAN Common Market on Health Services: Challenges Health Services: Challenges

AFTA/WTO: Current status of AFTA/WTO: Current status of LiberalisationLiberalisation

Legal Profession:Legal Profession: only Malaysian citizens or only Malaysian citizens or permanent residents admitted to the Bar. Foreign permanent residents admitted to the Bar. Foreign lawyers can appear before Malaysian court with lawyers can appear before Malaysian court with sepcial Admission certificates from AG’s office. sepcial Admission certificates from AG’s office. Admission regulated under Legal Profession Act, Admission regulated under Legal Profession Act, slightly dfferent for Sabah/Sarawakslightly dfferent for Sabah/Sarawak

Medical Services:Medical Services: – Right now, only recognised medical colleges and their Right now, only recognised medical colleges and their

graduates who must be citizens/permanent residents, allowed graduates who must be citizens/permanent residents, allowed to practice in the country. to practice in the country.

– Foreigners allowed on temporary licenses depending on Foreigners allowed on temporary licenses depending on application from employing or contracting institutions; usually application from employing or contracting institutions; usually for medical post-graduate training/research, but still must be for medical post-graduate training/research, but still must be registered with MMC and given temporary or limited registered with MMC and given temporary or limited registrations; registrations;

– Such registrations are not available for family or general Such registrations are not available for family or general practitioners, great difficulties even with foreign spouses of practitioners, great difficulties even with foreign spouses of Malaysian citizensMalaysian citizens

AFTA 2013/GATS/WTOAFTA 2013/GATS/WTOWhat does this mean for Malaysia?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 group—no 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 ASEAN—MMC is looking into this to see if this contravenes the AFTA charter vis-à-vis our Medical Act.

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?

Will AEC go the way of EU?ASEAN Secretary-General One Keng Meng:ASEAN Secretary-General One Keng Meng: ““The EU has a common currency. They have free movement The EU has a common currency. They have free movement

of people. We don’t think SEA countries are ready to do this. of people. We don’t think SEA countries are ready to do this. ““What we care seeing in ASEAN is more the movement of What we care seeing in ASEAN is more the movement of

professional people, skilled people. We cannot be like the EU professional people, skilled people. We cannot be like the EU which allows free movement of people. which allows free movement of people.

““Many of our countries are still relatively insecure, and if you Many of our countries are still relatively insecure, and if you have complete free movement of people, you can see have complete free movement of people, you can see thousands more coming into a small country or thousands thousands more coming into a small country or thousands more going where the market is good. more going where the market is good.

““The local population may not be ready to welcome the The local population may not be ready to welcome the competition from the guy next door.”competition from the guy next door.”

Will Malaysians be so ready to welcome our ASEAN brethren?Will Malaysians be so ready to welcome our ASEAN brethren? Will our doctors be prepared for the challenges and Will our doctors be prepared for the challenges and

competition?competition?

Source: http://english.vietnamnet.vn/2006/10/625580/Source: http://english.vietnamnet.vn/2006/10/625580/

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

““There is a canker corroding the soul of society. There is a canker corroding the soul of society. Economic rationalism: the all-pervasive nature of Economic rationalism: the all-pervasive nature of competition; anti-social behaviour in many aspects of competition; anti-social behaviour in many aspects of life and across all levels of society; life and across all levels of society; the unrestrained the unrestrained consumerism of a surging global populationconsumerism of a surging global population, together , together with the consequent deterioration of our natural with the consequent deterioration of our natural environment; and the dizzying rate of escalating environment; and the dizzying rate of escalating social and technological change are, for many people, social and technological change are, for many people, signs of cultural disengagement illuminating signs of cultural disengagement illuminating industrialism’s final convulsions. These convulsions industrialism’s final convulsions. These convulsions are reflected in increasing corruption, crime rates and are reflected in increasing corruption, crime rates and levels of stress, soaring public investment costs, levels of stress, soaring public investment costs, disenchantment with our institutions and a growing disenchantment with our institutions and a growing mistrust of authority.”mistrust of authority.”

Richard David Hames. Burying the 20th Century, 1997, Business and Professional Publishing,

Australia

People’s Health Movement

People’s Health Movement

People’s Charter for Health

People’s Charter for Health

Health as a Human Right; Is a Human Right?

Health as a Human Right; Is a Human Right?

Health worker density – Global Discrepancy / Inequity

Health worker density – Global Discrepancy / Inequity

Health workers migrate toward richer countries; loss from poorer lower-income country esp. public sector

Migrant health workers from poorer nations usually drift toward richer nations

So, what do I feel about So, what do I feel about globalisation, AFTA, and health?globalisation, AFTA, and health?

I’m cautiously optimisticI’m cautiously optimistic I don’t favour unrestrained free trade which can impact I don’t favour unrestrained free trade which can impact

significantly on weaker institutions and societies, often creating significantly on weaker institutions and societies, often creating more pain and hardshipmore pain and hardship

Globalisation is not inevitable or unstoppable, there are viable Globalisation is not inevitable or unstoppable, there are viable alternative models alternative models (not TINA i.e. ‘there is no alternative’) (not TINA i.e. ‘there is no alternative’) where where trade/capital is not the centre of civilisational or human progresstrade/capital is not the centre of civilisational or human progress

Cultural, traditional and humane activities, local meaningful Cultural, traditional and humane activities, local meaningful betterment of individuals or groups are perhaps a more desired betterment of individuals or groups are perhaps a more desired goalgoal

There might still be time enough to modify or help reshape the There might still be time enough to modify or help reshape the not invariable not invariable postures of free trade and globalisation excesses.postures of free trade and globalisation excesses.

Do we all have a collective will to think and act differently?Do we all have a collective will to think and act differently?

Myths of Globalisation and the Free-trade Paradigm Myths of Globalisation and the Free-trade Paradigm ~ Graham Dunkley (Free Trade—Myth, reality and alternatives, 2004, ~ Graham Dunkley (Free Trade—Myth, reality and alternatives, 2004,

Zed BooksZed Books

3 false assumptions:3 false assumptions:– Globalisation is now well advancedGlobalisation is now well advanced– It is inevitable and unstoppableIt is inevitable and unstoppable– It is overwhelmingly good for virtually everybodyIt is overwhelmingly good for virtually everybody

Adverse impacts include:Adverse impacts include:– Integrative effects (homogenisation of legal or Integrative effects (homogenisation of legal or

administrative practices)administrative practices)– Displacement effects (destruction of one culture Displacement effects (destruction of one culture

by another)by another)– Disruption effects (social or other dislocation)Disruption effects (social or other dislocation)

Myths of the Free-trade Paradigm Myths of the Free-trade Paradigm ~ Graham Dunkley (Free Trade—Myth, reality and ~ Graham Dunkley (Free Trade—Myth, reality and

alternatives, 2004, Zed Booksalternatives, 2004, Zed Books

5 false assumptions:5 false assumptions:– Trading is anciently integral to human natureTrading is anciently integral to human nature– Free trade, free markets and private initiative Free trade, free markets and private initiative

are best for most exchange are best for most exchange – ‘‘comparative advantage’ is the best basis for comparative advantage’ is the best basis for

all goods and servicesall goods and services– Trading and free trade have, on balance, Trading and free trade have, on balance,

overwhelmingly net positive benefits for all overwhelmingly net positive benefits for all concernedconcerned

– Amount of trading has gradually increased Amount of trading has gradually increased over time, indicating inevitable globalismover time, indicating inevitable globalism

4 Alternative Models4 Alternative ModelsFree Market Economic Rationalist Free Market Economic Rationalist

(Smith/Ricardo) approach(Smith/Ricardo) approachMarket Interventionist Market Interventionist

(Keynes/Kaldor) approach(Keynes/Kaldor) approachHuman Development (Marx/Sen) Human Development (Marx/Sen)

approachapproachCommunity Sovereignty Community Sovereignty

(Gandhi/Schumacher) approach(Gandhi/Schumacher) approach

Human Development (Marx/Sen) Human Development (Marx/Sen) approachapproach

Amartya Sen (Nobel laureate) accepts general Amartya Sen (Nobel laureate) accepts general market principles, current forms of globalisation, market principles, current forms of globalisation, reasonably free trade and longer-term growth-reasonably free trade and longer-term growth-oriented goodsoriented goods

But believe in ‘human capacity development’ i.e. But believe in ‘human capacity development’ i.e. capacity expansion which implies collective capacity expansion which implies collective benefit provisions such as infrastructure, health, benefit provisions such as infrastructure, health, education, literacy, training, female employment, education, literacy, training, female employment, general social development; also people general social development; also people sustenances through collective security and sustenances through collective security and market-derived income; some public market-derived income; some public redistribution which leads to social justice.redistribution which leads to social justice.

Gandhian Principles…Gandhian Principles…AhimsaAhimsa (Non-violence) (Non-violence)Satyagraha Satyagraha (non-violent recitification of wrongs, (non-violent recitification of wrongs,

restrained political action)restrained political action)Sarvodarya Sarvodarya (respect and justice for all)(respect and justice for all)SwadeshiSwadeshi (sovereignty and self-reliance for (sovereignty and self-reliance for

communities and nations)communities and nations)

Gandhi regarded & opposed rampant economic growth as morally Gandhi regarded & opposed rampant economic growth as morally corrupting, free trade as socially destructive and copying of the west corrupting, free trade as socially destructive and copying of the west as degrading...as degrading...

He advocated national self-reliance and self-restraints to consumption He advocated national self-reliance and self-restraints to consumption (Satya Sai Baba’s “ceiling on desires”), simple technologies and (Satya Sai Baba’s “ceiling on desires”), simple technologies and lifestyleslifestyles

Schumacher (1973)Schumacher (1973)Heavily influenced by Gandhi, Buddhist Heavily influenced by Gandhi, Buddhist

precept of “right livelihood”precept of “right livelihood”Individuals should do what is morally right and Individuals should do what is morally right and

environmentally requisiteenvironmentally requisiteEconomic policies should be ethical, Economic policies should be ethical,

ecological, people-centred and spiritualecological, people-centred and spiritualAppropriate and intermediate technology and Appropriate and intermediate technology and

development, without creating too much development, without creating too much unnecessary mobility, structural instability, unnecessary mobility, structural instability, community decay and general ‘footlooseness’community decay and general ‘footlooseness’

medical globalization by dr david quek

Health & Medicine