Bangalore heart trip – self-inflicted malady of Malaysian healthcare

Letters
by GS

When Chua Soi Lek first came to office, he apparently called for a meeting of all senior officers and when asked about the priority of problems at the Ministry of Health, he reportedly was inundated with numerous comments about the dastardly troubles private hospitals had created and how they and their devious doctors were leeching the poor Malaysian public and something had to be done urgently. The gullible Chua, ever willing to show-off the political strongman that he conjured himself to be, wasted no time in implementing the shelved PHFSA and together with his DG, utilizing the BN’s brute but now mercifully clipped majority in parliament, brushing off all objections against the Act just so he can show who’s boss. Needless to say despite all of Chua’s and Merican’s big talk and assurances, the first victim who got thrown into jail was a registered doctor, a stark reminder of the previous government’s callous and appalling methods of governance.

New Health Ministers are almost always a shoo in for our health ministry officials who have become rather slick in cornering incoming, inexperienced and invariably unknowledgeable Ministers into making silly decisions. All Ministers are political animals and make distorted decisions essentially because the minister is fed only half the story or the story he generally likes to hear. And so it is with the new health minister Liow Tiong Lai.

While Tanzanian president, Jakaya Kikwete, was going on an all out war against witchdoctors (read bomohs, sinsehs, etc) who were gorging out eyes of albinos and the Brazilians were calling in the army and possibly Cuban doctors to help battle the mortal incidence of dengue in that country, back in Malaysia, the hapless Liow had thrust upon him a meaningless business turf battle between pharmacists and doctors as his first task. The Brazilians must have wondered about the priority of the Malaysian health minister and cannot be faulted if they thought that Malaysians had indeed licked the dengue scourge and were actually moving on to bigger stuff.

Far from it. The dengue fever outbreak in Brazil had infected 55,000 people, and killed 67 Brazilians so far this year with half of those killed by the mosquito-borne illness being under 13-years-old. But Malaysia’s “Disease Control Director”, Hasan Abdul Rahman reported a proportionately higher mortality ratio of 9,889 people diagnosed, with 26 of them dead for the first three months from January to March alone of this year. Maybe we may have something to learn from the Brazilians or more likely our stats are out of sync.

But these problems will pale into comparison as the new and inexperienced health minister has made a second momentous decision. That of shipping unfortunate children with congenital heart disease to Devi Shetty’s “world famous” heart center 2000 miles away in Bangalore, the Narayana Hrudayalaya. Even Chua, known to be a brusque decision maker refused to take this decision. But the new health minister had no qualms sending these children off….or was he pushed into make this decision.

When the NST published their under-researched cum marketing piece for the IJN on the lack of heart surgeons and the need for critical care for paediatric cardiac surgical patients in a center spread on 2/4/08, they didn’t quite delve into the factors as to why this country has not caught up with the rest of the world or at least India, despite the government spending millions to curb the rising incidence of heart disease. Paradoxically, after 50 years of Merdeka, we are in fact sending off patients overseas for treatment just like the Mauritius, Ghana, Nigeria, Sierra Leone and Bangladesh to the Narayana Hrudayalaya Institute of Medical Sciences (NHIMS) Do we not have the expertise? Elementary. It is just poor management of our resources.

PUBLIC HOSPITALS OFFERING CARDIAC SURGERY

The government has five heart units. The unit in Penang was established in 1995 at a cost of RM30 million, followed by Johor Bahru in 1997 for RM40 million and Kuching in 2001 for RM55 million. A new unit was set up at Alor Star when the new Sultan Bahiyah hospital was being constructed midway causing the hospital to have serious delays in its opening and another at Serdang Hospital which has been designated as the Ministry’s heart center for the Klang Valley. Surprisingly despite the government spending millions on infrastructure, little attention was paid to manpower leaving many of its units underutilized or not operational.

There are no paediatric cardiac surgical services at government hospitals save for a small number being attempted by an expatriate surgeon in Kuching. The Penang unit although busy in the beginning, had its work slowed down when the initial surgeon resigned. It further attracted controversy when expensive and untested cardiac equipment bought for millions of ringgit ended up as a white elephant. It was in the news again in 2005 when surgeons left the unit in droves when anesthetists there tried to take control of the cardiac surgical ICU which has always been the domain of cardiac surgeons throughout the world. The unit was then briefly run by an Indonesian-born doctor who surprisingly was awarded a JPA scholarship to do his training. However patients complaining at the greatly-lengthened waiting list reportedly as a result of the new surgeon being unable to do bypass surgery there saw the Ministry moving some of its doctors from Johor Bahru to cover the unit. The Indonesian surgeon, in a bizarre move by the MOH, has been transferred to head the Serdang unit.

The Unit at JB was initially run by a British trained Malaysian surgeon who left for Singapore leaving the unit now running only on a single theater at times. The Kuching Hospital unit is one of the better run units at the Ministry. One of the reasons for this is the high level of commitment of doctors there and the support financially by the local community. Despite the lack of manpower, the Ministry is planning to open more units in other areas such as Ipoh, Kuantan and Kota Kinabalu. In KK alone, the MOH announced last month that it will be spending RM70 million. Even planning administrators in the Ministry have argued that that there should be a period of consolidation instead of splurging more capital until manpower problems are sorted out. But these reservations have apparently been over-ruled by the surgeons and anesthetists. It is always nice to splurge … if it is not your own money, especially if it brings you fringe benefits like more overseas trips for “lawatan sambil belajar”

PRIVATE HOSPITALS OFFERING CARDIAC SURGERY

There are in total 23 units doing cardiac surgery in the private sector. One in Alor Star, 4 in Penang, one in Ipoh (apparently now defunct), 9 in the Klang Valley, three in Malacca, one in JB, one in KK and one in Kucing. Only the Adventist Hospital in Penang and Gleneagles in KL do paediatric cardiac surgical cases in significant numbers. The rest are essentially adult units. Most private units are solo runs by individual surgeons. As a result they do small numbers. However the Penang and Malacca units cater for quite a number of foreign patients especially from Indonesia.

IJN

In the early eighties, the GHKL was the only heart unit the MOH had. It was controversially corporatised to IJN soon after Mahathir had his heart surgery. Many then thought that perhaps corporatisation of this service will soon see Malaysia self sufficient in this particular area but as always in the Malaysian scene, corporatisation comes with strings attached. IJN’s founders made a deal where all heart cases in the central region must be solely given to them. They didn’t want any competition.

But despite being a monopoly they couldn’t hold on to their surgeons. One paediatric cardiac surgeon resigned to go to Gleneagles while two more found cushy jobs in Saudi. So it has gone back to the same routine of trying to train more surgeons. Despite the high volume of cases it does, it apparently lacks space which may be resolved when its new building is commissioned. Interestingly IJN offered to run the Serdang Hospital Heart Unit for the Ministry but this deal was obstructed by the Ministry’s own surgeons. You sometimes wonder if everyone in this area is really working for the common good of patients..or for themselves…at the expense of the general public…with the Ministry and their political masters…the MCA doing nothing.

TRAINING PROGRAMS

So why are we not training enough heart doctors? There are three university heart units based at the UH, HUKM and HUSM in Kubang Kerian respectively. But the volume of surgery and procedures done are small, especially in Kubang Krian despite the disproportionately large incidence of coronary, valvular and congenital heart disease in Kelantan. The UIA in Kuantan apparently has been enthusiastic about setting up a heart unit there but again there was a problem regarding manpower and commitment by some of its specialists and of course the unending destructive rivalry between the MOH and the Universities. The price you pay if you don’t have your own hospital.

The first open heart unit this country ever had was the one established as early as 1969 at the University Hospital by NK Yong who took up the post of Foundation Professor in Surgery when the UM’s Medical Faculty was first set up. He had trained at Kentucky University and despite virtually no trained staff he performed Singapore’s first open heart surgery in 1965 after painstakingly assembling and training a cardiac team for two years following his return from the US in 1963.

His presence at the UH saw the emergence of new surgeons such as Saw Huat Seong and the late Razali Hashim. The unit was further strengthened by an expatriate surgeon from the Christian Medical College in Vellore, George Cherian. But all this came to an end when Razali passed away prematurely almost 20 yeas ago. Saw Huat Seong is in private practice in Singapore, George is in Kansas and NK Yong is of course retired and is now a famed wine connoisseur. The heart unit at the UH today is more renowned for fist fights and slapping incidents with no trainees forthcoming. While heart units around the world progressed by leaps and bounds, the UH unit stagnated and in fact regressed. The country’s pioneer unit fell victim to medical politics and to the tantrums of the remaining surgeon when heart disease was the pre-eminent killer with irresponsible University authorities just looking on, doing nothing or dabbling in trying to sell off university grounds.

UKM, which initially suffered a similar fate when it set up its unit a decade ago, has progressed much better and proposed a training program for cardiac surgery last year to the Ministry but it has yet to get off the ground. Again medical politics and unbridled, cumbersome, attritional professional jealousy has been the bane that threatens the progress of heart treatment in this country. The MOH and university authorities are in particular guilty of not dealing with these problems firmly, instead pandering to the whims and fancies of individual specialists against national interests leading Malaysian patients now possibly to that dusty road to Bangalore.

THE NARAYANA HRUDAYALAYA

The center is primarily the brain child of Devi Shetty who initially trained at Guys Hospital in London where Philip Deverall, a British pioneering and innovative paediatric heart surgeon was based. He has no formal postgraduate cardiac qualifications unlike most Indian cardiac surgeons. However, apart from the thousands of cases he has carried out, he has conducted hundreds of seminars, wrote innumerable papers, created many training programs and of course built and managed quite a few heart hospitals. Devi Shetty is living proof that clinical and operative skills may not necessarily be congruent to academic qualifications, something our local MMC (Malaysian Medical Council) should wake up to. Dedication and commitment could be far more valuable factors. In fact in all likelihood; Devi Shetty might not even get a job if he applies for one at the MOH as his qualifications would have been deemed by our “elite” council members as “not recognized”

Shetty returned to India in 1989 to set up a hospital for the Birla group in Calcutta before ultimately moving onto Bangalore to found the Narayana in 2001. He is married to Shakunthala Shetty, the daughter of the wealthy construction magnate Sri Charmakki Narayana Shetty, who owned the land where the 800 bedded hospital is situated. The Narayana Hrudayalaya is located in the Bommasandra Industrial Area on the outskirts of Bangalore on 25 acres of land, 30 km from the old Bangalore airport and 50km from the new one. The grimy road leading to the hospital where the pillars of Bangalore’s off/on Metro project stick out like sore thumbs may not really be palatable to Malaysian patients or parents used to our highways. But the hospital itself is a remarkable story.

The hospital design is simple and furnishing is bare. It has 25 operating theaters for cardiac surgery alone of which half are currently operational. Shetty’s group which includes surgeons trained in India, Australia, Britain and Russia carry out an astonishing 20 to 30 open heart surgeries a day, clocking close to almost 6000 cases a year. Of these a third are congenital cases.

Devi Shetty is one of India’s many rising entrepreneurial hospital pioneers who have contributed immensely to not only healthcare in India but also to its economy. They believe not only in bringing world class healthcare to India’s poor but are firm believers of strict financial prudence so that treatment remains extremely cost effective, a culture virtually absent in the Malaysian healthcare scene especially in government hospitals. In a country where the incidence of congenital heart disease is 8 per 1000 births against a questionable 1 per 1000 in Malaysia, India has 180,000 children born with congenital heart defects every year with 90,000 requiring early intervention at the neonatal stage.

Shetty’s strategy for success is simple. Focus on maintaining good results which are the accepted 2% mortality for adult cases and an incredible 5% mortality for congenital heart surgery considering that some very complex cases end up here. And an innovative packaged price for treatment. Heart hospitals are expensive. And if you are going to extend complex world class surgery to the poor, then, to make that buck, you need to operate a large volume of cases which is not a problem in India. Shetty maintains a fixed price of almost RM10,000 ringgit for each paediatric case no matter how complex the lesions are, making his money back through volume.

He doesn’t compromise on equipment which is pretty similar to the ones Malaysian hospitals have. He further saves on costs especially on medication, equipment and consumables which are indigenously manufactured. But the most important asset he has is the great depth in staff required to look after patients. And this he does by having active academic programs which is headed completely by a dedicated academic dean. No one is actually sure why Chua was attracted to this hospital. Perhaps he was impressed by the shear numbers of the assembly like care patients received in diagnostics, theater and especially the ICU. Or maybe he was influenced by an ex-senior health ministry official who is the Dean of a local private medical school which has a twinning program with a medical school in Bangalore where Shetty maintains a branch.

Whatever it is, Shetty has done remarkably well. And this he managed to achieve through sheer hard work and perseverance. To operate such a large volume of cases with a low mortality he would have had to climb that agonizing learning curve and cross a lot of dead bodies, something Malaysian surgeons are anathema to, focusing rather on safe, less complex cases. To be successful in paediatric cardiac surgery you will have to run through that deadly gauntlet that ended the careers of Professor James Wisheart and Janardan Dhasmana at the Bristol Royal Infirmary in 1999. Both found out to their costs that taking the risky gamble of operating on paediatric cardiac surgical patients with iffy paediatric cardiologists, anesthetists and ICU staff can not only end your career but may get you profoundly vilified for the rest of your life.

But certainly Shetty’s hospital is not the only one doing similar surgery at these prices. There are almost 200 centers in India that offer heart surgery in India. In South India alone, the level of work that is carried out at the Narayana is done in 11 other paediatric cardiac surgical centers with the total number of paediatric cardiac surgical units throughout India numbering about 20. Some of these centers like the Amrita Heart Institute, Cherian Heat Foundation, Madras Medical Mission, Ramachandra Medical College, CMC Vellore, MIOT and the Asian Heart Institute in Bombay produce very good results but do not match Shetty’s costs. On average, the cost of treating a congenital heart defect can cost between RM20-30,000 per case. Surprisingly only a single government hospital, the All India Institute of Medical Sciences (AIIMS) in Delhi, does any neotatal cardiac surgery of note. And every heart surgeon in the private sector in India will swear that the price of similar surgery at the government funded AIIMS is far costlier then the ones done in private centers, a testimony that accountability in subsidized healthcare is almost always never accountable to anyone, anywhere around the world including Malaysia.

SOLUTIONS

The MOH stated that an agreement had been reached to operate on 200 children at a cost of RM10,000 for each child over a period of one year excluding incidental costs. These costs would be probably flight fares, food, accommodation, etc which may put the cost at about RM15,000 or more, provided there are no complications. Paediatric cardiac surgical cases are generally divided into cyanotic and acyanotic babies, meaning blue and non-blue babies. It is the blue babies that are difficult to manage, are costlier to operate on and generally would require complex surgery including initial palliative surgery if expertise for complete correction is not available in the first instance.

The Ministry could:

1. Outsource non-blue baby and palliative surgery for blue babies to local private hospitals at a competitive price as this will be logistically more suitable for the family. Blue babies that will require complex staged surgery could perhaps be flown to Bangalore although there will be risks involved for the 3 hour flight and that perilous road journey to the Narayana itself.

2. Alternatively it could ask local surgeons or their surgical teams in “not so busy” private hospitals to operate in the Ministry’s government units so that there are savings in consumables and theater time. Since the Ministry has the infrastructure but not the staff, perioperative care could also be contracted out.

3. Or it could invite foreign surgical teams or surgeons to operate at its heart units on a regular basis to do surgery. Cases that don’t require urgent surgery could be accumulated and be done on a regular monthly basis with our local surgeons and hospital staff looking after them. It would be a good learning experience for them although cases need to be carefully chosen.

4. Or allow private hospitals to employ these foreign surgeons or teams directly and the Ministry outsources the work to these hospitals. Foreign medical staff, especially surgeons, anesthetists and cardiologists could be offered incentives like PR and citizenship etc so that they stay back in this country.

5. And importantly, the Universities and the MOH have to revise their training programs to ensure that Malaysia’s expertise in this area rises to match the number of patients in this country.

Whoever did this marketing for the Bangalore team may have done Shetty a large favour and a disservice to cardiac care in this country. But this story is the natural end result of a poorly managed service that saw no proper audit in cost production ratios. It is sad refection of the state of services in this country where for far too long the focus has been on constructing sophisticated infrastructure without paying attention to human development in direct contrast to India where the reverse has taken place.

Before the Minister dives into the uncharted National Health Financing Scheme, he should perhaps ponder if outsourcing healthcare to private hospitals that offer competitive pricing is a better option. The Ministry should refrain from reinventing the wheel all the time by building more heart units that only make contractors and suppliers rich, and instead save its financial resources and perhaps outsource its work to hospitals that provide a service at very cost effective prices. You can save a whole lot of money in places like Kota Kinabalu where instead of blowing 70 million ringgit, you can buy services from the Sabah Medical Center where its cardiac operating theater and 12 ICU beds are almost always lying idle.

Competition and innovation is the key to lower prices and better services. If the Malaysian public is to be saved, the confrontational policies of the previous Minister and DG must end. There must be greater cooperation between the large numbers of private doctors and the public service. Failure by Liow to handle this impasse effectively will ultimately see not only cardiac going India way but a whole lot more of other specialties.