Still here

We took an evening stroll down the Tonle Sap river at Chroy Changvar today. The exact same place I described in this blog post where I wrote about ‘the kind of day I wish to live all my life’. Well, guess what? 3 years later, I still get to live that kind of day, but with more fun company with my wife and son by my side. We’ve been spending the last 4 months in Phnom Penh, with some periods of time back in Malaysia (our visa only lasts for 1 month per entry), and so far, it has been a pretty fun stay!

Walking along the Tonle Sap river

I am here for my doctoral thesis project to enable value-based health care at HBB Clinic. For that, I implemented a cloud web-based electronic medical record (EMR) that I had developed myself (learned coding from scratch, JavaScript to be precise – React.js to be even more precise). I had to develop it myself because currently there’s no EMR that captures all the data needed to assess value of care all in one system - including clinical data, patient-reported outcomes, activity-based costing and timing data. 

Screenshot of sample patient from my EMR

Phnom Penh might not be the most convenient city to live in, but I guess it is the activity that we do here every day that made the stay more meaningful than living in a big city with a better amount of resource. There is a different kind of satisfaction when you wake up in the morning and know exactly what to do and being aware that every decision will make an observable difference. Another huge plus-point is being able to do all this while being flexible with our time - very important for a family with a one-and a half year old!

I usually wake up early to make sure I wake up before Umar does. I could get a solid couple hour of work done at this time. When Umar wakes up, we get ready for breakfast. Kamaliah usually prepares breakfast while I take Umar for shower, but sometimes we just get ready for the day and go to a nearby ‘Mamak’ restaurant when we miss eating ‘roti canai’ and ‘the tarik’.

While here, Kamaliah manages a hearing care center called HCC, started by my family a year ago. She’s in charge of 3 full time staffs working there, so sometimes she will have meetings with HCC staffs in the morning, so we depart to HBB later in the afternoon.

Prof Sharaf, Malaysian Orthopedic Surgeon and long-time family friend, visits HCC

So, I am back to doing what I was doing 3 years ago, in charge of the 5-staffed HBB Clinic. HBB is around 30 minutes away from HCC. We always go there together. At HBB, I help the staff use the newly implemented EMR, listen to their suggestions, teach them a bit on value-based care and do meetings to discuss about HBB in general while Umar plays with the cat and Kamaliah looks after him. Sometimes, we get visitors from Malaysia, so we take them for a tour around Phnom Penh and HBB.

Teaching the staff to use the EMR

During this time, I also oversee a renovation of the clinic. It has been 4 years since the clinic was launched – it’s time for a new look!

Before

After

Before

After

In the late afternoon, we take walks, sometimes along the river like today, sometimes in shopping malls, or if we’re too lazy to walk we’ll just hangout at one of the new hipster cafés or Boba tea joints. The shopping mall is Umar’s favorite place because he gets to play at the indoor play area called ‘Kidzoona’ which has all sorts playing props.

Umar playing doctor-making-burger

We are almost at the end of our stay in Phnom Penh. While I won’t say that it is absolutely the best times of our lives, it is certainly a valuable moment that we will cherish. I mean, life is Boston is good, it has everything (thanks Amazon) and access to knowledge and learning is unbeaten anywhere else in the world. But I can’t be totally flexible with my time because of class, meetings and appointments. Nothing beats life back home in Malaysia too. Nothing can replace the satisfaction of being close to your families and being home where you truly belong. 

But living here in Phnom Penh is a unique experience, where most of it has to do with the amount of time we get to spend as a family. While doing work, we get to see every second of Umar growing up, learning new things. Everything we do involves the whole family. It hasn’t been all smooth, Umar has his tantrums and we get totally exhausted some days, each of us had times when we got really sick. But all in all, it is very unlikely that we will forget the times spent here. With HBB Clinic being here to stay, I guess we will always be coming back.

Kamaliah's 27th Birthday

One morning not a long time ago, as I was preparing to go to class, I heard Kamaliah say:

“Semalam abang tengok ratio lelaki:perempuan untuk predict anak kita boy/girl lagi ke??” (Were you looking at the male:female ratio to predict our baby’s gender again??).

The previous night, we were surveying on Google for the best strollers around (still contemplating between Nuna and Uppababy). Somewhere along the way Kamaliah fell asleep, and suddenly I find myself pulling up graphs for the Malaysian population’s gender ratio and the predicted age-dependency ratio. The next morning, when Kamaliah saw all these graphs on her Macbook, she immediately knew what I was up to (it was not her first time seeing those graphs).

Kamaliah will tell me that I am lame for predicting our child’s gender based on the latest ratio (107 males : 100 females), and for worrying too much that the high dependency ratio in 2050 will cause our child to be burdened by high taxes to finance healthcare for the old population (a positive argument for national health insurance).

Such a pity marrying someone who’s so much into health economics! Kamaliah learned these less useful things from me, but on the other hand, what I learned from her is so so much more. Let me name a few. Kamaliah taught me to cook good Malaysian food. One of our favorite do-together thing now is our cooking! You see, I was hopeless before, but Kamaliah persisted in teaching me and now I can cook Malaysian food…not that great as her…but edible. I also always enjoyed going to the Asian grocery with her, and her eyes will lit with excitement and she will go “Abang, abang, abang tengok ni!” for every single item she found that is made in Malaysia.

Another thing I learned from Kamaliah is to replace ‘screen time’ with ‘people time’. We spend so much more time together these days, and we had a lot of weekend adventures together. We went whale watching, strolled through Salem in the midst of Halloween season, watched our very first Broadway theatre in New York, went seafood hunting in Cape Cod, and drove through the roads to New Hampshire to admire the beauty of autumn foliage. One of best sayings we also learned from the whale-watching tour guide is that “sometimes people spend too much time looking at these whales on their phone screens that they forgot to enjoy the majestic experience of being in front of these big creatures”. Since then we put our phone down, enjoyed experiencing one of the largest animal on earth in front of our eyes, and do not care much anymore about likes and comments on social media. We’ve practiced living in the moment since then. It is so much fun when you have one person you can share all these great memories with. One like and live comment from her is all I need.

However, all of these learning could not beat the exciting lesson of being future parents! We can’t wait to welcome our baby into this world. During our last doctor’s appointment, we can already see our baby move his/her hands. It was so surreal, and literally changed my perspective on life. For the first time it feels so real that we will be having someone who is totally dependent on us, everything we decide, everything we do will affect him/her. People say that once you have children, everything you do, you will have them in mind. I guess we can start to feel that.

Happy birthday Kamaliah, my wife, my love. Thank you for being so strong, patient and supportive. I pray to Allah to always keep you within his blessings, each hour and every day, and be the light that guides you, each step along life’s way. Thank you for all the great times, and let’s look forward to growing up (and old) together as parents, insyaAllah!

Our First Wedding Anniversary

Last weekend Kamaliah and I celebrated our first wedding anniversary. We spent time on a private island north of Pulau Kapas in Terangganu. The trip was much more of a honeymoon than the one we had last year in Cambodia, which we end up seeing patients at their houses instead. People say the first year of marriage is the hardest, I guess because as in any process of learning, the beginning is the toughest part. It was even tougher because 2016 was a year of drastic change for me. Several months after we got married, Kamaliah found out that she was pregnant. Not long after, Hospitals Beyond Boundaries shot to international prominence. She was there in New York when it all happened. Kamaliah had to bear the brunt of me shifting attention from her to the public which constantly barrage me with questions, interview requests and speaking engagements.

Upon returning to Malaysia, we received the distressing news that our baby's heart was no longer beating. It was such a hard thing to accept. At that same time, I was so occupied with prior speaking engagements and interviews, something that I regretted. I remembered the day she miscarried, I came back at night from a talk, and saw her crying on the bed. I was lost for words, and we only spent the night in silence, hugging each other till morning.

I still regret that I didn't spend my time at her side during the moment that she needed me most. But Kamaliah still stood by my side, and was always my number one supporter. She was always there to cheer me up with her wide smile. From the first day I met her, I've always had it in my mind that she is a person with an infectious smile. People just couldn't help smiling when they see her smile. She brings cheer to every room she enters, and I am blessed to have her exuding cheerfulness into every seconds of my life.

One year spending time with her, I realized that unconsciously, my life priority has slowly changed. If I can summarize everything she has taught me the past one year to one word, it would be: "humility". Being the super ambitious young man I used to be, it took a strong woman like her to change me. For the first time in my life, I find great satisfaction in fulfilling the need of someone other than myself. I begin to think as a couple, no longer as my own self. At a time that I thought I was "oh-so-human-look-at-me-I-am-humanitarian', she taught me what being a real human is all about. About sharing, caring about those who are close to us on top of caring for strangers, and knowing that no matter how amazing your life achievements are, it would be depressing if there is no one for you to share it with.

Kamaliah, I would like to thank you for holding on and teaching me what the real important things in life are. Thank you for being such a great wife, and I am looking forward to the years and experiences we'll forge ahead as husband and wife. Happy first anniversary to us, love you to bits!

Happiest Day of My Life

I remember every time I go to an old relative's house, wedding pictures were always the ones that is kept displayed in the bedroom, most likely on the vanity table. Those pictures were a window to a time period when they look really beautiful, and we'd say "lainnye muka atok masa muda!". Some of their spouses died when I was really small, and the pictures were the only way for me to see how they look.

These digital age, we rarely get our photos printed, we always say we'll print them someday, but in the end never get the time and energy to actually go to a print shop and frame it. Someday, all those photos will be gone when our laptops breakdown...even the ones we thought will be safe in Cloud drives will disappear along with the login passwords that will be lost to dementia or death. In the end, physical printed photos will be the only evidence that we once lived.

I don't know if I will ever go out to print another picture, but if I never did, this photo is enough to represent the life that I had lived...Someday, if I get to live long..if my grandchild or great grandchild sees this picture, I just want them to know, that what they see, is a snapshot of the happiest day of my life.

Me Before You

Earlier this month, my wife pleaded to watch the movie Me Before You, an adaptation of a novel by the same title by Jojo Mayes. Although I was not always fond of book-to-movie adaptations (a cynical outlook that proliferated throughout the years precipitated by movie adaptations such as World War Z, Dreamcatcher and The Great Gatsby), I yielded to her persuasion and decided to give Me Before You a try. A smile settled across her face, her eyes creasing with pleasure as I told her we were finally going to see the movie.

To my surprise, I actually enjoyed the movie, with some conversations in it stuck in my mind long after the credits finished rolling. A dialogue that made me reflect was towards the end of the movie, when Lou, who was taking care of Will, a young man progressively paralyzed from an accident (although not medically plausible, unless he suddenly caught Guillain-Barre syndrome, succumbed to a spine cancer or his spine decided to spontaneously degenerate at a young age), asked a question along the lines of “where would you wish to be if you were still healthy?”

Will, who was a wealthy young banker, was portrayed as an avid traveller and an adrenaline junkie before he met with the accident. I expected him to answer things like skydiving in New Zealand, surfing in Hawaii or scuba diving in the Great Reef Barrier, but his answer perplexed me:

"Paris. I would sit outside a cafe in Le Marais and drink coffee and eat a plate of warm croissants with unsalted butter and strawberry jam. I want to be in Paris as me, the old me, if I shut my eyes now, I know exactly how it feels in that little square. I remember every sensation”

I could instantly relate to what he said.

I guess that when our basic ability was taken away, the activities that seemed presumptuous and routine, were the ones that we miss doing the most. Not skydiving, not scuba diving, not wall climbing. When we are left paralyzed in a wheelchair, the thought of not being able to do simple things like having a cup of coffee in a café without the hassle of trying to fit behind the table, having someone to carry us up the curb, or the stresses brought by being unable to charge our electrical wheelchair because the plug won’t fit French electrical socket made us miss the person who we used to be most.

Although I abjured the movie’s devastating ending that sort of advocate assisted suicide, I am glad that my wife brought me to see this movie for its message of gratitude. I pray we would all stay away from such debilitating disease, and still be able appreciate the little things in life and be thankful for what we have.

The scene from the movie reminded me of my time in Geneva. After work, I would sit outside a cafe in Le Grand Rue, a cobbled-street alley in between teetering apartment blocks, to drink hot coffee and eat a plate of warm crepe with chocolate, banana and peanuts. It's one of the place I keep visiting when I closed my eyes.

The Kind of Day I Wish to Live All My Life

I spent the night at the clinic and woke up at 6 a.m. I woke up, washed my face and performed Subuh prayers. Later I boiled hot water and had my morning coffee overviewing the small lake by the clinic. The sun had began to rise and I enjoyed it listening to Sigur Ros on my phone while sipping one of the best Cambodian coffee. By 7 am our laboratory staff began sweeping the floor of the clinic. I cleaned and rearranged everything inside the clinic, and then went for a morning shower around 7.30. By the time I got out of the shower 2 patients were already at the waiting area. Lucky I slipped into my jeans and t-shirt in the toilet! I took off the towel from my neck and exchanged it with my stethoscope that has been hanging on the IV drip stand yesterday. It was last used on a student who came in the middle of the night. Now my stethoscope and I am ready to take on a new day. Our main doctor had to go to his university from morning till afternoon, hence I am the only doctor at the clinic. I had to depend the staff nurse to translate the patient’s history. I saw patients until 12pm, a total of 5 patients in the morning. One case of inguinal hernia, one case of UTI, a follow up for hypertension, a follow up for renal stone and a case highly suspicious of basal cell carcinoma, which I referred to a dermatologist for biopsy.

At noon one of the obstetric and gynaecology doctors we interviewed and selected to employ last week came to discuss on her contract. We discussed and concluded the contract, and hired her as part of HBB staffs. Later I had lunch at the clinic with all our staffs and stole a bit of time to read on microfinance and community based health insurance since I have a meeting with one of the microfinance institutions in the evening. I performed zuhur prayer before the meeting. The meeting started at 2 pm. We discussed to start a community based health insurance for the community around our clinic. I am sure that this project could benefit the community tremendously. The meeting ended around 3.30 pm. I made my way back to HBB clinic, arriving at 4 pm. I took a short 15 minutes nap and woke up refreshed, and performed Asar prayers.

After Asr prayers, I saw that our doctor has seen the last patient. We had our evening tea around 5 pm. By 6, all the staffs had gone back to their homes. I had nothing to do for the night so our male nurse invited me to follow him to take a walk by the junction of Phnom Penh’s 4 rivers. We took a bike there and walked along the river banks where there was stark contrast between the poor people in boat houses and the big hotels by the river. We went down to see the boat people and I decided to start a food package program for them the next time Malaysian volunteer comes.

We walked until Maghrib and performed prayers at a nearby mosque. Then we went for dinner by the roadside. We saw one HBB medical student volunteer was eating there alone. We joined him, and I had a good Pho noodle. After dinner we went to Costa Coffee by the Royal Palace. I had a long talk with our male nurse about the future of HBB. We went back to HBB clinic around 10.30 pm. I prepared my sleeping blanket on the floor of the clinic, performed Isya and went to sleep, ready to take on tomorrow

Contradistinction

This old lady was lying on the bed when we came up to her house. We couldn't speak Khmer, hence we gestured our way, signaling that the food package were gifts for her. Then, we realized that she was too frail to walk. Wanting not to disturb her rest further, we made our way down from her house. It was then that she suddenly called 'wait!' in Khmer. To our surprise, she crawled her way to her door to see us go, and when she saw all 13 of us handling all these food packages...she started to cry. One of our doctors went back up and hugged her tight. It was one of those moments that I will remember for the rest of my life. A moment where I will always go back to when I feel dissatisfied with life. In the words of Leo Tolstoy:

"In contrast with what I had seen in my circle, where the whole of life is passed in idleness, amusement, and dissatisfaction, I saw that the whole life of these people was passed in heavy labour, and that they were content with life. In contradistinction to the way in which people of our circle oppose fate and complain of it on account of deprivations and sufferings, these people accepted illness and sorrow without any perplexity or opposition, and with a quiet and firm conviction that all is good. In contradistinction to us, who the wiser we are the less we understand the meaning of life, and see some evil irony in the fact that we suffer and die, these folk live and suffer, and they approach death and suffering with tranquility and in most cases gladly. In complete contrast to my ignorance, they knew the meaning of life and death, labored quietly, endured deprivations and sufferings, and lived and died seeing therein not vanity but good…"

A Guide to a Meaningful Life

Upon reading articles about what makes a life of purpose and happiness, I tend to find recurring themes. People who are successful and perceived their lives as happy and meaningful were the ones who never set money, social status and fame as their life purpose. Here I have summed up the recurring characteristics I found about people who reach the end of their lives feeling that they lived a meaningful life:

1. They believe in a religion / God

2. They have close relationships with family, friends and the community

3. They have a stable marriage

4. They do what they love everyday; or better, they make it their career

5. Their daily working hours are flexible; or better they are their own boss

6. They often travel to discover new things

7. They are easy to give charity

8. They are debt-free (it is interesting to note that this  point still refers to money. But being debt-free doesn’t mean being rich. It is about living within your own means. You don’t need to be rich to be happy, but you do need to be free of debts)

It is also important to discover these things when we are still young, the earlier we set out how we want our lives to be, the higher chance that we will be successful. Once we are aware of these things, we are able to escape the ‘rat-race’ of our career and be above it. You will soon discover the false things that people think is important. The fact is, what a person thinks as important in a career, might not seem important to another. 

So if what you pursue is social recognition in career, you would most likely fail, because the one you are trying to impress is a just a small fraction of the worldwide population, whereas people outside your field wouldn't care much about your position in the company / government. What people care is how much you have touched their lives.

So I hope this serve as a simple guide and reminder to the youths, and I will end by attaching a poster of this beautiful manifesto on living a full life:

First Day of 2016, Full of Optimism!

As I am writing this, I am sitting at HBB Clinic Phnom Penh, on 1^st January 2016, 3.35 PM. The weather has been very good throughout the day, clear skies, warm but windy. One side of our clinic is surrounded by water, which makes the environment around our clinic yet cooler and serene.
The clinic is much lively today, with our HBB team members, HBB clinic staffs, and 30 volunteers from 3 different universities all gathering here for a briefing followed by training session for a community survey around the clinic area tomorrow. Perhaps seeing the crowd of people at our clinic, many of the local kids also came to see what was going on, and in the end joined us at our clinic.
All of them just had lunch at our clinic this afternoon, followed by a briefing session led by my cousin who volunteered with us for the past 2 weeks. Right now the 30 of them are broken down to 5 groups, each having their training session at different parts of the clinic. Some stayed at the lunch place, some into the meeting room, some went to our consultation room.

I love to see all these students at work, and am very thankful for their hard work for HBB. As I look around the clinic, I see faces full of hope and lighted up with excitement. As I sit here writing at the consultation table as each group is having their own session, an overwhelming feeling came over me. It is the kind of feeling that I can never begin to explain. A feeling of happiness, thankfulness, peacefulness and purpose. It feels good to leverage a whole group of talented people coming from all corners of Malaysia, to come here to a piece of foreign land 2000 kilometres from home to do this house-to-house survey and medical check-up.

I know I can never capture this moment into a single picture, and the only way to do justice is to write about it.

Right from the beginning, I know I want to do this all my life. I want to spend a lifetime of service, not just doing it myself, but influencing and convincing more and more people to do the same. For all of us, HBB is not just an organization, it has a lot more to do with our personal lives. We didn't have to compartmentalize any of our life’s ambitions: family, good friends, professional passion or philanthropic mission. They all converged into a single goal. Someday when I can sustain HBB to be a full-time career, I will never again have to choose the time between family, friends, work, and charity. With HBB, it all converges into one. I guess this convergence will be my new year’s resolution…this year and years ahead

Health in All Policies (HiAP) in Malaysia: Now More Than Ever

I refer to the statement made by our Deputy Director-General of Health, Datuk Dr Lokman Hakim in the New Strait Times article ‘Multi-agency Effort Needed to Tackle Diseases’ on 18 December 2015.

In the wake of recent national issues that directly affects health such as that of vape, bauxite mining and leptospirosis, the Deputy Health Director-General's comment on the necessity of multi-agency effort to combat diseases came at fitting time. Although the focus of his comments was on leptospirosis, there is a larger and growing national concerns that commends such effort: non-communicable diseases such as diabetes and hypertension (NCDs) is on the rise, infectious diseases such as dengue and leptospirosis is becoming epidemic across the country, health care costs are spiralling up, inequities are growing. On top of that, we face urgent environmental problems that contributes directly to health hazards: the recent haze, bauxite mining in Kuantan, water contamination to name a few.

Lacking the mandate, authority and organizational capacity, the prevention of these issues that require nation-wide interventions are largely beyond the power of Ministry of Health. We as medical doctors can plead for things like lifestyle changes, tough legislation against vaping, high taxation for tobacco, but we cannot re-engineer social and political environments in ways that puts health at its core.

Many developed nations have long recognized the importance of inter-sectoral efforts in tackling diseases and can be traced back to the 1978 World Health Organization (WHO) Alma-Ata declaration that formally acknowledges of the importance of intersectoral action for health. It was later carried forward in the Ottawa Charter for Health Promotion (adopted in Ottawa in 1986), which discussed “healthy public policies” as a key area for health promotion, and gave rise to the concept of “Health in all Policies” (HiAP) in 2006 during the Finnish Presidency of the EU.

The WHO defines HiAP as “an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts, in order to improve population health and health equity”. An early example is the “North Karelia Project” launched in 1972 aimed to reduce the impact of coronary heart disease in the Finnish region of North Karelia through engaging other sectors such as community organizations, dairy and meat producers, schools to improve community health. The project, which involved the support of the Finnish authorities and the WHO, resulted in significant reductions in cardiovascular disease mortality and has been noted as a successful model for cross-sector collaboration.

Some may argue that we already have elements of HiAP in place, taking an example when the Ministry of Health collaborates with the Ministry of Education to promote health education, dental health and routine immunizations. However, HiAP is more than a collaboration between 2 agencies. HiAP in other countries has moved on to centralize health efforts by establishing councils chaired by the Health Minister, with members from each ministries and agencies that affect health and wellbeing, such as the Ministry of Agriculture, Forestry, Rural and Regional Development, Urban Wellbeing  and Housing, Domestic Trade, and even including the local authorities and city planners to convene at least twice a year to discuss the current national issues that affects health of citizens either directly or indirectly.

Back to our beloved country Malaysia, taking example of issues such as vaping and bauxite mining in which there is still no coherent effort between agencies and ministries to tackle the problem, it is evident that it is high time we adapt HiAP in our approach to become a developed nation by 2020. A developed nation is not only a country that is economically sound, but also a country in which its citizens are physically and mentally healthy, as reflected by its citizens’ life expectancy.

While serving as an intern at the Social Determinants of Health Unit in WHO headquarters in Geneva, I had the chance to be a part of a working group that examines case studies relating to HiAP in developing countries. I have noticed that while HiAP is a new concept to the developing world, many are already approaching the WHO for advise and technical assistance to start implement HiAP in their respective countries. Each countries has their own social, political and economic factors that affects health. What works in one country might not work in another, however I do not see why we shouldn't start by asking for assistance. Health is a core element in people’s well-being and happiness. In the end, policies made in regard of health is not about political, social and economic interests. It is about ensuring that we leave behind a healthier world to live in, for or children and future generations to come.

Laying the Foundation of Social Health Enterprises (SHE) in Developing Countries. Paving a way for Universal Health Coverage?

I have been tinkering around with this concept called “Social Health Enterprise”, finding ways for it to be applied to Hospitals Beyond Boundaries. Social Health Enterprise is actually a new term that has never used it before in literature or research. It just struck me that they always use the term 'social enterprise within health care' in literature and researches, figured it would be too long to write. So for the purpose of brevity, I shall introduce the term “Social Health Enterprise”, in short SHE.

Social Health Enterprise is derived from the concept of Social Enterprise. Many of us are not yet familiar to the basic concept of ‘social enterprise’ itself, so here's me trying my best to put it in simple terms:

Social business / enterprise is a midway between a charity and a business. It is like a charity in terms that it does good and solves a social problem, but it is business-like in which it operates as a business, generating profits from sales of products or service. The unique feature is that all profit cannot be taken as dividends by investors/shareholders, instead it is reinvested in the business, for the improvement and extension of services or used for programs that benefit of the wider community. In his book, Nobel Prize Winner Professor Muhammad Yunus characterizes social business as an enterprise created and designed to address a social problem, and it is a non-loss, non-dividend company, i.e. it is financially self-sustainable. All profits generated by the business are reinvested in the business itself (or used to start other social businesses), with the aim of increasing impact on the community.

Now you may ask why am I alternating between the terms ‘social business’ and ‘social enterprise’? People have long discussions on the use and differences between these terms. I am not going to elaborate on these discussions, but simply put, social business is the brainchild of Professor Muhammad Yunus and the business has to stick to these 7 principles:

1. Business objective will be to overcome poverty, or one or more problems (such as education, health, technology access, and environment) which threaten people and society; not profit maximization

2. Financial and economic sustainability

3. Investors get back their investment amount only. No dividend is given beyond investment money

4. When investment amount is paid back, company profit stays with the company for expansion and improvement

5. Gender sensitive and environmentally conscious

6. Workforce gets market wage with better working conditions

7. ...Do it with joy

I believe that social enterprises are similar, but they hang more loosely around these principles. For the sake of discussion, I stick to Social Business when describing business in relation to Prof Yunus’ endeavor, and social enterprise to describe those businesses in general. Generally, I am referring to the same thing. 

So, when it comes to business and charity in healthcare, I like to ask this question:

“Why is it that you can find thirst-quenching 1 dollar can of Coca-Cola anywhere in the world, but not life-saving 12-cents malaria medicines?

In his book ‘The White Man’s Burden: Why the West’s Efforts to Aid the Rest Have Done So Much Ill and So Little Good’, William Easterly poses a similar question (he used Harry Potter book analogy, not a fan, sorry!) that becomes a central theme in his book. Easterly hails Professor Muhammad Yunus as a ‘searcher’ who can afford to solve these kind of problems by combining innovative entrepreneurship skills to solve a public problem, through his breakthrough idea on microcredit, and later social businesses.

Actually, I have been thinking about this concept of social business within health care since HBB's inception in 2012. I think HBB was born at the right time when social entrepreunership was at its infancy and growing well in Malaysia. Thanks to myHarapan, HBB's mentor organization, I managed to meet Professor Muhammad Yunus the father of social business himself. I met him in South Africa on October 2013, at the back of a stage, at a moment when I was freaking out because it was nearly my turn to talk to more than 1000 audience in the hall. I did not have much time and explained all about HBB to him as brief as I can. I asked him a few things about his theory on social business. I asked him where I can go to learn best about social enterprise. He told me the best place to learn is to go back to the community I am trying to serve and learn from them. Wow, okay that was profound. I was thinking of Stanford or something. That is the beauty of social business. It is innovative and tailors to the community that the best way to learn is to be on the ground. It is not rigid that you have to go and sit in classes all day long.

Professor Muhammad Yunus and I at the backstage during One Young World Summit in South Africa. Seconds before my turn to talk

The hype of social enterprises escalated when Obama came to Malaysia, the first sitting president to do so since 1966, for the fourth Global Entrepreneurship Summit (GES) in Kuala Lumpur. It was then that the Malaysian Global Innovation & Creativity Centre (MaGIC) was first announced, and in the Budget 2014 proposal later that month, Prime Minister Najib Razak announced an RM50-million (US$15.3-million) allocation for it. 

MaGIC's mandate is to encourage innovative start-ups and entrepreneurship in general, however a lot of attention was given to social enterprises as a way to solve community's problems. Unfortunately, health care in social enterprises was quite in the side line. For example, a statement from the Secretary-General of the Treasury at MoF during MaGIC's launch was: 

"MaGIC would be an independent body that will act as a one-stop centre for all kinds of entrepreneurs – not necessarily just high-tech and those related to ICT, but also entrepreneurs dedicated to the services sector, agro-based products, logistics and so on,” 

...And so, health care is part of that ‘so-on’ sector.

Since then I spent a lot of time researching social enterprises in healthcare throughout the years. They are quite a lot actually, and it has been around for quite some time in the developed world. For example, it was being promoted in the UK in 2005 by former NHS Chief Executive Sir Nigel Crisp, followed by statement by the Secretary of State Andrew Lansley declaring a wish to transform the NHS into ‘the largest social enterprise sector in the world’. However, despite from various efforts from the Department of Health, such as Social Enterprise Investment Fund (SEIF) and The Right to Request programme, there is still inadequate evidence to support the effectiveness of social entrepreneurship within healthcare in the UK. One of the main reasons being the UK already has a strong public-funded healthcare provided by the National Health Service (NHS), putting the private healthcare sector, in which social enterprises operates in, considerably smaller and less extensive than its public equivalent. 

Furthermore, many social enterprises are public service mutuals or ‘spin-outs’ from the NHS, which are organisations which have left the public sector (i.e. spun out) but continue to deliver public services. As a result, the responsibility of initiating social enterprises within healthcare in the UK are put to mainly former NHS staffs, clinicians, those who mostly don’t have the courage to start their own social business when they are already comfortable in the NHS. Because of the public’s accustomization to the NHS branding in which the majority of health services in the UK are under, social enterprises also lacks the confidence that the NHS branding provides. 

I believe that social entrepreneurship can play a more effective role in the health care of developing countries, like most countries in Southeast Asia, including Malaysia. This is because, in contrast to developed nations, many developing countries adapt a two-tier health care system where they have a quite seperated public and private funded health care system. Those who could afford purchase additional health care services or receive better quality and faster access thorough the private health care. Those who could not afford will have to go to the public healthcare, which are multiple times more crowded than the private. 

To date, there has been no coherent and strong effort to utilize social enterprise in health care in two-tier health care systems, when in fact, developing countries have a backdrop of public institutions becoming increasingly viewed as inefficient, ineffective and unresponsive, and the private sector becoming more profit-oriented and only caters to those who could afford health care. So there is a huge gap here and there is a need for a health care system that bridges between the two. Even in Malaysia, the private spending for health has overtaken the public spending since 2004. In absence of health financing reform, our health system will likely become increasingly privatized both in funding and service delivery. The public sector has only about 10% of primary care clinics but handle almost 40% of outpatient visits. The public clinics manage larger proportions of chronic diseases as compared to the private sector. We have tried to solve this problem by proposing 1 Care for 1 Malaysia system, but it got a strong opposition from the public, because perhaps it is too big a change to happen in an instant. I think a social health enterprise can be an alternative by bridging the public and private one step at a time, encouraging private practitioners to play a role in public service, and benefiting their business at the same time. 

So here is my definition of Social Health Enterprise (SHE):

A social health enterprise is a healthcare business with an objective to fulfil a public health purpose. It uses market-based mechanisms to operate, but its aim is to solve a community’s health problems. Profits are reinvested for the improvement and extension of services or used for public health programs for the benefit of the wider community.

Inspired by Prof Yunus' 7 Principles of Social Business, I came up with the characteristics of a 'Social Health Enterprise', in which HBB clinic will operate like:

1. Starts as a primary health care facility, with operations guided by a Family Medicine Specialist (FMS) and a Public Health Physician

2. The objective of the healthcare business is to overcome a community’s public health problems; not for profit maximization

3. The health care business attains financial and economic sustainability without depending on continuous donations

4. Profits are reinvested for the improvement and extension of services or used for public health programs for the benefit of the wider community

5. Investors can only get back their investment amount. No dividend is given beyond investment money.

6. Staffs receives monthly salary based on the country’s market wage with increments based on time or performance. No bonuses are given as any surpluses are reinvested

7. Strives to achieve Universal Health Coverage (UHC), by working with other private sectors and the local government.

Now point number 7 is very important as I find it missing from the many social enterprises in health care in developing nations. I find that many social enterprises in healthcare in developing countries too disease-specific. They usually focus on eradicating a single disease, like malaria, HIV, TB, treat cataract, saving children with thalassemias. SHEs must be more than that, it has to provide a social safety net, so that the poor, no matter what disease they have, can afford health care for their disease. This is in line with the concept of Universal Health Care (UHC). 

UHC is defined by the World Health Organization as:

"Ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship"

UHC is firmly based on the WHO constitution of 1948 declaring health a fundamental human right and on the Health for All agenda set by the Alma-Ata declaration in 1978. The DG of the WHO, Dr Margaret Chan went as far as to say: 

"Universal coverage is the single most powerful concept that public health has to offer. It is the best way to cement the health gains made during the previous decade. It operationalizes the highest ethical principles of public health. It is a powerful social equalizer and the ultimate expression of fairness"

My former boss at the WHO in Geneva loves discussing about UHC when I was there, and he gave me an article written by a health economist called David Stuckler, discussing a lot about the three dimensions of UHC. Upon reading his article I was interested in the financing part of UHC. There are many methods to finance UHC, most commonly used are social health insurance, tax-based, single payers, but what interest me the most is: "community based health insurance". I think it best fits what we are trying to do at HBB .

Dr Eugenio and Victoria, former bosses at the WHO

As with everything, theories must be tested and tried, and that is exactly what HBB will be trying to do. For our clinic, we are going to devise a community based health insurance system that works best for vulnerable communities. Since currently we are focusing on maternal and child health, perhaps we will start by insuring pregnant mother and their newborn child against catastrophic healthcare cost in the event that complications arises. Then we can extend to the general population. Step by step, we are going to keep revising the system until it is workable and replicable to other communities at large, until it can be adapted to the whole nation; which is the aim of UHC.

I think this field of SHE can be grown and tried on small communities, and extend from there. I would like to develop further this concept of SHEs and find out its challenges. I would like to spark a discussion on this. For example, if we can get all private practitioners to run SHEs and play a role in public health, what is it that they get other than satisfaction in helping patients who could not afford? The government has to come out with an appealing agreement or incentive, like NHS's 'The Right to Request programme' and their health departments's Social Enterprise Investment Fund (SEIF).

I believe this concept of SHE looks promising can be further developed (if I am not optimist about my own idea, nobody will, right?). Healthcare sector is also a very promising sector for social entrepreneurship because it affects the livelihood of a person directly. I am no expert in health financing and health economics. Maybe if I become one someday I can start publishing papers in journals, or better yet write books about SHEs. But for now I do need your opinions. There might be organizations out there that is doing something similar, and maybe everything I wrote above has already been thought up by another organization. But it doesn't matter and that is the beauty of social businesses. We do not compete with each other because we know that we are all trying to achieve the same objectives. So if you have any feedbacks, comments, suggested case studies, do let me know