Malaysia used to be an over-performer in health, but in recent years, Malaysia is increasingly trailing behind Taiwan, Hong Kong, and Singapore.
In an earlier paper titled “The White Paper: Health is Wealth”, we enumerated the daunting challenges to our health system.
In the ensuing article, we discussed the key determinants of the transformation of our nation’s health in order to achieve Malaysia’s health-specific vision, which enshrines the principles of equity, accessibility, affordability, and efficiency.
This is in harmony with the core ethos of the Rukunegara towards “creating a just society where the prosperity of the country can be enjoyed together in a fair and equitable manner”.
The 15th General Elections (GE15) has been called under the most unimaginable extraordinary circumstances. Notwithstanding the politics, corruption, unemployment, inflation, rising food prices and cash handouts rank highly on the electorates’ minds when they cast their ballot papers.
The Covid-19 pandemic has unforgivingly exposed the acute-on-chronic structural and systemic weaknesses of the nation’s health care system.
There is unanimous consensus from 14 studies commissioned since 1985 on the dire need to reform Malaysia’s health system. Despite this loud clarion call for transformation, the health reform agenda has been stalled for decades, simply because of a lack of political will from successive governments in power.
Malaysia’s Below Par Health System Performance
An “Asian tiger” in the previous century, Malaysia used to be an over-performer in the arena of health. However, Malaysia’s performance in recent years has been lacklustre and we are increasingly trailing behind comparator countries such as Taiwan, Hong Kong, and Singapore.
On the measure of life expectancy for males at age 60, a proxy measure of non-communicable disease (NCD) management, these countries are improving from a higher starting point, and at a faster rate, thus further widening the gap.
Considering that it would be easier to improve life expectancy from 60 towards 70 years, than it is to improve from 70 towards 80 years, this widening performance gap must be a wake-up call to all politicians, our health technocrats and more critically, a call for urgent action by the voting citizens.
More embarrassingly, even where Malaysia has traditionally been strong – Maternal and Child Health (MCH) – we have not made much progress since 2000.
Make Health a Key Election Issue
The macro-criticality of health is echoed by global institutions. Even the International Monetary Fund (IMF) now concurs that “public investment in health and education boosts productivity and growth, and reduces inequality of opportunity and income” and “increases the resilience of lower-income households to economic shocks … which are expected to become more frequent and disruptive”.
It is high time that health becomes a major election issue and our elected leaders are held accountable to ensure that the health and well being of all Malaysians are protected, health outcomes are systemically improved, and inequalities are reduced.
Public discontent with the rising costs of health care, its run-of-the mill quality, and long waiting times is gaining volume. Politicians who ignore the rakyat’s sentiments of the presently uninspiring health care deliverables do so at their own peril.
What are the Major Health Issues?
This document lists the key policies which we would like to see addressed in the manifestos of the political parties and/ or coalitions contesting the GE15.
Have the politicians, political parties and/ or coalitions given much thought to the insufficient investments in health? Can they offer an alternative to the currently unsustainable health financing model?
And what are their tangible propositions to transform the presently outmoded health care delivery system that does not create value for patients, especially those with chronic NCDs.
NCDs are lifelong and may be asymptomatic initially, in contrast to communicable diseases, which are acute and episodic. Public health initiatives, across different sectors, levels of government, and society – i.e. a whole-of-government and whole-of-society approach – is paramount to reduce the risk factors for NCDs, which include dietary, lifestyle and environmental factors.
Our epidemiological transition to NCDs which spans the life course, the need to care for an ageing population, to be always in a preparedness mode for emerging communicable diseases, and the rising health expectations of the citizens poses several challenges to politicians, and political parties and/ or coalitions.
To address these challenges demands a reform model that positions the patient/ person/ rakyat (rather than the doctor or health facility) at the centre of the health equation and a proactive health strategy that prevents disease and promotes wellness in a cross-sectoral, integrated, comprehensive, and coordinated manner.
And leveraging on technology that enables new models of health care, which are needed to improve effectiveness and efficiency, thus creating value for the patients.
We need to solve today’s problems with innovative thinking, optimise resources, create better synergy using new tools and methods, and create value and choice within a health empowering ecosystem. We cannot solve today’s problems with yesterday’s thinking!
A Commitment to a Real and Substantial Increase to the Health Budget
There is now a clear consensus on the amount of funding which is needed to enable the Ministry of Health (MOH) to deliver high quality health care.
The touted figure is 5 per cent of the gross domestic product (GDP). The short-lived Budget 2023 did not reflect this aspiration at all and only offered a paltry 1.98 per cent GDP, as in 2022. This would be like a band-aid to a health care service that has been underfunded over several years.
In order to upgrade its crumbling health facilities and infrastructure, face the challenges of NCDs, and deal with the ageing population, more needs to be allocated to the health budget.
Voters want to know how serious political parties and/ or coalitions are towards increased funding in a genuine effort to resolve the nation’s health crisis.
High-income countries, a group Malaysia is poised to join, spent 12.6 per cent of GDP on health.
Health Financing Proposals
The present health financing system is fragmented, which leads to low-value health care, characterised by duplication of services and an uncoordinated health care delivery system which is focused on ad hoc demands for curative care, rather than comprehensive and coordinated management of NCDs over a life course.
This contributes to silos in the health care delivery system as, by and large, public financing goes to public facilities and private financing goes to private facilities. This is a key weakness of the current health financing system.
Budget 2023 was very silent on any form of health financing proposals. What are your party and/ or coalition plans on health financing reforms?
Transformation of MOH
The purposes of the public sector reforms are to streamline service delivery and strengthen its stewardship and public health functions, while reducing duplications, silos and conflicts of interests. Primary health care has to be prioritised and strengthened, with a strong emphasis on integrated care.
Health delivery services – namely primary, secondary, and tertiary health services – need to be consolidated into a single integrated health services programme to break down silos between clinics and hospitals and reallocate resources efficiently and equitably.
Bolster public health and health promotion with stronger whole-of-society partnerships with civil society and local governments.
In recognition that health determinants lie beyond the health sector, MOH must bolster health protection and lead an inter-ministry and inter-agency whole-of-government mechanism within the context of the health in all policies (HiAP) government philosophy.
Streamline policy-making functions to cover the whole health system, both public and private.
Strengthen the regulatory and enforcement functions of MOH by bringing together all regulatory and enforcement functions into a single programme; thus harmonising them and reducing duplication.
It is also important to clearly separate the regulatory and provision functions of MOH in order to reduce conflicts of interest.
Similar functional independence must be created for the research functions of the MOH to reduce conflicts of interest.
The end result of these public sector reforms is a stronger and robust MOH focused on public health and stewardship of the health system, and agile non-profit public health facilities able to compete with the private sector and ready to transform towards innovative new models of integrated care.
Nurturing a Value-Based Private Health Care Milieu
We need a dynamic private health service sector which provides access to affordable and high quality health care for our citizens. This is best achieved when the private and public health care sectors work in tandem rather than in isolation.
As the government lacks the funds to finance this Health Reform Plan, especially to increase hospital beds and services to OECD standards, the private sector should be incentivised to invest in health assets (new hospitals, NCD centres, innovations in health delivery, upgrading of clinics to migrate into group practice) through public-private partnership (PPP) programmes.
Incentives (tax breaks, grants and subsidies) should be given to encourage the private sector to set or support social enterprises, community health care, and other humanitarian projects.
The Association of Private Hospitals Malaysia (APHM) was lamenting the lack of incentives in Budget 2023 to enhance PPP.
How does your party and/ or coalition envision the future PPP roadmap towards better utilisation of the “20 per cent of resources in private hospitals which are underutilised, while public hospitals were overburdened”?
Human Resource for Health
The issue of human resource for health has plagued the MOH over the recent years.
What strategy does your party and/ or coalition have in your manifesto to address the challenges of house officers and junior medical officers and the (toxic) work culture and bullying in the MOH?
Leveraging on Technology
In 2019, the MOH Health Information Systems (HIS) Committee unanimously converged on a few top HIS solutions which best met the needs of the nation and the specifications set by the MOH after a systems display by multiple IT vendors.
Had it not been for the change of government in 2020, citizens would have been beneficiary of their National Lifetime Record.
Mobile technology, telemedicine, and artificial intelligence; and lifelong and distance learning would have been better developed, further enhancing human resources for health.
A few of our public health talents are in the frontline developing robust and resilient surveillance systems that can prevent, detect, and respond to infectious disease threats immediately by incorporating disease reporting, genomic sequencing, wastewater sampling, environment sampling, zoonotic diseases, and antibiotic use.
Since the pathogen does not recognise boundaries, Malaysia can take the lead in future public health preparedness by initiating a regional and global collaborative system.
The reforms proposed build on consensus from past studies and incorporate, in an eclectic manner, global best practices contextualised and aligned with the core ethos of the Nation.
The principles of the reforms are:
Dr Musa Mohd Nordin is a paediatrician, Dr Yap Wei Aun is a health systems specialist, and Asst Prof Dr Farhan Mohammad Rusli is a public health physician.
Source: Code Blue, 17 October 2022