Everyone should be able to receive the full spectrum of health services without suffering financial hardship. — Photos: Filepic
GE15 is history.
The Prime Minister has emphasised focusing on the cost of living, an economic issue whose foundation lies in good health, for health is wealth.
Good health is everyone’s most valuable possession, for life is meaningless unless one remains healthy.Covid-19 was Malaysia’s worst public health disaster, with the healthcare system on the verge of collapse on occasion, laying bare its chasms.
Chronic underfunding and underinvestment in the public healthcare sector exacted and is still exacting a heavy price from the rakyat.
The government’s pandemic response contributed significantly to the numbers of cases and deaths, with Malaysia having the highest death rate per capita in Asean countries and among the highest in Asia.
The primary lesson from Covid-19 was the massive impact of inequity and structural disadvantage on its course and outcome.
To date, there has been no indication that concrete measures have been taken to address fundamental health and healthcare issues.
Health is central
Previous governments made international commitments to Universal Health Coverage (UHC) and Sustainable Development Goals (SDG) of which SDG3 is “Good health and well-being.”
The government ratified the Paris Agreement, a legally binding treaty on climate change, with the goal to limit global warming to below 2°C, preferably to 1.5°C.
UHC means that everyone receives the health services they need without suffering financial hardship.
It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation and palliative care throughout life.
UHC delivery requires adequate and competent healthcare professionals with an optimal skill mix at every level and who are equitably distributed, adequately supported and enjoy decent work.
UHC enables everyone to access services that address the most significant causes of disease and death and ensures that the service quality improves the health of recipients.
SDG3 requires the addressing of the social determinants of health; promotion of intersectoral approaches for health; and prioritising of health in all policies and healthy settings.
The Paris agreement requires economic, social and scientific transformation to reduce greenhouse gas (GHG) emissions, with Malaysia’s commitment to reduce GHG by 45% by 2030.
Issues for 2022-2027
Currently, the common themes of the health issues include the following.
The primary focus of the new government should be to prioritise health in all policies.
Any spending on health and healthcare should be viewed as an investment for the future and not an expenditure item.
> Increase in the budget allocation of the public sector
Malaysia’s healthcare investment has been chronically inadequate, with 2% of its GDP spent on healthcare, compared to 5-8% in countries of similar developmental status.
Inefficient and regressive out-of-pocket health payments (about 35% of total health expenditure (THE) rendered many families financially insolvent because of catastrophic health expenditures, with private expenditure accounting for 47.6% of THE.
The current public sector budget allocation has to be increased to 5%.
Additional budget allocations are necessary to rectify the chronic underfunding and underinvestment, e.g. repairs, replacements and renovations.
However, increased health financing and allocations must be accompanied by cost inflation containment, improved efficiency, and waste reduction.
> Healthcare financing reforms
The government should establish a new statutory, non-for-profit agency, accountable to Parliament, to manage all public healthcare funds.
This agency would fund and purchase healthcare, from both public and private providers, strategically and impartially.
Its strategic, efficient and transparent functions should ensure coordinated and efficient use of providers to meet public needs; more effective integration across all care levels; and a shift in expenditure from hospitals to primary to community care and public health.
There are different options for funding e.g. general taxation, payroll tax, consumption tax, donations, cost recovery from employers, etc.
Malaysia had among the highest number of Covid-19 fatalities in the region.
> Separate Health Ministry (MOH) regulator and provider functions
The MOH’s current dual roles have been the root cause of policies that have contributed to the inequitable public-private sector divide and even a perception of double standards.
It is time to end the current approach.
The separation of MOH’s regulator and provider functions will permit it to provide strategic and policy leadership; strengthen and expand its current public health and research functions; and drive the intersectoral coordination needed for health promotion and protection by monitoring the performance, quality and safety of all public and private healthcare facilities and services, as well as population-based health improvement targets.
The current MOH provider functions should be taken over by corporatised public-owned, not-for-profit entities with decentralised decision-making to local facility levels.
> Coherent human resources development and management
Healthcare professionals (HCP) are the lifeblood of any healthcare system.
The current production, employment, deployment and remuneration are inefficient and ineffective.
It has to be replaced with a coherent system in which decisions are based on strategic plans founded on regular and timely data.
The establishment of a Healthcare Commission, similar to the Police and other Commissions, will facilitate synchrony in the production, deployment, staff resilience and management of human resources in the public sector.
> Reorientate healthcare delivery
There is a compelling case to shift from hospitals to primary to community care and public health.
The total health expenditure of the hospital sector increased from 48.3% in 1997 to 55.3% in 2019, far ahead of primary care.
About 15% of hospital admissions are for conditions manageable in primary care.
There is poor coordination between primary and hospital care; as well as within and between the public and private sectors.
The driver is to shift expenditure from hospitals to primary to community care and public health.
> Revise all health laws
There are about 30 health laws listed on the MOH website.
There is overlap of some of these Acts with other Acts e.g. some sections of the Poisons (Amendment) Act 2022 are not consonant with the Dangerous Drugs, Medical, Dental, Private Healthcare Facilities and Services, and Personal Data Protection Acts.
A revision of all health laws is necessary to ensure that they are fit for purpose, avoid misinterpretation and are consonant with the basic rights guaranteed by the Federal Constitution, UHC and SDG3.
> Patient safety and quality care
Adverse events due to unsafe care are a leading cause of disability and death.
It has been estimated that one in 10 patients in high-income countries is harmed while receiving hospital care, with nearly 50% of them preventable.
Globally, about four in 10 patients are harmed in primary and ambulatory care, with up to 80% being preventable.
In OECD countries, about 15% of total hospital activity and expenditure is directly caused by adverse events.
Malaysian reports of 53% management errors in public primary care clinics, and 15.3% adverse events and 49.7% near misses in public hospitals are disconcerting.
The 2016 Hospital Sultanah Aminah Johor Bahru fire was an example of a fatal patient safety issue.
There is a need to emphasise patient safety and quality care, as investments in reducing patient harm lead to significant savings and better patient outcomes.
Even the simple act of engaging patients, if done well, can reduce the harm burden by 15%.
> Improve health literacy
Malaysians’ health literacy with regard to healthcare, disease prevention and health promotion was 49.1%, 44.2%, and 47.5%.
It was limited to senior citizens (68%); and those with lower education level (64.8%), and lower household income (49.5%).
Measures have to be taken to improve the public’s health literacy, particularly the vulnerable, to improve everyone’s health.
> Climate change
GHG from fossil fuels is a major contributor to climate change and air pollution.
Many policies and individual measures, e.g. transport, food and energy choices, can reduce GHGs with major health benefits.
The impact of climate change on human health, especially air pollution, is well known.
The phasing out of polluting energy systems, and the promotion of public transportation and active movement, could both lower GHGs and reduce air pollution.
Will there be a political will?
Health is a public good with large societal returns on investment.
Covid-19 has exposed the criticality of continued and increase in public investments in health and healthcare.
The governing coalitions have included some or all of the above issues in their manifestos.
It is time to walk the talk to ensure that the healthcare system is futureproofed from its current unsustainable situation.
Will the new government be up to the task? Or will health and healthcare be kicked down the road to the next government?
Time will tell.
Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email starhealth@thestar.com.my. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.
