Data shows that the often overlooked and forgotten, but indispensable, hospital cleaners, are also predominantly women. — WAO
AS the announcement of Budget 2025 looms, it is important to reflect on the hits and misses of Budget 2024 – in particular, efforts to bolster our healthcare ecosystem.
With increasing concerns abound on our strained and overburdened public healthcare system, weakened by chronic under-investment, there are polarising views of how best to address the gaps in our healthcare infrastructure. In this, the wellbeing of our healthcare workers must not be forgotten. Thus, it becomes pertinent to examine the healthcare budget through a gender-responsive lens, particularly to centre the needs of our healthcare workers, who are mostly women.
For the uninitiated, gender-responsive budgeting (GRB) analyses budgetary allocations to best support people based on their differing needs. A gender-responsive approach acknowledges the differences in situations, roles, opportunities, contributions and needs of women, men, boys and girls and seeks to equitably bridge any potential gaps in access to public goods, such as healthcare. Understanding the intersectionality of healthcare and gender is important in making sure the healthcare budget responds effectively to the needs of everyone in Malaysia.
The broader care landscape
As with most care industries, the healthcare workforce is feminised, staffed predominantly by women. As of 2021, according to the Health Ministry’s Human Resources for Health report, 64% of public sector doctors are women, whereas 96% of nurses are women. Allied health services, including medical social officers, physiotherapists, and the often overlooked and forgotten, but indispensable, hospital cleaners, are also predominantly women.
Healthcare is a significant part of the larger ecosystem of care services, which also includes social care services such as eldercare and childcare. Also part of this ecosystem is unpaid care work – care done in private spheres at home – which can often supplement and absorb care that might otherwise be placed on the public healthcare system, as families take over caring for patients who are discharged from hospitals.
A gender-blind approach cannot equitably support our healthcare workforce, as the needs of women and men as patients and workers differ. A gender-responsive approach is, thus, necessary to account for the needs of our healthcare workforce.
Healthcare in Budget 2024
In Budget 2024, healthcare was allocated RM41.2bil, the second highest allocation just behind education, although still far short of the recommended 5% of GDP from the World Health Organisation, estimated at around 2% of GDP. Currently, those who rely on public healthcare, particularly those from the B40 and the economically disadvantaged, are confronted with overcrowded hospitals and an overburdened workforce.
Concerns surrounding the dissatisfaction of contract doctors, attrition of healthcare workers, including nurses and doctors need to be addressed; Budget 2024, as pointed out by the Galen Centre and the Malaysian Medical Association (MMA) did not include an allocation for human resource planning or development. Given the declining human resources, components such as maternity leave and other benefits and rights critical for retaining the workforce and achieving a healthy work-life balance, self-care, and family care might be jeopardised. Does privatisation, then, present a gender-responsive solution?
A gender-caring pivot: Strengthened allocations in human resource management and development can support a more gender-balanced care workforce. — WAO
Investment over privatisation
In light of the ballooning healthcare costs and a shrinking workforce, there seems to be a conscious pivot towards expanding public-private partnerships as alternative solutions in healthcare provision, outlined in the Health White Paper and more recently proposed by the Health Minister. This decision was not received well among the larger public, with concerns that this move would make healthcare exclusive.
Privatisation has historically resulted in exploitation and overwork of critical healthcare and their allied services, such as the issue faced by hospital cleaners exposed during Covid-19. It increases the fear of vulnerability and endangers comprehensive social protection. This will further marginalise workers in our healthcare system, largely women, who often shoulder child and elder care burdens and earn less than living wages without government protection and can increase the attrition of essential care workers.
In addition, the nature of the contract system, which impacts a broad range of healthcare workers, from doctors to hospital cleaners, contributes to precarity because it denies job security. This is particularly concerning for the vulnerable, such as hospital cleaners, as layers of subcontracting can lead to exploitation.
Moreover, contract hiring is typically tailored for tasks that must align with a predetermined time frame. Healthcare and allied services, which encompass the duties of doctors, nurses, and hospital cleaners, are neither ad hoc nor piecemeal but rather require continuous employment. It is, therefore, unsuitable, even exploitative in principle, to retain contractual positions for these essential services.
The issues raised by the National Union of Workers in Hospital Support and Allied Services (NUWHSAS) highlight the potential pitfalls of privatisation, where employees lack the space to collectively voice concerns without fear of retaliation. There is also concern amongst other allied health professionals that their wellbeing is sidelined. Privatisation, without centring the needs of our healthcare workers, can exacerbate the issues currently faced by public healthcare. Healthcare workers, must be consulted and included in the decisions about them. Labour rights, including the right to collective bargaining, are the cornerstone of their workplace wellbeing.
Healthcare workers’ voices should be centred in decision-making, especially in matters concerning their welfare and wellbeing. Therefore, it is crucial for Budget 2025 to invest further in our healthcare workers through allocations for better human resource management and development. Increasing healthcare investment to 5% of GDP across the next five years must be the ultimate goal for healthcare financing.
This can more than double what is currently allocated, which can ensure healthcare workers are adequately protected and their wellbeing is prioritised, and place us in similar spending to our neighbours (Thailand spends around 7% of GDP, whereas Singapore spends 4%).
Strengthened allocations in human resource management and development can ensure better support for the mental health of healthcare workers, as well as training and retention of healthcare workers in government sectors. These initiatives can support a more gender-balanced care workforce. The retention of our healthcare workforce is paramount for the resilience of the public healthcare system, preventing issues such as brain drain and precarity.
A Budget that cares
Wellbeing must also be secured through investments meeting the care needs of our healthcare workers at home. While previous budgets had welcomed allocations for childcare in government buildings, there must be more focused support for these facilities to be onsite, in hospitals, available at hours which align with the work schedule of our healthcare workers. Family leave, especially for healthcare workers with young children, could improve retention by helping them manage care responsibilities. Simultaneously, there must be more efforts to encourage male healthcare workers to actively participate in care responsibilities at home, as sharing care leads to more equitable outcomes, especially for women.
The recent debacle involving the announcement of the shortening of maternity leave for primary care physicians, which was quickly backtracked, is emblematic of a lack of gender-responsive decision-making. This is an issue which can be potentially remedied by increasing women in decision-making positions.
The budget is a policy instrument capable of promoting welfare and securing rights, as it works to allocate funding to address and alleviate issues. Gender-responsiveness can strengthen this, considering how the differing lived experiences and needs of healthcare workers, as women and men, are accounted for when making budgetary allocations. In this, allowing for civic spaces where healthcare workers’ concerns are expressed and acknowledged can facilitate the allocation of the appropriate budget, thereby securing their well-being, promoting retention and a strengthened healthcare workforce.
Anis Farid is a Research Project Manager at Women’s Aid Organisation while Ilaiya Barathi Panneerselvam is a senior research officer. Both are part of the RE:CARE Project, looking into building the resilience of the care workforce and infrastructure in Malaysia for future crisis-preparedness.
