REFORMS of the healthcare system are long overdue and urgent. The Seventh Malaysia Plan (1996-2000) promised a new district hospital in Lawas. Kam Agong, a resident there, who was pregnant with her eighth child in 2002, died from excessive bleeding after delivery. She was only 44 years old and otherwise in good health. Twenty years after her death, the hospital remains an unfulfilled promise. High-risk pregnant women still need to undertake long arduous journeys to either Miri or Kota Kinabalu for specialist care and caesarean sections.
There have been 14 studies since 1985, with near unanimous consensus, but yet reforms have been amiss.
Challenges to our health system
Our past leaders had bequeath us a health system which performed above its expectations and was respected globally. In the previous century, deaths of pregnant women, infants and children were relatively low, given Malaysia’s economic status compared with countries with similar economic development.
However, improvements in such critical indicators in the 21st century has stagnated – deaths among pregnant women, infants and children made no discernable progress for the last two decades since 2000.
Similarly, although life expectancy has been improving, the pace of improvement in life expectancy among males who have reached the age of 60 – proxy for non-communicable diseases – is glacial, compared with comparator countries. There were only 11 years (male) and 12 years (female) gain of life expectancy over a 50-year period, from 1970 to 2020.
Furthermore, although Malaysians are living longer, they are not spending those extra years in good health. According to the 2019 National Health and Morbidity Survey, 1.7 million (8.1%) live with all the three non-communicable (NCD) and 3.4 million with two NCD. And 73.6% of total health loss was due to NCD.
Inequalities in health are rife. The Khazanah Research Institute (KRI) reports wide inequalities.
Life expectancy is shorter in states with lower incomes. Diabetes, hypertension and hypercholesterolemia are more prevalent in lower income groups.
Mental health problems are more common in lower income families. Such data provides evidence that tragic stories such as Kam Agong are not mere anecdotes, but a systemic problem for Malaysia.
Much ink has been spilled to highlight the everyday experience of Malaysians faced with inadequate public investment in health – the auditor general in 2018 reported that hospitals were understaffed, overcrowded and underfunded.
Much praise has been heaped on our healthcare services, especially for hospitals that service expatriates and high income individuals, but the reality for the masses is that we are only ranked 84th on the Healthcare Access and Quality (HAQ) Index.
The HAQ Index measures a person’s access to quality healthcare that would protect one from amenable mortalities due to 32 different diseases. And we are well behind our neighbours Sri Lanka, Thailand, Singapore, Taiwan and Japan on the HAQ Index for the years 1990-2015.
Key determinants for health transformation
As alluded to by researchers at the Khazanah Research Institute (KRI) as recently as April 2022, there is extensive evidence to show that societal factors such as education, housing, welfare, environment and occupation have a greater impact on nurturing the public’s long term health.
Often described as the social determinants of health; social, economical, commercial, environmental and educational conditions are undoubtedly the most powerful influencers of people’s health.
In as much as the reforms of the Health Ministry (MoH) is overdue, it is not the be all and end all of the state of the nation’s health.
We would be missing the forest from the trees if the nation is yet again led to think that a better and reformed MoH would transform the people’s health. The nation faces multiple challenges to reduce health inequalities and improving it.
It is obvious from the KRI report that one of the most powerful drivers of good health is the ability to secure an adequate income. The Covid-19 pandemic has further amplified this problem.
The number of families and children experiencing poverty has increased from a poverty rate at 5.6% in 2019 to at least 8.4% of all households in 2020 due to the pandemic.
We are hopeful the White Paper will reframe the national health agenda.
The people’s health needs to be valued as an asset, and health aspects must be considered by the government across all its policies. The government needs to drive policy decisions which would create social, economical, commercial, environmental and educational situations, for the people’s healthier life.
Apart from the reformation of the healthcare system, these wider and more powerful social determinants of health must be prioritised, and the inequalities in health addressed appropriately and urgently.
The social determinants can only be successful if it is incorporated within the context of health in all policies (HiAP) of the government.
HiAP takes health implications seriously across all sectors, to ensure they synergise to enhance population and health equity, and avoid harmful health impacts.
One of the most difficult conundrums of a health reform agenda is the lack or failure of multi-sectoral integration of agencies and relevant authorities.
As MoH labours on the seriousness of NCD, to tackle it does not only involve reform.
The neighbourhood and built environment play crucial roles in enabling the practices of healthy lifestyle.
We tell people to exercise yet there are no safe paths within the vicinity of the community, no proper bike lanes, poor road works that support pedestrian and bicycle use, and poor facilities for hiking trails and nature reserves.
Stunting (low height for age) of our children below five years has increased from 13.4% in 2015 to 21.8% in 2019. Short term effects of malnutrition includes impaired brain development, lower IQ and a weakened immune system, with recurrent infections, while in the long term, it leads to shorter adults, greater risk of NCD, lost productivity and increased healthcare costs and premature deaths.
There are multiple compounding factors that need to be addressed holistically which goes beyond the reform agenda. This includes addressing the low-income status of families, alleviating poverty, offering better housing and social security safety net, improving health education and ensuring food security.
The reformed system should invest in better preventative healthcare services (68% of total health expenditure spent on curative care services in 2018), which would ensure good antenatal care, exclusive breastfeeding in the first six months of life, optimum complementary feeding in the first two years and optimising family-based diet for two to five year olds.
The collaboration and synergy of multiple ministries and agencies are essential to ensure success of nurturing the good health of our young and most vulnerable, within the context of HiAP.
The major areas in the healthcare ecosystem that need to be reformed are, namely, transformation of the public health sector and regulatory reforms of the private health sector, enabled by sustainable financing.
This new paradigm in healthcare is captured in the maxim, “Technology-native, person-centred integrated care, based on value and choice, supported within a health empowering ecosystem”.
And as the dictum goes, health is wealth. Good health leads to the people’s well-being, enhances their productivity and better contributes to the well-being and prosperity of the nation.
Dr Musa Mohd Nordin, Paediatrician, Dr Yap Wei Aun, Public Health Physician, Asst Prof Dr Farhan Mohammad Rusli, Public Health Physician.