3i: Health

Preamble

The MOH assumes the largest responsibility for the performance and delivery

functions of public health. It fulfils these responsibilities by carrying out a variety

of intervention strategies and services centred on preventive care (i.e.

immunisation programmes) and disease control, from primary up to tertiary care.

Short-, medium- and long-term planning and coordination are required to

produce better health outcomes for the population.

The COVID -19 pandemic has exposed and tested the resilience of the health

system, especially of the public healthcare sector. Insufficient funding and

investment in infrastructure development over the past two decades, combined

with lack of planning for human resources in the public sector, manifested in

high bed occupancy rates in major public hospitals–a problem that had already

existed before the pandemic, and was further exacerbated by it–and Hartal

Doktor Kontrak, a nationwide workers’ strike organised by young medical

officers in protest against the government’s contract system appointment.

The Malaysian population’s health is also at risk due to rising trends and burdens

of non-communicable diseases. If the government and society were to continue a

‘business-as-usual’ approach, the situation would deteriorate and, worse, with

little or inadequate support still. The status quo is clearly not sustainable, and

plans for improving and strengthening the health system must be put in place

now. There are large gaps to be closed, especially in the running of primary

healthcare.

I: Investment in Public Health & Public Healthcare

From 2009 to 2019, public health financing for the MOH stagnated at around

2% of GDP. Health made up only 8.5% of total government expenditure in

2018, just slightly over half the rates of similar upper-middle-income countries

such as Thailand and South Africa, which ranged from 13% to 15%. This low

rate does not mean Malaysians were much healthier, therefore requiring fewer

health resources; on the contrary, low health allocations directly contributed to

the overstretching of the public health system. As the Director General of

Health, Dr. Noor Hisham Abdullah, admitted in a 2019 news report: “We are

currently underfunded, understaffed, underpaid, overworked, overstretched and

with overcrowded patients.” In its election manifesto for the 2018 general

election, the Pakatan Harapan coalition had pledged an allocation of 4% of GDP

for the MOH; this is a good starting point to address the chronic funding

situation in the public health sector.

1. Prioritise health by giving it a budget exceeding 4% of the gross

domestic product.

i. Significantly increase the budget for MOH with immediate effect. The

funding from this budget should be separate from the COVID-19 fund.

ii. Target a 4% GDP public health expenditure within five years, and

increase it after that.

(Dr. Lim Chee Han, Agora Society Malaysia/People’s Health Forum, Proposal 3I-1)

2. Ensure equity in healthcare financing by implementing cross-subsidy

mechanisms based on principles of progressive taxation.

The “social wage” in the form of subsidised healthcare must be increased

because the wages of an average worker in Malaysia are low--only about one-

sixth of wages in western countries. Any scheme requiring them to pay more for

health would be unjust.

(Dr. Jeyakumar Devaraj, People’s Health Forum, Proposal 3I-2)

i. Reject health financing schemes that rely on funds from the general

public through mandatory contributions similar to the Employees

Provident Fund, or mandatory health insurance schemes.

ii. Raise tax income from the richest sections of society and corporations to

increase the funds available for healthcare financing.

(Dr. Jeyakumar Devaraj, People’s Health Forum, Proposal 3I-2)

II: Healthcare Capacity & Development in the Public

Sector

Overwhelmingly crowded conditions and long waiting periods for healthcare

service in the government hospitals and health clinics are still a common scene,

as reflected in soaring bed occupancy rates of over 70% in all state hospitals in

2019, even before the pandemic. Besides the healthcare workforce, healthcare

facilities and physical capacities must be expanded to accommodate and meet

local demands, especially in urban areas where over three quarters of the

population reside. In recent years, the number of hospitals in the private sector

have mushroomed in response to this surging healthcare demand. As of 2019,

there were more private hospitals (208) than public ones (154). Nonetheless,

private healthcare is not a sustainable solution as many lower middle class and

low-income groups cannot afford private hospital fees. Thus, it is the

responsibility of the government to take on this burden of providing a social

safety net for urban communities. Moreover, setting up more private hospitals

serves to encourage more specialists to migrate from the public sector to work in

these hospitals, to the detriment of training and healthcare in the public hospitals.

3. Impose a moratorium on new private hospitals.

This includes a ban on expansion of beds in existing private hospitals.

(Dr. Jeyakumar Devaraj, People’s Health Forum, Proposal 3I-3)

4. Build more hospitals in urban areas.

Construct more hospitals or expand existing ones in urban areas, where there is

greater demand for healthcare.

(Dr. Lim Chee Han, Agora Society Malaysia/People’s Health Forum, Proposal 3I-4)

III: Health Workforce Sustainability

One of the most important goals in rebuilding post-pandemic is to safeguard the

collective health and well-being of the Rakyat. This cannot be achieved without

strengthening the bedrock of the public healthcare system, namely its workforce,

which is currently under tremendous pressure owing to the health crisis. Simply

put, we need to focus on two things: increasing the supply of public health staff

to fill in available vacancies, and improving their retention within the public

system, with the ultimate aim of creating a high-morale workforce that can

contribute towards consistent healthcare services.

5. Exempt healthcare staff recruitment from the Human Resources

Optimisation Policy.

All public healthcare personnel appointments are currently managed by the

Public Service Department, and are consequently tied to the Department’s

Human Resources Optimisation Policy, which contains a directive to trim civil

servant numbers by 1%. Under this policy, new appointments may only be

carried out on a rotating basis. An appeal was made by the MOH to the Public

Service Department in 2019 for healthcare staff to be exempted from these

recruitment policies. This should be implemented immediately to enable more

recruitment of healthcare staff, to overcome the shortage of healthcare workers

and stop the deterioration of quality in public health service delivery.

(Dr. Chee Heng Leng, Citizens’ Health Initiative/People’s Health Forum, Proposal 3I-5)

6. Establish a Public Health Services Commission to set up a transparent

promotional system.

Poor staff retention and high attrition rate from the public to the private sector

continues to drive the workforce crisis even further, causing delays in services

that impact most Malaysians.

(Dr. Chee Heng Leng, Citizens’ Health Initiative/People’s Health Forum, Proposal 3I-6)

IV: Primary Healthcare

In 2019, the National Health and Morbidity Survey reported worsening trends of

non-communicable diseases (NCD), reflecting higher rates of obesity, diabetes,

hypertension and hypercholesterolemia. NCD-related hospital admissions have

historically been a significant burden on tertiary care services, and this trend is

projected to worsen with the growth of an ageing population. As a result, the

government will have to deal with competing demands on public services, even

as the cost of care rises exponentially. Currently, about half of the MOH budget

is used for tertiary care, which is essentially the largest budgetary category,

estimated to cost RM14.4 billion in 2019. This crisis provides an opportunity to

enhance the role of primary care as the cornerstone of community healthcare, by

providing timely health advice and screening through established trusting

relationships between patients and their general practitioners (GPs). As the

population grows older and the burden of chronic disease increases,

implementing good family health practices, such as encouraging a practice of

visiting the same doctor, is extremely important in capturing the benefits of

continuity of care in the community.

7. Implement a Family Doctor System.

The MOH should implement a family doctor system with policy frameworks that

support better coordination of health promotion, patient advocacy, illness

prevention and end-of-life care. Currently, 70% of GPs are in the private sector,

but a significant portion have also signed up for the ProtectHealth PeKaB40

programme, a healthcare initiative focused on early detection and prevention of

non-communicable diseases among the low-income communities, which

complements the often overwhelmed outpatient government clinics. The budget

for such public primary care programmes should be increased accordingly.

(Dr. Lim Chee Han, Agora Society Malaysia/People’s Health Forum, Proposal 3I-1)

8. Integrate private and public primary care services.

Introduce a capitation funding system for primary care services, whereby private

GPs are contracted and funded by the MOH to cover and treat a certain number

of patients over a period of time and within a determined geographic location,

according to their place of practice. This way, GPs have “guaranteed patients”,

allowing them to spend ample time on health prevention strategies as well as

driving excellence in chronic disease management of the population.

(Dr. Chee Heng Leng, Citizens’ Health Initiative/People’s Health Forum, Proposal 3I-8)

V: Social & Inclusive Care

The country has seen an increase in suicide cases especially during the pandemic,

with women comprising 83.5% of 1,708 suicide cases reported between 2019 and

May 2021. More than half of the suicide deaths were individuals aged between 15

and 18 years. This is part of a long-term trend as communities continue to face

the double whammy of psychosocial and economic impacts.

9. Draft a comprehensive action plan for mental health and psychosocial

support for women.

The COVID-19 pandemic has profoundly affected women, many of whom have

been overburdened and hard hit, both at the workplace (especially in health and

social sectors) as well as at home. The increase in workload due to lockdown and

quarantine measures, on top of having to juggle multiple roles, has exacerbated

the toll on women’s mental health. In mapping out crisis responses to the

pandemic, the Government must ensure that adequate access to psychosocial

support resources targeted at women are put in place and strengthened, on top of

demonstrating adaptability and rapid responses, and that current and future

health policies include women’s concerns as a prime consideration.

i. Increase the number of psychiatrists, qualified counsellors and clinical

psychologists.

ii. Improve access to mental health services and treatments targeting

vulnerable women.

(Dr. Roohaida Othman, IKRAM, Proposal 3I-9)

10. Apply universal approaches in migrant-focused health.

Inclusivity of care also means emphasising migrant health.

i. Replace the over-securitisation approach with universal engagement in

managing migrant-focused healthcare. This should stem from an

intention of balancing between disease control, economic concerns and

social well-being in often fluid circumstances.

ii. Collaborate with civil society and community-based organisations in

health screening and contact tracing processes to ensure cultural safety in

healthcare services.

iii. Make available migrant health data, especially to relevant groups working

on this issue.

(Dr. Sharuna Verghis, Health Equity Initiatives/People’s Health Forum, Proposal 3I-10)

11. Give stateless persons universal access to basic healthcare services and

remove cost barriers for non-citizen children.

To better promote inclusive care, the government must provide stateless persons

universal access to basic healthcare services for stateless persons, such as

childhood immunisation programs and subsequent maternal and child health

follow-ups, with minimal administrative and financial barriers.

(Maalini Ramalo, Development of Human Resources for Rural Areas Malaysia, Proposal 3I-11)

Allow all non-citizen children (up to the age of 18) with at least one Malaysian

parent to access public healthcare at the same rate as Malaysian citizens, upon

provision of the Malaysian parent’s identity card. Non-citizen children should

also be enrolled in the National Immunisation Programme free of charge, and

allowed to take part in public-school-related health programmes such as dental

check-ups and other initiatives.

(Bina Ramanand, Family Frontiers, Proposal 3I-12)

12. Formulate a pandemic preparedness plan.

This includes enhanced collaborative efforts between local and regional

manufacturing capacities of vaccines, as well as inclusive social protection

systems at home.

(Dr. Chan Chee Khoon, People’s Health Forum, Proposal 3I-13)

Concluding Remarks

Despite the existence of heavily subsidised universal healthcare for citizens, there

are severe cracks in the system, as revealed and exacerbated by the COVID-19

pandemic. These key recommendations are part of a system-building effort to

better serve the Rakyat during the present crisis and for decades to come.