This article first appeared in Forum, The Edge Malaysia Weekly on May 1, 2023 - May 7, 2023

“State of Health” is a new monthly column on health policies, health systems and global health, focused on strategies to strengthen the population’s health delivered by the public, private and non-profit sectors to achieve Health for All. “State of Health” replaces “Stethoscope”, the previous monthly column on public health policies.

On March 29, it was announced that members of parliament and senators will undergo mandatory annual health screenings in parliament. This is an excellent measure, one that we hope signals a move towards a national programme where regular health screening is normalised and widely accessible for the general population. Why? Because Malaysia is rapidly ageing.

According to projections by the Department of Statistics Malaysia (DoSM) (Population Projections Malaysia, 2020-2040), by 2031, there will be more people over 40 years old than under. The implications of this demographic shift will be dramatic for all facets of public and private life. Apart from addressing climate change, thriving as an ageing country will be one of the biggest existential challenges for Malaysia in the foreseeable future, for two main reasons.

First, the incidence of ill health is higher in older people compared with younger people. According to the National Health and Morbidity Survey 2019, the prevalence of hypertension is 44% among adults aged 40 to 60 but 61% in the 60 and above age bracket. The prevalence of diabetes is 23% among adults aged 40 to 60, but 30% in the 60 and above age bracket. The prevalence of cardiovascular disease is 14% in the 40 to 60 age bracket, but 37% among adults aged 60 and above. The dramatically higher rates for older people demand a systematic solution.

Second, the costs of rising disease go beyond the health system. The costs are not only directly seen in rising healthcare cost and demands on the health system, but also in the secondary ripples of lower quality of life, loss of healthy years as well as greater stressors on caregivers and social welfare systems, among many others.

At its root, managing an ageing society requires an effective approach to managing the frequency and financial and non-financial costs of disease. One of the most vital and long-term strategic planks in such an approach is putting in place a cost-effective, systematic and population-wide health screening and monitoring programme. In a best-case scenario, this national programme would provide or ensure periodic assessments of every individual’s key health stats, enabling better management of health risks particularly among ageing cohorts.

We recognise, however, that a programme on this scale is a significant and complex multi-­year undertaking, requiring the coordination of many moving parts. In our view, the devil of implementation lies in systematically marshalling resources to solve four key challenges.

The first challenge is to screen more people. Community outreach activities will continue to be important in registering populations for health screening and referral for future monitoring. Incentives such as personal income tax deductions for out-of-pocket screening expenditure should also remain. However, to ensure that the net of enrolment is cast as widely as possible, it is high time to consider more assertive policies such as targeted cash incentives or store vouchers, especially to get first-timers into the system and habit of screening.

The second challenge is to deliver more breadth of screening, both towards more at-home self-tests and allowing tests to be done by more healthcare providers other than just doctors. In the medium term, improving the delivery of screening may be more of a logistical issue (for example, collection of home testing kits) or an outsourcing issue (appointing “approved” screening providers, for example). Nevertheless, we must be more forward-looking and allow for an ecosystem where tech-enabled advancements in screening methods can be trialled and rolled out nationally, particularly for conditions of serious import to ageing societies such as neurodegenerative diseases.

The third challenge is to make periodic screening more affordable. On this score, major measures are arguably already in place for lower income groups in the form of free screening programme PeKA B40 and other similar state-sponsored schemes. On the flip side, health-conscious higher income households are willingly paying top dollar for extensive screening packages at hospitals and premium screening centres. It is for the middle class that better funding models are needed, either in terms of reducing out-of-pocket spending or insurance premiums or both. We also recommend that private payers (such as insurers and employers) ring-fence their health spending on preventive care (including screening), or to eliminate co-payments for preventive care (like the mandatory requirement in the United States’ Affordable Care Act passed under president Barack Obama).

The final challenge is to integrate the proposed national health screening programme to two foundational components of Malaysia’s health system:  (i) community health interventions delivered by primary healthcare providers; and (ii) electronic health records. At the individual level, periodic screening without the accompaniment of monitoring and advice by community health workers or primary healthcare providers is essentially a data-gathering exercise without an intentional health management plan. At the collective level, having health screening data in disparate databases is a missed opportunity for applying analysis on (anony­mised) data towards the improvement of disease identification and management.

Taking concerted action in each of these areas will make the difference between merely responding versus effectively managing the country’s ageing demographic shift. Here, we make the argument for a phased state-by-state or group-by-group strategy. States such as Selangor, Johor, Perak and Pulau Pinang are arguably in the most ready position to embark on a systematic “joined-up” approach towards implementing mass periodic health screening. Population enrolment by age cohort in these states can be deepened via existing state-sponsored screening programmes and outreach efforts, with support from additional federal-level incentives or behavioural “nudging” research.

The states’ developed logistics networks as well as high internet penetration will make at-home screening easier, not to mention the presence of innovative companies, both established and start-ups, that can help deliver improved, cost-effective screening methods. Institutional infrastructure and processes for public-private partnerships and outsourcing of healthcare screening and other healthcare services already exist, providing a natural sandbox for development of new funding models such as age-based or income-based co-payment as well as targeted subsidies by state bodies such as zakat. Finally, the data infrastructure is also already established through state health programmes such as Selangor’s SELangkah.

Lessons on infrastructure, processes, operations and nationwide integration can be translated to other states, with additional state-driven adaptations for regions with significant geographic and connectivity issues such as the Peninsular East Coast and Sabah and Sarawak. Ambitious, fast-moving states such as Sarawak may even leapfrog this adaptation process by learning from the experiences of more similar benchmarks outside Malaysia. Indeed, as health and healthcare are both state and federal responsibilities (according to the Federal Constitution), state government-led initiatives and a friendly competition “race to the top” is desirable.

In any case, even with a state-by-state roll-out, the role of federal policy, funding and coordination is very much needed. Even with the head start in infrastructure and others, it will still take a commitment several factors bigger than current state expenditure to achieve mass screening. The state with arguably the most ambitious vision, Selangor, allocated RM3.4 million to free screening programme Selangor Saring, which reportedly benefited nearly 40,000 people. But there are about one million households (or four million people) in the B40 and M40 categories in this state alone, according to DoSM.

Granted, not every individual needs to undergo state-subsidised health screening. Tests should focus on those above 40 with lifestyle risk factors as well as healthy elderly persons who belong to age cohorts at most risk for neurodegenerative diseases. In order to get there, though, it is imperative to establish risk profiles, and this is where we make the case for aiming for mass registration and simple online risk assessments for people above 40 years of age.

The state-by-state approach is essentially a learning by doing optimisation mission. The state-by-state approach can be led by state governments experimenting with different ways to deliver screening, creating a friendly competition and a race to the top. Ultimately, though, these efforts must be combined into a national-level effort. Japan, South Korea, Taiwan and Singapore are among the Asian countries that have put in place mass screening programmes for population cohorts above 40 years of age, completely free of charge for qualifying groups such as older age cohorts, and heavily subsidised for others. The programmes are strongly promoted with public education campaigns and targeted outreach activities. The programmes are also joined up to community health services that provide other preventive care such as health education, counselling and peer support.

The thrust of Malaysia’s planning and policy needs to anticipate the path of morbidity and costs posed by our ageing population. In healthcare, apart from ensuring that health funding is progressively raised to recommended benchmarks (which is a topic for another time), this means focusing resources — including brainpower — on preventive public health measures much more than previously accomplished. Health screening is a vital cornerstone of long-term health policy and makes for smart ageing society management. In five years, it should be a matter of course for every Malaysian, and as accessible (if not more accessible) as taking one’s driver’s licence.

Nell Omar is senior partner at Angsana Research and Consulting, and works on strategy in the healthcare sector. Dr Khor Swee Kheng is CEO of Angsana Health, specialising in health systems and policies.

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