Tuesday 26 Sep 2023
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This article first appeared in Forum, The Edge Malaysia Weekly on June 26, 2023 - July 2, 2023

Malaysia has long signed up to the World Health Organization (WHO) aspiration of “Health for All”. In 2015, the country also committed to the United Nations’ Sustainable Development Goals (SDGs), which include universal health coverage (UHC).

Malaysians, especially members of parliament, should now ask whether the Ministry of Health’s White Paper recommendations — largely drafted by consultants with prejudices and even vested interests before translation — will help the nation meet these commitments or, instead, actually hinder their achievement.

The Covid-19 pandemic exposed some inadequacies in Malaysia’s public healthcare system in terms of provision and under-­investment. Clearly, overall health system reforms are needed to improve Malaysians’ well-being.

Health markets the world over rarely function well in providing healthcare for all. Instead, they increase costs and charges, limiting access. Worse, growing reliance on market solutions in recent decades has steadily undermined UHC.

To be sure, there is much to commend in the document, especially in identifying many major problems. Although the White Paper reflects the limited and biased perspectives of its many authors, the many policy suggestions to address them are useful to consider.

Health inequalities growing

Recent decades have seen healthcare trending towards a two-tier system — a perceived higher quality private sector and lower quality public services. Many medical doctors, especially specialists, leave the public service for the much more lucrative private practice.

This “brain drain” has worsened already deteriorating public service quality and increased waiting times. Hence, more of those with the means have turned to private facilities. As private hospital charges are high, many who can afford it buy private health insurance.

If left unchecked, the gap between private and public health sectors — in terms of charges and quality — will grow, increasing healthcare disparities between the haves and have-nots.

Social solidarity in health financing through cross-subsidisation — with the healthy financing the ill, and the rich subsidising the poor — would make universal coverage and equitable access possible.

Better healthcare

Malaysia must urgently strengthen the public health services’ ability to provide comprehensive health protection with adequate financing. Healthcare costs have gone up due to more ill health and privatisation, but less public procurement.

Everyone — both at the national level and in families — is facing more unexpected health threats, including illness, disability or death, and greater economic vulnerability due to catastrophic and other rising medical expenses, costly coping strategies and greater income insecurity.

In 2019, “premature” death, disability and illness cost 32.5 million Malaysians 7.7 million years of healthy life! Malaysians each lost an average of 2.8 months yearly — or almost a quarter of their lives — to ill health.

Almost three-quarters of the cases were due to preventable non-communicable diseases (NCDs), mostly due to malnutrition. While preventable NCDs accounted for 74% of total health losses in Malaysia in 2019, only 7% of all health spending went to preventive health and health promotion.

Healthcare spending, outcomes

The provision of healthcare in Malaysia has delivered significant protection, primarily via public delivery, financed by government revenue. Public services have provided a near UHC to its population.

The country has seen rising healthcare spending. But there is no simple direct relationship internationally between health spending and well-being. In other words, more health spending does not guarantee better outcomes.

Although total health spending has been rising, it remains relatively low in relation to income and well-being indicators. In 2019, such spending was only 4.3% of Malaysia’s gross domestic product (GDP) or output, with 45% spent by the health ministry. Out-of-pocket personal health spending came to 1.5% of GDP in 2019.

While the public sector has more hospital beds, doctors and nurses in terms of absolute numbers, it also serves a lot more patients compared to the private sector. Unsurprisingly, public services were under pressure well before the pandemic. In 2019, 87% of outpatients and 70% of hospital admissions were seen at government facilities.

Such relatively low health spending and decent outcomes imply the greater “cost-effectiveness” or efficiency of public expenditure. Nonetheless, much more could be achieved with better policies and spending — for example, professionals, including specialists, need to be retained with improved terms of service.

Chronic underinvestment in public services over the last four decades has undermined overall healthcare. Malaysia’s underfunded health system has nonetheless raised life expectancy, mainly by reducing child and maternal mortality from the 1960s.

Policy recommendations

To enhance health and well-being in Malaysia, healthcare system resilience must better protect Malaysians from current and future challenges. Most important is greater public healthcare financing, both absolutely and relatively, but also appropriately.

Recent Khazanah Research Institute reports reject much repeated but dubious claims that current government healthcare spending is too high. Instead, revenue-based financing should be the dominant form of health financing to ensure equity and efficiency.

By mainly focusing on personal curative interventions, public health policy and spending also do not pay sufficient attention to other determinants of health and well-being as well as health inequities. Health promotion should involve more preventive efforts.

To better address the socioeconomic determinants of health, a more comprehensive and integrated approach should assimilate health into related public policies to better address well-being and ill health.

Affordable and healthier food options, physical exercise and healthier lifestyles for all need far greater emphasis. For example, a healthy daily school meal programme — introduced when Japan was much poorer than Malaysia today — has since ensured its life expectancy is the highest in the world a century later.

An all-of-government approach would ensure meals planned by health ministry dietitians would be mindful not only of nutrition but also food costs and safety. Malaysian parents will not knowingly allow their children to be fed with food grown using toxic pesticides.

This can be ensured with the participation of the Minister of Agriculture and Food Security. Farmer organisations can be contracted to supply the needed food stuff with initial support from its extension services. This will, in turn, improve the safety of all farm produce as well as the health of all Malaysians.

Overall, it is not clear how the White Paper recommendations will take us towards meeting the Malaysian government’s major health commitments — to the people and to the international community — of UHC to ensure “Health for All”.

Nazihah Noor is a public health policy researcher pursuing her PhD in Switzerland. She led two Khazanah Research Institute reports on health system issues in Malaysia. Jomo Kwame Sundaram, a former economics professor, was United Nations assistant secretary-general for economic development. He is the recipient of the Wassily Leontief Prize for Advancing the Frontiers of Economic Thought.

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