This article first appeared in Forum, The Edge Malaysia Weekly on January 8, 2024 - January 14, 2024

At the heart of the Ministry of Health’s Health White Paper’s (HWP) Pillar 2, “Advancing Health Promotion and Disease Prevention”, is a transformative vision for public health. Pillar 2 ambitiously seeks to reorient the health ecosystem, embedding the principles of health promotion and disease prevention not just in policies and guidelines but as a fundamental part of everyday life.

This commentary aims to provide a critical examination of the three key reforms central to Pillar 2, evaluating their potential to meaningfully impact public health outcomes. It questions whether these reforms can effectively guide the health ecosystem towards the aspirational goals Pillar 2 sets out.

Reorienting the health ecosystem as envisioned by Pillar 2 is both a bold and necessary undertaking. However, it requires navigating a complex dynamic among diverse stakeholders (including patients, healthcare professionals, financial entities, pharmaceutical companies, researchers, support groups, regulatory bodies and government units, among others), each with distinct perspectives, interests and objectives. This shift is further complicated by anticipated bureaucratic and political challenges and the emergence of digital health technologies, such as artificial intelligence, which present unique challenges in bridging health disparities exacerbated by socioeconomic and cultural factors.

The successful reorientation of the health ecosystem hinges on innovative strategies and strong leadership to convert this ambitious vision into concrete outcomes. A crucial question that emerges is whether we have the leadership capable of bringing this visionary concept to fruition, including harmonising the varied stakeholder interests with broad public health goals.

Following the vision of reorienting the health ecosystem, Pillar 2’s first strategy focuses on enhancing public health resources and functions, which is particularly pertinent in the context of the rising prevalence of non-communicable diseases (NCDs) and the inherent unpredictability of infectious disease patterns.

A key component of Pillar 2 is developing a robust infrastructure, including forming public-private partnerships (PPPs) to bolster disease prevention efforts. The strategy also advocates for integrating artificial intelligence (AI) and big data into public health decision-making, enhancing emergency preparedness, and using public communications informed by behavioural science to counteract health misinformation and promote a health-conscious culture.

However, the integration of PPPs in public health presents challenges. Empirical studies show that PPPs can lead to ethical dilemmas and operational complexities. Concerns include conflicts of interest between profit and public health goals and the risk of neglecting marginalised groups. Operationally, a lack of comprehensive legislative frameworks, particularly in developing countries, has led to the ad hoc formation of PPPs, raising concerns about credibility and sustainability. Furthermore, the effectiveness of PPPs differs across health areas; while infectious disease control shows positive outcomes, partnerships aimed at non-communicable diseases (NCDs) often face criticism, owing to conflicting interests between public health and private sector goals.

The emphasis on emergency preparedness is crucial but requires sustained funding and political support. The implementation of AI and big data technologies, while beneficial, raises significant concerns about data privacy, security and the risk of increasing health disparities. The control of these technologies by private entities adds complexity, potentially leading to conflicts between commercial and public health interests and robust governance and ethical frameworks.

Lastly, the success of public communication strategies hinges on their ability to connect with diverse populations. This necessitates culturally sensitive messaging that includes languages spoken by indigenous and migrant communities, ensuring inclusivity and effectiveness in reaching all segments of the population.

Building on the need to strengthen public health functions, the next strategy under Pillar 2 emphasises the importance of an integrated, inter-sectoral approach. This strategy recognises the complex nature of health and the need to address the social determinants through coordinated efforts among various government sectors, private entities and civil society organisations. The formation of inter-sectoral task forces aims to facilitate a more cohesive health and social care system, ensuring that health strategies are comprehensive and inclusive.

Effective coordination, however, faces challenges such as divergent agendas, resource limitations and bureaucratic hurdles. The Covid-19 pandemic highlighted the exemplary leadership of the Ministry of Health but also the critical need for improved coordination across different sectors and ministries, especially to protect vulnerable and minority groups.

Equally, the ambition for a whole-of-government approach is commendable. However, avoiding the risk of diffused accountability across ministries and agencies leading to service gaps requires a buy-in of the unified vision transcending individual sectoral interests, strong leadership and governance, trust among sectors and stakeholders, supportive policies and legal frameworks, adaptability and flexibility for ongoing collaboration and improvement, and equity and inclusivity, especially of the disadvantaged.

In addition, the strategy calls for a whole-of-society approach, urging meaningful engagement with civil society organisations. Their critical involvement is key to bolstering health service design, emergency response and policy development, although their role in mobilising local resources and connecting communities to formal health systems is often underutilised. Effective public health reforms require an enabling democratic environment that supports the active participation of these organisations, enhancing the overall legitimacy and effectiveness of health governance.

Furthermore, addressing social determinants of health means considering global challenges such as economic downturns, climate change, food insecurity and increasing conflicts. These factors exacerbate inequalities and lead to the emergence of new vulnerabilities, broadening the group of individuals exposed to precarity. Therefore, policies need to extend beyond targeting the extremely poor with cash assistance, focusing on broader healthcare access and addressing the multi-dimensional aspects of poverty and equity. This comprehensive approach is essential for effectively addressing health inequities and ensuring equitable healthcare access in the face of emerging global challenges.

Building on the theme of inter-sectoral collaboration, the HWP’s third strategy focuses on incentivising healthy behaviours by promoting healthy choices through positive reinforcement and encouraging employer-led health initiatives.

It also proposes shifting towards value-based healthcare models that reward healthcare providers for providing effective and quality care rather than quantity of care. Thus, healthcare providers may be compensated based on specific performance metrics, such as patient health outcomes, quality of care and efficiency.

These approaches must be carefully considered. Incentives for healthy behaviours risk overlooking the socioeconomic disparities that shape health choices, particularly for marginalised groups that may not benefit, owing to economic barriers.

The transition to value-based healthcare, which rewards providers for quality rather than quantity of care, requires diligent oversight. There is a risk it could neglect complex or less profitable health conditions and unfairly penalise providers serving high-risk populations.

In addition, implementing workplace health incentives in Malaysia poses unique challenges. Financial incentives have shown mixed success globally, often failing to induce long-term behavioural change. Malaysia’s labour rights context — with issues such as artificially suppressed wages, an unrealistic minimum wage, extended work hours, and systemic obstacles to unionising and advocating for better working conditions, especially for foreign workers — complicates the effectiveness of such incentives.

These complexities underscore the need for an inclusive, comprehensive approach that addresses the broader socioeconomic and labour conditions impacting health behaviour incentives.

The HWP lays out a crucial reform pathway, yet its success hinges on effectively managing diverse stakeholder interests, bureaucratic challenges, political dynamics, and the often conflicting goals of the private sector and public health. These reforms are not standalone; they demand simultaneous shifts across political, legal, social, economic and cultural landscapes, affecting a variety of groups.

Robust leadership, clear vision and broad stakeholder support are essential. Caution is needed against hastily restructuring, dismantling and devolving existing structures without adequate supportive environments and frameworks and viable options. The question remains: Are we ready with the right environment and structures to support such all-encompassing reforms?

Reflecting on the issues discussed — systemic improvements, health behaviour complexities, technology’s role in public health, stakeholder alignment, ethical concerns in public-private partnerships and incentivising health behaviours — it is evident that these reforms align with the HWP’s principles of equity, sustainability and resilience.

Advocacy for inclusive health reforms, sustainable health practices and a resilient health system, as championed by the People’s Health Forum, is key to navigating these public health challenges successfully.

Dr Sharuna Verghis is co-founder of Health Equity Initiatives and senior lecturer at the Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia. Health Equity Initiatives is a co-convenor of the People’s Health Forum.

Save by subscribing to us for your print and/or digital copy.

P/S: The Edge is also available on Apple's App Store and Android's Google Play.