The time for healthcare reforms is now


It’s important that the Covid-19 booster shot is not viewed as a magic bullet that will resolve the pandemic, as many other public health measures are needed as well. — Bernama

Happy New Year to all readers of Vital Signs.

In this first column for 2022, this writer would like to make several predictions for health in Malaysia this year.

Omicron concerns

We have now entered the third year of the Covid-19 pandemic, which is showing no signs of ending.

Omicron is only the latest SARS-CoV-2 viral variant to enter Malaysia, and it raises different concerns for our health system.

According to the US Centres for Disease Control and Prevention (CDC), the Omicron variant is more transmissible, compared to the Delta variant, has a shorter incubation period, and is more likely to cause breakthrough infections (i.e. infections after you have been vaccinated).

There are some early signs that Omicron causes less severe disease compared to Delta, but this is not a reason to celebrate prematurely.

If Omicron infects more people than Delta, including those fully vaccinated and those who are vulnerable like senior citizens, then our hospitals will still need to cope with a surge in patients.

Therefore, Omicron raises different concerns compared to Delta.

During last year’s June-September surge in cases in Malaysia, our vaccination programme was in full swing and there were large amounts of funding and priority to our health system.

If there is an Omicron surge in 2022, we will need to accelerate our vaccination programme by also vaccinating the unvaccinated (like children and non-citizens) and boosting the vaccinated.

Doing this requires large resources, like time, money, public education campaigns, and building trust in science, vaccines and government competence.

And the vaccination campaign may distract us from other important public health initiatives, especially if the National Recovery Plan is fully implemented and the narrative becomes “booster is a magic solution” for an endemic Covid-19.

Not a magic bullet

To be clear, everyone should get Covid-19 vaccine boosters if they are eligible.

Boosters can protect against the Omicron and Delta, and will help you protect your loved ones too.

But there is a risk that boosters will be sold as a “magic bullet” by governments who are unable or unwilling to do the hard work of implementing other public health solutions on top of boosters.

History tells us that governments love “magic bullets”.

In 2020, governments around the world relied heavily on lockdowns and movement restrictions to manage Covid-19.

In Malaysia, we used the different names of movement control order, EMCO, CMCO, RMCO and TEMCO – each with different levels of restrictions.

In 2021, governments around the world relied heavily on vaccines to manage Covid-19.

In Malaysia, our National Covid-19 Immunisation Programme was a rare bright spot in a year of political instability and ineffective government responses, vaccinating more than 95% of all eligible vaccine recipients, including children and non-citizens.

Therefore, in 2022, it is likely that governments around the world will rely heavily on boosters to manage Covid-19.

There are several reasons for this.

One, people are tired and want the pandemic to be over, and there is a strong temptation to promise that “Covid-19 will be over once we are boosted”.

Two, focusing on boosters can distract from implementation issues for other public health solutions.

And three, a booster programme is a highly-visible and easily-measured government project, and therefore, more desirable than restricting mass gatherings or improving living conditions for foreign workers.

The heavy reliance on lockdowns in 2020, vaccines in 2021 and boosters in 2022 is understandable, but regrettable.

The public health response for Covid-19 cannot be reduced to single “magic” solutions, because the pandemic is complex and needs multiple solutions at the same time.

These solutions include a well-enforced National Testing Strategy, a real-time integration between positive self-testing using rapid saliva tests to digitalised contact-tracing, and behavioural changes in society.

The public health solution for Covid-19 must also include effective enforcement of predictable laws without double standards, and strong leadership by example from political leaders.

Backlog of other diseases

In the two full years of the pandemic, we may have postponed weddings, graduation ceremonies and holidays.

But diseases like diabetes, cancer or depression cannot be postponed.

There are no comprehensive publicly-available statistics for the number of cancelled surgeries, delayed appointments or rescheduled tests and scans in Malaysia, but the number is unlikely to be small.

This backlog of non-Covid-19 cases is likely to grow larger in 2022, unless there are conscious, deliberate and specific steps to address it.

These steps should include appropriate task-shifting and partnerships with the private sector.

Task-shifting is a priority for the World Health Organization (WHO) and involves appropriately delegating specific healthcare tasks from a more specialised to less specialised health professional.

For example, a senior consultant cardiologist in the National Heart Centre transfers a stable patient to a private general practitioner (GP), or a nurse takes blood instead of a doctor.

In Malaysia’s health system, there is a decades-long trend towards getting more specialists (not just doctors, but specialist nurses, specialist pharmacists and specialist assistant medical officers) to do the work.

This trend is understandable, but can be harmful if we have too few specialists trying to do too much.

It is encouraging that there is a clear partnership with the private sector to clear the backlog of non-Covid-19 cases.

But there should be transparency in three specific areas:

  • The services being transferred to the private sector
  • How are the tenders awarded, and
  • The prices of services.

In the long run, there should also be a coherent plan to ensure that transferring services to the private sector does not hollow out our public sector.

‘De-hospitalising’ healthcare

Before Covid-19, hospitals were perceived as one of the safest places in the world.

It was a high-trust environment, where patients trusted their doctors and nurses, and relatives of patients united in solidarity as their loved ones fought disease.

After Covid-19, hospitals are not perceived to be safe any more, due to their high infection risk.

One reason why medical appointments are delayed is because patients are scared to come to the hospital.

Therefore, one of the most important strategies for hospitals in 2022 is to renovate, transform processes and reduce infection risk, while changing the public perception of safety.

Even then, it might not be enough.

Two years of Covid-19 have shown patients the value, convenience and effectiveness of virtual consultations, digital health and non-hospital care.

In a way, the pandemic has shortened the trend of de-hospitalisation from two decades to two years.

If de-hospitalisation is done correctly, patients will win by having greater access, greater convenience, lower cost and potentially better outcomes.

If it is done in a ruthless profit-driven and opportunistic way by non-healthcare companies seeking to make a fast buck, then patients will lose because standards will drop.

Therefore, the Health Ministry must set appropriate guidelines to ensure that digital health start-ups are operating with the highest standards of professionalism and ethics.

These guidelines must be strict enough to ensure quality, but flexible enough to encourage innovation.

Human capital crisis

Imagine working 80 hours a week for two years almost non-stop, caring for Covid-19 patients, performing PCR (polymerase chain reaction) tests or managing contact-tracing.

Multiply that by the 50,000 doctors, 65,000 nurses, 15,000 assistant medical officers, 13,000 pharmacists, 5,000 environmental health officers and 6,000 medical laboratory technologists in the public sector for our population of about 33 million, and we can get a sense of how collectively burned-out they are.

We do not have comprehensive statistics on how many health professionals are burning out or leaving the public sector as a result of burnout.

But we can look at the Hartal Doktor Kontrak (contract doctors’ strike) movement to see that we must take action, instead of waiting for comprehensive statistics.

We may face a crisis in human capital for health in 2022.

Just like financial bankruptcy, this crisis will develop slowly, then escalate suddenly.

Therefore, we must take immediate steps to avert this crisis.

There are no magic solutions, and we must implement a set of solutions at the same time.

One, better terms of service should be offered to all contract health professionals, specifically longer contract terms, higher pay, and more opportunities for education and promotion.

Two, there should be more task-shifting and transfer of duties to the private sector (as discussed above).

Three, there should be more training of community health workers to support the professional corps.

Four, there should be conscious and deliberate steps to reduce fatigue through limits on workweeks, mandatory holidays and enforced rest between shifts.

And finally, these short-term steps must be accompanied with long-term reforms in the way we train, recruit, pay, retain and promote our health professionals.

These are the predictions of this writer for 2022.

In short, our health system will still retain its fundamental effectiveness, but a lot of that effectiveness is because of the intrinsic motivation and discipline of our health professionals.

Covid-19 will continue affecting us, but it cannot be an excuse to avoid the hard work of reforms to our healthcare system that are already decades overdue.

Dr Khor Swee Kheng is a physician specialising in health policies and global health. He tweets as @DrKhorSK. The views expressed here are entirely his own. For more information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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