Last year (2023) was an annus horribilis (“horrible year” in Latin) for Malaysian healthcare.
Nicotine delisting from the Poisons List on April 1 (2023) was the primary event that was deleterious to Malaysians’ health.
It opened the floodgates to advertising, promotion and sales of nicotine products; entry of tobacco companies to the vaping market; and most importantly, legalised sales of nicotine products to everyone, including minors below 18 years, which is still occurring.
The important issues for Malaysian healthcare in this year of 2024 are discussed below.
Nicotine addiction
Despite the World Health Organization (WHO) director-general’s statement on June 2, 2023, that “e-cigarettes and vape must be regulated, dismissing the tobacco industry’s claim of harm reduction with these nicotine products” and urging “please protect your citizens, especially your children”, the colossal bungle of nicotine delisting was only somewhat mitigated by Parliament passing the Control of Smoking Products for Public Health Bill 2023.
The shocking omission of smoking devices in the Bill, with the statement that safety standards of these devices would be regulated by the Domestic Trade and Cost of Living Ministry, and manufacturing by the Investment, Trade and Industry Ministry, will pose a regulatory conundrum.
The regulations of the Bill, which will hopefully be implemented this year (2024), can only limit the damage to the health of young Malaysians, many of whom could potentially become nicotine addicts.
Unlike Covid-19’s acute impacts, the effects of nicotine delisting will not be obvious immediately, but in the medium to long term.
More infections
Mutations of the SARS-CoV-2 virus, which causes Covid-19, are continuing to occur globally.
Waves of new Covid-19 infections will occur this year, which the health system should hopefully be able to cope with.
What we know of long Covid is far from being complete.
However, the limited Malaysian data that we have now already raises the question of whether long Covid will be the next chronic public health burden.
Dengue cases increased markedly in 2023.
Hopefully, the trend will go south in 2024, or at least, not increase further.
The virus with pandemic potential that most worries many is avian influenza (i.e. bird flu), as mutation can make it easily transmissible to humans.
Multiple human cases of bird flu were reported in China and Cambodia last year (2023), together with two outbreaks of the highly pathogenic A(H5N1) influenza in Cambodian poultry farms.
Large and continual outbreaks of avian influenza in birds and mammals increases the likelihood of mutations.
Added to that the mixing of bird and human influenza genetic materials, and there is potential for a new virus with pandemic possibility.
Non-communicable diseases
Non-communicable diseases (NCDs) will continue to rise with increasing undiagnosed and uncontrolled numbers, because of uncoordinated control.
This will strain service delivery in the underinvested, overworked and crowded public healthcare system.
The effects of backlogged surgeries during the Covid-19 pandemic, and inadequate or no treatments for NCDs, will inevitably lead to premature and excess illness and death.
Patient safety
A previous Health Minister informed Parliament that 46 public hospitals were more than half a century old, and more than half of the equipment is more than a decade old.
All these patient safety hazards have not been addressed by a definitive action plan, with timelines to upgrade the old hospitals and outdated equipment.
The fundamental principle in medicine, primum non nocere (“first, do no harm” in Latin) appears to have been ignored.
The public has a right to know how safe care is in the public sector.
Are there any indicators that patient safety improved in 2023?
The Parliamentary Public Accounts Committee abdicated its responsibilities when it found no one accountable for the procurement, without contract, of defective ventilators during the Covid-19 pandemic.
Will patient safety be ignored in 2024?
Medical workforce
Doctors’ crucial role in healthcare delivery was evident during the Covid-19 pandemic, when some doctors had to play God and decide who was to be ventilated or not – a difference between life or death.
Junior doctors play a vital role in hospitals as they are the ones implementing the decisions of the limited number of specialists and consultants.
While transfers have been the norm in the public sector for decades, junior doctors were treated poorly last year, with only a fraction getting permanent posts and transfers being messed up.
The multiple factors for the chaotic situation included poor coordination and communication between Putrajaya and community healthcare facilities; ignorance of facilities’ needs and requests; and an insensitivity to the attitudes and needs of junior doctors.
Medical unemployment and disgruntlement will continue with the issue of contract doctors inadequately addressed.
The best and brightest will continue to seek employment abroad.
It is expected that junior doctors’ problems will continue this year, but hopefully, there will be fewer management mishaps.
Medical technologies
New technologies, e.g. diagnostics, smart drug delivery mechanisms, genome sequencing, machine learning, mRNA (messenger ribonucleic acid) technology and artificial intelligence (AI), will increasingly impact on healthcare.
A fundamental element of electronic health records (EHR) is maintaining the confidentiality of patient health data.
Equally important is the public trust that their health data will indeed be kept confidential.
The Health Ministry’s statement that EHR will be rolled out throughout the country by 2026 is very unlikely to occur.
If a third or half the country has EHR then, Malaysia would have already done very well.
After the adverse publicity surrounding the MySejahtera app, has public trust been regained when it comes to data safety?
Issues of patients’ confidentiality and security, patient safety, and the successes and failures of new technologies, will continue to be problematic.
This is particularly so with the use of AI in healthcare.
The accountability and framework for safe and effective use of AI to meet the needs of all users has yet to be formulated.
It is vital to always remember that new technologies are just tools.
Discrimination and careful evaluation are critical for humane healthcare, and not just technological exuberance.
Increasing expenditure
Healthcare expenditure and medical inflation will continue to rise because of:
- Our ageing population
- NCDs, including long Covid
- Infectious diseases
- New technologies
- Increasing patient demands, and
- Unrestrained middlemen and rent seekers in healthcare.
Increasing out-of-pocket expenditures in the private and public sectors will lead to more families facing financial ruin if they or their relatives get catastrophic diseases, e.g. cancer, heart attack or stroke.
More general practitioner (GP) clinics, and even some private hospitals, will close because of financial unsustainability, staff burnout and indiscriminate regulatory implementation.
There will be mergers, acquisitions and closures of some private medical schools because of financial unsustainability and reducing demand.
GPs’ minimal or non-involvement in management of NCDs in public sector patients will impact negatively on population health and the risks of infectious diseases and NCDs.
Public trust and health policies
Healthcare will be increasingly provided by non-health sectors with technological tools, posing regulatory problems.
The Health Ministry’s budgetary allocations cannot assure improved patient safety and quality care unless wastages, inefficiencies and the role of middlemen and rent seekers are reduced markedly; and there is an open and just culture within the ministry.
As long as health policies are formulated without genuine consultation with stakeholders, success will be limited or absent.
Public trust will continue to wane for various reasons, including poor risk communication; non- or poor compliance to standard operating procedures; failure of authorities to engage meaningfully with the private sector, universities and civil society; misuse and abuse of social media; lack of transparency; and poorly considered policies.
Will the pressure for change in public healthcare delivery come to a head this year and lead to improvements?
Last year (2023) was the first after the Covid-19 pandemic that exposed numerous examples of irresponsibility, unaccountability and incompetence, underpinned by arrogance and poor insight.
None of the data available indicated that our population health improved in 2023.
The 15th General Election led to the Madani government, formed by component parties that all emphasised on health and healthcare in their manifestos.
There was much hype about the Health White Paper, which was adopted by Parliament last July (2023).
Since then, the hype has died down to a whimper.
Will 2024 be a year of reckoning for the healthcare system?
Stay healthy, all
Healthcare is avoidable by staying healthy.
A healthy diet, maintaining an appropriate weight, regular exercise, sufficient rest, safe sexual practices, avoiding nicotine exposure, moderate alcohol consumption, and keeping vaccinations current are necessary.
This requires effort, smart lifestyle choices and the occasional medical check-up.
NCDs, infectious diseases and other health risks can be minimised by compliance with one’s individual responsibilities and vaccination.
Wishing all readers good health in 2024. Take care of yourself and stay safe.
Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email starhealth@thestar.com.my. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. 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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