Our healthcare system was never the same again post-pandemic

The public healthcare sector workforce was pushed beyond their limits during the Covid-19 pandemic. — Filepic

Covid-19 was Malaysia’s worst public health disaster.

The death rate per capita was the highest in Asean and the second highest in Asia.

Today’s column addresses some of the healthcare delivery issues during the pandemic.

Four waves

The first Covid-19 case in Malaysia was reported on Jan 25, 2020.

In a 2024 study published in the Frontiers in Public Health journal, Health Ministry epidemiologists described the pandemic in Malaysia in four waves, according to the dominant SARs-CoV-2 viral strain:

• Wuhan – 29 weeks from January to August 2020
• Beta – 30 weeks from September 2020 to March 2021
• Delta – 43 weeks from April 2021 to January 2022, and
• Omicron (from January to April 2022, when Covid-19 was declared endemic in Malaysia.

During the period from January 2020 to January 2022, the reported cases in the Wuhan, Beta, Delta and Omicron waves numbered 9,375, 333,488, 2,467,804 and 1,646,047 respectively.

The average weekly incidence rate was 1.48, 32.91, 169.89 and 304.53 per 100,000 population respectively.

During this period, a total of 4,456,736 cases and 35,579 deaths were reported, according to the study.

The World Health Organization (WHO) declared the global pandemic over on May 5, 2023.

From confidence to harsh reality

Malaysia has a dual healthcare delivery system.

The public sector has been plagued by chronic under-investment with staff shortages, neglected workforce planning, problems with staff retention, capacity issues, increasing waiting lists, bed capacities above safety levels in some hospitals, neglected infrastructure and deteriorating equipment.

At the start of the Covid-19 pandemic, the then Health Minister stated in a press release on Feb 12, 2020, that the WHO regional director had advised the government to be prepared for the spread of the SARS-CoV-2 virus.

The Health Ministry’s assessment was that Covid-19 was in the early containment phase and that it was preparing for the late containment and mitigation phases.

According to media reports then, the Health Minister said that the WHO director-general had commended Malaysia’s preparedness and ability to address the infection.

The Health Ministry’s response to the Association of Private Hospitals of Malaysia’s (APHM) offer to assist in April 2020, was a request for ventilators.

I remember a conversation with the APHM president, who lamented that offers of more assistance was not taken up then.

It was déjà vu for me as the Nipah outbreak came to mind, and my reply was that it would not be long before the ministry would come calling.

ALSO READ: Remembering the Nipah virus outbreak

As with Nipah, the private healthcare sector was roped in to help when the public healthcare sector could not cope, particularly from July to September 2021, when the public sector verged on collapse.

The harsh reality was that subsequent events exposed Malaysia’s unpreparedness for the pandemic because planning was woefully inadequate.

Impact on healthcare delivery

Initially, the public healthcare sector was able to cope with the increased patient load.

The private healthcare sector was ignored at first, but as cases continued to increase, it was called on to assist – the slogan became a “whole of society” approach.

Nurses and junior doctors were overworked, with those joining the healthcare workforce at that time truly encountering a baptism of fire.

There were staff absences, for various reasons, that impacted on healthcare delivery.

Private general practitioners (GPs) were not spared.

Initially, they had to make their own personal protective equipment (PPE) or utilise PPE supplied by volunteer groups.

Quality and transparency in sourcing PPE were thrown out of the window.

Some PPE suppliers had no experience and delivered unsuitable products.

This meant that GPs, like hospital doctors, had to go without PPE, reuse single-use items, use expired PPE and/or use homemade and donated items.

I recall the heartwrenching efforts to supply PPE to GPs in the Klang Valley.

Later, GPs had to provide Covid-19 vaccinations, implemented during the Delta wave, in addition to their routine tasks.

Some patients were reportedly difficult, with some GPs reporting verbal abuse.

The bed and equipment capacity of the public healthcare sector was severely stretched with more and more requisitioned for Covid-19 patients.

The Armed Forces had to build field hospitals to meet the increased demand for beds.

There were shortages of PPE and ventilators in the public healthcare sector initially.

The procurement of ventilators from China in 2020 was disastrous, with only 28 of the 136 ventilators usable.

Despite extensive enquiry, the Dewan Rakyat’s Public Accounts Committee (PAC) could not determine who was accountable.

The PAC’s October 2023 report focused on excess PPE in stock, but did not address the shortages at the initial stages of the pandemic. Such shortsightedness was incomprehensible.

Elective and diagnostic procedures were severely delayed or cancelled.

There were reports of the harnessing of technology to support remote care.

The impact on antenatal care was significant.

According to a systematic review by Universiti Kebangsaan Malaysia (UKM) academics published February 2024 in the PLOS One journal, pregnant women worldwide felt that maternal health services during the Covid-19 pandemic lacked psychosocial engagement, was of poor quality with lack of information, had poor communication, experienced disruption in medicine supply and immunisations, and was unable to fulfil maternal demand for antenatal services.

This was reflected in the 2021 Malaysian maternal mortality rate of 68.2 per 100,000 births, a number last seen in the mid-1980s.

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The public has been significantly impacted by Covid-19, the extent of which has yet to be determined.

Many are suffering from conditions that will now take much longer to treat than they would have before, and for some, their illnesses have become, or will become, untreatable.

Patients have suffered, and will continue to suffer, harm that could have been avoidable if the healthcare services had been in a healthier position entering the pandemic.

The impact on population health too, including mental health, has been and will continue to be significant.

Unanswered questions

There are many unanswered questions about healthcare delivery during the Covid-19 pandemic, including:

• How could the public healthcare sector have been adequately staffed entering the pandemic?
• What impact could human resource utilisation have had on healthcare delivery during the pandemic?
• How should healthcare workforce planning improve going forward?
• To what extent did low public healthcare sector bed numbers impact healthcare delivery during the pandemic?
• How can public healthcare sector beds be sustainably expanded, distinguishing between ward and critical care beds, in addition to beds in other settings?
• How did the quality of healthcare support services impact staff and patients during the pandemic, and how can this be improved in the future?
• How did inadequate funding, and historical underfunding, of the public healthcare sector impact healthcare delivery during the pandemic?
• What lessons can be learnt from healthcare workforce deployment across the public healthcare service during the pandemic, as well as the use of the private healthcare sector?
• What were some of the positive healthcare delivery changes brought about by the pandemic, and how might some of them be sustained?
• How can healthcare workforce deployment in future crises be better managed, including issues of disruption of training, excessive hours and burnout?
• How can volunteers and non-governmental organisations (NGOs) be better utilised in future healthcare crises?
• What lessons can be learnt about the deployment of field hospitals during the pandemic?

Better planning and investment

The Covid-19 legacy will continue for years to come.

If the government wants public healthcare services to prioritise reducing waiting lists and backlogs, then the healthcare system must be provided with the necessary resources.

It is vital that the government acknowledge the reality that the healthcare workforce cannot continue to work under continuous and intense pressure.

This workforce is Malaysia’s greatest asset and healthcare cannot be delivered without them, but the pressure of providing public healthcare with chronic underinvestment, staff shortages and working in increasingly unsafe conditions in buildings of varying degrees of deterioration with increasingly obsolete equipment, has pushed them beyond their limits.

The healthcare workforce retention crisis must be addressed immediately, and in the longer term, the workforce must be expanded significantly.

The long lead times for training medical professionals means existing shortages will be magnified in years to come, and gaps will be worsened by retention issues that will likely worsen before they get better.

There is a need for transparent healthcare workforce planning.

This must include proper consideration of all the aspects that produce a doctor: from medical school places to house officer posts, availability of specialist training, as well as the equally important infrastructure and teaching capacity needed to train them.

Similar workforce planning applies to nurses and other healthcare professionals.

It is also vital that the government communicates honestly with the public about public healthcare service pressures.

These services will never be the same as before the pandemic, and they will also need sustained investment in resourcing and staffing to deliver the level of care that the public understandably expect.

In summary, it is the government’s duty to ensure that the healthcare services are safely staffed and able to respond effectively to future pandemic(s); increase capacity to respond to future pandemic(s); and to ensure better planning to avoid service disruptions.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email [e-mail]. The views expressed do not represent that of organisations the writer is associated with. The information provided is for educational and communication purposes only, and 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.