Selamat Hari Merdeka, Malaysia!
For the last three National Days, Malaysia has seen three separate Prime Ministers and Health Ministers.
This instability has had three negative effects:
- The Health Ministry (MOH) has had to adapt to the new strategies and political directions of each minister,
- The pandemic response might be distracted by shifting national priorities, and
- Long-delayed multi-decade health reforms cannot get started.
The new Health Minister, Khairy Jamaluddin, is joining the ministry from a successful stint as the minister-in-charge of Covid-19 vaccinations – a responsibility he still carries in his new portfolio.
His team has implemented a system that has procured vaccines for 110% of our population, vaccinated more than half a million Malaysians per day at peak speed, and completed vaccinations for 45% of our entire population in six months.
During that time, Khairy has been as transparent as possible, sharing procurement information to the Parliamentary Public Accounts Committee in January and July (2021), and sharing granular National Covid-19 Immunisation Program (PICK) information on GitHub.
He has also reached out to Opposition Member of Parliament Dr Ong Kian Ming to support Operation Surge Capacity in Selangor, in a rare and effective example of bipartisan collaboration.
The minister has many immediate items on his agenda.
Many of these items have been endlessly proposed by many experts in the past 18 months.
A short summary of priorities can be divided into six categories:
- Strengthening public health systems, like testing, tracing and integration with the MySejahtera app.
- Creating “mobile surge healthcare capacity” of doctors, nurses, ventilators and medicines.
This is needed as the pandemic's epicentre has shifted from Sabah late last year (2020) to Klang Valley currently (mid-2021), and is projected to move to other states like Perak and Johor in the upcoming months (late 2021).
- Creating a SARS-CoV-2 viral variant strategy, which requires genomic testing and better standard operating procedures that are better balanced between health and economic needs.
- Starting to think of Covid-19 as endemic.
This requires shifting our activities from “campaign mode” to “routine mode”.
- Providing rest to exhausted frontliners and ensuring they receive adequate personal protective equipments (PPEs), allowances and administrative support.
- Continuing the vaccination programme, but begin to implement “endemic Covid-19 vaccination strategies” of preparing for booster vaccinations (which requires procurement, financing, administration and public-private partnerships).
There are also four currently under-prioritised areas.
One, we need easy-to-follow ventilation guidelines for businesses and commercial buildings, to complement the ventilation guidelines for residences released in July( 2021).
Two, Khairy must also look at ways to reduce health inequalities, especially because between 10-30% of daily deaths are brought-in-dead (probably because they lack access to healthcare).
Three, there is increasing evidence of long Covid, with patients reporting symptoms that last months.
And four, the mental health infrastructure in Malaysia is not coping well with prolonged lockdowns.
The minister must do all this within the first 100 days, as promised by the Prime Minister.
However, 100 days could be too long, when daily cases are in the 20,000 range and daily deaths have been between 100-300 since July (2021).
Therefore, there is a need to decide on the most urgent demands of today.
I propose two over-arching immediate priorities:
- Bringing down the number of preventable deaths, and
- Preventing the health system from being overwhelmed nationwide.
We can expect that Khairy will deploy his considerable energies, intellect and inclusive approach to his stint in MOH.
However, Covid-19 has developed a momentum in Malaysia that may take several months to resolve.
In other words, even if perfect policies are implemented on Day One, they will still take four to eight weeks to show results.
The first sign of progress will be fewer daily cases, followed by fewer hospitalisations two to four weeks later, and fewer deaths two to four weeks after that.
That ideal scenario depends on our testing strategy.
There are three important gaps about our current testing strategy that must be addressed.
One, we are not testing enough, as our test positivity rate is between 5-15%, while the World Health Organisation (WHO) recommends less than 5% as a benchmark for adequate testing.
Two, we are over-reliant on the accurate, but expensive and slow, PCR (polymerase chain reaction) tests, instead of the cheaper and easier antigen rapid test kits (RTKs).
The relative lack of RTK accuracy is an acceptable trade-off to allow us better contact-tracing.
And three, the information from testing is currently manually fed into the contact-tracing system, when it should have been automated and electronic after 18 months of Covid-19.
These gaps are structural and deep-seated, and cannot be resolved easily.
In other words, while we can expect Khairy to work furiously to resolve the issues, there will be no magic overnight solutions.
This means that we must manage our expectations accordingly.
Health ministers do not need to be doctors.
In fact, doctors may be bad health ministers, especially if they have trained in hospitals all their lives and only see more medicines, surgeries, hospitals and clinics as the best way to achieve health.
A good health minister must look beyond healthcare to improve the health of Malaysians.
This column has repeatedly stated that health is more than just healthcare, and that the social determinants of health (like poverty eradication, good housing conditions, nutritious food, access to public parks for exercise and safe employment conditions) are perhaps more important than more hospitals.
Therefore, Khairy must work with other ministries, in a health-in-all-policies approach.
This does not mean that he takes over their roles, but that inter-ministry collaboration must be more visible, systematic and effective.
In this respect, his strong experience, networks and collaborative approach from his time in the Science, Technology and Innovation Ministry (Mosti) and the Special Committee on Covid-19 Vaccine Supply (JKJAV) will help his inter-ministerial approach in MOH.
Of special note is the relationship between MOH and the economic and security agencies.
Currently, the National Security Council and the nascent National Recovery Council dominate decision-making for lockdowns, workplace SOPs, vaccination privileges, and the National Recovery Plan.
MOH must feature more strongly in these decision-making bodies.
After the immediate urgent priorities are addressed and there is some breathing room, Khairy must consider starting the long-overdue reforms of our health system.
These reforms are difficult and politically risky, but necessary for Malaysia to continue fighting Covid-19,while delivering routine care.
Lessons from other countries indicate that reforms take 10-30 years.
Therefore, the ideal solution is to kick-start the reform process by establishing a Health Reform Commission through an Act of Parliament.
This Commission will set and supervise necessary reforms for a period of 10-15 years, before transitioning into a Health Service Commission.
Prime Ministers, governments and Health Ministers come and go, but the Commission should remain.
Based on Khairy’s track record in vaccinations, we have good reason to be confident that there will be a change in Malaysia’s pandemic fortunes.
Nonetheless, we need an improved health system and a team of 32 million Malaysians to turn our fortunes around, and not rely on individual heroism of either frontliners or ministers.
We wish Khairy all success.
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 firstname.lastname@example.org.