This is the final Vital Signs column for the foreseeable future.
Vital Signs started three years ago in July 2019, intending to examine Malaysia’s health system and propose solutions to strengthen public health, public policies and global health.
Sixty-five articles later, this writer has decided to step away to pursue two projects.
One, building a company that will try to implement the solutions that have been described in this column for primary care in Malaysia and South-East Asia.
And two, co-leading a strategic purchasing project in the Saw Swee Hock School of Public Health at the National University of Singapore.
Gratitude, respect and reforms
This writer is stepping away with two main feelings: gratitude and respect.
Gratitude to three groups of people: to The Star and her editors and journalists; to fellow co-authors who are inspiring health professionals, scientists, social scientists and healthcare leaders; and to the readers who have reached out with comments, suggestions and feedback.
Respect for the immense breadth and depth of Malaysia’s health system, and the skill, courage and sacrifice of the frontline health professionals in that system.
Here are several reflections from the last three years of Vital Signs.
One, the complexity of the health system of just one country required multiple articles that frankly, barely even scratched the surface.
Two, the Covid-19 pandemic dominated the last two years of our lives, and elevated the stature of health in the minds of policymakers and the public.
It could have taken a decade of writing to achieve the same impact on policymaking that the pandemic had.
Three, this column may have filled a health policy vacuum in Malaysia’s media landscape, and this author hopes that other authors will go even further in health and public policy analysis.
We can agree that health and public policy analysis is crucial for Malaysia’s health system. and we can certainly agree that reforms to our health system cannot be delayed any more.
Since 1981, Malaysia has had 15 to 20 attempts to reform our health system (the exact number depends on what you mean by “reform” and its scale and comprehensiveness).
That works out to be one reform attempt every two to three years, led variously by the Health Ministry (MOH), the Economic Planning Unit (EPU), the Prime Minister’s Office, or through Malaysia Plan programmes.
This is why we must all support Health Minister Khairy Jamaluddin’s Health White Paper initiative, scheduled to be tabled in Parliament in November (2022).
Stakeholder consultations have been ongoing since the beginning of this year, collecting suggestions and data from practitioners, academics, civil societies and the private sector, among others.
The Health White Paper envisions the creation of a Health Reform Commission accountable to Parliament, with the commission helping to guide, supervise and govern the reform process.
A Health Reform Commission
This writer has previously written about the need for a Health Reform Commission.
The main intention of this commission is “survivability”, in the sense that the commission should be structured and capitalised to sustain its work for 15-20 years.
Experience from Japan, South Korea, Taiwan and Thailand since the 1970s suggests that 15-20 years are needed for successful health reforms, given the sheer complexity of health systems.
The survivability of the commission is even more crucial in Malaysia, as we are now in a period of political instability.
We have had three Prime Ministers and three Health Ministers since the first Covid-19 case was reported in Malaysia in January 2020.
Instability is not suitable for multi-decade reforms, and this is where the commission plays an important role.
In its deliberations, the commission should consider three main aspects to strengthen our health system.
Each aspect is equally important, and all aspects are inter-linked.
One, Malaysia needs new terms of service for our human capital for health, specifically the 200,000 or so frontline doctors, nurses, pharmacists, paramedics and other allied healthcare professionals.
We need ways to retain them in the public sector, instead of losing them to the private sector or to other countries.
Two, Malaysia needs new, diversified and sustainable sources of funding, and more efficient and better-governed uses of funding.
The RM1 and RM5 fee to use a public clinic or hospital dates back to 1982, and must be revised upwards to increase MOH funds and increase self-responsibility for health, while continuing to protect the B40 group through means-testing.
A contributory scheme similar to Germany, Indonesia, Japan, Singapore and Thailand should be launched in phases in Malaysia.
And we need better procurement systems to eliminate waste, corruption, fraud and abuse.
Three, the commission should consider the proper organisation of the health service.
Large political economy questions like “how much private sector versus public sector deliver?” must be resolved through the political process, using principles of efficiency, effectiveness and equity.
More technical questions like “how much hospital versus clinic care?” can be resolved at the MOH or commission level using best practices from other countries, health economics data and careful strategic planning with the available resources in the ministry.
A fresh start
Malaysia’s health system remains reasonably resilient and strong, thanks to the frontline health professionals who operate with tremendous skill, courage, sacrifice and service.
Their semi-military precision and discipline is holding Malaysia’s public healthcare system together, despite years of being “underfunded, understaffed and overworked” (as described in the Auditor-General’s Report in 2018).
This situation cannot hold on forever.
The system that we built since 1957 must be rebuilt to be relevant in the 2020s and beyond, in a pandemic era with an ageing population, increasing non-communicable diseases like diabetes, and an increasingly lower tax collection that prevents the government from spending on health and social services.
There is a reform opportunity with the Health White Paper and the Health Reform Commission, and this provides us with a once-in-a-lifetime opportunity to strengthen our health system for ourselves and our families.
This decades-long journey must begin in 2022.
In stepping away from Vital Signs, this writer is filled with gratitude and respect, and a sense of humility and adventure in his next steps.
Please do reach out with comments or suggestions for collaborations, and we will try to stay in touch.
This column ends the way it began, dedicated to all frontline health professionals across Malaysia.
Your country is grateful for your skill, courage, sacrifice and service, and I hope that we will always do the right thing for you.
Thank you to all gentle readers – good luck and goodbye for now.
Dr Khor Swee Kheng is a physician specialising in health policies and global health. He can be reached at firstname.lastname@example.org. The views expressed here are entirely his own. For more information, email email@example.com. 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.