How can we tell if our health system is healthy?

Malaysia’s health system is so large, complex and inter-connected that there is no one solution for all its problems; but we can improve it together by first deconstructing the system and understanding it.

“WHAT are the patient’s vital signs?” asks the emergency physician as the unconscious patient is hurriedly wheeled into the Accident and Emergency Department.

A team of nurses and paramedics spring into action, coordinating their efforts towards one single objective: the stabilisation of the patient’s blood pressure, pulse rate, breathing rate and temperature – his vital signs.

Every doctor seeing every patient in almost every setting will check the patient’s vital signs.

These signs are religiously taught to every medical student, because they often mean the literal difference between life and death.

Vital signs are, well, vital because the human body should always be in homeostasis (i.e. a state of physiological equilibrium, or more simply, balance).

Any readings outside the normal ranges, either too high or too low, will cause concern; the larger or the more sudden the deviation, the bigger the concern.

Doctors will search for the causes, and treat if necessary. This is the basis of medicine.

So, if there are vital signs for the human body, are there vital signs for a country’s health system too?

How would we know if Malaysia’s health system also requires urgent life-saving measures?

Are there vital signs for health systems? Or are they so big that a few numbers or data points will not be able to properly represent their “health”?

These are good questions for citizens, as health is too important to be left to governments, the private sector and non-governmental agencies (NGOs) alone.

In the World Health Organisation’s (WHO) “whole-of-society” approach to health, all citizens can and must be equal and thoughtful participants in health systems, and not just passive recipients of health services.

Fortunately and understandably, all Malaysians already want urgent reforms for cheaper, better and more accessible healthcare.

However, we cannot successfully implement any reforms before we understand our health system slightly better.

There is one colossal challenge though: Malaysia’s health system is a “hyperobject”, which is so large that we can only understand it through patient and systematic deconstruction, and so complex that there are no simple explanations or solutions.

The term “hyperobject” was introduced by Prof Timothy Morton in 2010 in his book The Ecological Thought.

He suggested plastics, Styrofoam or climate change as examples of things so massive that they transcend time and space.

I will share two more examples: although we use WiFi and ATMs daily, it is difficult to grasp the full extent of the Internet or the US$80 trillion (RM333.2 trillion) global economy – objects so massive that they stretch our understanding, and perhaps even our control.

Too huge to comprehend

WHO divides health systems into six building blocks – workforce, financing, delivery, essential medicines, information systems and governance – each of which are infinitely complex.

To demonstrate the gargantuan size and complexity of Malaysia’s health system, here are some fun facts for each block.

In 2017, Malaysia spent a total of RM56 billion on health, with 3.5 million inpatient admissions and 70.1 million outpatient attendances in 417 hospitals and 9,849 clinics.

The Health Ministry’s 2017 annual report runs to 490 pages, and the ministry has approximately 268,000 employees, with 65,000 nurses, 35,000 doctors, and 27 different sub-categories of allied healthcare professionals (from dieticians to entomologists).

There are at least 26 different laws (PDF) governing Malaysia’s healthcare, at least 86 clinical practice guidelines by the Academy of Medicine Malaysia that list best medical and treatment practices for a variety of different medical conditions, and hundreds of ways that Malaysia can fund our healthcare.

These massive numbers prove that Malaysia’s health system is so gargantuan and complex that it could become incomprehensible or ungovernable, despite our best efforts and intentions.

Some may then argue that we must return to our previous “small /simple” health system, but that’s impossible.

Indeed, the success of yesterday’s system created today’s “large/ complex” system. We can see this in our larger and healthier population, all of whom live longer, have with more complicated diseases, are more educated and demand better quality care.

To understand and improve our health system, we must accept that it has complex and inter-connected problems with multiple root causes, and that there are no easy, magic or overnight cures.

While we can and must simplify processes and bureaucracy, there will still be no single/ simple solutions to the rising cost of healthcare, the over-supply of junior doctors or long queues in public hospitals, to name just three problems.

With many causes, there must be many solutions. Therefore, what Malaysia needs is a basket-of-solutions.

As our health system issues do not have only one single best answer, we must adopt a multipronged approach because there are many right answers.

Then, we will need everyone in society, from the Prime Minister to the man (and woman) on the street, to help implement these solutions, with all citizens actively participating in the health system that we jointly own.

Part of the solution

This column aims to be a part of that basket-of-solutions.

In it, we will deconstruct our large and complex health system into its smaller component parts, provide more light (rather than heat) into the public discourse, and deliver solutions for a large and complex system with more civil participation.

We will examine our system in digestible weekly doses using a structured, neutral and pragmatic approach.

Every column will look at a single element, peel back the layers, connect it to other relevant (and sometimes surprising!) elements, and discover some practical improvements.

This methodical approach and holistic view will also never neglect the urgent issues of the day.

Malaysia’s health system isn’t dramatically dying in our arms. A better description is of a complacent middle-aged person with some mild-to-moderate disease, who needs better lifestyle choices and a few bitter remedies to avoid deteriorating.

We still have time (but not a lot) to “save” our health system. If we work together on that basket-of-solutions, we can surely achieve the health and well-being that we Malaysians all want and deserve.

Dr Khor Swee Kheng has postgraduate degrees in internal medicine and public health, and has worked in five health sectors across three continents. He is currently specialising in health systems and policy in a public university and a local think tank. The views expressed here are entirely the writer’s own.

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