When all ministries implement the Health in All Policies principle, promoting health will naturally become the mission of the entire government without too much effort.
MEET Makcik Rahimah, who is 70 years old and who has recently moved to Kuala Lumpur to stay with her son after living alone for 10 years.
She can no longer stay alone due to poor vision, knee pain and some forgetfulness.
In Kuala Lumpur, she stays in a cramped three-bedroom apartment with two other adults and four children.
It’s on the third floor of a four-decade-old, dimly-lit building without elevators, which is close to a small chemicals factory.
Her daughter-in-law risks losing her job by taking time off work to drive Makcik Rahimah to appointments at three different clinics, braving traffic, parking and waiting.
This is a very common scenario in urban Malaysia, where 78% of households are located (PDF).
For Makcik Rahimah, we can remove her cataracts, inject steroids into her knees, and maybe even prescribe medicines to reduce her forgetfulness.
We can also provide home visits by nurses and organise her referrals so that she only needs to attend one clinic every three months.
However, for better health outcomes for Makcik Rahimah, more institutions must be involved.
The Housing and Local Government Ministry must introduce stronger and clearer building code requirements for an ageing society, e.g. better lighting, wheelchair access, and slip-proof floors.
The Transport and Entrepreneur Development ministries can provide a regulatory framework or incentives for companies to improve transportation access to health facilities.
A tri-ministry effort between the Economic Affairs, Human Resources, and Women, Family and Community Development ministries, must introduce legislation mandating all companies provide flexi-work arrangements to balance personal responsibilities with national economic growth.
City halls (dewan bandaraya) and town councils (majlis perbandaran) must enforce their urban planning and zoning laws.
All of this may sound like “more government regulations stifling society and businesses”, but it’s not.
One, regulation in the public interest is the prime duty and moral imperative of governments, especially health-promoting social regulations.
Two, smart regulations will provide a safe legal space for entrepreneurs to develop innovative solutions that will place health at the centre of their businesses.
Three, the political and economic benefits of a caring government and a Malaysian health-industrial complex are priceless.
Words for a healthy cause
Last week, we saw how health outcomes disproportionately depend on social determinants of health, like poverty eradication, housing and employment.
This week, we will examine the three steps to apply the World Health Organisation’s Health in All Policies (HiAP) principle, i.e. rhetoric, implementation and evaluation.
The first step towards HiAP is rhetoric, which requires explicitly formalising and communicating a new mindset.
Malaysia has had ad hoc inter-sectoral HiAP interactions (PDF) since the 1970s, such as improved water supply and sanitation by the Rural Development Ministry.
To evolve from such interactions that are only done when necessary, we need a clear top-down mandate, instructions and definitions.
To achieve that rhetoric, a political decision can be made at the Cabinet level that the government and all its ministries, agencies and departments will begin implementing the HiAP principle.
The good news is that this rhetoric has unlimited benefits and almost no political cost.
The bad news is that without practical guidance on how to implement HiAP in real-life policy-making and systems design, it is easier said than done.
The second step of implementation is then the crucial one.
Based on my experience in systems design, I propose three SMART (Specific, Measurable, Attainable, Relevant, Time-bound) targets once all ministries appoint a director-level Health Ministry (MOH) liaison.
This senior civil servant must come from their operations section, and will work directly with a same-level MOH counterpart.
The liaisons’ first target is to insert some simple and relevant language into the vision, mission and/ or objectives of all ministries (where possible and without over-engineering), and then to run a simple PR (public relations) campaign.
Although this may seem simple, mere words outlining a common vision or mission cannot be underestimated because they are social constructs that unite people around a common cause.
Let’s consider a ministry seemingly far from health. The Defence Ministry’s objective is “to protect and defend the national interest, which is the cornerstone of the sovereignty, territorial integrity and economic prosperity of the nation”.
It can be slightly changed to “… economic prosperity, health and well-being of the nation”. This puts health alongside their core mission without replacing it.
The liaisons’ second target is to define a set of policy, project or resource allocation decisions where Health Impact Assessments (HIAs) are mandatory, e.g. for all projects costing more than RM100,000.
Today, HIAs are a part of Environmental Impact Assessments or EIAs (PDF) governed by the Department of Environment (DOE), which focuses on construction, agricultural or environmental projects.
The use of HIAs must be delinked from EIAs and expanded to non-DOE jurisdictions.
There are many HIA tools with bells and whistles, but I suggest a no-frills option of a Yes/ No question during decision points: i.e. “Will this project have any potential impact on the health and well-being of Malaysian citizens?”
If “yes”, then the HIA kicks in. There is a natural risk of a “no” answer to avoid paperwork, but this risk is ever-present and should be mitigated by existing oversight mechanisms.
Obviously, decision-makers will need to be trained on a few concepts, but this simple additional step is a good balance between benefits and costs.
The liaisons’ third target is to formalise new inter-ministry operational channels.
With 25 ministries and 1.6 million civil servants, Malaysia definitely needs to “de-silo” our gigantic government; HiAP will help.
These mid-level contacts do not need to be extensive or complicated.
It could take the form of a monthly meeting, permanently-embedded officers, temporary secondments or attachments, or just allocating a physical office labeled “MOH Liaison” to keep health at the top of all civil servants’ minds.
All this will help improve the inter-ministry collaborations on health.
Let’s return to the Defence Ministry. It is directly responsible for the health and welfare of soldiers and veterans.
Its routine duties are also indirectly health-promoting, by protecting our borders against illegal migrants who are not screened for communicable diseases, bio-terrorism, or drug interdiction.
In return, MOH efforts to promote physical exercise provides a larger pool of potential soldier recruits as one surprising benefit.
This inter-sectorality with health exists for all ministries.
The final step is evaluation of the HiAP approach. This step needs no elaboration because it already exists in our current government’s operating model.
Indeed, the most important evaluators of HiAP’s success aren’t even inside the government; they are Makcik Rahimah, and all those caring for her.
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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