Maintaining trust in public health

One for the album: One reason Malaysians trust our public healthcare system is because of the experiences they’ve had with it, including happy occasions like birth.

 PUBLIC health is a beautiful profession.

It serves us in ways that are invisible, like childhood vaccinations, better nutrition, safer workplaces and stronger air quality standards.

When done well, we often forget that public health was there all along.

Similarly, we often forget that science is the basis of the electricity, smartphones and refrigerators that we use every day.

We take public health for granted for two main reasons:

• Because it is familiar and embedded within our daily routines; and

• Because we have benefited from it for years.

It is very fortunate that almost all Malaysians have high trust in our public healthcare system.

This trust was built after decades of seeing our doctors, nurses, medical assistants, pharmacists and paramedics in the four corners of Malaysia working endlessly to deliver effective healthcare services.

We trust the public healthcare system because the system is familiar to us.

That familiar public healthcare system is a nation-building tool because almost all Malaysians have had at least one life-changing event in a public hospital or clinic.

Together with our families and friends, we have experienced happy childbirths, agonising sickness and sad deaths in our public hospitals or clinics.

We trust the public healthcare system because we have shared collective experiences in it.

And we trust the public healthcare system because of the human relationships that we form from it.

A decade after leaving the Health Ministry, I’m still in touch with many colleagues and several patients.

The term “in sickness and in health” applies not just to marriages, but also equally to the powerful human relationships that we build from our public healthcare system.

If patients do not trust their doctors, nurses, the public health system, or even basic science, they will not take their medication or undergo surgeries.

If citizens do not trust that car safety belts, Covid-19 vaccines or face masks will protect them, they will simply refuse to use them.

If citizens do not trust professional societies or health agencies, we will have a society-wide problem.

Trust is fragile

The crucial operative word is “trust”, which is the most fundamental element of health and healthcare.

We all know that trust is fragile.

Trust can evaporate quickly (if terrible decisions are made) or slowly (if there are decades of under-investment in our public hospitals and clinics).

Therefore, all health professionals and leaders must understand that trust must be continually maintained and cultivated, even if it is already earned.

In other words, we must not take the high trust in our public health system for granted.

There are many reasons for fragile trust.

Unfortunately, trust in our public health system also mirrors trust in the entire government.

Declining trust in governments is a worldwide phenomenon that predates Covid-19.

But the Covid-19 pandemic has accelerated this trend, with an Ipsos Mori survey in March showing that Canadians, the French, Germans, Japanese, Russians, the British and Americans have reduced confidence in their national governments’ ability to deal with Covid-19.

When citizens do not trust their government, they might lose trust in their public healthcare system too.

Trust in our public health and healthcare system is also under threat from decreasing scientific literacy worldwide.

For example, the average PISA (Program for International Student Assessment) scores for secondary school science subjects in Europe declined between 2012-2018, regressing to 2006 levels.

This means that the average student has less understanding of basic science concepts, potentially leading to decreasing trust in public healthcare systems.

This could be true for Malaysia too, where the average performance of 15-year-olds in science is 438 points, lower than the OECD average of 489 points.

Finally, trust in our public healthcare system is under threat from increasing prevalence of pseudoscience.

Pseudoscience is a collection of beliefs or practices that claim to be scientific, but are actually exaggerated, misleading or outright false.

Historical examples include snake oil salesmen and miracle cure peddlers.

Current examples include anti-vaxxers and homeopathy “experts”.

There are many ways that trust in our public healthcare system can erode.

Therefore, we have to continually work to maintain and enhance that public trust, and not let it diminish.

Keep public health apoliticalMalaysia is going through a turbulent political and pandemic period now.

Public health principles, expertise and judgment are being challenged on a daily basis.

Fighting the pandemic has been and is the toughest professional experience for all of us, as we have to fight a mutating virus, a fatigued healthcare system, a long-suffering population and a shrinking economy.

We must keep our public health system apolitical, for two main reasons:

• So that it can devote its entire energy to fighting the pandemic; and

• To maintain the high levels of public trust in the system.

If it becomes politicised or is seen as being used as a political tool, then we will not be able to fight Covid-19 effectively.

Another excellent reason to keep our public health system apolitical is because governments and prime ministers come and go, but our public health system must remain timeless.

We can keep our public health system apolitical in three practical ways.

One, there must be equal standards for all public health decisions, applicable to any sector, industry or workplace.

The standards must not change according to whims and fancies, but must be as predictable as possible to allow for the rakyat to plan. There must also be no double standards for enforcement.

Two, the data for public health decisions must be made transparent on a systematic basis.

In other words, all data must be released all of the time.

Given the trust deficit, more data will improve public trust in the government, public health system and in individual health professionals.

Three, Malaysia must begin a national conversation on the right way to organise our health system.

Covid-19 has elevated the importance of health and health security in Malaysia.

Perhaps it is time to create a Health Service Commission that reports directly to Parliament, to allow adequate public scrutiny for such an important public service.

The Health Service Commission is a complex concept intended to deliver better health for all Malaysians (not just change reporting lines), and we will discuss this in future columns.

Ring-fencing health from partisan politics is crucial for Malaysia, to preserve public trust in the system and to continue fighting Covid-19 effectively and professionally.

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

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