KUALA LUMPUR, June 5 — A medical expert called for more investments into primary care and changing the health financing system, amid Malaysia’s growing epidemic of non-communicable diseases (NCDs).
Professor Dr Adeeba Kamarulzaman — dean of the Faculty of Medicine, Universiti Malaya, and an infectious diseases specialist — told a forum hosted by CSO Platform for Reform Tuesday that Malaysians should be as concerned about diabetes and obesity as they are of contracting the Covid-19.
“If we could get people to be as afraid of diabetes and obesity as they are of Covid-19, we would be doing well,” she said.
Her remarks came in light of recent alarming statistics reported by the National Health and Morbidity Survey (NHMS) 2019 published by the Ministry of Health (MOH), where the prevalence rate of diabetes in adults increased in Malaysia from 13.4 per cent in 2015 to 18.3 per cent in 2019, with an estimated 3.9 million Malaysian diabetic adults as of last year.
Half of Malaysian adults were overweight or obese as of 2019, according to the survey.
Dr Adeeba further shared with the forum a recent study conducted in the US that found as many as 10 per cent of hospitalised Covid-19 patients with diabetes died within seven days of admission, pointing out that diabetes and obesity are two of the major risk factors in getting severely sick or dying from Covid-19.
“And we know what drives it, it’s the inflammation,” she said, adding that the inflammation from these NCDs cause the same outcome in diseases like dengue, for example.
She further emphasised that living with diabetes and obesity are just as life-threatening as other acute health complications such as heart attacks and stroke, and that acute infectious diseases are also worsened by NCD.
“Having diabetes and being obese is life-threatening beyond just all the other complications that you hear of, of having heart attacks, stroke, and (so on). Even in acute infectious diseases, these two conditions worsen compared to someone who doesn’t have diabetes or obesity,” she said, adding that it will not be an easy task to address NCDs, but “address it we must”.
Dr Adeeba also told the forum that in her conversation with a paediatrician colleague recently, she found out that a significant number of individuals diagnosed with Type II Diabetes consist of the young population, as young as 10 years of age.
“We are seeing more and more young people with Type 2 diabetes, I’m talking about 10 year-olds having Type 2 diabetes.”
Dr Adeeba Kamarulzaman, dean of the Faculty of Medicine, Universiti Malaya
“Imagine the cost of it to this young person but also to the health system,” she said, and pointed out that the growing issue with NCDs in the country needs to be addressed post-Covid-19.
Type 2 diabetes, which is the most common form of diabetes, happens when the body becomes increasingly resistant to insulin.
“Perhaps after Covid-19 we need to take a deep breath and sit down to take a look at how we can really tackle NCDs. It has to be tackled from all angles, perhaps sugar tax, to perhaps massive education campaigns, to restricting different things, but whatever it is, it should be evidence-based and there is plenty of evidence out there and plenty of evidence to be learned from local research and what works,” Dr Adeeba added.
The NHMS 2019 reported as many as one in three Malaysian adults have low levels of health literacy. This, according to Dr Adeeba, contributes to the poor lifestyles of some individuals that led to development of NCD.
“There are also things that make this difficult to tackle. Excess ingestion of carbohydrate makes diabetes and obesity worse and there are links to low income and knowledge in terms of people eating too much carbohydrates, because it fills the stomach (compared to) other healthier food.
“In our society where it’s very paternalistic that ‘doctors know best’, it still exists. We need to move away from that end, and we need to utilise social media, we know that’s where people are these days. Those things are relatively inexpensive, so in terms of, compared to billboards, which don’t work anyway.
“So, getting smart people together to think about how can we penetrate the public with messaging around healthy living, healthy eating, exercising, would be super important,” she said.
Strengthen Primary Care And Public Health
When asked about where investments should go into, in terms of improving health care systems, Dr Adeeba firmly stated that primary care should be the main area of investment.
“There needs to be strengthening of primary care and public health, as in the public health system. Primary care is where the public goes to, and it should be there to provide preventive care, as well as primary care as we know it.
“Thus far, Malaysia has put a lot of investment in secondary, tertiary and acute care, you know, built lots of hospitals. But the focus now should shift towards strengthening primary care and improving, well, first of all, the 20 per cent who already have diabetes, making sure that their management is good to reduce the complications, making sure that they get the right health education, and everything else, dietary advice and lifestyle advice and all that,” she explained.
Dr Adeeba also added that the current 4 per cent of the nation’s GDP that is put into health care is not enough, stating that “we should be around seven or eight (per cent), (which) sounds like a lot of money, but it’s still probably not enough.”
RM1 Payment For Health Care Unsustainable
More than 70 per cent of the Malaysian population utilises the public health system, which shows an underutilisation of the private sector, a great gap between the public and private health sector.
Dr Adeeba thinks that the integration of the two houses of Malaysia’s health care can happen with a re-evaluation of the health financing system, which she highlighted as a vulnerable point in the health care sector.
The medical expert opined that the current scheme of RM1 outpatient payment to access public health facilities by the Ministry of Health (MOH) will not be sustainable for the country.
“Several things need to happen, I think the first would be to re-examine the health financing system, which has been an Achilles heel. If I’m not mistaken, 21 consultations on what would be the best health financing system we should have, the RM1 that 70 per cent of the public is paying to access the KKM facilities is not going to be sustainable in the long run,” said Dr Adeeba.
She further added that the problem with congestion in public health facilities cannot be solved unless a better health financing system is put in place, as opposed to the unsustainable RM1 payment scheme.
“I think until we fix that, it’s going to be very difficult to kind of level the overcrowding in public system versus the 40 per cent of the specialists in the private system that is looking after 30 per cent of the people.
“I think the first thing that needs to happen is the re-engineering of the health financing system.”
Dr Adeeba Kamarulzaman, dean of the Faculty of Medicine, Universiti Malaya
Malaysia’s public health care system is financed from general taxation. Previous administrations have mooted some form of social health insurance to inject more money into health care.
In terms of primary health care, Dr Adeeba also pointed out that private general practitioners (GP) are underutilised as the public clinics are overcrowded, and said that mechanisms need to be put in place to better balance the usage between the public and private health sectors.
“Currently you see the overcrowding in Klinik Kesihatan and private GPs are underutilised. So, having a mechanism to draw people to the private GPs, I think there’s been attempts with Peka B40 and programmes like that in the past, so this needs to be looked at in further details,” said Dr Adeeba.
The previous Pakatan Harapan administration implemented a health screening programme called Peka B40 in a bid to reduce NCDs among low-income people, where the bottom 40 per cent (B40) can get screened at participating private clinics for free.
Work With CSO, Community-Based Services
In addition, Dr Adeeba thinks that government collaboration with civil society organisations (CSO) and community-based services is still lacking, and the financing and strengthening of non-government organisations (NGO) who provide health services need to be addressed, particularly with the current shift in demographics with an ageing population.
“I think also working with CSO and also community-based services, we don’t do that well enough. We don’t finance and strengthen our NGOs who are providing these services, particularly with chronic conditions and as we face the other crises, which is the ageing population.
“We need to work with community based organisations to provide that support for the elderly, to provide that support for the disabled, but they need to be compensated for it,” she emphasised.
She added that some kind of mechanism needs to be in place to provide financing, as well as programme monitoring and evaluations “so that NGOs become professionalised in part and parcel of the health system”.
In terms of Malaysia’s public health system in response to Covid-19, Dr Adeeba concluded that “a true partnership between the MOH, academia, private practitioners and NGOs in civil society would be important moving forward.”
“I think there was a feeling in the beginning that it was only MOH responding, and it probably would’ve lightened the load for them if everyone was brought to the table and to strategically look at where the gaps are and where different parties can play a big role,” she said.
