The Covid-19 pandemic has impacted healthcare systems around the world, stressing their capacities and threatening to push them past their breaking point. Healthcare systems in many countries have now found themselves struggling to cope with the additional demands of the pandemic.
Malaysia is no exception. The increased load of patients and demand for services has strained the Malaysian healthcare system. At the same time, the current pandemic reinforces the idea that healthcare reform is needed and strategic investments must be made to develop a more resilient healthcare system that can provide universal healthcare to all Malaysians.
The Malaysian public healthcare system, which has done remarkably well by most measures to date, now faces several urgent challenges. These challenges include epidemiological shifts that have led to an increased number of people living with non-communicable diseases as well as a rapidly aging population in need of support.
The challenging economic climate both locally and globally has also resulted in more people from the low- and middle-income groups seeking healthcare at public health facilities.
As the former Minister of Health, Datuk Seri Dr. Dzulkefly Ahmad, stated during his tenure, “The question that begs an immediate response from the Government of the Day, and the Health Minister, in particular, is whether the healthcare model that has been successful in the past is viable or adept enough to handle the current and future health challenges of Malaysia?”.
These challenges are not unknown to the Malaysian government and its policymakers. The 11th Malaysia Plan identified the need to create a sustainable health system and strengthen population health.
The Ministry of Health has since identified that creating a sustainable health system will require the improvement of existing processes, the optimisation of human and material resources, development and maintenance of IT, and the building of collaborations with the public (among others).
Improving the health of the population however, will require healthcare reform that transforms the delivery of primary care health services, the strengthening of existing healthcare services, sustainable healthcare financing, and public-private collaboration. All of these will require strategic planning and investments in the short, mid, and long term.
There are three main areas that require focus and significant investment in the short and mid-term to meet the current and future health challenges of Malaysia. These areas are:
- the development of healthcare workforce,
- strengthening public health in the community and primary health care delivery, and
- a comprehensive and sustainable information technology infrastructure in all health facilities.
1) Development of healthcare workforce
There is no healthcare without a workforce. As stated by the World Health Organization, “Health systems can only function with health workers; improving health service coverage and realizing the right to the enjoyment of the highest attainable standard of health is dependent on their availability, accessibility, acceptability and quality.”
Many countries face the challenge of having a shortage in healthcare workers. Without enough healthcare workers, healthcare systems cannot meet the demands for health services, especially in rural, remote, and under-served areas.
The Malaysian public health system does not have enough of the healthcare workers that it requires, but it is prevented from addressing this problem due to budgetary constraints. Further complicating the healthcare workforce shortage is the brain drain from the public health system to either the private sector or to other countries that is fuelled by poor working conditions, low salaries, and the lack of opportunities for career development and specialisation.
The irony of the situation is that while the Malaysian public health system grapples with a shortage of physicians and surgeons across various specialities and other allied healthcare professionals, there is a growing number of medical, pharmacy, and dental graduates who are unable to get permanent positions within the public health system due to budgetary constraints.
A significant investment of financial resources and planning is required in order to ensure that the Malaysian public health system is staffed by the healthcare workforce that it needs. The Malaysian Medical Association recently called for more long-term planning for permanent positions for medical officers, allied health workers, and specialists.
There also needs to be a prioritisation of issues such as fair remuneration, opportunities for career development and specialization, work-life balance, and the distribution of healthcare workers across the country. The increased financial cost of having higher numbers of healthcare workers should be viewed as an investment in the health of the Malaysian population.
Increasing the size of the public health system’s healthcare workforce will also enable the development of services and innovations that improve the accessibility and delivery of healthcare to the public. According to the Pharmaceutical Services Programme, as the number of pharmacists joining the public health system increased between 2004 to 2016, the number of Medication Therapy Adherence Clinics run by pharmacists in public health facilities increased from one clinic to 840 clinics.
During this period, innovative pharmacy services such as Ubat Melalui Pos and Drive Thru Pharmacies were also developed. These services have become essential to ensure that patients continue to get their medication throughout the Covid-19 pandemic. As such, the increased investments into developing the public health system’s health workforce will be necessary to not only meet the demands of the Malaysian public, but also to spur on the development of new and innovative services.
One area that an increased healthcare workforce can empower in the short to mid-term is the primary health care services network, which is discussed in the next section.
2) Strengthening public health in the community and primary health care delivery
Building a resilient public health system that provides universal health coverage and equitable access to all Malaysians will require the strengthening of public health as well as the enhancement of our primary health care services.
Regarding the strengthening of public health, more investments must be made to support the public health initiatives of the Ministry of Health. The public health focus areas that will require increased and sustained focus include promoting health and equitable health gain, health protection, injury prevention, food safety, disease control, and combating threats to public health. The Covid-19 pandemic has underscored how these areas, especially the final two, are vital to the health of the Malaysian population.
The push to drive healthcare closer to the public and the community will require several actions to be taken. This includes firstly the integration of the extensive public and private primary health care providers.
Malaysia boasts of having a well distributed network of general practitioners in the private sector, as well as a network of public community clinics. Integrating the two will allow for the sharing of resources and expertise, as well as provide comprehensive coverage for Malaysians living in both urban and rural areas.
This integration will also be instrumental for the establishment (or perhaps, re-establishment) of the Family Doctor system, where Malaysians and their families can be cared for by a regular primary care doctor or general practitioner who is familiar with their specific health needs and can be the coordinator of their health care, referring them to specialists and other allied healthcare providers when necessary.
Strategic investments and development are also required to establish health care services that treat patients closer to their home. This will include the development of a nationwide home or domiciliary care provider to support patients with palliative care needs as well as the elderly population.
Other healthcare services that can be developed to provide care closer to home include community mental health clinics, and low-risk birth centres. The further development and expansion of telehealth services such as mobile health services, health services provided on-demand through online applications (aka “uberised” health services), and virtual consultations will aid in the further decongestion of our public health facilities, and improve the accessibility of healthcare.
Strengthening the primary health care network and enhancing its delivery will help decongest our country’s public hospitals and reduce the barriers to health care access that are associated with travel costs and transportation. Care can also be provided closer to home by healthcare workers who are most familiar with the patients and the communities they live in.
The development of these new services and initiatives must, however, include extensive engagement with the communities served due to the wide variation of healthcare needs in each community. Community empowerment measures such as health clinic advisory panels, as well as community engagement councils must be supported to ensure that the services developed are practical, relevant, and acceptable.
Finally, community healthcare services for the Orang Asli, the poor, and those living in under-served areas must be strengthened. The Covid-19 pandemic has highlighted how the health of the entire population is closely tied to the health of those most disadvantaged among us. Services need to be structured and developed to ensure that their comprehensive healthcare needs are met, and that barriers to accessing healthcare are lowered for these marginalised groups.
3) Development of sustainable IT infrastructure
The strengthening of the public health system and its services requires there to be a sustainable IT infrastructure at every health facility. The availability of useable IT resources and equipment that are well-maintained will allow for the telehealth and mobile healthcare services mentioned earlier to be developed and implemented.
Having a proper IT infrastructure will also allow for the public health system to begin using cutting edge technologies such as artificial intelligence to improve the quality of care being delivered and to further empower databases such as the Malaysian Health Data Warehouse, which will be essential in the Ministry of Health’s efforts to improve population health.
The challenges and problems being faced in this area are not unknown to the Ministry of Health. The Ministry has previously identified that several challenges exist with regard to its IT infrastructure. This includes:
- inadequate and inconsistent funding,
- fragmented ICT implementation resulting in different health information systems being implemented across different health facilities that are unable to communicate with each other,
- incomplete readiness of ICT infrastructure in health facilities,
- inadequate data for strategic planning and management, and
- inadequate ICT skills and competency.
Additional issues that have also been identified include the lack of local subject matter experts to implement projects, the lack of capability and capacity in managing health IT operations and maintenance, and the lack of enforcement of IT policies – adherence to the policies.
A healthy and sustainable IT infrastructure can significantly improve the efficiency and effectiveness of the public health system’s health facilities and the delivery of its services. It is clear, however, that the current IT infrastructure available requires urgent and sustained investments in order to ensure that both material and human resources are available for the development and maintenance of the infrastructure, as well as the implementation of long-term health information systems across the public health system.
Without these investments, it is unlikely that the public health system will be able to fully gain the benefits of information technology, nor utilise new and upcoming health information technologies for the purposes of improving the health of the Malaysian population.
The problems and issues facing the Malaysian public health system as well as the actions and investments needed to address them are neither new, nor are they unknown to the leadership and policy makers within the Ministry of Health, as well as to the researchers covering this subject.
What is needed is the political will to make sustained and strategic investments into the areas highlighted above in order to ensure that every Malaysian is able to receive high-quality healthcare whenever they need it.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.