The national health care system reforms proposed recently by Health Minister Khairy Jamaluddin are commendable. The shift of focus to primary health care, promotion of wellness and the need for decentralisation, optimal inter-agency collaboration, and provision of quality care for all (including marginalised groups) provides a golden opportunity to address the many gaps in Sarawak’s current health care system.
The Health Cluster of the Sarawak Civil Society Organisations – Sustainable Development Goals (CSO-SDG) Alliance welcomes the opportunity to contribute towards the Health White Paper. Our five key recommendations are as follows:
Decentralisation To Facilitate Development Of Effective Primary Health Care
To move forward, decentralisation to the state level with the necessary resource and structures put in place is a top priority.
The state will then need to decentralise further so that primary care clinics can serve as vibrant hubs of health and social care catering to the needs of diverse communities through working in partnership with them, community health promoters, and other relevant agencies including appropriately funded non-governmental organisations (NGOs).
A well-funded, well-planned structure will rejuvenate primary health care in Sarawak, promote wellness and facilitate collaboration, leading to more user-friendly, effective, and efficient community health care services, with the potential to reach people in their own homes.
The framework for decentralisation should enable both vertical and horizontal integration of health services so there is effective communication and planning with hospitals and the varied primary health care providers.
This will enable the most apt service to be given at the most appropriate time and facilitate seamless transition of care for consumers. As transport costs and human resource training are essential to providing accessible, quality services in Sarawak, such crucial funding needs to be protected through ring-fencing.
Transparent Data On Addressing Inequalities And Resource Allocation
Data on needs, access to health care, out-of-pocket expenses, and resource allocation need to be accurately collated in a timely manner and made public.
In the multiple dimensions of poverty measurement, all needs and groups should be captured, including people in remote areas not covered in the national household income and basic amenities survey and those who are awaiting citizenship status.
Action should be taken to ensure levelling-up in health care services provision so that no one is left behind.
Governance To Be Representative And Broad-based
Both the proposed Health Reform Commission and the White Paper Advisory Council need to have equitable representation from Peninsular and East Malaysia and key stakeholders, including consumers and implementers with lived experience.
They should commit to establishing and maintaining transparent systems to enable public monitoring of whether the service is reaching the marginalised and providing quality universal health coverage.
Avenues for consultation with persons with lived experience of physical and mental health conditions should be created at all levels of planning, decision-making, and service delivery.
Legislation should also be enacted to establish a Health Ombudsman so there will be an independent channel to deal with patient’s complaints.
Utilising Technology And Enabling Access
The future of health care will involve creative, effective use of technology both to share information and training, and to enable early intervention, treatment and specialist support in remote locations.
For Sarawak, there is an urgent need for the essential infrastructure to be made available throughout the State. Being able to gain a reliable internet signal is not an adequate measure of internet accessibility.
As the school lockdown during the Covid-19 pandemic exposed, many are able to send text messages but cannot download data, while others have no internet access at all.
By 2030, the goal should be to provide telemedicine services to all rural clinics and to distribute the latest technologies (e.g. cervical and breast cancer screening) that enable early detection of conditions even in remote areas.
National policy decisions, e.g. the “acceptance of online payments only” for Ministry of Health services, may aggravate their access and utilisation in already underserved areas.
Addressing Health Holistically
1. Mental Health
Since 1990, mental ill-health has been acknowledged as a leading cause of disability in Malaysia. The pandemic has increased the incidence of mental health problems. More resources are needed to close the existing gap between physical and mental health services, with a focus on mental health promotion and preventive upstream interventions
2. End-Of-Life Palliative Care And Domiciliary Care
Malaysia is an ageing society. Developing domiciliary care and extending palliative care services into rural communities will help reduce pressure on hospital beds.
3. Caring For Caregivers
Another gap is the lack of support for the caregivers of the elderly, those with chronic physical and/or mental conditions, terminal illnesses or disabilities — including children with special needs. Psychosocial and financial support is needed, as are services that help share the stress of caring.
4. Early Support For Families With Special Needs Children
There needs to be an emphasis on early detection and diagnosis which then leads to accessible and quality early-intervention programmes and inclusive education.
5. Adolescent Health
Adolescent health is often overlooked. Adopting strategies for their healthy development and mental well-being have a lifelong beneficial effect. Youths need access to empathetic, non-judgmental health information and treatment, including mental and sexual reproductive health.
Wider accessibility and life skills training could reduce the development of severe mental health issues in adulthood, suicides, and sexually transmitted diseases, including HIV.
6. Access To Health Care for Stateless People And Foreign Workers
This was omitted in the initial proposal. A country cannot be healthy and productive unless all have affordable access. This is needed on humanitarian and practical health grounds.
During the Covid-19 pandemic, vaccination was extended to all as it was recognised no one would be safe unless everyone is safe. Sarawak has many people who have been denied citizenship despite living their whole lives in the state.
Denying them health care and access to education is not in line with the United Nations’ human rights conventions. On the same grounds, while foreign workers are now covered by life and medical insurance, their living and working environments should be monitored.
7. Addressing Social Determinants Of Health
Social determinants of health are highlighted in the proposals but collaborative structures to enable all Ministries to harmonise their efforts is not given any attention.
The health of a nation is determined by the following factors:
- 20 per cent by access to quality health care services.
- 30 per cent by public adopting promoted healthy behaviours.
- 10 per cent by the built environment.
- 40 per cent by socioeconomic factors such as eradication of poverty, income security, quality education, appropriate housing, and support from family and communities.
Investing in health means investing in all of these areas. While Sarawak ranks third in terms of Gross Domestic Product after Selangor and the Federal Territories, it is the third poorest state, as measured by the 2020 Household Income Estimate and Incidence of Poverty Report, and has acute shortages of health workers and many dilapidated clinics and schools. This needs to change.
The Health Cluster of the Sarawak CSO-SDG Alliance calls for cross-party support from Sarawak politicians to ensure the Health Reform White Paper meets the needs of all living in the state.
This is a once-in-a-lifetime opportunity to fundamentally reshape health care and create sustainable structures which advance the SDG agenda by providing quality, universal health coverage (both geographical and financial), reducing inequalities and addressing the range of social determinants that determine a country’s health.
The statement has been endorsed by the following member organisations:
- Befrienders Kuching
- Kuching Parkinson’s Society
- Mental Health Association of Sarawak (MHAS)
- National Cancer Society of Malaysia Sarawak Branch (NCSMSB)
- Organisation for Addiction Prevention Treatment and Rehabilitation (OAPTAR)
- Pink and Teal EmpowHer (Persatuan Kesedaran Kanser Wanita)
- Sarawak AIDS Concern (SAC)
- Sarawak Women for Women Society (SWWS)
- Society for Cancer Advocacy and Awareness Kuching (SCAN)
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.