Important Health Information That Can Be Incorporated Into GE15 Manifestos – Prof Dr Andrew Kiyu

There’s excessive concentration of power and authority at the central level. Grant decentralisation and greater autonomy over the health sector for Sarawak.

Note: I am taking the point of view of someone from a state where there is a gross disparity in health care compared to Peninsular Malaysia.

Our health care issues are more basic in terms of inadequate coverage by physical health care facilities, especially for those who most need them in the rural and remote parts of the state.

A big part of the problem arises due to too much concentration of power and authority at the central level, to the detriment of addressing the needs of the local populations.

What health policies should be in all political parties’ GE15 election manifestos?

All political parties should address the issues that were proposed to be in the Health White Paper, namely: much-needed systemic and structural reforms that will tackle and correct the underlying problems; move from sick care to health care and wellness; address the maldistribution of equipment, capacity and skill mix between the public and private sectors in the health care system; and tackle the social determinants of health, such as poverty, and providing quality education equitable access to services for all, etc.

All parties should commit to increasing national investments in the health sector to reach 5 per cent of the gross domestic product (GDP).

Specifically for Sarawak, political parties should grant decentralisation and greater autonomy over the health sector for Sarawak.

This will enable Sarawak, together with the national government, to address health care system gaps in Sarawak in terms of service coverage, quality, delivery, and human resources (in terms of numbers as well as distribution); improving the physical conditions of many rural clinics that are in a poor state of repair; quarters for staff; and providing basic public utilities to the health facilities.

These shortcomings in the health care system in Sarawak are primarily caused by the centralisation of decision-making at the federal government level in relation to policy, planning, finance, delivery, implementation and sustaining a health care system.

There is a lack of understanding of the infrastructural and geographical challenges of a big state and its scattered rural population and the expectations of the people in the decision-making process at the national level and in the execution of such decisions.

The Sarawak state government has in place the Post-Covid-19 Development Strategy 2030. This strategic plan is anchored on six economic sectors, which includes Social Services.

The catalytic initiatives for Social Services include, inter alia, Medical and Health Services, setting up and construction of the Sarawak Infectious Diseases Centre, and social intervention programmes like centres for the elderly.

To address the shortcomings due to centralisation as mentioned above and to enable the Sarawak government to implement the Post-Covid-19 Development Strategy, it is necessary for executive authority over health to be transferred to the State Authority under Article 80(4) of the Federal Constitution, with an agreed amount of funds to be agreed upon or determined pursuant to Article 80(6).

Alternatively, arrangements for the performance of federal functions – particularly over the setting up, maintenance, human resources and equipment of hospitals, clinics, etc. – to be implemented or undertaken by the state government with the provision of necessary funds, as provided under Article 80(5), could be agreed upon between the Sarawak and federal governments.

Universal Health Coverage

Currently, the main narrative regarding Universal Health Coverage (UHC) at the national level is narrowly interpreted to mean universal health insurance coverage.

This narrow interpretation of UHC is detrimental to states and regions where geographical and physical coverage and access to physical health care facilities is still around 80 per cent of the population compared to the much-touted “presence of a clinic every five kilometres” in peninsular Malaysia.

There is no use in having universal health insurance coverage when health care facilities are non-existent or are very difficult to access.

The other issues listed below are abstracted from the recent statement by the nine members of the Sarawak Civil Society Organisations-Sustainable Development Goals (CSO-SDGs) as inputs to the proposed Health White Paper.

They include:

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.

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 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 MOH services, may aggravate their access and utilisation in already underserved areas.

Addressing Health Holistically

i. 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.

ii. 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.

iii. Caring for the Caregivers
Another gap is the lack of support for caregivers of the elderly, and 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.

iv. Early Support to Families with Special Needs Children
There needs to be an emphasis on early detection and diagnosis, which then leads to accessible, quality early intervention programmes and inclusive education.

v. 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.

vi. Access to Health Care for Stateless People and Foreign Workers
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 was 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 UN 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.

vii. Addressing the Social Determinants of Health
Social determinants of health are highlighted in the proposals, but collaborative structures to enable all ministries to harmonise their efforts are not given any attention.

The health status of a nation is determined by the following factors:

  • 20 per cent by access to quality health care services;
  • 30 per cent by the public adopting promoted healthy behaviours;
  • 10 per cent by the built environment, and;
  • 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 relatively high in terms of gross domestic product, 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.

Thus, the social, economic and environmental determinants have to be improved to have greater improvement in the health status of the population.

Prof Dr Andrew Kiyu is a public health medicine specialist and field epidemiologist at the Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak.

  • This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.

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