Will 2023 Be A Year Of Reckoning For Malaysia’s Health Care System?

GE15 led to a new government, with the major coalitions having health and health care in their manifestos. Will there be substantial changes in health and health care management?

2022 saw Malaysia recovering from the devastation of Covid-19 in 2021, with the floods and the Batang Kali landslide providing the finale for the year. Lives were lost in the landslide and the floods with thousands made homeless by the latter.

Covid-19 was Malaysia’s worst public health disaster. The cumulative number of confirmed reported cases exceeded 5.0 million with 36,713 reported Covid-19 deaths on December 4, 2022.

Malaysia’s global ranking in the cumulative number of confirmed cases rose from 89th position on November 18, 2020 to 27th position at the end of 2022. The deaths per million of the Malaysian population became the highest in ASEAN on August 31, 2021 and had stayed in the pole position since then.

Covid-19 overtook heart disease as the number one cause of deaths in 2021. Maternal deaths doubled from 117 in 2020 to 300 in 2021. The maternal mortality ratio (MMR), which is the number of maternal deaths divided by the number of live births in the same year, increased by 2.75 times from 24.8 per 100,000 live births in 2020 to 68.2 per 100,000 live births in 2021.

The last occasion that Malaysia had such an MMR was about four decades ago in the mid-1980s. The 2021 MMR was an indictment of the Malaysian health care system – it failed many pregnant women.

The silence of the government, particularly the health authorities, was deafening.

More Covid-19 Cases Sequelae

Continuing mutations of the Covid-19 virus will continue to impact globally.

There has been a resurgence of influenza in many countries in late 2022. In some countries, respiratory virus (RSV) infections in children have surged. Together with Covid-19 in the background, this has led to fears among medical experts that the collision of influenza, RSV and Covid-19 could lead to a potential “tripledemic.”

While there is no scientific definition of this term, there are already reports that hospitals in many countries have been overwhelmed. While the three viruses are present now, their prevalences are not peaking at the same time.

Will the “tripledemic” or even “twindemic” (Covid-19 and influenza) occur in Malaysia? Only the cavalier would discount this likelihood. What will be its impact on the health care system, which teetered on the verge of collapse in 2021?

China dismantled many of its strict zero Covid-19 policies in November to December 2022. It has ceased mass lockdown of entire cities, restrictions on travel within and between regions, and allowed those infected with Covid-19 to isolate at home instead of in centralised facilities.

Because of its policies, a significant proportion of the China’s population has no immunity to Covid-19, whether from infection or through vaccination.

What will be impact of the Omicron in China? Will Omicron behave like it did globally i.e. more transmissible, but less severe than older variants? Or will Omicron behave differently in China?

What is certain is that with more infections, newer variants may emerge and that China will spend 2023 catching up with the rest of the world. One scientific model (article accessed December 27, 2022), using 2022 data from Hong Kong and Shanghai, predicts that there will be about a million Covid-19 deaths in China in the next few months.

Another scientific model (article accessed December 27, 2022) predicts that the Covid-19 death toll in China will be about half a million by April 2023 and 1.6 million by end 2023 if the country continues on its current path.

What will be the impact of the increase in China’s Covid-19 cases on Malaysia, and, if so, how?

Knowledge of Long Covid, a condition with myriad clinical features, is incomplete. A review (article accessed December 27, 2022) of 194 studies involving 735,006 participants published in the Lancet of December 1, 2022, reported that “45 per cent of Covid-19 survivors, regardless of hospitalisation status, were experiencing a range of unresolved symptoms at four months.”

If that is extrapolated to Malaysia, it would involve about 2.25 million reported cases, with higher actual numbers because of under-reporting. Could Long Covid be the next public health disaster in Malaysia?

2023 could be the year the world, except China, finally figures out how to live with Covid-19. Any prediction that Covid-19 will end in 2023 is not only premature, but naïve as the only thing predictable about Covid-19 is its unpredictability.

Non-Covid-19 Diseases

The incidence of non-communicable diseases (NCD) will continue to rise with increasing undiagnosed and uncontrolled numbers because there are no coordinated control measures.

The dengue spike in 2022 will continue to take its toll in 2023.

This will impact on Long Covid and NCDs and their complications; and also strain service delivery in the underinvested, overworked, crowded public health care system.

The backlogged surgeries following Covid-19, although cleared, together with poor or no treatments for NCD, will inevitably lead to premature and excess morbidity and mortality. Unfortunately, such data is unavailable in the public domain.

Public Trust and Health Policies

Health care will be increasingly provided by non-health sectors with technological tools e.g. internet purchases of pharmaceuticals and medical devices.

The Health Ministry’s budgetary allocations cannot assure improved patient safety and quality care unless wastages, inefficiencies, and the role of middlemen are reduced markedly; and there is an open and just culture within the ministry.

As long as health policies are formulated without genuine consultation with stakeholders, success will be limited or absent.

Public trust will continue to wane for reasons that include poor risk communication; non- or poor compliance to standard operating procedures; failure of authorities to engage meaningfully with the private sector, universities, and civil society; misuse and abuse of social media; lack of transparency; and poorly considered health and health care measures.

At a tipping point, the pressure for change will be unstoppable and the government of the day will have to oblige.

Increasing Health Care Expenditure

Health care expenditure and medical inflation will continue to rise because of the aging population; NCDs; Long Covid-19; other infectious diseases; new technologies; increasing patient demands; and the unrestrained middlemen in health care.

Increasing out-of-pocket expenditures in the private and public sectors will lead to more families facing financial ruin if they or their relatives get catastrophic diseases e.g. cancer heart attack, stroke, Covid-19; or are made redundant.

More general practitioner (GP) clinics and even private hospitals will close because of financial unsustainability, health care staff burnout, and stringent implementation of regulatory requirements.

Medical Workforce

Medical unemployment and disgruntlement will continue, with the issue of contract doctors yet to be adequately addressed.

The best and brightest will seek employment abroad, with Malaysia one of the few countries that trains doctors, at public expense, for other countries.

The Health Ministry’s response to the public disclosure by the previous Dean of Medicine of the University of Malaya, that about 30 of its best and brightest are lost to Singapore annually, was, to say the least, pathetic. With such attitudes, how could there be solutions to the junior doctors’ plight?

There will be mergers, acquisitions, and closures of some private medical schools because of financial unsustainability and reducing demand.

General practitioners’ minimal or non-involvement in management of NCDs in public sector patients will impact negatively on population health and the risks of Covid-19, other infectious diseases, and NCDs.

Medical Technologies

New technologies, e.g. portable and individual diagnostics, smart drug delivery mechanisms, genome sequencing, machine learning, artificial intelligence etc., will increasingly impact on health care.

mRNA technology modified the Covid-19 pandemic significantly by preventing 12.2 million deaths in developed countries between December 8, 2020 and December 31, 2021 (article accessed December 27, 2022). Its potential for vaccine development for other diseases is increasingly exploited.

Issues of patients’ confidentiality and security; patient safety; and the successes and failures of the new technologies will be problematic.

New technologies are just tools. Discrimination and careful evaluation are critical for humane health care and not technological exuberance.

Will Health Care Improve In 2023?

Covid-19 and the floods exposed numerous examples of irresponsibility, unaccountability, and incompetence that were underpinned by arrogance and poor insight.

GE15 led to a new government, with the major coalitions having health and health care in their manifestos.

Will there be substantial changes in health and health care management? Or will 2023 be a year of reckoning for the health care system?

Stay Healthy and Stay Safe

Health care is avoidable by staying healthy. A healthy diet, maintaining an appropriate weight, regular exercise, sufficient rest, safe sexual practices, avoiding tobacco smoking, moderate alcohol consumption, and keeping vaccinations current are necessary.

This requires effort, smart lifestyle choices and the occasional medical check-up.

Long Covid-19 and other health risks can be minimised by compliance with one’s individual responsibilities and vaccination.

Wishing all readers good health in 2023. Take care and stay safe.

Dr Milton Lum is a Past President of the Federation of Private Medical Associations, Malaysia and the Malaysian Medical Association. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.

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

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