The Covid-19 pandemic was unprecedented when it ravaged the world, including Malaysia. The SARS-CoV-2 virus, the result of many previous mutations will re-emerge as another pandemic under a new name in the future.
If its devastating impact still eludes us, then we have not learned anything. A dire need to reset our health care priorities should be in the offing, and we must ensure sustainability of the health care system.
Improving the health care system is a complex process involving regulators, payers, suppliers, providers, and the patients themselves.
The Delivery System Is Suffocating
The current brain drain is affecting the health care delivery system adversely. When the human capital in the health care system is constrained, the service also gets choked up.
Improving our human capital pays huge dividends. The migration of a portion of local medical graduates to Singapore and other countries has caused grave concerns.
It is obvious that these talents are seeking good working experiences, with an eye towards good career prospects. if they are trained abroad, it would be natural for them to stay on in that country and prosper. The host country would gain, and Malaysia would experience a brain drain.
The situation is no different with our talents who stayed at home. Those who chose to specialise or subspecialise will incur huge costs for the government. The government should continue to train more specialists and subspecialists in various areas of medicine, biomedicine, and allied health sciences, including in those in new areas to sustain and enhance the health care delivery system.
Th Human Capital Is In Disarray
It is undeniable that human capital is the key component and the engine that powers the entire health care system. Human capital that involves knowledge, social, and emotional fundamentals appear to be in disarray in the current climate.
There have been many suggestions to retain medical human capital. The most important priority for health care workers is to gain experience. Therefore, there should be efforts to:
- Strengthen credible centres with cutting edge facilities.
- Open up access to more centres with multiple core specialties.
- Draw up a structured plan for a credible career pathway.
- Allow senior trainee doctors to have access to subspecialty exposure, such as the MMed programme.
- Develop essential subspecialties that are already well established over decades in many countries worldwide — a good example being clinical/medical immunology, proven to be an important subspecialty during the Covid-19 pandemic and a subspecialty that can provide research opportunities.
- Attend to health care workers’ woes, adjust salaries, and make promotions easier and based on training and proficiency, regardless of whether they are in public or teaching hospitals.
Research Capacity Is Not Optimal
Research cannot be divorced from good health care and underpins good quality health care. Research has moved the medical sector towards advancements in diagnostics and treatments. Where are we? Who among our scientists have been nominated for, let alone won, the Nobel Prize?
Let us remind ourselves that more than two decades ago, in 1998, the then-Prime Minister challenged the Malaysian scientific community to win the Nobel Prize by 2020.
Research should be regarded as an investment which requires funding agencies to build a sustainable research ecosystem that drives meaningful outcomes and positive impacts on the community, rather than merely counting the number of papers published or students supervised.
Research in health care generally takes longer to reach a meaningful outcome and requires several funding rounds that should be properly monitored for scientific impact rather than to fulfil an administrative requirement of the funding agencies.
All stakeholders must appreciate that research direction may change when there are unexpected or novel findings which may also lead to new knowledge and novel methods in patient care.
The refusal of funding agencies to facilitate such (unexpected but necessary) changes has seen research investment gone to waste. Proper understanding of the scientific research culture needs to be inculcated so that interesting findings can be pursued and not be wasted after one round of meagre funding, just because the required number of papers published did not meet the set target.
Research in health care must aim to be translational in nature, and require clinical and non-clinical groups to work within a common framework for the public.
For example, it is observed that for laboratory tests that cannot be performed in Malaysia, we prefer to send the specimens abroad, rather than make the test available locally, e.g. molecular genetic tests for rare primary immunodeficiencies.
While we may obtain the diagnosis, the other country will build their research capability at our expense. It is obvious now why such tests are available free or at best a fraction of its true cost abroad.
It is disappointing that existing centres with molecular biology expertise in local universities do not develop such genetic tests for patient at reasonable costs as a value-added component to their fundamental research structure.
The Budget Is Not Enough
In 2022, the government allocated a budget of RM32.4 billion for the Ministry of Health (MOH). A health care portal has forecasted that the national health care costs will reach RM91.1 billion by 2025.
A paltry sum of RM32.4 billion would be insufficient for the MOH to carry out high-impact research. In any case, the MOH’s core responsibility is delivery of clinical services for patient care, and thus any research activity is desirable but not mandatory.
However, more value-added research can be yielded if the MOH embraces collaborative research with non-MOH institutions, in a win-win situation.
The core business of universities is research to upend teaching. However, patient care for medical faculties is still a required component.
Research institutions require funding, of which allocation for research is its most important source. Looking at such allocations per GDP, Malaysia spent slightly less than 1 per cent of GDP on research in 2018, although in Eleventh Malaysia Plan (2016-2022) recommended an increase to 2 per cent (compared to Israel at 4.95 per cent, South Korea at 4.81 per cent, Switzerland at 3.37 per cent, Japan at 3.26 per cent, the United States at 2.84 per cent, and Singapore at 1.95 per cent. (Zakri Abd Hamid. Opinion, New Straits Times, 2021)
Malaysia did not honour its intention to increase research spending and remained at 1 per cent. That translated into RM19 billion against a GDP of RM1,871 billion (USD434.1 billion in 2022).
Certainly, the amount of RM19 billion to be distributed to many disciplines leaves a meagre mount for the use of medical science for the many institutions in the country. It is an impossible feat to produce cutting-edge research with insufficient funding, as the pandemic had illustrated.
It is imperative to pursue aggressively research on emerging and re-emerging Infectious diseases. Lessons have been learned from this pandemic thus far, but we still lack home research data.
Even as the pandemic was progressing, we had little capacity to study how vaccines was affecting the population, and the effects of Covid-19 infections, including long Covid, hybrid immunity, as well as adverse events and long sequalae of mRNA vaccines.
Without home strength research capacity, we are likely to accept all recommendations without questions from established external organisations, with no provision to modify for local situations.
Health Care As A Partnership
Given the complexities, being clear about the roles of all stakeholders in the health care system is imperative. Consequently, the national budget for health care in its true form must be based on common pillars and not on individual ministries. The latter will only culminate in non-communication that hinder good governance in providing optimal health care for the public.
The national budget for health care should at least have a target 5 per cent of GDP for the delivery system, and at least another 2 per cent of GDP for research. A partnership of the public-private sector involving health care delivery would also require a relook to better serve the general community at large.
Partnerships would naturally entail that data be share equally among all partners on an open platform that is easily accessible, with no party claiming sole ownership.
Hence, TIGERS opine that these partnerships between all players within the health care system should seek to drive the health care reformation and transformation, by identifying tangible and innovative solutions to overcome challenges facing the current health care systems.
The Translational Immunology Group for Education, Research and Society (TIGERS) comprises:
- Prof Dr Lokman Mohd Noh
- Dr Amir Hamzah Abdul Latiff
- Prof Dr Rahim Md Noah
- Assoc Prof Dr. Adli Ali
- Dr Intan Juliana Abd Hamid
- Assoc Prof Dr Intan Hakimah Ismail
- Prof Dr Norazmi Mohd Nor
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.