Sihat Bersama 2030 Concept Note – Dr Abu Bakar Suleiman

Malaysia’s unsustainable health spending has prompted the need for reform since the early 1980s, yet complex challenges have hindered progress, causing a lack of political will. This Concept Note provides a helpful starting point for future initiatives.

The Health Advisory Council (HAC) was formed in 2019 to advise the then-Health Minister, Dr Dzulkefly Ahmad, on health sector reforms, and the council prepared a report before the change in government occurred in 2020.

Based on this report, members of the HAC, Dr Yap Wei Aun, Datuk Dr Musa Mohd Nordin, Prof Dr Adeeba Kamarulzaman, and others have worked to prepare this Concept Note.

This Concept Note is compact yet comprehensive, with observations, diagnosis, and recommendations on health reform. The recommendations made are based on the numerous studies on health reform conducted by the government since the mid 1980s, and has taken into account different initiatives in health care that have been implemented locally.

This Concept Note is structured in a way that would be useful and constructive for any new government initiative on health reform to start from, and conduct studies to formalise the health reform agenda and plan its execution.

The government’s concern on the need for health reform driven by the realisation in the early 1980s that health spending funded largely by the federal budget would not be sustainable, and additional resources for health needed to be mobilised to complement this.

Despite numerous studies on health reform being completed, there were no decisions made by the government on the health reform agenda. This is not surprising as health reform is very complex, politically sensitive, and takes decades to implement fully.

The political will and appetite for change to initiate health sector reform in Malaysia has so far been lacking. Some examples of health sector reform in other countries emphasise the need for an enabling political environment and courageous leadership to successfully implement the complex changes that are involved to transform health care:

The Bismarck Model

This is named after Chancellor Otto von Bismarck, the Prussian Chancellor who unified Germany in the 19th century through the development of a welfare state that included social health insurance which covers everybody.

It is a system of about 200 employer based private health funds run on a not-for-profit basis, with contributions by employers and employees through payroll deductions.

In this model, health care providers and payers are private, and the funds are run with tight regulations of medical services and fees paid for services delivered.

Bismarck, while a soldier, understood the importance of social health insurance in providing social cohesion in his efforts to unify Germany.

This system is also found in Japan, Belgium, Switzerland, and to some degree, Latin America.

The Beveridge Model

William Beveridge designed the National Health Service (NHS) model, where health care is provided and financed by the government from tax collections, and hospitals and clinics are government owned.

There are no payments for services, and medical treatment is a public service for citizens. Some doctors are government employees, and some are private doctors.

Beveridge worked with Aneurin Bevan to obtain the approval of Parliament to start the NHS after the Second World War. Beveridge and Bevan were from opposing political parties but were able to work together to start the NHS, which has through the years received the backing of all political parties in the United Kingdom.

This model is seen in Italy, Spain, Hong Kong, and most of Scandinavia. In its purest form, it is also practised in Cuba and in the United States Department of Veterans Affairs.

The National Health Insurance Model

In this model, which is a compulsory health insurance model, health care providers are private, while the payer is the government health insurance fund, where it is compulsory for citizens to contribute to.

South Korea, with a strong military-backed government, implemented this system in the 1970s, and required 20 years to fully implement it. Taiwan similarly with a strong government implemented this system in the 1980s and needed 15 years for complete implementation.

Canada is another country practising this system.

The success in implementing health reform in Germany and the UK is a reflection of courageous and far-sighted leadership. The South Korea and Taiwan experiences were successful as a result of strong and stable governments with great focus on execution.

Presently in Malaysia, our government is strongly reform-minded and action-oriented, and understands the weaknesses of the existing health services that is in urgent need of support in a meaningful and constructive manner.

The government is well aware of the widespread dissatisfaction with the state of our health services. They should be open to new ideas and proposals to improve the health services and to transform it through an approach that is focused in a health reform agenda.

While working for health reform for the medium and long term, there must also be initiatives that can improve the health services on the immediate and short term.

In setting a health reform agenda for the medium and long term, the recommendations and content in the Concept Note would be a good start to consider the type of system to be developed, and to be implemented.

No health system is perfect, and whatever is to be implemented in Malaysia has to be contextualised to meet the needs of the local population.

It would take at least a decade to put in place a sustainable health financing system and to transform health care delivery appropriate for this century, with the characteristics as described in the Concept Note.

What is important is to start working on the health reform agenda immediately.

In the short term, it is important to address current pressing issues, and put in place measures that can be implemented quickly to overcome the problems.

This will include initiating new innovative ways of delivering care, appropriate adoption of new technologies in health, and to internalise lessons learnt from managing the recent Covid-19 pandemic into regular health services.

The use of hospitals must be carefully and critically reviewed. The services that can only be delivered in hospitals will continue to remain as hospital services.

Other services that are presently delivered in hospitals, but can be delivered in clinics, community centers or at home, should no longer be delivered as hospital services.

These “extension” services, which were successfully delivered outside the hospital with the support of technology and health staff outside the hospitals during the Covid 19 outbreak, should be organised so that it becomes a regular feature of the health services in the immediate future.

Hospitals and clinics should be organized to be run as seven-day hospitals and clinics, and each day become the same as any other. As existing staff will continue to work the five-day week, additional staff will be needed to implement this.

This approach will increase the productivity of hospitals and clinics, which are valuable and expensive investments.

Relevant medical specialists and other health professionals now working in hospitals need to be posted to health centres and clinics, and telemedicine consultations will become regular features of the health services.

The training of young doctors including house doctors, nurses, pharmacists, and others presently done in hospitals, can also be conducted in selected health centres and clinics in the future.

The proposal in the Concept Note to integrate divisions in the Ministry of Health responsible for primary, secondary and tertiary care, to ensure the delivery of integrated, continuous, and coordinated health services, into one major Health Services Programme is long overdue. Work to implement this should begin as soon as possible.

Public health capability and capacity to deal with future disease outbreaks must be strengthened as soon as possible. This involves investments in laboratory testing and data analysis using artificial intelligence (AI), tools at local levels, so that responses to disease outbreaks can occur in a timely manner at local levels.

It is hoped that this Concept Note will be accepted by the government and acted upon to improve the health services in Malaysia through setting a health reform agenda.

This includes considerations to improve health services in the medium and long term, in the immediate and short term and to create a health financing system that is sustainable.

A health system of high quality, that is equitable, responsive and cost-effective covering all residents in Malaysia will contribute to our aspirations of social justice in our caring society.

Dr Abu Bakar Suleiman is chairman of the Health Advisory Council.

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