The previous Health Minister, Khairy Jamaluddin, announced in January 2022 a proposal to seek parliamentary approval of the Health White Paper (HWP) to future-proof Malaysia’s health care system for the next 15 years.
The HWP advisory council, co-chaired by previous Health Minister Dr S. Subramaniam and Axiata Group chairman Shahril Ridza Ridzuan, was established on August 30, 2022.
Its role was to contribute ideas, recommendations, and advice to the Ministry of Health (MOH) in the process of developing the HWP. These actions fired the imagination of health care professionals and their organisations, as well as the general public, many of whom participated in the organised events and submitted memoranda to the HWP advisory council.
When the current government took office in November 2022, those who questioned about what would happen to the proposed HWP were reassured when the HWP received bipartisan support.
About six months have lapsed since Parliament adopted the HWP in June 2023, and the hype about the HWP has died down to a whimper.
Shortcomings In Health White Paper
There were several fundamental shortcomings in the HWP, some of which are discussed below.
The fundamental principle in health care is Primum Non Noncere (“First do no harm”). Yet there was no mention of patient safety in the HWP, a monumental omission that is difficult to comprehend.
There is global evidence that unsafe and poor-quality health care causes significant morbidity and mortality to affected individuals. The economic case for patient safety is the undisputed fact that investments in the reduction of patient harm can and does lead to significant financial savings, and more importantly, better patient outcomes.
The HWP was aspirational with identification of some issues in Malaysian health care and possible solutions. Yet, there was no mention of goals and specific benchmarks to measure progress or otherwise.
This was unfathomable, as government proposals like the Malaysia Plan have specific targets and metrics, with mid-term reviews to report on the progress made. How can Malaysians know what and when to expect the changes proposed in the HWP?
The HWP states that the regulatory, provider and purchaser roles of the MOH will be separated, leaving the MOH to concentrate on regulation.
The HWP envisages that the provider role will be undertaken by autonomous public health care facilities, and the purchaser role by a “strategic purchaser” entity that will procure services from providers in the public and private sectors.
However, the HWP was silent on the implementation of these organisational entities. What do these statements in the HWP mean?
Malaysian governments since the mid-1980s have appointed various consultants to advise on national health financing, expending millions of ringgit in consultancy fees.
Yet, until now, there is no national health financing scheme. These reports are nothing more than just reports.
The HWP mentions the establishment of a dedicated fund for health care, but without specifics. The HWP also mentions an increase in government investment in public health to 5 per cent of GDP, from the current approximate 2.5 per cent. Is this achievable when there are no milestones on the road?
All health systems can only function with health care workers whose availability, accessibility, acceptability, and quality will determine whether universal health coverage and equitable access to health care services (United Nations Sustainable Development Goal 3 to which Malaysia is committed to) is achievable.
I have talked about the quality of medical education more than a decade ago. Reports of house officers in the MOH who are poorly trained and experienced, with consequent increase in medical errors and incompetency, are of concern.
Yet, the HWP skirts the specifics of the current pressing issues of health worker development, recruitment, and retention.
That the implementation of HWP requires empowered and effective implementation and monitoring organisation(s) is a given. The HWP’s proposal that “an independent monitoring body such as a special task force, committee, council, or commission will be established to future-proof the proposed health reforms” is vague and indecisive.
The HWP states that “the role of this body will be to monitor, advise, and report on the status of health reform implementation to the Parliament and the people”.
Does anyone involved in the drafting of the HWP know the difference between the powers of a special task force, committee, council, or commission?
Any health sector reform needs to address the elephants in the room, two of which will be discussed in this article. Firstly, the impact of corruption and corrupt practices on health and health care expenditure and development; in particular, the role of middlemen and rent-seekers.
The Public Accounts Committee report that nobody could be held accountable for the 104 defective ventilators out of 136 purchased from China in 2020 speaks volumes.
Secondly, the lack of diversity in the MOH health care workforce has led to the restriction of any hope for professional development for those working in public health care.
This has led to the haemorrhaging of many highly skilled health care professionals to the private sector and abroad. The issue of meritocracy in the MOH was not addressed in the HWP.
Whither Health White Paper?
When the HWP was adopted by Parliament in June 2023, notwithstanding its shortcomings, many in the public health workforce were still hopeful of changes in the public health sector.
After all, the parties in the government, without exception, made promises on health and health care in their election manifestos, some more detailed than others.
Since then, there have been no announcements on the governance mechanisms for the implementation and monitoring organisations in the HWP. Steps to address the shortcomings in the HWP have yet to be initiated.
The MOH had an increase in its budget for 2024. However, it is paltry when the aspirations stated in the HWP is to “Increase health funding under public sector management gradually to 5 per cent of GDP”.
Many doctors who are familiar with the shenanigans of politicians giving lip service towards addressing the deficiencies in the chronically underfunded and overworked public health sector, were sceptical when the HWP was adopted by Parliament.
Many have expressed pessimism as to whether the HWP will ever be implemented. However, there are few who remain optimistic.
The bottom line is that the Covid-19 pandemic has shown that there were times when the Malaysian health system was on the verge of collapse. If Malaysia has not learnt from this near-miss and starts implementing the HWP, the health system may not get another chance when the next outbreak comes along.
Chosen change is usually more palatable than forced change. Whither the HWP?
A legitimate question for the Madani government is whether there is any seriousness in ensuring that a start be made in implementing the proposals in the HWP. Or will it be kicked down the road to the next government?
Is there political will and leadership to act? Or was the HWP adopted for political purposes, offering hope but no action?
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.