There is a need to shift from a curative and treatment-focused mindset to a focus on wellness and preventative or promotive healthcare
Thank you very much to the NUS Saw Swee Hock School of Public Health for inviting me to speak at this Public Health Thought Leadership Dialogue.
In this regard, before I continue with my lecture, I would like to take this opportunity to pay tribute to the outstanding professional working relationship that has developed between Minister Ong Ye Kung, Singapore’s Health Minister and myself. The decision to open our border was not an easy one especially the causeway, which is one of the busiest land crossings in the world.
We knew once we advised our respective Prime Ministers that the time had come to open the land border, we would effectively become one epidemiological area. We had to trust each other’s judgement and trust in each other’s pandemic response and data.
In the weeks and days leading up to the announcement, Minister Ong and I consulted each other, almost daily, until we were both able to make the crucial judgement call. I learned much from his analyses of the situation and we are now both extremely relieved that the reopening between our countries has been done safely.
The title of my speech today is ‘Future-Proofing Public Healthcare’. Now this sounds extremely aspirational, perhaps overly so, and some of you would be right to ask what we mean by ‘future-proofing’ when we’re already having to address the so-called ‘problems of tomorrow’ today.
Future-proofing equitability of access means we must also be efficient in how to achieve our ambitions of coverage and quality within the ecosystems in which we operate. Malaysia’s dual health care system, comprising both public and private health care providers, ensures a reasonable level of physical access for the majority of the population.
Both are important players in Malaysia’s health care delivery system. While private providers tend to be in urban areas, the public health care sector is fundamental to Malaysia’s health ecosystem with an extensive network of public health and disease surveillance services, clinics and hospitals across the country. Mobile health teams serve in areas where physical facilities are not feasible.
Nevertheless, I must admit, the public and private sectors are not yet well integrated. Malaysia’s dual healthcare system is largely dichotomous, with the primarily tax-funded public sector on the one hand, and fee-for-service private sector providers on a parallel track, funded primarily via for-profit private insurance and out-of-pocket payments.
The public sector caters for two-thirds of outpatient and inpatient cases but 75 per cent of specialists in Malaysia are in the private sector. Resources, burden of work and data are not easily shared between the two sectors, leading to delays in diagnosis and treatment, unnecessary repeat investigations and added costs.
During the pandemic, these twain tracks did meet when, under emergency conditions, the government procured services for public vaccination from private GP clinics and sent non-Covid cases, decanted them to private hospitals. We decanted non-Covid patients from public hospitals to private healthcare facilities when we hit surge capacity during peak Delta.
Expanding public-private partnerships
Even today, we have continued this approach to reduce some of the public sector’s case backlog. We had something like 50,000 surgical and medical cases which were delayed because of the pandemic and bringing together the public and private sector in massive surgical initiatives, we have been able to lower this to about 30,000.
We plan to expand such public-private partnerships further so that we can effectively maximise all the existing healthcare capacity in Malaysia, including those from the non-profit sector, in a way that reduces service ‘dark spots’ and waiting times, while ensuring that costs are contained and fair.
The close partnership between sectors can also increase treatment options for our lower- and middle-income groups, including oral health services and Traditional and Complementary Medicine services which are mainly driven by the private sector. To ‘future-proof’ this for Malaysia however, several structural changes need to happen including: the development of feasible payment models, strengthening strategic purchasing, ensuring good demand mapping as well as putting in place better processes and tools for referrals and consultation (including shareable electronic medical records). These are just some of the structural reforms needed to implement greater public-private partnership sustainably and ultimately, deliver better equitability of access in the long-term.
But one note of caution, more public-private partnership does not mean that service quality in public facilities remain at current levels. In fact, future-proofing equitability of access requires us to ensure that public sector hospitals and clinics are set on a path of significant and lasting service improvement.
As a first step, one of the key structural reforms that Malaysia is currently studying is to grant greater operational autonomy to our public hospitals, so that these overburdened and constrained flagship institutions are given the room to be more responsive to the changing needs of the population. We intend for this change to also facilitate better integration and public-private partnerships.
In the long run, this would allow the Ministry of Health (MoH) to focus on policy, regulation, research, public health surveillance and interventions, while devolving service delivery.
Bringing ‘health’ back to healthcare
We can’t be complete in talking about future-proofing if we do not talk about genuinely bringing ‘health’ back into healthcare because right now, it is more sickcare. I’m speaking here about the need to shift from a curative and treatment-focused mindset to a focus on wellness and on preventative or promotive healthcare.
Part of the major work here is strengthening the resourcing and policy attention on primary care towards becoming more holistic, with multi-disciplinary teams monitoring and ensuring early intervention amongst local families and communities. In this era of chronic disease and an ageing population, primary health care is better positioned to provide closer care to the community.
Singapore’s recently announced ‘Healthier SG’ initiative is very much in line with our thinking on this front, and we hope to learn from your experience in enrolling every resident to a regular family physician and setting up individualised health plans.
Another major plank of this work is to acculturate health and wellness into the population until certain practices become the norm such as regular exercise, good nutrition and regular health screening. I will be travelling round the country to launch Malaysia’s National Screening Month in collaboration with various parties such as the Ministry of Family and Women Development, the Social Security Organisation, the private and civil society organisations.
Many people have missed out on health screening over the last two years with no baseline. We will be targeting 1.5 million Malaysians over 40 who have never had health screening, to be screened over the next few months. We want to nudge and encourage our population to continuously take steps towards better health and self-care.
Community empowerment is of course an extremely important component and part of the structural reforms is to work more effectively with civil society organisations and community change agents to increase health literacy as well as to address barriers rooted in social determinants of health such as income, poverty, education, housing, the local environment, and many others. Nudges and campaigns are not enough when there are structural obstacles in the way of better public health outcomes.
Public health officials are social justice warriors
Asking people to eat healthily is difficult when they can only afford fast, processed food. Asking them to exercise regularly is futile when juggling multiple jobs and side hustles just to keep up with the cost of living. We need to reimagine the build environment, urban planning, waste management, and other non-health determinants of health.
I have reminded my public health officials that public health officers are social justice warriors and they were social justice warriors previously. They need to bring back the spirit of seeing health in all policies and become advocates for health across government, throughout society, in each ministry and agencies and bring down the socioeconomic barriers to better health outcomes.
In this regard, we have started the ‘Agenda Nasional Malaysia Sihat’ or the ‘Healthy Malaysia National Agenda’, which is a cross-stakeholder ‘whole of society’ platform set up in 2021, involving relevant ministries, private sector organisations and civil society organisations and to strengthen the programme and partnerships together with the community by changing the way we live, not just in terms of the healthcare system, but every other determinant that is important to healthcare outcomes.
I am also bringing to our Parliament a landmark legislation which if passed and enforced effectively, can result in significantly better health outcomes for many years to come. While the idea is not new, Malaysia hopes to be the first country in the world to enact a tobacco generational end game.
If this law is passed, Malaysians born after 2005 will never ever be able to buy or use any smoking products anymore. The end. The end for smoking and tobacco. There are those who believe that banning is never the solution, I am determine to make this work. — The Health
Sustainable healthcare financing
In these last few months, my ministry has been holding stakeholder engagement sessions with a diverse range of stakeholders to discuss respective groups’ wishlists and priority areas for the Health White Paper. Compared to a few years ago, there is now even a greater recognition that the public healthcare system is chronically underfunded, and that how the system is financed plays an important role in advancing universal health coverage.
Underfunding has resulted in a plethora of issues, from understaffing to badly maintained infrastructure to outdated equipment. With limited publicly managed funds, opportunities to integrate the public and private sectors through strategic purchasing is also severely limited.
All these issues contribute to high out-of-pocket payments. Although Malaysia has relatively low incidences of impoverishment due to catastrophic health spending, out-of-pocket payments is still very high compared to other upper-middle-income countries, at 34.5 per cent of total health expenditure (as of 2020). These levels of out-of-pocket payments are a major concern especially when we have a high prevalence of chronic diseases, as it would likely lead to delays in treatment and greater illness due to cost avoidance.
Thus, for many years now there have been consistent calls for a healthcare financing model that is dedicated, sustainable and progressive. But as many health policymakers will tell you, it is easier said than done.
I was told that one stakeholder had even quipped that “equitability is expensive”. There is more than a grain of truth to that remark, particularly given the steady inflation of healthcare costs which is itself due to market failures in the healthcare system.
Healthcare financing framework
And so, a critical area of reform we are currently considering as part of the Health White Paper is, not surprisingly, healthcare financing. Almost 10 years ago, in 2013, Singapore’s Finance and Health Ministers embarked on a significant review of Singapore’s healthcare financing framework towards having the State shoulder, a larger share of healthcare costs that had been, up to that point, predominantly borne by patients and households in co-payments and other market mechanisms. Malaysia is also at a critical juncture in terms of rethinking healthcare financing, though our current circumstances are very different from Singapore’s.
While Singapore’s public healthcare has a financing model that consists of tax-funded subsidies, a medical safety net fund (MediFund), mandatory basic healthcare insurance (MediShield Life) as well as a national medical savings scheme (MediSave), Malaysia’s public healthcare sector is predominantly, if not fully, funded by federal government taxation. In the medium term, federal taxation will likely continue to be the main or anchor source of healthcare funding for Malaysia due to its inbuilt equity.
But the question before Malaysia and before me, running this now is, will relying on federal taxation be sustainable long-term? What would future-proofing healthcare financing look like for us? The answer to the first question is of course
no. It’s no longer sustainable and the system will break.
Since the onslaught of Covid-19 on lives, livelihoods and our collective sense of security, financing health care is increasingly being seen as an investment rather than an expense. Indeed, investment in the healthcare system should be perceived as an investment for the country’s development, just like investment in education.
On this note, raising the government’s allocation on healthcare spending is an option being discussed seriously with my Cabinet colleagues, especially as Malaysia’s total healthcare spending to GDP ratio, at 4.7 per cent, is far below the middle-income country average of 6.6 per cent.
Providing equitable access
If you stripped that and you look at Malaysia’s spending on public sector healthcare is at 2.6 per cent of GDP. It is below the average of four per cent GDP amongst middle-income countries and below the 5-6 per cent of GDP recommended by the World Health Organisation. At the same time, I need to be realistic – increasing the allocation from the Federal Government Budget has its limits and constraints, particularly in the medium term as the economy recovers from the pandemic. We are confronted with the spectre of possible global stagflation and extremely tight fiscal position.
The healthcare fund must be sufficiently large to fully harness the power of risk pooling, effectively spreading the risk amongst individuals who are healthy with those who have pre-existing conditions, a group who today would either not be eligible for private insurance coverage or who would not be able to get affordable coverage given their high risk.
So, if we want a future-proofed Malaysia’s healthcare system that provides equitable access to better quality health services long-term, including better preventative and promotive care, we need to have a dedicated healthcare fund that is both tax-funded and that is supported by contributions from the people who can afford to do so, be it in the form of co-payments or social insurance or a combination of these progressive contribution methods.
And this is easier said than done. This is a huge and tough political call. For equity, contributions into the healthcare fund should be on a sliding scale in line with an individual’s income and be fully subsidised or waived for low-income groups.
These principles are not new. They have been discussed and debated in Malaysia for the last 20 years if not longer, but I think the Covid-19 pandemic has lifted the veil and shown the true human costs of not resolving this issue.
One of the critical missions of the Malaysian Health White Paper, therefore, is to put forward a statement of intent on how the country’s healthcare model can be put on a sustainable footing, at the same time addressing past legitimate concerns on the architecture, phasing, costs and governance of this particular reform. — The Health
YB Khairy Jamaluddin is Minister of Health Malaysia. This is an excerpt of his keynote address at the Public Health Thought Leadership Dialogue on “Future-proofing Public Healthcare” organised by the NUS Saw Swee Hock School of Public Health, Singapore in June.