Editor’s note: This is a three-part letter on the writer’s reasons for the current state of Malaysia’s healthcare.
Read Part 2 here.
IT IS good that we are undertaking a reform of health in the form of the “Health White Paper”, expected to be tabled in Parliament sometime this year. I hope that there will be extensive public engagement and ownership of this critical and long overdue initiative.
Having served in our national health service for many decades and been involved intimately with health services delivery, allow me to add some reflections on the direction of these reforms.
At one point in time, Malaysia’s health system was highly praised by the World Health Organisation (WHO), especially for its excellent primary care services. However, those days have long passed and today some of our neighbours offer better health services than we do.
We need to ask what have been the challenges or factors that have relatively regressed our healthcare and health services? What has made our population unhealthier with a non-communicable disease (NCD) pandemic?
Some possible reasons are outlined below:
Ministry of Disease (MOD), not Ministry of Health (MOH)
In healthcare, often the loudest voices dictate resource allocation and development. Specialisation and sub-specialisation have engulfed healthcare and clouded issues.
Medical schools enamour students in curative fields and most healthcare professionals, especially doctors who hold much of the “power”, have lost a prevention focus. The “brightest and best” of our medical personnel tend to opt for a hospital-based profession and career.
We no longer run a MOH but a MOD; an institutionalisation of medicine. Sadly, public health has not been able to advocate for substantive growth in preventative services.
Our initial primary care success of antenatal and child health clinics in the 1970s and 1980s, with immunisation, growth and development focus, has not been sustained. It has also not been duplicated in urban settings where 70% of our population lives.
Hence, hospitals take up a large proportion (60%-70%) of health resources in terms of funding, manpower and development.
In recent decades, there has been an “explosion” of tertiary-level specialised services as means to “meet” the health needs of the community; but these are meeting disease needs and not health needs.
Our current model is doctor and illness-focused, expensive, fragmented and institutional-based. Hence, we tend to focus on disease and not health.
This “curative” model is inappropriate for the majority of the population, not financially viable and is a never-ending thirsty black hole.
A public addicted to curative services
We have nurtured our public to depend on doctors and curative health services. The cry of the public is for more hospitals nearer to their homes, more specialists at their doorsteps and more quick fixes for their medical problems.
Our public has been weaned on a diet of curative services offered by doctors and focused on specialists. They are now addicted to this model – specialist care and curative care.
The public has little concept of prevention. They desire to live as they choose and ask us to fix their health problems with drugs or procedures.
This is very much akin to our public transport problems, where the public has been weaned on a diet of cars and become addicted to them. Hence, it is extremely difficult to institute a meaningful public transport system and resolve the resultant urban chaos.
Similarly, in healthcare, we have an enormous uphill task of changing the mindset of the public to a sustainable health outlook rather than a fix-the-disease outlook.
The damage of private health services
The private-public divide also worsens our health services.
I have many friends and colleagues in the private sector – some doing excellent work. They are trying to help patients. But the private sector is almost totally dedicated to treating disease; they thrive on the NCD epidemic.
The growth of big business in the health industry has meant that it is now predominantly profit-driven; hence, there is no major incentive to promote preventative health.
The commercialisation of healthcare and the use of healthcare as a means of obtaining financial wealth has undermined the trust of individuals and communities in healthcare professionals, and even Governments.
Our Government has also begun investing in private healthcare – a serious conflict of interest.
There may also be a subtle opposition from the private sector and big business (private hospital groups) to a preventative approach as they thrive on a curative model and sick people.
Inadequate financial resources, health spending by Governments
It would be tempting to infer that improvements in the health of our society have been brought about by improvements in health services.
However, we are aware that while advances in health services have some impact, particularly immunisation and access to primary health services (maternal-child clinics), the major decrease in mortality is related to improvements in socio-economic status, education, infrastructure, utilities (safe water supply) and transport.
For example, every doubling of the gross domestic product (GDP) per capita more than halves the under-five mortality rate in children.
Having said that, how much Governments invest in health will determine outcomes for children and adults with severe illnesses (those that require intensive care). Here, we have failed.
Our limited national expenditure on health infrastructure has meant that many cannot receive intensive care in our public hospitals unless they can afford the exorbitant private hospital fees. – July 24, 2022
Datuk Dr Amar-Singh HSS is a consultant paediatrician.
The views expressed are solely of the author and do not necessarily reflect those of Focus Malaysia.
