JULY-AUGUST , 2022 | THE HEALTH

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

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 outof-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 .

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 .