Malaysia subscribes to the World Health Organization’s priority objective of universal health coverage (UHC), which has been defined as “ensuring that all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services”.

Malaysia has UHC. However, some of the recent studies of the healthcare system’s performance raises concerns.

Harvard School of Public Health study

The Harvard TH Chan School of Public Health is carrying out a study for the Health Ministry (MOH). It concluded in its March 2016 report: “Malaysia’s health system is at a crossroads. The system has very effectively countered the health challenges it was designed to address, namely, high levels of maternal mortality, infant mortality and under-five mortality, and has achieved excellent outcomes.

“But the health system faces new challenges in the face of a rapidly evolving context characterised by demographic and epidemiological transitions, a shifting socio-cultural environment, technological changes and rising income levels, which have contributed to a nutritional transition, increasing health risks and new user expectations.

“In effect, Malaysia demonstrates a classic case of asymmetric transition, where the rapid transitions in context have not been matched with a corresponding transition in the health system to better address the current and future needs of the population.”

Maternal mortality

The healthcare system has made substantial progress since Independence. However, since 2000, some of the health indicators have not improved to the same extent as other countries in the region.

An example is the maternal mortality ratio (MMR), which did not achieve its Millennium Development Goal of 11 per 100,000 live births by 2015.

Sri Lanka, which together with Malaysia had previously been held up by the World Bank as an example to learn from (Source: World Bank. Investing in maternal health: Learning from Malaysia and Sri Lanka 2003.), had the same MMR as Malaysia in 2000, but its MMR was lower in 2015.Malaysia, Sri Lanka, Asean, health system, healthcare, maternal mortality, Star2.com

Premature mortality

A team from the University of Malaya (UM) studied anonymised mortality data from the Statistics Department for 1998 to 2006. They found that socially disadvantaged districts had worse mortality outcomes compared to more advantaged districts.

The mortality outcomes within ethnic groups were less favourable among the poor and premature mortality was concentrated among the poor of every ethnic group.

They concluded that the findings “suggests that national policies should emphasise the degree of need rather than ethnic-based policies to ensure that support is provided and distributed in an equitable manner. This is vital to prevent the gradient in health from becoming any steeper”. (Source: Are the Poor Dying Younger in Malaysia? An Examination of the Socioeconomic Gradient in Mortality. PLoSONE 2016 11[6]: e0158685. doi:10.1371/journal.pone.0158685. Accessed Nov 30, 2017.)

Chasm in primary care

Primary care delivered by the Klinik Kesihatan and/or outpatient clinics in the public sector, and general practitioner clinics in the private sector, are the foundations of the healthcare system and UHC.

A team from the MOH and UM surveyed primary care clinics from June 2011 to February 2012.

They found that private primary care clinics and doctors outnumbered their public counterparts by 5.6 and 3.9 times respectively, but the private clinics were significantly less well-equipped with basic facilities and provided a more limited range of services.

The per capita densities of primary care clinics and workforce were higher in urban areas.

“Within the public sector, the distribution of health services and resources was unequal and strongly favoured the urban clinics. Regression analysis revealed that rural clinics had lower availability of services and resources after adjusting for ownership and patient load, but the associations were not significant except for workforce availability.”

They concluded that “geographic expansion alone is inadequate to achieve effective coverage and the role of the private sector in primary care delivery should not be overlooked”. (Source: Chasm in primary care provision in a universal health system: Findings from a nationally representative survey of health facilities in Malaysia. PLoS One, Feb 14, 2017; 12(2):e0172229. Accessed Nov 30, 2017.)

Catastrophic illness and health spending

A catastrophic illness is a severe illness requiring prolonged hospitalisation and/or recovery. It results in expensive health spending for many.

A multi-institutional team studied whether current health coverage extended to catastrophic illnesses, which inevitably incurs catastrophic health spending, and found that the “coverage varies from universal for dialysis, cataract surgery, medicines for organ transplant and CML (chronic myeloid leukaemia), to practically none for HCV (hepatitis C virus), stroke, psoriasis and epilepsy surgery.

“Coverage of targeted therapies for solid cancers, knee replacement surgery, anti-TNF for arthritis and coagulation factors for haemophilia were poor, while iron chelation for thalassaemia, coronary revascularisation, epoetin and anti-retrovirals were barely adequate.”

They concluded: “Coverage for catastrophically costly treatments is uneven and inequitable in Malaysia, despite most of these being affordable.

“Decisions on coverage are driven by political-economic consideration.”

An Asean study found that the proportion of previously solvent patients who experienced economic hardship following a cancer diagnosis was highest in Malaysia (45%) and Indonesia (42%), and lowest in Thailand (16%). (Source: Policy and priorities for national cancer control planning in low and middle income countries: Lessons from ASEAN Costs in oncology prospective cohort study. European Journal of Cancer, Feb 6, 2017. Accessed Nov 30, 2017.)

Royal Commission on health and healthcare

The Harvard group advised: “While transformative change cannot be achieved overnight, Malaysian policymakers would be wise to implement stepwise innovations which will strengthen the Malaysian health system in order to more effectively address population needs and changes in the national context.”

The healthcare system is encountering considerable complex challenges.

As health and healthcare involves everyone, its strategies and solutions require the involvement of all stakeholders and not just policymakers.

This is particularly so when patient engagement is at the heart of accessible and safe care that is vital to achieving UHC that supports the United Nations Sustainable Development Goals, the theme of the 11th Malaysia Plan, which prioritises healthy lives and promotes well-being for all.

As such, there is a strong case for the establishment of a Royal Commission on health and healthcare to inquire into and report upon the existing and future need for safe and quality healthcare services, and the resources to provide such services; and to recommend the necessary measures to ensure that everyone stays healthy and continues to have access to UHC, and that no one is left out.

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations, Malaysia, and the Malaysian Medical Association. The views expressed do not represent that of any organisation the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.