Howard Lee & Ana Gella Opong
The Malaysian healthcare system operates as a dichotomous system wherein a unique public-private partnership exists to solve the prevailing problems of low human and technology resources availability in the government run institutions. The public is given a choice between the overburdened but affordable government hospitals and the perceived excellence and efficiency of private-owned institutions as exhibited by the shorter wait times and abundance of experienced specialists.
There also exists a hybrid of the two wherein the government hospitals, in its bid to keep its specialists from leaving, operate a “pay” wing, as is the case of the University Malaya Specialists Centre (UMSC), which allows Malaysians and foreigners alike to have access to services at par with those of the best private hospitals in the country, yet pay relatively lower fees.
Touted as one of the best healthcare systems in the region, critics have, however, pointed out that the Malaysian healthcare system is not as effective and successful as it seems to be. The Malaysian public is now faced with more frequent dengue haemorrhagic fever epidemics and have been exposed to drug-resistant tuberculosis. The prevalence of malaria and HIV/AIDS in the country are also on the rise despite the decreasing global trend. Cases of re-emerging infections are also on the right, arguably stemming from treatment non-compliance despite the subsidised cost of drugs especially in government hospitals and clinics.
With these in mind and the country’s vision to be a developed country by 2020, the Ministry of Health (MoH) published the 10th Malaysia Plan (10MP) in 2011 as the Country Health policy framework for the years 2011-2015. Four (4) years into its existence, the question of its success still remains, especially when obvious lapses exist in the framework itself. From the point of view of healthcare policy analysts, the Malaysian system is often described as a Jekyll and Hyde provision of Healthcare.
One of the four federal government strategies involves the empowerment of the individual and the community to be responsible for their own health. Though well-meaning and a probable solution to the high attrition rate among healthcare professionals in the public sector, the framework has left out strategies that promotes health promotion and disease prevention through educating the public from all walks of life. One clear strategy that the MOH have put in place is the investment in Information and Communication Technology (ICT) products such as the MyHealth portal wherein the public are able to access health information and health advice via the internet.
Considering the lack of existing strategies focusing on health education and the long waiting hours in government hospitals, having a portal that gives generic health advice at the end of one’s fingertips may attribute to the increasing numbers of reinfection as people may be driven to self-medicate without proper medical guidance. This also further marginalises living in areas without electricity, and consequently the internet.
Another factor that leads individual and community empowerment is far from attainable is the evident broken access to a healthcare facility due to the lack of public transport connectivity, as is especially true for semi-urban and rural areas.
Though the MOH has indeed identified the need to focus on health promotion and healthy lifestyle practices, it contradicts itself in the same breath by encouraging primary and secondary healthcare institutions to focus more on healing and recovery and not prevention. The disconnect in the programmes that the MOH has itself identified to provide more funding for and the focus of its public health initiative will ultimately leave the Malaysian proletariat in health limbo.
Promotion of a Dichotomous Healthcare System
To provide quality healthcare to the greater Malaysian public, the MOH has been encouraging the dichotomous system, lauding its necessity and ability to provide Malaysians with services at par with that of the developed world. However, the MOH has likewise admitted that the same system it promotes and places on a pedestal, is flawed as it contributes to the mal-distribution of resources and underutilization of high-end and expensive technology with the government has equipped its hospitals with.
Adding to the confusion is MOH’s admission that though it still remains as the regulatory body for healthcare institutions, public and private alike, it has limited control over hospitals and it cannot force them to abide by specific standards of care. Furthermore, the MOH has reported that questionable quality of care and service standards were identified among private hospitals. These, notwithstanding the insufficient cooperation of private hospitals in collaborating health statistics reporting, is enough reason to, at the very least, put a stop to the active promotion of the dichotomous healthcare system.
THE POSSIBLE SOLUTION
Within the past 10 years, the otherwise clinical world of healthcare has identified the key role played by medical anthropology and patient participation in ensuring a successful and effective healthcare system, especially one of a national scale. It is therefore essential that the Malaysian government of the future includes their working knowledge of the Malaysian society in policy making and its subsequent implementations.
Independent Nurse Practitioners (INPs)
In light of the widespread Human Resource problem in the healthcare system, a system has to be put in place in order to identify talents in within the existing labour pool. Despite the lack of trained doctor-specialist, there exists a healthy supply of nurses both from the existing pool and those graduating from the various colleges in the country. A screening procedure may be implemented wherein those who are capable and/or passionate about nursing can specialise as Independent Nurse Practitioner which will not only enable them to diagnose and advise a course of treatment for diseases, but would likewise allow the existing Rural Health Units (RHU) to have the manpower it needs to be open to the public and provide more efficient and better quality healthcare services.
As is in developed countries, Independent Nurse Practitioners function with the most minimal physician supervision. When deployed to rural and semi urban areas, they are likewise able to immerse themselves into the community allowing them to identify the essential health-centric programmes which will benefit the community the most. They would likewise have the responsibility to lead a group of nurses and healthcare workers in implementing health promotion activities which may include health education, community health practices, and encouraging better health seeking behaviours within the community.
Though a fairly new intervention in Malaysia if implemented, the practice of utilising INPs within the healthcare system have been in place in Canada, the USA, UK, and others, allowing better accessibility to quality healthcare services.
In the absence of an efficient public transport system both in urban and rural areas, a more effective, albeit temporary solution should be made available to those who need it. Though it has been reported that an RHU or 1Malaysia clinic exists in every 5 km radius, simple observation of those situated around Klang and Kinta Valleys, shows these facilities unmanned or not accommodating, at best. The provision of mobile clinics, simple as they may be, allows the Malaysian public access to basic healthcare services all the while encouraging them to seek medical advice as soon as symptoms happen, and not when diseases progress, consequently leading to more patients going to hospitals.
Mobile clinics however are only effective if manned by trained personnel who know the proper medical triage and referral procedures so as to provide the necessary care for medical cases which can be treated onsite while offering emergency transport for those who may need immediate medical attention. Mobile clinics may likewise be utilised as well-baby clinics and can provide the necessary post-natal follow up check up for new mothers who do not have easy access to a healthcare facility. These, among others, are types of primary healthcare services essential to the general well-being of the populace, while the government works on the existing facilities and the quality of services they provide.
Health Promotion and Disease Prevention over Cure and Rehabilitation
One of the glaringly obvious lapses of the existing National Health Policy is its emphasis on cure and prevention despite the identified need for health promotion. It is important that a policy in put in place where the citizenry is armed with the knowledge of health lifestyle practices and one that encourages good health-seeking behaviours. While this approach needs the least resources and virtually no technology, it is one which, if done successfully, has the most effective long-term effects.
The MOH has made significant progress in outlining the future of Malaysian healthcare but it has somehow lost touch with the basics of public health. It successfully identifies the lapses of the existing healthcare system but, at the same time, solutions to the identified lapses are not included in the next National Health Plan, as is in the case of the 9MP, 10MP nor the 11MP. To ensure that a progressive public health policy is in place, it has to address the problems identified through an evaluation of the previous policy and at the same time make the necessary advancements that will enable the country’s health system to be at par with that of the developed world.