Chapters concerning Health cluster under the CSO Platform for Reform

 

Download the CSO analysis report here.

Below are the text drafted by myself, vetted by Dr Sharuna Verghis, representing the health cluster.

Introduction:

The “Health” cluster paid courtesy visits to the then Health Minister Dr Dzulkefly Ahmad and Deputy Minister Dr Lee Boon Chye. The cluster did not make any explicit demands. However, some members did call for more financial allocation for the public health sector, the spotlight on brain drain and an urgent solution to the lack of permanent positions for housemen, and ensuring non-discriminatory and universal access to healthcare for migrant communities.

 

The 4% gross domestic product (GDP) allocation from the government budget for the MOH was a major promise, and it was badly required, but the minister caved in and did not push for it after just one year in office, blaming it on the current economic situation, as well as the debt and liabilities from the previous government.35 That was a major disappointment.

There was some progress in other major promises in the Buku Harapan, though still far from addressing the core issues, the biggest of which was support (not just financially) for the measures to tackle non-communicable diseases, rare diseases and mental health issues.

Demands proposed to the Pakatan Harapan government based on the Buku Harapan:

There was no concrete demand or proposal to the PH government on this issue, though the CSOs could broadly agree with some of the policy directions/ideas proposed in the Buku Harapan, e.g. higher budget allocation for the MOH, more (but careful) public-private partnership, and seriously tackling non-communicable diseases and mental health issues in the community.

Pakatan Harapan’s achievements and shortcomings

PH’s performance as government with regard to health should be evaluated by looking at not only the Buku Harapan manifesto promises but also the policies implemented and practices cultivated by the Minister and Deputy Minister concerned.

 

On the Buku Harapan, observations are summarised in the following table:

 

	Promise	Status	Remark/Comment
1.	Ensure that financial allocation for the Ministry of Health is increased to 4% of GDP by the first term of administration.	F	The 2019 and 2020 Budgets tabled for the MOH are equivalent to an (estimated) 1.89% and a (forecast) 1.90% of GDP, respectively. Though the real sum has increased for both years, the magnitude of the percentage increase was marginal. Even if PH had continued to be the government, given the magnitude of increase for the subsequent three financial years, it is quite unlikely that it would have been able to uphold its promise.
2	Introduce the healthcare scheme, "Skim Peduli Sihat".	F?	The government did not implement the model as stipulated in the Buku Harapan and was in practice in Selangor. However, it rolled out “MySalam”130 and “PekaB40”131 programmes, which were rather different in design and purpose.
3	Pursue closer collaboration between government health centres with private clinics.	A/ I	Yes, evidently through the PekaB40 health screening programme, two-thirds132 of the participating clinics were in the private sector.
4	Increase budget allocation and provide incentives to tackle rare diseases.	A/ I	The government set aside RM50 million133 for treating rare diseases and other health conditions in the 2019 Budget. Since the sum is shared with other disease

128 Berita Harian. (2019, Sept 11). 21 IPG disyor tutup mulai tahun depan. https://www.bharian.com.my/berita/nasional/2019/09/605989/21-ipg-disyor-tutup-mulai-tahun- depan

129 Malaysiakini. (2020, Jan 5). Laporan: Mahathir utus surat minta Maszlee undur. https://www.malaysiakini.com/news/505951

130 MySalam official portal. (Accessed: 31 Aug 2020). https://www.mysalam.com.my/b40/info/

131 PeKaB40 official portal. (Accessed: 31 Aug 2020). https://www.pekab40.com.my/eng

132 Bernama. (2020, Jan 11). Health care scheme for B40 group a 'game changer' – Dzulkefly. https://www.malaysiakini.com/news/506734

133 New Straits Times. (2018, Nov 2). 2019 Budget: RM50m allocated to treat rare diseases, Hepatitis

B.  https://www.nst.com.my/news/nation/2018/11/427586/2019-budget-rm50m-allocated-treat- rare-diseases-hepatitis-c

			areas, the amount for rare diseases is smaller and never sufficient.
5	Focus on non-communicable diseases.	A/ I	The government carried on and implemented some items in the policy proposal134 planned under the previous administration on non-communicable diseases: i)  excise tax on sugar-sweetened beverages135 ii)  health screening service for B40 under PekaB40 136 programme iii)  designating all food and beverage outlets in Malaysia as smoke-free areas.137
6	More government resources will be channelled to mental health care.	A/ I	A higher budget allocation for mental health was allocated in both 2019 and 2020,138 though the sum was still small.139
7	Provide compulsory pneumococcal vaccination for all children under the age of two years.	A/ I	Announced in the 2020 Budget speech, the government would provide free pneumococcal vaccines140 for children. Toward this end, a budget had been allocated. The program was supposed to have been implemented in June.
8	Provide incentives for the establishment of the palliative care centres across the country.	F	There is no easily accessible published evidence to suggest that the government has done this. However, by the Health Minister’s own indirect ‘open admission’ in his speech,141 he seemed to suggest that the available palliative care in the country was insufficient.

134 MIMS Today. (2018, Jan 18). Malaysia implements 13 health policies, sparking national debate. https://today.mims.com/malaysia-implements-13-health-policies-sparking-national-debate

135 Official portal of Royal Malaysian Customs Department. (Accessed: 31 Aug 2020). Sugar sweetened beverages.  http://www.customs.gov.my/en/pg/Pages/pg_mainssb.aspx

136 PeKaB40 official portal. (Accessed: 31 Aug 2020). https://www.pekab40.com.my/eng

137 New Straits Times. (2019, Dec 30). Smoking ban at all eateries comes into force on Wednesday. https://www.nst.com.my/news/nation/2019/12/551849/smoking-ban-all-eateries-comes-force- wednesday

138 Code Blue. (2019, Oct 25). MOH gets tiny mental health 2020 Budget raise. https://codeblue.galencentre.org/2019/10/25/moh-gets-tiny-mental-health-2020-budget-raise/

139 New Straits Times. (2020, Feb 17). Mental health costs Malaysia RM14.46bil or over one per cent of its GDP. https://www.nst.com.my/news/nation/2020/02/566428/mental-health-costs-malaysia- rm1446bil-or-over-one-cent-its-gdp

140 Malay Mail. (2020, Jan 3). Pneumococcal vaccination starts in June with 2020 babies, says deputy minister. https://www.malaymail.com/news/malaysia/2020/01/03/pneumococcal-vaccination-starts- in-june-with-2020-babies/1824316

141 Borneo Post. (2020, Jan 12). Country’s palliative care less than satisfactory—Dr Dzulkefly. https://www.theborneopost.com/2020/01/12/countrys-palliative-care-less-than-satisfactory-dr- dzulkefly/

9

MOH to solve the problems faced by younger doctors or "housemen".

A/ I

Fewer working hours142 at one stretch to reduce overwork; shorter training programme143 (the compulsory service had been reduced from 24 months to 18 months) and more positions created144 to reduce the waiting period for housemanship.

Indicator: Achieved (A), Started and (was) In progress (I), Failed (F)

 

Both the Health Minister and the Deputy Health Minister were actively engaging with health- related stakeholders and media, issued statements or held press conferences frequently to clarify policies and/or incidents. Examples of various town-hall meetings (but not exhaustive) with the stakeholders included: private general practitioners, pharmacists, Muslim groups (Maqasid Syariah) and the pharmaceutical industry sector145 (twice).

 

The then Health Minister Dr Dzulkefly Ahmad also set up a seven-member Health Advisory Council146 on 27 March 2019, which consisted of academics, private hospital specialists and public health experts, to advise the MOH on healthcare delivery, performance and reform. This led to the presentation of the “National health reform: Impetus, principles and pillars” at the National Institutes of Health (NIH) on 15 Aug 2019, and the incorporation of the ideas in the Sihat Bersama 2030 proposal,147 which had been ready for Cabinet approval. The proposal is a policy to revamp the health financing system, it was highly controversial and the details of the proposal are not available in the public domain.

 

However, PH’s medicine price-regulation policy proposal was (and is still) a challenging one for the ministry, which engaged in more than 40 closed-door meetings with various stakeholders. There is huge resistance, especially from the pharmaceutical industry, private hospitals and some pharmacist organisations. The intention of the medicine price-regulation policy is a matter of public interest—to ensure fair and affordable pricing for medicine required by patients. The disagreement between the MOH and the private sector can be also

142 The Sun Daily. (2019, Apr 22). Fewer work hours for housemen. https://www.thesundaily.my/local/fewer-work-hours-for-housemen-BY809245

143 The Star. (2018, Sept 22). Excellent trainee doctors to have shorter course to reduce wait for housemanship training. https://www.thestar.com.my/news/nation/2018/09/22/excellent-trainee- doctors-to-have-shorter-course-to-reduce-wait-for-housemanship-training

144 The Malay Mail. (2019, Nov 8). Health Ministry pushing for 10,000 additional slots for medical officers, says minister. https://www.malaymail.com/news/malaysia/2019/11/08/health-ministry- pushing-for-10000-additional-slots-for-medical-officers-say/1808220

145 Information Department. (2019, Aug 7). Jemputan media ke "sesi town hall YB Datuk Seri Dr. Dzulkefly Ahmad Menteri Kesihatan Malaysia bersama industri farmaseutikal siri II". http://epress.penerangan.gov.my/epress/epress/view_acara.php?evt=14553

146 The Star. (2019, Mar 27). Health Advisory Council set up with seven panellists to advise ministry. https://www.thestar.com.my/news/nation/2019/03/27/health-advisory-council-set-up-with-seven- panellists-to-advise-ministry

147 Malaysiakini. (2020, Jan 1). Cabinet to get healthcare reform proposal by month-end: Dzulkefly. https://www.malaysiakini.com/news/505543

observed in other policy proposals such as the separation of dispensary148 and the reimbursement amount149 for the private general practitioners in the PeKaB40 programme. Political will from both the minister and deputy minister was strong to withstand the pressure, especially when the smoke-free zone in eateries was first implemented. In addition, Dr Dzulkefly Ahmad had a strong conviction for setting up a national electronic medical records (EMR)150 system in all MOH hospitals and clinics in different phases.

 

On the Pharmaniaga concession issue,151 the minister initially made the tough call of not extending the contract with the pharmaceutical company, and this won applause from the public. However, those who are long-term observers of the medical supply distribution operation deemed that this decision could be too drastic and implicate Pharmaniaga in engaging in inefficiencies, whereas the latter had actually performed well to meet the MOH’s expectations.152 In the following week, the minister announced that the concession will be extended for another 25 months153 to allow a soft landing for both sides, as the MOH was also too reliant on the Pharmaniaga set-up.

 

The credit to controlling the first wave of the COVID-19 pandemic in Malaysia has to be given to both the Health Minister and Deputy Health Minister of the PH government, although the professional and competent bureaucrats in the MOH brought strong leadership to the government’s response to the pandemic. However, the same cannot be said about the handling of the influenza outbreak at end-2019 (and beginning of 2020). The government was reacting too slow, too little, and it could have ended up a more costly affair. On 30 December 2019, the health director-general denied154 the gravity of the outbreak, and it took another two weeks before the situation stabilised.155

148 Free Malaysia Today. (2019, June 13). Raise doctors’ fees before taking out dispensary, says think tank. https://www.freemalaysiatoday.com/category/nation/2019/06/13/raise-doctors-fees-before- taking-out-dispensary-says-think-tank/

149 The Malay Mail. (2019, Jan 30). Doctors shun Health Ministry’s ‘take it or leave it’ health screening scheme. https://www.malaymail.com/news/malaysia/2019/01/30/doctors-shun-health-ministrys- take-it-or-leave-it-health-screening-scheme/1717833

150 The Edge Markets. (2019, July 2). Electronic medical record system for all M'sian hospitals, clinics to cost up to RM1.5b, says minister. https://www.theedgemarkets.com/article/electronic-medical- record-system-all-msian-hospitals-clinics-cost-rm15b-says-minister

151 The Star. (2019, Oct 31). Dzulkefly: Health Ministry ending Pharmaniaga's concession for medical supply distribution. https://www.thestar.com.my/news/nation/2019/10/31/dzulkefly-health- ministry-ending-pharmaniaga039s-concession-for-medical-supply-distribution

152 Loh Foon Fong. (2019, Nov 1). Mixed views over medicine prices. The Star. https://www.thestar.com.my/news/nation/2019/11/01/mixed-views-over-medicine-prices

153 The Star. (2019, Nov 8). Pharmaniaga's concession to end in the next 25 months, says minister. https://www.thestar.com.my/news/nation/2019/11/08/pharmaniaga039s-concession-to-end-in-the- next-25-months-says-minister

154 New Straits Times. (2019, 31 Dec). Influenza infections still within normal parameters, says Health DG. https://www.nst.com.my/news/nation/2019/12/552217/influenza-infections-still-within-normal- parameters-says-health-dg

155 New Straits Times. (2020, 13 Jan). Influenza situation under control. https://www.nst.com.my/news/nation/2020/01/556067/influenza-situation-under-control

Observations and critical analysis of the PN governance:

As the PN government is new, a major period of its governance has been under the Movement Control Order. In general, the new Health Minister, Dr Adham Baba, and two deputy ministers, Dr Noor Azmi Ghazali and Aaron Ago Dagang, could have shown stronger leadership during this health crisis. However, the MOH, under director-general Dr Noor Hisham Abdullah, continues to excel, although he attributes the success to the MOH team and the leadership of the Prime Minister who acted on the professional advice given by MOH. Within the unique circumstances of this period of crisis, the success that can be credited solely to the PN political leaders in managing the pandemic is unclear. Notably, the government took the advice of the MOH and director-general of health seriously210 and implemented and coordinated various measures.

 

Measures related to migrant workers or undocumented persons were less coherent. The crackdown, arrest211 and deportation of these groups of people are not aligned with good

210 The Star. (2020, Jul 22). PM played key role, says Health DG. https://www.thestar.com.my/news/nation/2020/07/22/pm-played-key-role-says-health-dg

211 South China Morning Post. (2020, May 1). Coronavirus: hundreds arrested as Malaysia cracks down on migrants in Covid-19 red zones. https://www.scmp.com/week- asia/politics/article/3082529/coronavirus-hundreds-arrested-malaysia-cracks-down-migrants

public health practice and policy. The manifestation of eight clusters212 in the immigration detention depots (DTIs), including a few large clusters (such as the Bukit Jalil DTI213), could be attributed to the lack of adherence to good public health practice, which was in contrast to many countries that suspended immigration detention in the wake of the pandemic214. These measures led to many undocumented migrants going into hiding and going hungry.215

The Health Minister also made a few unsubstantiated remarks, such as “drinking warm water216 can kill the virus,” while his deputy was caught for violating the MCO SOP.217

212 New Straits Times. (2020, July 12). 8 immigration detainees test positive for Covid-19. https://www.nst.com.my/news/nation/2020/07/607997/8-immigration-detainees-test-positive-covid- 19

213 Malaysiakini. (2020, May 26). 187 new cases; Bukit Jalil depot is second-largest Covid-19 cluster. https://www.malaysiakini.com/news/527348

214 Magda Majkowska-Tomkin. (2020, Apr 29). Countries are suspending immigration detention due to coronavirus. Let’s keep it that way. Euronews. https://www.euronews.com/2020/04/29/countries- suspending-immigration-detention-due-to-coronavirus-let-s-keep-it-that-way-view

215 Free Malaysia Today. (2020, Apr 22). With no help from embassy, thousands of Rohingya to go hungry in Selayang. https://www.freemalaysiatoday.com/category/nation/2020/04/22/with-no-help- from-embassy-thousands-of-rohingya-to-go-hungry-in-selayang/

216 The Star. (2020, Mar 20). Health Minister's 'warm water method' to kill coronavirus questioned. https://www.thestar.com.my/news/nation/2020/03/20/health-minister039s-039warm-water- method039-to-kill-coronavirus-questioned

217 The Star. (2020, Apr 28). Noor Azmi, Razman plead guilty to violating MCO. https://www.thestar.com.my/news/nation/2020/04/28/noor-azmi-and-razman-arrive-at-gerik- magistrate039s-court

Recommendations

COVID-19 has shown that the public healthcare sector plays the most crucial role in protecting people’s health, especially during a crisis. The deteriorating economic situation in the country has also led to many members of the public’s resorting to public healthcare, and demand is expected to rise in the coming months and years. Therefore, it is crucial that the government of the day provides a significant increase in financial resources to the MOH in the 2021 Budget.

As for reforming the health sector, the PH government ticked many promises laid out in the Buku Harapan although these promises did not address the structural issues. However, it still scored poorly for not allocating sorely needed funds to the Ministry of Health--funding being the biggest indicator of political will.