Bigger budget health allocation an absolute necessity

WHEN Prime Minister Datuk Seri Najib Razak proudly declared that Malaysia has the best healthcare system worldwide (as rated by a monthly magazine, International Living), many social media users responded to his statement with cynicism. This reaction was perhaps due to the discrepancy between the magazine’s evaluation of public and private healthcare and the reality experienced or perceived by Malaysians.

Most people do not give much thought to planning for their health, let alone healthcare policies, until illness strikes and the need for medical assistance arises. Perhaps we Malaysians do not realise how fortunate we are.

In terms of health systems, our country’s model has inherited the Beveridge model from the UK, in which the government acts as the major healthcare provider and payer in addition to the roles of public health planner, regulator and enforcer.

In this welfare-based system, many Malaysians may have taken their right to health for granted, unlike in Singapore and Indonesia, where individual responsibility is more heavily emphasised. There, citizens are more mindful about their own health savings, insurance premium and co-payments for healthcare services.

Those of us who utilise healthcare services would typically rate the system according to the following factors: (i) Accessibility: whether facilities are located within a proximate distance to their community, (ii) Affordability: whether fees charged are reasonable and in accordance with their household income (iii) Efficiency: the waiting period to receive treatment should be reasonable and not impede the patient’s work and life, and lastly (iv) Quality care: care should be delivered in an effective and professional manner, and the patient treated with respect. 

Our Ministry of Health (MOH) often claims that Malaysia’s health system is progressive and pro-poor, as public health financing is largely derived from general taxation (where the richer get taxed progressively more) and public healthcare majority users are mostly from the lowest two socioeconomic segments (Quantile 1 and 2, poorest 20% and the next 20%) of society. Moreover, co-payment user fees (unrevised since 1982) are extremely nominal (i.e. RM1 for outpatient visit, RM5 for specialist visit). This amounts to approximately 2% revenue collection against healthcare spending.

The crux of the issue is whether the MOH has adequate finances to meet the rising demand, and a holistic long term strategic plan to (i) expand the infrastructure and facilities capacity (ii) increase the health workforce while (iii) improving efficiency of healthcare delivery (i.e. containing cost but increasing productivity).

The global rise of medical costs is being felt in Malaysia’s private health sector too. The 2017 Global Medical Trend Rates report has forecasted Malaysia’s medical inflation rates to experience a 12.0% net increase, twice the Asia net average (6%). This increases pressure on the MOH to contain costs, especially given the mere 7.7% increase in allocation in the 2017 Budget.

Recently, the Director General of Health Dato Dr Noor Hisham Abdullah told the media that “(the MOH hospitals are) seeing an additional 10 million outpatientslast year compared to the 45 million received in 2015”. This number translates to a 22% increase in service demand.

To that end, health minister Datuk Seri S. Subramaniam was right in claiming that the 2017 budget allocation was not enough and to urge for greater resource allocations next year.

Private hospitals are also the victims of rising medical cost. Last year, these hospitals suffered a 20-30% drop in patient volume as more patients opted for public health service. The National Health and Morbidity Survey 2015 found public perception towards treatment charges in private healthcare to be somewhat negative, with 25.9% respondents nationwide giving it a ‘poor’ rating.

An increasing proportion of those from middle and lower household income classes could not afford to utilise private healthcare services, let alone in the event of a catastrophic illness. Out of the total population health expenditure in 2015, only 8% of contributions were made from private insurance. While not entirely conclusive, one may safely assume that under 10% of citizens had private insurance coverage. A greater volume of patients may turn to public health facilities in coming years. The government must be prepared for this increased pressure on health services.

Granted, greater financial resources does not necessarily guarantee an improvement of services; nevertheless, last year’s stretched budget did affect Public Health and Medical Care, with across-the-board reductions for most services and supplies line items.

If MOH still continues to operate under-resourced, the likelihood of basic test materials and medical supplies running out of stock may become a more frequent and familiar scenario. In line with the increasing public demand for healthcare services, more resources should be given to MOH’s development budget to expand the current capacity of the healthcare system as well as to alleviate the current stress in the system.

After considering various adjustment factors such as the forecasted 15% medical inflation rate, typical salary  increases of between 10-20% per department, and a projected higher healthcare demand from the public, the MOH should minimally secure a 15% larger budget allocation compared to what it received last year (in other words, more than RM28.5 billion).

Spending priorities should be to ensure that at the very least, all drugs listed in the National Essential Medicine List (NEML) and basic test reagents are readily available at all times. Furthermore, MOH should channel an appropriate level of funds towards increasing capacity and improving service delivery in all its healthcare facilities, especially in congested urban hospitals.

A responsible government should set its priorities right for the type and amount of public investments to make, to reflect how much they care for the well-being of the people. For this, long-term strategic planning, not firefighting, is the way to go. It is my hope that, when the 2018 Budget is tabled, the MOH receives a fair allocation that matches its needs.

Published at The Malaysian Insight, Voices, Oct 1, 2017.

族群和睦关係省思

话说好几周前，我注意到友人在面书上分享黄明志最新创作的音乐视频（MV），曲名为《阿里阿狗和木都》。若读者有所不知，黄明志是个颇有爭议性的嘻哈艺人。他就曾在10年前推出了一首《Negarakuku》而大红大紫。当时那首歌被批评为反政府、反伊斯兰教、反马来人和污蔑国歌，而他成为了马来右翼份子的箭靶。强烈对比当年那首「成名曲」，《阿里阿狗和木都》非常政治正確地描述我国三大种族，即华巫印裔之间的族群和谐。副歌里更如此唱：「友谊永固，同心同魂（…kawan selama-lamanya，satu hati satu jiwa）」。

我並未质疑黄明志和其他艺人欲通过歌曲与视频释放善意，努力促成族群和睦关係。只是，我们到底如何才能跳脱表面的族群和谐象徵，去回应现实中复杂的课题，尤其是那些造成我国多元种族社会出现互不满意互不信任、无法良好融合相处的矛盾？

多元社群超越三大种族

首先要指出的是，我国的族群和谐画面一般都只强调三大种族的团结。令人詬病的是，这论述遗漏了我国存在的多元社群，比方说半岛的原住民、东马的土著以及混血族群例如峇峇娘惹、欧亚混血人和印华混血人。这样的画面也似乎暗示著这些社群不入主流，只能委屈退居到被边缘化的「lain-lain（其他族群）」类別。虽然身为公民的一份子，这种排斥性的待遇或忽略往往可能造成这些族群的困惑，让他们觉得自己不受国家认同和重视。

联昌国际银行基金会（CIMB Foundation）在今年初发佈了一个有关族群关係的报告，发现有89.5%马来裔、79%华裔和68.7%印裔受访者拥有很多或几乎所有的朋友都来自本身族群。这显示在日常生活中，各族缺乏深入交流。黄明志MV里宣导的阿里、阿狗和木都的故事似乎不是现实常態。捫心自问，究竟有多少MV观赏者其实非常渴望这类的跨族友谊？如果有，那么到底在现实生活中是什么障碍阻止这类友谊建立？

单一源流教育不是捷径

有些人，包括政治人物，似乎把单一源流教育系统的倡议当成有效地拉近我国族群关係的一种万灵丹。上个月，在一场TN50国家转型计划的政治研討会里，巫青团执委沙里尔韩旦（Shahril Hamdan）直言单一源流学校基於「孩子从小就长时间接触交流」，可成为「促进族群团结的方程式」。但，单一源流学校有可能会是他口中所谓促进族群团结的「捷径」，又或者我们该问，这提议理想吗？

或许某些人已忘了（或不认同）我国独特之处和优势正来自多元文化语言的社会背景。这个多元性恰恰正是吸引许多游客慕名而来並爱上我国的原因。我国自我標榜「真正的亚洲（Truly Asia）」，不是偶然的。

前首相阿都拉巴达威曾建议在国小推动母语课程。当时他表示：「我们应该学习友族的语言，根据需求与时並进」。纵然当时的政府可能拥有其他的议程（若搁置母语科师资短缺的问题不谈），这还是个值得讚扬的语文政策。政府可参考多元语言国家如加拿大和瑞士落实双语政策。孩童们必须学习两个主要的国家语言；前者学习英语和法语，后者则是德语和法语。

语言不应成为障碍

別误会，我全力支持不同源流的学生增加交流互动的机会。这是正面的行动，应该鼓励和表扬。语言不应成为不同族群学生们的交流障碍，因为国民型学校的学生也学习马来文。

即便如此，我仍坚信仅仅语言无法確保族群和谐，尤其是当国民仍根据肤色和宗教被赋予不同的差別待遇和权利。即使学校孩童共用一室，他们仍经常意识到或被提醒自己与他人的不同。近年来就有两宗案例印证问题的纠结：其一是非穆斯林学生被迫在斋月期间在洗手间进食用餐，其二是在另一所国民学校连杯子也被区分为穆斯林和非穆斯林专用杯。

没错，没有孩子一出生就是种族主义者。然而在孩子的成长过程中，在耳濡目染下得到的讯息会影响他们如何看待事物。某些族群偏见可能因此渗透年轻人的思想，进而形成族群歧视的根源。有鉴於此，政府和社会应创造一个优良有利的环境，让孩子们从小就能有积极正面的观念与各族同胞做朋友。

检討积极平权措施

积极平权措施（Positive affirmative action）是一个全世界普遍实践的政策。如果执行妥当，它拥有巨大潜能达到社会正义的目標。因此，积极平权措施应专注於把资源导向最符合资格寻求援助的个人。

一般上主流的积极平权措施是根据阶级作分配资源，虽然在某些国家的少数民族（例如原住民族群）也可享有优惠待遇。

一旦积极平权措施被滥用和扭曲，那些没受惠的人民难免会深感不满，觉得这措施毫无社会正义可言。在我国，或许有些人会认为自己被贬至「次等」公民，不满其他人基於肤色和宗教身份就可享有更多的优惠权利。如此的不满情绪或可酝酿很久並传给下一代。若政府和社会不认真看待，日后这將会是颗计时炸弹，会一再出现令人难堪或不安的衝突。不公平待遇的印象若被默许持续下去，这將会是国民团结精神、跨族群的信任和相互接受的重大障碍。

政府与议员们应不时检討我国现行的政策、法律和宪法，並积极地確保这些条文都能符合「自由、平等和博爱」的普世价值观。若没採取实际行动处理人民的不满根源，再多的表面跨族和谐画面会有用吗？到底何时马来西亚人方可接纳各自不同的身份背景，並得以平等公民自居、共享这片土地？

刊登于《東方日報》東方文薈版2017年9月2日

Reflections on racial harmony in Malaysia

WEEKS ago, I noticed on my Facebook feed that some friends were sharing the latest music video produced and composed by Namewee, entitled “Ali, AhKao dan Muthu”. Namewee is a controversial hip-hop artist who was once condemned by Malay right-wing groups following the release of “Negarakuku” 10 years ago. His song carried some anti-government undertones, and he was accused of disrespecting Islam, the Malay race and insulting the national anthem.

In stark contrast to his previous song, “Ali, AhKao dan Muthu” is a politically-correct portrayal of racial harmony among the three main ethnic groups in Malaysia, namely Malay, Chinese and Indian. Its chorus goes “…kawan selama-lamanya, satu hati satu jiwa”.

While I do not dispute Namewee’s well-meaning intentions (and indeed that of other artistes) who are working hard to promote interracial harmony via songs and videos, how can one transcend stereotypical symbolism of interracial harmony to address the elephant in the room – the real complicated issues that create discordance, mistrust and discontent among the multiracial community?

Firstly, racial harmony in Malaysia typically emphasises the unity of only three major races, leaving out diverse communities, for example, the aboriginals (or ‘Orang Asal’) in Peninsular Malaysia, the native bumiputera in East Malaysia and mixed parentage groups such as baba-nyonya, Eurasian and Chindian, as if they do not fit into the whole picture but only the fringe ‘lain-lain’ position. These groups might feel disconnected or disillusioned at being excluded.

Secondly, a study on interracial relations published by CIMB Foundation on January 2017 found that 89.5% Malay, 79.0% Chinese, 68.7% Indian respondents reported having a lot or almost all of their friends from their own racial groups, pointing to a lack of deeper racial interactions on a daily basis.

This is indeed a disturbing reality, and one that contradicts the “Ali, AhKao dan Muthu” friendship propagated by Namewee’s video. The question we must ask ourselves is this: how many Malaysians actually desire such inter-racial friendships, and if they do, what are the real life obstacles that prevent these relationships from forming?

Certain people, including politicians, have alluded to the single-stream schooling system as the magical silver bullet that will bolster interracial harmony in Malaysia. Some weeks ago, during a TN50x session on politics, UMNO Youth exco Shahril Hamdan claimed that having single stream schools could be “the formula to achieve unity among races” based on “constant engagement with one another from a young age”. But is this “short cut” to promote unity, as he claimed, really something desirable?

People often forget that Malaysia’s strength lies in the diversity of our multicultural-multilingual plural society. This diversity is very reason why so many travellers, from near and far, fall in love with our country – a country that is indeed a Truly Asia, a well-known international recognition.

The former Prime Minister Abdullah Ahmad Badawi once proposed to introduce ‘home language’ classes in national schools.

"We should be learning the languages of other races in line with today's needs," he said.

Although the then government had other motives for that proposal (and if we disregard the issue of shortage in mother tongue language teachers), it was nevertheless a praiseworthy policy proposal mirroring language policies practiced in other multi-lingual countries such as Canada and Switzerland. In those countries, children are made to learn dual major languages in school (English and French for the former; German and French for the latter).

Make no mistake, I am all for students from different backgrounds coming together and interacting more frequently with each other. Such positive actions should be strongly encouraged, moreover language should not be the barrier since vernacular school students are taught in Bahasa Malaysia too.

Still, I argue that language alone will not guarantee racial harmony especially not when Malaysians are still accorded different treatments and rights based on their race and religion. Even if school children were to share a classroom, they would still be constantly aware and reminded of how different each is to other.

One need only recall the incident when poor non-Muslim students had to eat and drink in the restroom during Ramadan, or, in another case how cups were separated according to Muslim and non-Muslim in another national school.

It is true that “no child is born a racist”. Some years ago, a documentary produced by local filmmaker Jason Lim showed that as children grow up, the messages they receive from the surrounding environment shapes and influences the way they perceive things.

Under adverse circumstances, certain racial stereotypes could infiltrate young minds, forming the basis for discrimination. The government and society should do more to cultivate a good environment for children to form multiracial friendships from a young age.

Positive affirmative action is an accepted worldwide practice. When applied appropriately, it holds much potential to reach the goal of delivering social justice. However, to attain that goal, policies for positive affirmative action should focus on channelling resources towards qualified individuals who need the assistance the most.

Class-based positive affirmative action is usually the mainstay, though in certain countries the absolute minorities (e.g. aboriginal tribal communities) do enjoy certain preferential treatment. The abuse and distortion of affirmative action creates social injustice and unhappiness for those who are non-beneficiaries of the system.

In Malaysia, certain quarters might feel they are rightly or wrongfully treated as ‘second class’ citizens, and perceive that some enjoy more privileges and opportunities than themselves. Such sentiment could brew over a long time and pass down through generations if nothing is done to weed out the roots of this dissatisfaction stemming from differential treatment according to racial and religious lines.

Left unchecked, it could even erupt into ugly (not necessarily violent) conflicts. Such cases have already unfolded now and then in our country. If the perception of unfairness is allowed to persist, it would be a real stumbling block to realise the true spirit of national unity, trust and mutual acceptance among various ethnicities in Malaysia.

The government and lawmakers must periodically re-examine our existing policies, laws and constitution, and strive to ensure that these reflect the universal values of liberty, equality and fraternity.

What use is there in propagating a superficial rhetoric of interracial harmony, if no concrete action is taken to deal with the underlying causes of dissatisfaction among the grassroots? When will Malaysians be able to embrace their different identities and daily practices, yet be treated as equal citizens sharing this land? 

Published at The Malaysian Insight, Voices, Aug 28, 2017.

谁该为您的健康负责？

標题的答案似乎已呼之欲出。在正常的情况下，大部分人都可能这样答：当然是自己啦！。事与愿违，现实里很多人言行不一致，並没有好好照顾自己的健康。常人说：预防胜于治疗。如果国人都认真地遵照这常理智慧，那么政府在公共卫生和財政规划方面就轻鬆多了。

现实是残酷的。2015年度的《国家卫生和病情调查报告》（National Health and Morbidity Survey 2015）显示，有30%的大马人口超重（overweight），再有17.7%的人过胖（obese）。换言之，若按照世界卫生组织1998年的体重指数（BMI）指南標准，接近半数的大马人口拥有不健康的身形。若根据大马临床实践指南標准，不健康身形人口的比率更高，逼近2/3人口（64%）。

不爱运动爱美食

其中的问题是，国人不爱运动。如果依据《国际体力活动调查问卷》（IPAQ）的定义，估计有33.5%人口被鉴定为「非活跃」的。其实该问卷对于「活跃」的標准要求並不高，如国人能至少每週有5天每日步行超过半小时，或进行中等激烈的运动。然而，1/3的国人连这点都办不到。

不健康的饮食习惯与患上非传染性疾病的偏高风险息息相关。其中泰勒大学2014年的研究发现有64.1%的国人至少每天都在外吃一餐，同时又有31.9%的人习惯在晚餐后仍进食一餐高份量的饮食。

不少大马人常以马来西亚是美食天堂为借口，说这里拥有太多难以抗拒的美食怎能不多吃？那看似有道理，但放眼全世界再检视这说法，就可发现其实美食与肥胖並没有直接关联。
倘若属实，美国和英国其中这两个世界上最胖的国度应同时拥有最多最好吃的美食，何时轮到被公认为西方美食国度意大利和法国呢？看看泰国和印尼，两国的美食也可媲美大马一样载誉全球，却在肥胖国度的排位上低于我国，那又是为何呢？

公共健康危机

社会无法不重视缺乏运动和不健康饮食习惯对公共卫生所带来的严重祸害。仅仅是非传染性疾病病例，已佔据了大马73%的死亡人口。在2012年，至少有70%的大马人被诊断患上非传染性疾病。在2015年，涉及到呼吸管道、心臟血管、消化系统、泌尿生殖系统和癌症相关的非传染性疾病都挤上了十大入院的病例种类排名，病例总数为120万次。

就仅谈治疗糖尿病的花费，估计已达国家卫生预算的16%。2014年一份卫生部报告统计显示，若综合所有的直接和间接费用，政府需为每名糖尿病患者每年支出3750令吉充作治疗费。

那么，健康问题是否该全怪个人没照顾好自己，而政府就可以置身度外，对確保社区国民健康事宜毫无责任？非也，本人不这么认为。

政府难以推搪

大马政府已有很多宣传管道可整合设计出有效的推广健康运动，包括使用本身和官联公司旗下的电台、电视台以及纸媒。提倡活跃能动生活和良好饮食习惯，若在政府有效的宣传指挥下必能事半功倍。可惜，我们在日常生活体验到的反而是连环轰炸的各类快餐广告出现在各大电视台、电台、报纸和宣传看板上。政府其实可创意地鼓吹健康饮食文化，例如把健康讯息置入流行动画例如本地製作的《Upin dan Ipin》，让孩童从小就接触到正面的健康资讯培养良好习惯。学校食堂的饮食选项和营养更不可忽略，尤其是要阻止一些食堂经营者售卖太油或太甜的食物给学生。

至于小学和中学的体育课，我国政府仅安排每週80分钟，被拋于多个区域国家之后：新加坡和韩国拨出每週120分钟、中国105-135分钟，日本则是125-130分钟。问题在于我国的体育课鲜少被重视，只因它不是考试科。家长也应以身作则带领孩子走出並接触户外，以培养热爱运动的习惯。那么户外活动总需要个空间吧？

到了最后，从城市规划的角度来看，政府的责任更难以推搪。政府应根据人口密集度提供足够大小的公园和休閒空间，特別是在稠密的城市地区。据国家城市化政策下的標准，每1000人应享有2公顷的公共空间。地方政府应鼓励人民多步行和骑脚车，所以当务之急是改善行人道和脚车道的衔接网络。那么，能「动起来」的人民或许会更愿意使用公共交通，捨弃私家车。

总而言之，在改变社会行为以达至更好的公共卫生结果的角色上，政府其实能做的还有很多。但人民本身也该回应政府的呼吁，尽本分照顾自己的健康。若双方都配合得体，我国绝对能减少公共卫生和健康问题，那么或许再也不会有人说大马美食和健康不能兼得。

刊登于《東方日報》東方文薈版2017年7月22日

Who is responsible for your health?

The question seems like a no-brainer. Under normal circumstances, the answer is most likely ‘our own good self’.  But in reality, some people do not take care of their health as well as we would like to think. The common wisdom is ‘Prevention is better than cure’; if every Malaysian took this axiom seriously, it would surely ease the task of the government in terms of public health and financing.

The reality is stark. The National Health and Morbidity Survey 2015 recently showed that 30% of the Malaysian population is overweight, while a further 17.7% are obese. In other words, nearly half of the Malaysian population was found to have an unhealthy body size based on the World Health Organisation’s (1998) Body Mass Index (BMI) guidelines. The percentage goes even higher, at 64%, if we are to use the Malaysian Clinical Practice Guidelines).

Based on the definition given by the International Physical Activity Questionnaire (IPAQ), 33.5% of the population is identified as ‘inactive’. This is unsurprising news, given that one third of the Malaysian population do not practise moderate intensity level of physical activity such as walking for more than 30 minutes per day for minimally five days a week.

Unhealthy dietary practice is correlated with a higher risk of non-communicable diseases (NCDs). A study found that 64.1% Malaysian individuals eat at least one meal per day outside of the home daily, while 31.9% habitually eat a heavy meal after dinner.

As a natural defence, many Malaysians would be quick to claim that Malaysia has too much irresistable good food. But contrary to popular belief, there is no correlation between good food and obesity. If that were true, then countries such as the United States and Britain, two countries that currently top the obesity rankings, should also top the world for the best food, instead of countries renowned for their culinary fare such as Italy and France! On a more regional note, Thailand and Indonesia, countries which have equally tempting food choices as Malaysia, are in fact ranked lower than our country in the obesity rankings.

Society cannot afford to ignore the serious consequence of lack of exercise and bad eating habits to public health. NCDs are responsible for 73% of deaths among Malaysians. In 2012, at least 70% of Malaysians were diagnosed with NCDs. As of 2015, NCDs in respiratory, circulatory, digestive and genitourinary systems as well as neoplasms (cancer) made it to the top 10 principal causes of hospitalisation, totalling 1.2 million cases. The cost of treatment for diabetes alone is estimated to account for 16% of the national Malaysian healthcare budget, while the combined direct and indirect per-patient costs for diabetes was found to be RM3,750 in 2014.

Yet, is it right to place the blame solely on the individual, and claim that the government plays no role in attaining good health outcomes in the communities? I do not think so.

The Malaysian government has many tools at their disposal to coordinate effective health promotion, including TV and radio channels as well as newspaper press. These are effective channels through which the government can encourage active lifestyle and good dietary habits among society. These days, we are constantly bombarded by various fast food advertisements on TV, radio, newspaper and billboards. Perhaps the government should emulate the US Food and Drug Agency (USFDA) in regulating food providers, especially fast food outlets, to have compulsory nutritional list on their standard menus.

The government could also come up with creative ways to encourage healthy eating habits using commercial activities. For example, the use of popular animation series such as “Sesame Street” or the locally produced “Upin dan Ipin” to promote good eating habits and encouraging physical exercise could potentially lead to a shift in lifestyle habits among minors, and further reduction in NCDs.

School-based nutrition plays a great role in altering social norms and behaviours. It is not helpful if some school canteen operators could get away with selling foods which are either too oily or too sweet. Current programmes involving poor students such as “Rancangan Makanan Tambahan untuk Pelajar Miskin” are a good platform to educate canteen and cafeteria providers on the importance of including more nutritious food items in their menu. The sale of junk food should be banned if they follow the guidelines set by the government.

In terms of physical education in primary and secondary schools, the government allocates just 80 minutes per week. We are lagging behind other countries in the region – Singapore and South Korea both allocate 120 minutes, China, 105-135 minutes, and Japan, 125-130 minutes. In Malaysia, physical education is seldom prioritised because it is perceived as less important than studying and passing for examinations.

While there has been an increase in the number of running and cycling events in the Klang Valley, such events should be encouraged in other states in the country and younger participants should be encouraged to participate. Parents need to lead by example, by teaching their children to love physical activities . This could be done through enrolling them in running clubs, frequently enjoying indoor or outdoor sports as a family, and limiting screen or internet time so as to encourage outdoor activities.

Finally, from an urban planning perspective, the government must provide sufficient parks and recreational spaces per population density, especially in the urban areas. Local governments can encourage higher activity levels by improving the connectivity of pedestrian walkways and cycling paths, and encouraging the use of public transportation over that of private cars.

In conclusion, there is plenty that the government can do to shape desirable social behaviours towards better public health outcomes. But society, too, must do its part by responding to these calls. If both play their roles right, Malaysia will surely be on the right track to reducing public health issues and living up to the mantra of “prevention is better than cure”. 

Published at The Malaysian Insight, Voices, July 9, 2017.

Revising the minimum wage levels in Malaysia

Imagine that you are the sole breadwinner in your family. You earn the current minimumwage of RM1,000 to feed a family of 4 living in Kuala Lumpur. How would you plan your daily expenditure and the expenditure of your family? You have only about RM8 per person per day to spend.

That was the underlying context for the “Poverty Line Challenge” organised by Suaram Penang for the past two consecutive years, which challenged participants to survive on only RM7.5 per day for five continuous days. This may be just a five day challenge to some, but in reality, 1.6% of households[1] (or about 106,800 households) in Malaysia had earned less than the minimum wage of RM900 per month in 2014. For the lowest expenditure class of households, on average they would spend 28% of their earnings on food and beverages, 30% on housing and utilities and another 9% on transport[2].

This begs the question of whether the minimum wage of RM1,000 is sufficient for a household living in an urban area.

According to the National Wages Consultative Council of Malaysia[3], the objectives of the minimum wages policy are to i) ensure basic needs of workers and their families are met ii) provide sufficient social protection to workers iii) encourage industry to move up the value chain by investing in higher technology and increase labour productivity and iv) reduce nation’s dependence on unskilled foreign labour.

Malaysia began implementing the minimum wage effective from January 1st 2013, where the monthly minimum wage in Peninsular Malaysia was RM900 and for East Malaysia, RM800. Effective since last year July, the monthly minimum wage was adjusted to RM1,000 and RM920, respectively. Under the minimum wage legislation, the minimum wage levels shall be reviewed every two years.

Critics blame this policy for harming the economy and forcing some businesses to close thus creating more unemployment. Some cast doubt because they feel that the labour productivity increases do not match up with the wage increment. On the other hand, others claim that the minimum wage is set too low and as such does not help the workers to cope with higher living cost in Malaysia. Proponents of a higher minimum wage, such as Malaysian Trades Union Congress (MTUC) and opposition parties repeatedly urge the government to set it at RM1,500 .

Figures from the Labour Force Survey seem to show some of the benefits of the minimumwage policy. This policy may be partially responsible for the improvement in labour force participating rate (LFPR) from 65.6% in 2012 (pre-minimum wage policy) to 67.7% in 2016. The implementation of the minimum wage policy also coincided with an increase in women’s participation in the labour force, where female LFPR reached 54.3% in 2016, up from 49.5% in 2012. The number of employed persons in Malaysia also increased from 12.8million in 2012 to 14.2million in 2016. This clearly shows that employment opportunities and labour participation in Malaysia were not negatively affected by the minimum wage policy. While the minimum wage policy has brought more socioeconomic benefits than harm, the current system in Malaysia is still far from ideal. Allow me to illustrate further.

The current minimum wage rates are only applicable to West and East Malaysia, as 2 general territories. However, inter-state difference is wide. For instance, is it fair to have workers in the Klang Valley and in Kelantan both receive the same amount of minimum wage? Even within a state there is huge disparity in living expenses: taking Selangor as an example, residents in Bandar Utama (an affluent township located in Petaling Jaya district) and Sungai Besar (a rural township in Sabak Bernam district) would have vastly different levels of living costs.

It may be true that some firms might consider laying off its workers due to cost saving when minimum wage is implemented. However, if the firm knows that the minimum wage level for rural or semi-urban area is significantly lower, they might consider moving into and setting up the business there, thus more job opportunities could be brought to the area.

Another issue is the fact that the current system does not distinguish between workers’ age. Employers are often reluctant to pay inexperienced ‘freshman’ workers too highly. In this case, a lower but reasonable wage for young workers may be a good balance. This also allows for the setting of a higher minimum wage at a later age, when the workers are more likely to shoulder bigger financial responsibilities for family needs. In United Kingdom, the government gazettes the National Minimum Wage hourly rates of £5.6 (RM30.33) to £7.05 (RM38.19) for 18-20 to 21-24 years old employees, respectively. However, the National Living Wage is applied to employees of age 25 years old and above, set at hourly rate of £7.5 (RM40.62).  Even more impressive is the fact that the UK minimum wage rates are adjustable or reviewed every half year. Can Malaysia emulate the same “age-sensitive” model?

One may have reservations and might worry that this proposal would complicate matters for the authorities and employers. One needs to be reminded that some countries set the minimum wage rates even according to different demographics, such as India, which has more than 1,200 rates across the country. I do not propose that we wholly follow the case of India, but at the very least, rates should be refined down to state or district level.

Many countries set the minimum wage at 30-60% of the median wage of their country. Thus, if our government takes 60% of the median household income[4] (RM4,585) divided by average number of wage earners per household (1.8), the minimum wage should be RM1,528. If we take the UK standard at 44%, then it would be RM1,120.

The current national minimum wage in Malaysia is set too low. If the lowest grade of workers from the Majlis Perbandaran Seberang Perai have enjoyed a minimum basic salary (including fixed allowance) of RM1,350[5] since 2012, there is no reason why the federal government cannot adjust the national minimum wage to an acceptable and fair level.

In setting minimum wage rates, the main consideration should be creating a social safety net that complements the existing social welfare system, which I believe is inadequate. The minimum wage should serve as a right for workers to avoid being exploited by the employers. Workers deserve sufficient wages to deal with basic living expenses, so they can live with assurance and dignity.

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[1] Prices, Income and Expenditure Statistics Division, Department of Statistics Malaysia.[2] Household expenditure survey 2014, Department of Statistics Malaysia[3] T. Shanmugam, “Early effects and challenges of minimum wages in Malaysia: Sharing of pre & post economic and social indicators”, Presentation at the National Minimum Wage: Symposium & Policy Roundtable, Johannesburg, South Africa, 2-4 February 2016[4] Household Income And Basic Amenities Survey Report 2014, Department of Statistics Malaysia[5] “Dasar baru pro-pekerja 2012 MPSP, gaji minima RM1,350”, Bulletin Mutiara, 16 Nov 2011.https://www.buletinmutiara.com/dasar-baru-pro-pekerja-2012-mpsp-gaji-minima-rm1350/

Published at The Malaysian Insight, Voices, June 4, 2017.

Prudent, strategic planning required for medical housemanship programme

It is stereotypical of Asian parents to dream of the day when their child dons the white doctor’s coat or the green surgeon’s scrubs. In fact, there are plenty of opportunities for one aspiring to be a medical doctor in Malaysia.

Over the years, Malaysia has experienced a boom in the number of medical programmes offered by private higher education institutions in order to cater for this demand.  Parents typically invest a hefty sum into a child’s medical education, which would take 4 to 5 years to complete. From just one college (namely, the Penang Medical College) in 2001 to 11 private institutions in 2014, the number of medical graduates from private institutions entering the workforce is 26 times more than what it used to be in 2001. Those who did not enrol in local institutions may opt to study abroad in one of the 310 recognised foreign medical institutions, some of which have lower entry requirements than local institutions. The sharp surge in the numbers of medical graduates seeking housemanship positions has caused a glut in the public system. In 2015, Malaysian Medical Council provisionally registered 5,147 medical practitioners; only 4,121 housemen having completed and vacated the local positions in the same year.

In a recent interview, Deputy Health Minister Dr Hilmi Yahaya stated that out of a total of 10,835 housemen placed in 44 teaching hospitals and Royal Military Hospitals, only 48.6% medical graduates who went through Public Service Commission interview in 2016 obtained a place[1]. Meanwhile, the Health Minister Dr Subramaniam conceded that the waiting time forhousemanship placement was between 6 to 9 months.[2] This prolonged wait caused anxiety and stress to the housemen, as they were left with no means of income and risked losing touch with the knowledge and skills acquired during their years of study.

Since 2008, the duration of the housemanship programme has increased from one year to 2 years. Now, housemen are required to cover 6 disciplines for their postings, namely Internal Medicine, Paediatrics, Surgery, Obstetrics and Gynaecology, Orthopaedics and Emergency Medicine (or 3 alternative choices of discipline). The total number and the turnover rate of house officer positions are determinants for a fresh houseman to secure a place in one of the training hospitals. On the other hand, the number of experienced specialists who are willing and able to supervise the house officers determines the quality of the housemanship programme.

Another difficulty lies in getting sufficient numbers of available specialists in each discipline. Within ‘Emergency Medicine’, MOH has only 139 specialists, and another 3 core discipline areas have less than 250 specialists each[3]. If one were to divide the aforementioned total number of housemen by 6 postings, there would be 1806 housemen on average seeking a placement in a certain discipline at any one point in time. Even if 100 specialists from a particular discipline enlisted as a mentor, he or she would have to supervise a group of 18 housemen on average. With such constrained resources, how could the training quality be good and sufficient under such circumstances? A study done in 2012 by the MOH further confirmed that in 48.4% of all cases, one mentor had to take on 6 mentees and above[4]. There were even cases of over 20 mentees to 1 mentor!

The ongoing ‘brain drain’ of specialists to the private sector and foreign countries is yet another issue contributing to the shortage of experienced specialists and consequently, poorer quality of training. It was found that between 2009 and 2013, about one-third of housemen reported to have extended their housemanship training at least once[5] ; 55% due to incompetence and the remaining 45% due to disciplinary issues. These “extensions” caused a bottleneck to the placement system within the training hospitals. Coupled with the large influx of incoming medical graduates over the recent decade, the training hospitals are becoming even more bloated and simply cannot catch up with the pace.

While the housemanship bottleneck issue cannot be solved overnight, policymakers should be more prudent in planning to anticipate the possible issues and prevent the situation from worsening. We recommend the following measures: Firstly, MOH should train more specialists and retain them in public sector. Besides that, MOH should also plan and design the housemanship programme better, especially to incentivise specialists to become mentors. In broader terms, the government should work with private sector hospitals, providing the latter with incentives to train housemen while sharing the cost burden of training. Finally, the MMC needs to have tighter regulations of local private and overseas medical education institutions to ensure medical graduates they produced are of desirable quality and not quantity.

Given that housemanship training is the bedrock of good skills and professional development for medical officers, government has to ensure that medical graduates receive proper skills training and have an overall satisfying experience during their housemanship period. After all,housemanship training is an important quality safeguard of the provision of medical services to the general public.

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[1] “More slots at training hospitals opening up for housemen”, The Star, 15 March 2017

[2] Hashini Kavishtri Kannan, “Med students told: Don't work illegally, wait for housemanpostings”, New Straits Times, 3 August 2016

[3] National Specialist Register, valid as of 24 Feb 2017

[4] Ang K.T. et al., “Mentoring Junior Doctors in Public Sector Hospitals, Malaysia”, Institute for Health Management, 2012

[5] Norrina J. et al., “Housemen Extension: The Concern of All”, Institute for Health Management, 2014

Published at The Malaysian Insight, Voices,  April 29, 2017.

政策和公共知识份子的角色

如何鼓励人民多乘搭公共交通，从而解决塞车问题？消费税当初应该推行吗？推广医疗旅游会否损及本地人在私人医疗服务上的利益？哪个是永续发展的模式，以确保自然环境与人文精神可被维护及发扬光大？

以上的问题都牵涉到政策讨论：有些具有政治意识，有些则可放在非常技术的层面来探讨。政策影响可大可小，大至决定你在这片国土上的个人身份权利，主宰你的衣食住行；小则跟你没直接关系。无论是良策或下策，有些政策的影响深远至几代人的事，例如70年代的新经济政策；有些政策则会带来永久性不可逆转的改变，比方说允许油棕种植业开辟原始森林的土地政策。

在我国，政策的拟定一般惯性是由上而下产生的。有时候纯粹是政治人物的个人意愿或突发奇想，例如英文教数理政策。一旦政策没经过仔细研究和深思熟虑，没以数据事实和扎实理论为根据推算未来，该政策的失败风险机率颇大。那么最后由谁来收拾烂摊子，代价由谁来负责？当中的问责追究机制，人民除了可委托反对党，本身能不能亲自有效地监督政府的表现？

在一些民众的认知里，政策似乎归属于政治圈子内的话题和权力而已，他们觉得遥不可及，也无从改变结果。遥不可及或源自于有些政策的技术复杂度，导致某些人因无力全面解读而放弃参与讨论。再说，对国家政治制度已失去信心和希望的大有人在，他们甚至认为讨论政策无济于事因为上台的还会是同一集团的同一批人。

前联合国秘书长科菲安南曾说过：“知识就是力量，信息就是解放。教育是进步的前提，对每个社会和家庭都一样”。同样的道理若用在我国的政治和民主教育，有何不可？倘若人民能掌握议题、对政策了解得更多，就能更自觉本身的权利，不会轻易被忽悠受摆布。如此一来，众人更能组织起兴论力量来反对和抵挡不合理不正义的政策，这就是民主成熟、理智进步的社会象征。

政策的讨论虽可在咖啡店里口沫横飞道长短，或在豪华酒店的会议厅里滔滔不绝，到底最后结果怎样还是得回到重点看论政策的人有没做足功课，拿出专业精神实事求是，分析解说能不能信服大众。没错，政策研究是一门学问。我身为槟州州政府的智库和公共政策研究中心的政策分析员之一，除了要做好这门学问，更有责任把思想种子散播出去，以期能发扬新观点促使它影响或改变这社会，达到一定的功用。要取信于社会大众，除了要使用易懂的语言持续性地与公众沟通交流，更重要的是能坚持把住本身的客观专业，公正不阿、问心无愧地交代和捍卫本身的研究结果。

既然是由公费资助的政策研究，必然要有其公共利益，研究成果也理应与公众公开分享。换言之，我是纳税人的雇员，终须对公众负责。而我在其位谋其事就得尽其责，成为公共知识份子之一。那么，我唯有走出冷气房面向大众，才能有效地做到坐言起行。

如果政策是个大版图，围绕着这个大版图的策议者对于时局布阵，防守进攻略都必须拿捏清楚。细节可有错但不能全盘皆落，至少大方向没走错。就如刘备三顾茅庐拜访诸葛亮留下后来的《隆中对》，从此奠定了刘备的蜀国在三国天下定局的立足攻略基础。又称《隆中三策》，诸葛亮提出先取荆州为根基，再夺益州为鼎足补给后方，进而角逐中原的战略构想。若说槟城是我们发挥影响力的出发点根据地，角逐政府决策的中原是我们的理想。那么，我们该有什么政策攻略打造一个进步有希望的马来西亚？我的研究院同僚们将在接下来每逢周日与大家谈政策，叙说故事。

刊登于《東方日報》東方文薈版2017年6月11日

2016 'watched' list

Whenever time is appropriate and convenient, Xiao Hui and I would prefer to watch movie together in our home theatre (because watching movie from a video beamer is so cool  =D ).

Since the day Yee Chern came to the world, there will be some time until we can both go to cinema together once again.

Anyway, almost all movies I watched in 2016 I really enjoyed. Usually I am the one more picky about selecting good movie. I do not usually go by popular blockbusters. Generally I appreciate great storytelling and cinematography, usually search for deeper meaning and inspiration out of movie. To me, movie is not purely served as entertainment.

Among my 2016 list, the best highly recommended movies which impressed me the most are Spotlight (2015) , The Lobster, Nocturnal Animals and 心迷宫。Most entertaining is A Walk in the Woods (2015) ; most touching is My Love Don't Cross That River (2014) (Korean); Best Sci-Fi action movie is Train to Busan. All others I quite like, except 'Don't Breathe' I regret watching.

2016 'watched' list:

Ola Bola (watched in cinema)
我来自纽约 The Kid from the Big Apple (watched in cinema)
Suffragette (2015)
The Danish Girl (2015)
Brooklyn (2015)
山河故人
Train to Busan (Korean)
心迷宫
Me Before You
Spotlight (2015)
The Lobster
A Walk in the Woods (2015)
Right Now Wrong Then (2015) (Korean)
My Love Don't Cross That River (2014) (Korean)
Don't Breathe
Nocturnal Animals

2017 'watched' list - so far:
Your name 你的名字 (Japanese) (2016)
Between Us (2016)
Arrival

2017 Birthday statement

In the event of becoming one year older (and hopefully wiser), i want to write something about my recent self.

Last year 2016 was a dramatic year with lots of things happened to me and around me.

The biggest positive thing ever happened to me, my wife and our families is only one -- Yee Chern. He is loved and adored by so many people (even strangers), we are blessed to have him in our family. We feel lucky that he is such a good boy, far better we expected before he came to the world. Even there was a few tireless nights occasionally, we have forgotten about the incidents when he woke up with his best charming smile thereafter. On a trivial note, whenever YC was in his 'bad' days, I would usually get the brunt more from the stress he caused to his mama :P Also to say, most of the times he really ‘performed’ well before our guests/friends, because we tried our best to fit best timing for him to meet you. This credit goes to YC mama. All normal and healthy babies do cry and have temper sometimes, especially when they are hungry or tired, ok?

I am glad that my wife Xiao Hui first made her decision to quit her job in Singapore moved in with me in Penang in her first trimester of pregnancy (which was then early 2016). Really want to thank her for the life-changing decision and the bold move. Life was relatively easy in Penang Island, where we lived in a comfortable and convenient area called Relau. We only moved back to the Klang Valley last October, so we spent at least 9 months in Penang living together, including a significant event and moment occurred on the 25th May =) So many beautiful memories I have collected in Penang for the wonderful 2.5 years living and working there. Therefore it is hard for me not talking about my Penang experience here.

Many northern Islanders very seldom passing by this place called Relau, some even regard it as a very ‘ulu’ ‘migrants haven’. Despite all the bad description which we do not agree, we really enjoyed staying there. All the major facilities are close to my old Penang place, ie. Bayan Baru market, Queensbay Mall, Airport, First & Second Penang Bridge, Tesco, etc. I appreciate the local Monday night market, where I made friends with a few vegetable vendors and a honest & chatty Kuih lapis baker from Balik Pulau. Also, the local Relau Agriculture Station and Relau Metropolitan Park I consider as the hidden gems of Relau worth visiting.

I don't think I can quite forget my balcony view ... the grand view of Bukit Jambul, I which certainly I would miss dearly in future. I had personal attachment to the hill. I was rather a frequent hiker to the 'Gazebo' peak of Bukit Jambul. I love the short hike, had even brought Yee Chern up once when he was just 4 months old. In fact, Penang hills are all in my eyes. I enjoy greenery, loathe any development that would destroy the hills.

Before Xiao Hui moved to Penang, I was also a rather frequent user of RapidPenang bus services. I really did not mind a bit of walking (1 + 2 km) and waiting. I really want to thank my colleagues for occasional drop off at the Penang general hospital for my bus. I appreciate Xiao Hui sometimes came meeting me in my Penang office area by taking RapidPenang bus, with Yee Chern still inside her womb. Public transport mode in Penang is still catering only for minority, and the bus journey from Relau to Pulau Tikus is hilly with ups and downs, bumpy sometimes. Really have to praise Xiao Hui for this adventure.

I miss working with many good people in Penang, including my dear wonderful Penang Institute colleagues and friends (not all from PI though, I must stress). I had pleasant experience also working with great personals from some local Penang NGOs. Their professionalism, expertise, boundless energy and long-term commitment to good causes, really amazed me. I learned much from them. From musician, filmmaker, environmentalists to arts and cultural lovers, I share many sentiments and views with them. They truly concern and vocal about certain issues which are close to their heart. I wish to see Penang continues thriving in a sustainable development manner. The beauty of its natural heritage cannot be overstated, cannot be substituted by any mega project. Some said Penangites (read: Islanders) can easily get to hill or beach side within 10 mins car drive. I simple do not have that kind of privilege here in Klang Valley now. So Penangites should appreciate and value what they already have right now.

I really miss Penang.

The move back to Klang Valley was actually previously planned under the pipeline, just that I personally did not expect it to come that early. I saw the opportunity came knocking on my door when I could apply for a transfer back to the KL office due to timely vacancy. My wish to focus on my research works on the Malaysian healthcare policies, prompted me the move back to the heartbeat of the country where national policies are made. KL office suits me just that, with a very supportive General Manager Dr Ong Kian Ming (MP for Serdang). Finally I can make use of my research skills on issues that I am most passionate about. That will be good for my career development, as I would like to be recognised one day for policy research contribution in the health sector. In Penang, I wore too many hats, attended to many state government duties, and I had to become an all-rounder for many socioeconomic issues. Though I appreciate the experience I gained and I had met many experts from different fields along the way, unfortunately that could not be a long term goal for me.

What makes the transition back to the KL office goes so smoothly is my nice colleagues and friends in this tiny KL office. They are very accommodating and supportive. Just within 3 months, I have produced some research works and turned some into press statements. Definitely I feel more productive, positive and upbeat here in the KL office. Fortunate enough, I share many common interests with my new colleagues here, be it food, hiking and games. Furthermore, now we have a very interactive common collaborative workspace environment in Uppercase Bangsar, I really enjoy working here. I make it a habit of taking public transport to work whenever possible, ie. ride LRT, combine with cycling and walking.

My hope and resolution for this year: 
In terms of family, for sure I want to see Yee Chern growing up happily and healthily. I will do my best spending more meaningful time with him, learn to sing and play more new songs, develop new interesting acts & tricks that keep him amused, read more books to him, bring him out more to explore the world. 
For Xiao Hui, I will try to make use of available time at home to share the household duties burden, also wish to have more time to do things we enjoy doing together, eg. watching movie at home. Hopefully we can make it for a long trip together as a family of 3 to the Trumpland to find Uncle Macha this year.

In terms of work, I hope to complete some of my healthcare policy research projects, hopefully publish a few papers (in whatever format), and engage the public to share my findings and thoughts about the current status and future of our Malaysian healthcare.

I also wish to make a few work or leisure trips to Penang this year. I am sure my friends in Penang would be equally joyous to meet me and my family too. It is okay to indulge in reminiscence sometimes, for the time being Penang to me is my second home in Malaysia =) Don’t forget Yee Chern is a Penang Lang.

In terms of personal fitness, I have a target to keep my weight below 80kg (which I did last year), and reduce further 5kg if possible. Go for weekend badminton training consistently; hike more hills around the region; occasionally join the weekly yoga (free) session in my workplace; cycle more to LRT station for work, cycle to car ratio should go higher than 70:30.

This year 2017 is highly likely to be a general election year. Though I know it is highly improbable event for the opposition coalition to win, given the current sociopolitical climate and circumstances. Still, I hope to see the fall of UMNO-BN as the ruling party for the Federal government. I do not want to just see the change of hands in government but reform agenda must take place to strengthen our institutions, liberate our society and make Malaysia a progressive, just and fair country for all.