Important health information that can be incorporated into GE15 manifestos – Prof Dr Andrew Kiyu

Note: I am taking the perspective of someone from a state where there is a stark disparity in health care compared to Peninsular Malaysia.

Our health care issues are more fundamental in terms of inadequate coverage by physical health facilities, especially for those most in need in rural and remote parts of the state.

Much of the problem stems from too much concentration of power and authority at the central level, to the detriment of meeting the needs of local populations.

Which health policies should be included in the GE15 election manifestos of all political parties?

All political parties should address the issues that have been proposed in the White Paper on Health, namely: the much-needed systemic and structural reforms that will address and correct the underlying problems; moving from health care to health care and well-being; address the misalignment of equipment, capacity and skills between the public and private sectors in the health care system; and addressing the social determinants of health, such as poverty, and providing quality education, equitable access to services for all, etc.

All parties must commit to increasing domestic investment in the health sector to 5% of gross domestic product (GDP).

Specifically for Sarawak, political parties should grant decentralization and greater autonomy over the health sector for Sarawak.

This will enable Sarawak, in collaboration with the national government, to address the gaps in the health care system in Sarawak in terms of service coverage, quality, delivery and human resources (in terms of numbers and distribution); the improvement of the material conditions of many rural clinics which are in poor condition; staff quarters; and provide basic public services to health facilities.

These shortcomings of the health care system in Sarawak are mainly caused by the centralization of decision-making at the federal government level in policy, planning, financing, delivery, implementation and maintenance of a health care system.

There is a lack of understanding of the infrastructural and geographic challenges of a large state and its dispersed rural population and the expectations of the people in the national level decision-making process and in the execution of those decisions.

The Sarawak State Government has put in place the Post-Covid-19 Development Strategy 2030. This strategic plan is anchored on six economic sectors including social services.

Catalytic initiatives for social services include medical and health services, establishment and construction of the Sarawak Infectious Diseases Center and social intervention programs like centers for the elderly, among others.

To address the deficiencies due to centralization mentioned above and to enable the government of Sarawak to implement the post-Covid-19 development strategy, there is a need for the executive power over health to be transferred to the authority of the State under Article 80, paragraph 4, of the Federal Constitution, with an agreed amount of funds to be agreed or determined in accordance with Article 80, paragraph 6.

Alternatively, arrangements for the performance of federal functions – particularly relating to the establishment, maintenance, human resources and equipment of hospitals, clinics, etc. – to be implemented or undertaken by the State Government with the provision of the necessary funds, as provided for in 80(5), could be subject to agreement between the Government of Sarawak and the Federal Government.

Universal Health Coverage

Currently, the main narrative regarding universal health coverage (UHC) at the national level is interpreted narrowly to mean universal health insurance coverage.

This narrow interpretation of universal health coverage is detrimental to states and regions where geographic and physical coverage and access to physical health care facilities is still around 80% of the population versus “health presence”. a clinic every five kilometres” much vaunted in the Malay Peninsula. .

There is no point in having universal health coverage when health structures are non-existent or very difficult to access.

The other issues listed below are taken from the recent statement by the nine members of the Sarawak Civil Society Organizations-Sustainable Development Goals (CSO-SDGs) as inputs to the Draft Health White Paper.

They understand:

Transparent data on the fight against inequalities and the allocation of resources

Data on needs, access to health care, out-of-pocket expenditures and resource allocation should be accurately collected in a timely manner and made public.

In the multiple dimensions of poverty measurement, all needs and groups must be taken into account, including people living in remote areas not covered by the national household income survey and basic amenities, and those awaiting citizenship status.

Measures must be taken to ensure the leveling of health service delivery so that no one is left behind.

Use technology and enable access

The future of healthcare will involve the creative and effective use of technology both to share information and education, and to enable early intervention, treatment and specialist support in remote areas.

For Sarawak, there is an urgent need for critical infrastructure to be made available across the state. Being able to get a reliable internet signal is not an adequate measure of internet accessibility.

As the school lockdown during the Covid-19 pandemic revealed, many are able to text but cannot download data, while others have no internet access at all.

By 2030, the goal should be to provide telemedicine services to all rural clinics and distribute the latest technologies (e.g. cervical and breast cancer screening) that enable early detection ailments, even in remote areas. National policy decisions, for example, “accepting online payments only” for Ministry of Health services, can worsen their access and use in already underserved areas.

Approach health holistically

I. Mental Health
Since 1990, poor mental health has been recognized as one of the leading causes of disability in Malaysia. The pandemic has increased the incidence of mental health problems. More resources are needed to close the gap between physical and mental health services, with a focus on mental health promotion and upstream preventive interventions.

ii. End-of-life palliative care and home care
Malaysia is an aging society. The development of home-based care and the extension of palliative care services in rural communities will help reduce the pressure on hospital beds.

iii. Caring for caregivers
Another gap is the lack of support for carers of the elderly and those with chronic physical and/or mental conditions, terminal illnesses or disabilities, including children with special needs. Psychosocial and financial support are needed, as are services that help share the stress of care.

iv. Early support for families with children with special needs
There needs to be a focus on early detection and diagnosis, which then leads to accessible, quality early intervention programs and inclusive education.

v. adolescent health
Adolescent health is often overlooked. Adopting strategies for their healthy development and mental well-being has a lifelong beneficial effect. Young people must have access to empathetic and non-judgmental information and treatment about health, including mental and sexual reproductive health. Greater accessibility and training in life skills could reduce the development of serious mental health problems in adulthood, suicides and sexually transmitted diseases, including HIV.

vi. Access to health care for stateless persons and foreign workers
A country can only be healthy and productive if everyone has access to it at an affordable price. This is necessary for humanitarian and practical health reasons. During the Covid-19 pandemic, vaccination was extended to everyone as it was recognized that no one would be safe unless everyone was safe.

Sarawak has many people who have been denied citizenship despite having lived their entire lives in the state. Denying them health care and access to education is not in line with United Nations human rights conventions. In the same vein, while foreign workers are now covered by life and medical insurance, their living and working environment must be monitored.

vii. Addressing the Social Determinants of Health
The social determinants of health are highlighted in the proposals, but collaborative structures that allow all departments to harmonize their efforts receive no attention.

The state of health of a nation is determined by the following factors:

  • 20% through access to quality health services;
  • 30 percent by the public adopting promoted healthy behaviors;
  • 10% by the built environment, and;
  • 40% by socio-economic factors such as poverty eradication, income security, quality education, adequate housing, and family and community support.

Investing in health means investing in all of these areas. While Sarawak ranks relatively high in terms of gross domestic product, it is the third poorest state as measured by the 2020 Estimated Household Income and Poverty Incidence report, and experiences a severe shortage of health care workers and many dilapidated clinics and schools.

Thus, the social, economic and environmental determinants must be improved to further improve the health status of the population.

Professor Andrew Kiyu is a public health medicine specialist and field epidemiologist at the Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak.

  • This is the personal opinion of the author or publication and does not necessarily represent the views of code blue.

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