 Hello everyone. Welcome to People's Health Dispatch. Today we are joined by Chihan from Third World Network and he's also the co-convener of People's Health Forum Malaysia. Chihan is here with us today to speak on the issues of health and healthcare that have been faced in Malaysia and give us a description of what has really happened there. Welcome Chihan. Thank you Gagaya and thanks People's Health Dispatch for the invite. I'm happy to share with you about the situation in Malaysia. Whenever we talk these days, we are starting with the issues of COVID and I think maybe let me start there. What is the present situation of pandemic there and how was the response in the last two years towards the COVID pandemic in Malaysia and is there something that you want to say about this? Yeah, I think currently the government is doing a good job, especially after they ensure that the vaccine supply is sufficient to give the overall population and even the booster doses. So this half of the population has at least been given second, the first booster dose. So that means, and also for the first two dose, we have more than 80% of the coverage. So for a vaccination campaign, you can say it's a huge success and actually this is the foundation for successful control of the pandemic and transition to the pandemic currently. But for the past two years lessons have been learned, especially when the time before we receive any vaccination, I remember the delta virus trend actually devastated our public health care system and caused a lot of deaths and hospitalization. And many actually have to even wait around in the hospital compounds even to sleep outside the camp, the temporary can set up by the government just to accommodate the large amount of infected patients at the time. This means that there are definitely some deficiencies in the public health system there. I think Malaysia is one of those countries with a mixed system where you have both the public as well as private. Could you speak a bit about, you know, the public health system there. How is it one, you know, how, how does it function, but also you know how strong or how weak it is because I think in your recent report, you have detailed a lot of things on the issues faced by public health systems in Malaysia, and how is the response of the government for these demands to. The question. Yes, Malaysia has gained independence from the British in 1957, and we actually inherited some kind of a structure and system from the UK, especially when the NHS is getting popularized in UK and there's some spirit and some fundamental values in views here in Malaysia. So, so in Malaysia we have, there's a two tier healthcare system, of course, a government become the main provider service health service provider, and also the single payer for the public health system. That works similarly as the UK, at least before, or at least before, I mean, the contemporary UK. Yeah. We have a sizable private sector here, but they function many on the market system. So, besides the standards of operation and infrastructures are being regulated. Other than that, even health data, even the pricing of the services are all determined by the market. There's not too much of a cross talk between the public and health private health system. And that's actually created some kind of attention, especially with the limited healthcare resources, especially the manpower especially the health practitioners, the labor for that. Yeah, but all in all, I would say our relation health care public health care system or the structure is pretty much intact. We do, we have three levels. The first level is the primary care, and then we secondary care and tertiary, tertiary being the hospital and primary care we do have lots of health clinics run by the government. It will have a ruler clinics. So, the statistic pose that 92.6% of population live within five kilometer radiance of a public health center. So it's quite a achievement if you look at the Malaysia geography. The distribution there will you know that there's a vast land in the East Malaysia. And with the kind of record 92.6 is actually kind of achievement for the government but it's not easy. There's still a lot of problems. And we do have a very good primary care in terms of immunization. There's something that we learned from the British time. We do have we do boost about 98.4 to 1.5 of infants born in 2018 administered with BCG. This is a very high, especially when even before pandemic there's already a lot of vaccine skeptic or anti-vaxxer kind of campaign in Malaysia still in 2018 we have this 98.4% of the coverage is considered very good. And the government did spend on health, totally from the taxpayers money, I mean from general taxation, we spend about 1123 per capita is equivalent to 260 USD per person per year. But one big problem for Malaysia is that the society and the population are not actually really healthy. The health trend is actually going down. There's a lot of reason, especially when you look at the major indicator such as overweight population, this comes close to half one in two are considered overweight. And I would say, probably including myself, that I have to take care of, and then one in five, having diabetes, and about a third of the population, they don't do regular exercise. So you can see there's a lot of health problem and the trends actually getting worse. So, if government cannot control at the primary care level, that's what the People's Health Forum reform is about we want to strengthen the primary care. So there's a lot of linkages problem, especially when you're talking about continuity of care or health promotion. There's a serious lack of effort on the ground, especially utilizing the private sector resources, because at the primary care, more than 80% of the DPs actually belong to the private sector. So it's a kind of resource for the public sector to handle. There's a lot of demand for the primary care. So they couldn't deliver because also they lack of budget to work with the private sector to take care of the population health at the primary care level. So the statistics told us that there's 2.8 million of hospital admission in the government hospital alone have very might that Malaysians has only 33 million of people. So it's about close to 10% of hospital admission per year and 48 million of outpatient attendance in the government clinics. That means there's a lot. So there's a lot of demand and this demands keep on palling on the government and yet the government budget does not really increase fast enough to keep up with the demands. So basically this big volume about the Malaysian health care problem and challenges right now. Because the private sector do have more hospital than the public one, they have 202 private hospitals and government only has 156 in 2020. But in terms of the admission is about 70%. The government has to take care of in terms of our outpatient is close to 90%. So all the burdens with government is kind of expected because in Malaysia, we provide the care as one of the social welfare services as with education is for free, or at a nominal sum. Because this is a fundamental right to the services for the population. So we still retain that unlike Singapore, they have already met for us to another system where people always have to pay this nothing for free in Singapore. So they also gain dependence from British. They don't do the same. So in Malaysia we are proud to say we still maintain that very cheap system where you only need to pay one ring it to see a doctor. This affair is with us since 1980s. So for close to 40 years, the rig doesn't change when you get to see a doctor firing it to see a specialist. You can find it anywhere. So it's close to close to free of charge. But there's a lot of challenges because the private sector is driving before the pandemic. One thing they are driving on is the medical tourism is a selling of the health services. Because they dim the Malaysia market is small enough, but they can attract in good proposition to attract a lot of Western and rich Gulf Arab countries, people to come to Malaysia to use the health service and we, Malaysia boost our health care standard and quality on par with Singapore and any Western countries. Yeah, so that actually costs a lot of strength because when you need to operate a private hospital with specialist, then you have to get it from somewhere. The usual place for the private sector to push specialist from the public sector or even within different private hospitals. So with the kind of growth in the medical tourism and the private health care sector, you can see that actually more and more government resources stream. And that's why you see there's a lot more private hospital. Before we go into a bit of the private health sector, I would like to ask you more about that in a while. Okay, you've been saying how important the public health system is because you're saying there is this huge demand budget, you know, does not always meet the demand the infrastructure is, I mean we have seen in the pandemic and all through that the resources are tight and there's always beds are low, the number of doctors are low, and nurses and so on. So, and, you know, globally we see there is a onslaught on this understanding of provision, we call, we say public provision of health care. So, is there any such thing and is there any, I mean, what is it that civil society or organizations and activists in Malaysia. You know, what is it that you, you have been demanding the government for one improvement of the existing public health infrastructure. And two from, you know, privatizing or from, you know, because we see in many countries, hospitals are slowly decreased or they're privatized and so on. Are there such issues in Malaysia. If so, how is it that, you know, are there any discussion with the government and debate and so on. So very good question about is a difficult one for the government government treats health sector as economic sector. That's the first problem that we face. Once they have this policy proposition that means they would actually not do much to actually stop the sector from growing, then the problem just excerpt it. But we want to actually from the civil society, often we want to go on to rectify the problem, actually to strengthen the public sector by investing more. Because currently, the public spending on the public health is very inadequate in Malaysia in 2018 before the pandemic. It's been 3.8% of GDP on health that includes the private spending, but it's, it's actually below the world's average 6.6 is not because we are healthier just that there's a reason for that. If you look at another indicator is the public's government expenditure on health in a total of government expenditure Malaysia only spend 8.5% of the government total government budget on health. If you look at the world's world average is 10.4 but if you compare with the similar economic social economic development country, the upper middle country such as South Africa and Thailand, you will see that they spend 13.3% and 15% on health. Obviously Malaysian does not spend enough on health. And this actually is the source of a problem, because if you say we do not build enough of the clinics and the hospital, then you need money. If you don't recruit enough specialists or don't trade enough, you also need money. And if you think about the private, the primary care that we do not have enough service to really take care of every citizen that also needs money to run. You can also have a program to outsource it to the private to join the program. Since you know we have a 70 to 80% of a GPS in the private sector. So that's what how I look at the problem. If a government thinks that health sector is for money making, then there will be inconsistency. I think this clash of looking at it as a right and looking at it as a market commodity is always the clash and a lot more in the health sector. So, I, from there I'll you know I'll use this into looking at you know, you're also saying, in addition to the public sector there is a vast private health sector there. So both in the code pandemic and in general, what is the analysis of this private sector, is it actually able to cater to the needs of the people and first of all, is it accessible, because you know in many countries we see the private sector is a lot more costly, because people have to spend a lot from their pocket to an extent of you know even selling their assets and so on. So, there is this always a conflict with private sector, many of us, you know, you and I find it a bit difficult. So, yeah, how do you see the private sector. And what is your analysis of critical critical comments. I have a question I think just like there's one additional point I focus to mention is that our society actually demand the government to spend close at least 4% of GDP on public health. So you just combine with a private expenditure you reach the 4% public expenditure alone has to be 4% and above. And that's what the former government when they took power defeating the long standing government before that. And they actually promised 4% in five years. So, in two years of their governments they feel they, they, they, yeah, the, there's, there's the collapse of the government. So they couldn't fulfill and we didn't see that they have the political view to fulfill the promise. The expenditure is coming to the general election time period again and this time the three main political coalition promise, they try to outbid each other they say 5% five years. So, the all three big one, they promise 5%. So, actually I hope, and we from the civil society we definitely will push the government to actually realize that, because it's actually a quite a steep increase in terms of the real money term, they really commit to getting 5% of GDP in five years that means every year they have to increase at least 10 billion we get Malaysia for the health budget. It's not the small feed. But anyway, so what the pandemic told us is that we, they exposed the public health system in terms of infrastructure, like I say just now in the beginning. There's a lot of demand for beds, because people seek is because due to COVID need special kind of environment to keep to contain the virus. So actually that time, simply the public hospital couldn't cope with that many search of demand for the base. And even that time, the private hospitals were not cooperative. They were into negotiation with the government talking about money terms. They refused to take COVID patients. They just want non-COVID. So they asked the government to decay in the non-COVID patients to their hospital, but don't want anything to do with the COVID because that will actually scare of other local patients, because if they will have a COVID section, then people will be afraid to go. There's one reason and then the maintenance of a COVID hospital condition is also quite strict and costly. So from that you know the system is not working when we have two tier system and not cross talk and the private sector only think about their profit, their reputation and public opinion about them. Then they're not, they don't put people's health as a priority. And don't think about people's benefit. So that's what we always wear when negotiating with the private sector. And in the last year, government even declared public emergency in Malaysia, partly due to political reason, but also they use a pandemic as a reason. I won't say excuse, but it's a legitimate reason to force the hospital, hospital to to to cooperate, to to accept COVID patients. There was the moment that they started to actually admit COVID patients. So you even have to use the emergency law to force them. So, so if the gap is now now we are into the endemic period, and the private hospital currently trying to going back to the normal days, and the doors open already for medical tourists. And in the latest government budget also they, they allocate budget for the development of this sector. So I would expect this problem will go on. And of course, to your, for your understanding, the specialist in Malaysia's are usually trained by the public sector, private sector never spend a cent on training specialist. And when they approach this, nothing like, like a football market you need to pay a transfer fee or something that's nothing like that. So they just coach. So there's a design, actually there's a 50% of. Retrition rate. What do you call attrition rate attrition rate. Okay, sorry. That's a 50% attrition rate from the government specialist. Among the age 30 to 39 50% with average three years of a post specialization experience, they just just leave going where or one, one they could go to Singapore or other overseas country but mostly they just cross over to the private. So it's like the government doing something for the profit of the private sector, this is not right. So, I'm happy to see that in one of the major political coalition in the manifesto in the generation current period. Now, they say they asked, they will want the private sector to train their own specialist I think it's a good proposal. At least they should be responsible for what they want to groom for their own specialist not to push from the public sector anymore. You know you're telling. Of course, taking away the train doctors these all some of the issues we have been facing. Another 10 days also but what about the patients, how is there this thing I mean, you know, you're saying that initially they were not admitting patients property and so on. Has there been any issues of overcharging of patients and you know, patients going to courts and something like that. Equitable financing issue in Malaysia, where 35% of doctor expenditure on health, which is come out pocket OOP, that means people should pay with their own money. When you know most of public healthcare services, you don't even need to pay much. This, this portion of OOP expenditure 1676% actually coming from the private. And there's one statistic told us that, tell us that about 30 or 43% of the population actually cannot afford private insurance there's a main cost of a lot of OOP in Malaysia. I won't say this is equitable because when you have a serious health issue such as cancer. This can really cost you the catastrophe financial catastrophe. They really have to sell house assets, just to finance the medicines the treatment to survive and there are some they knew they wouldn't want to cause this situation to the family they choose to die. This is the saddest thing for us in Malaysia because I think if we do believe in right to hell, we believe in solidarity in the care of every unfortunate people, including the cancer patients, and we shouldn't have this system at all, we shouldn't have people left to die because they couldn't afford. So there's one very big, we'll say it's motto slogan for people's health column, we say health for people not for profits. The other thing is that we shouldn't differentiate people by the ability to pay, because we believe firmly believe in right to hell. So I think if we can restructure the financing issue. Probably we can take care of everyone. There's no need to choose whether you want to live for money. So the financing thing is the major contention, because before the resolution of the parliament, the previous government already called for health white paper. They asked the civil society and patient groups and stakeholders to have the discussion and they drafting the health white paper. So the major issue is that they look into the health financing. So I'll say they have the difficulty in getting more financial resources from the finance minister from the government. So every year they keep at about 2% of GDP, although in the real term you see the money actually getting more and more for a year but it's not sufficient to keep up with the demand and the population growth, they couldn't keep up. So there are many different views about how to get more money. So some people actually want to go for social health insurance. So we changed the whole financing system to social health insurance. That means from the paper's health column point of view we think that this is additional tax. So if you say you want to have this social health insurance and asking everyone in the formal sector working, you want to take some kind of like 10% or some kind of tax from the working people, I would say this additional sum is a tax, where you previously would not have to do it. And once you have this social financing system, that means you need to have more layers of administrators, you have to enroll people, you have to check whether they are in the program. So all this actually making the system less efficient. So let's talk about how the government control the pandemic is a very good example, why we need to keep the current government general taxation system is that government being the regulator, fund the payer and the provider when they make decision, especially when the pandemic comes, you need fast decision you need a coordinated actions. So for the first two ways of pandemic government actually can keep it down within specific time and it was a success story. If when before the Delta, when alpha came, then the government succumbed, but I think that was also the same case for many governments in the world at the time. But for the first two ways to do government control it very well. One thing is that the public civil servant in the health ministry, they are very well coordinated they work together very closely, and it was the public sector will handle the pandemic. So, if we have some situation like the NHS, the current NHS in UK, they have to negotiate with many service providers. When the negotiation was not going well, then you have a lot of delays and miscommunication or lack of coordination. And then some western countries fail to really contain even in the very beginning. I think Malaysia show a very good example how we can do it, because the common lines are intact within our system. So, so we actually do not agree with social health insurance transition because I think it's just a political view that it's not the government do not have the money to pay for additional demand for the public expenditure just that they do not have a political support now, because after the pandemic, everyone asked for the increase, and all the competing parties right now they promise 5%. What does it show that means when people actually after the pandemic people do see there's a real need and people appreciate and start to prioritize health. That's when the government and political parties and politicians changes and say oh yes, we need to invest more everyone say so. And this thing about you know, going into social health insurance is also a bit tricky because it opens doors for privatization and somewhere like you're saying it's inefficient way of spending also because we are giving a lot of people's hard earned money to the sector, which actually takes its own profit and a lot of like you're saying administrative and managerial levels, excessive levels, and instead government can just build more hospitals, recruit more doctors and give the services. I think in India also we are having a similar, you know, argument all the time. But what happens is that when you argue against the health insurance model, it becomes like oh you are against welfare because but this is a double edged welfare where the welfare goes to the private sector at the cost of the public finances. Chihar it's, it has been wonderful talking to you, would you answer anything you know the elections are come around the corner, and you're saying also that civil society is, you know, epic efforts, I mean putting its demands forward and so on. So, how do you see the immediate demands and how is it that you know groups in Malaysia are organizing themselves, not just on health but also different welfare, you know, safeguarding these welfare measures. Could you, you know, signing off with you, if you could say, what is the way forward from here and what are you planning as people's health forum in Malaysia. So we will keep on engaging with the government and also we will put out our narrative in the media in public to convince the public that the way forward is for the government to show political view to try their best first to inject more money into the badly needed public sector. So that's one way before you consider other other financing methods like social health insurance, we do not wish to stay here. But after the pandemic, like you say is people talk about the social determinants for health. It's not just about health care. To move away from the notion of when we talk about health care is about sick care. Now people really want to prioritize about how to stay healthy the wellness part, and how that we can strengthen the primary care. That's the focus of our blueprint on health care, a health reform in Malaysia, published by People's Health Forum. I do think that the fundamental is with the primary care. We urge the government to set up a family doctor system where the family members would have their own dedicated doctors so that the doctor would know the medical history of your family and know about your families, probably every year they could see you once. And this additional income for the private GP as well if they enroll in that system. It's not something very farfetched because Malaysia already have one such program called B40 is to take care of the bottom income 40% of the hometown families to do health screening for them. It's already there just government has to expand it beyond the 40 and go up to the medium, medium, middle 40 and then a top 20. So to cover everyone because I don't think rich families are immune from health problem. They probably also have a lot. So it's nothing about the income level. So that's what we call for the reform to put more resources on health promotion and primary care health screening. And especially, we have one call for government to put a monitor of building new private hospital we think that 202 is already way more than enough, and we do not want them to expand the hospital beds. Yeah, so there's one call in our blueprint. People will say there's a bit socialist but I'll say is they have actually the current capacity to use more because on the bed of beds occupancy they roughly score about 50% also where the government hospital, most of the specialist major specialist hospital already more than 80% of the bed occupancy, very, very resource straps. So we hope that there's a more kind of a collaboration between the private and public hospital government actually can purchase respect a strategic purchase from the private sector at a cost price or at a price that government can agree. So it's a very tough thing to blow into but I think it's actually major beneficial if a gun the private hospital will purchase any very expensive equipment, they will actually want to have more usage. I if government is do not have enough of such a equipment and it has a long queue for those. Why not you just do some kind of arrangement. I think that's one thing we also call for strategic purchase, but must be on government's turn on the private sector's turn. Yeah. So basically, this is it roughly about what we think about how to take care, take care of the major problems in Malaysia on health. Thanks a lot, I think the complexities and you know the way forward. I'm sure that the people's health forum in Malaysia is able to, you know, increase its advocacy and activism and we wish you all the best in advocating for universal healthcare and the issues of patients and people in general.