SEPT 20 — The Covid-19 pandemic delivered a lesson in humility to health systems around the world. Whether it was ventilators in Japan, personal protective equipment in the United States, hospital beds in Malaysia, syringes in South Africa, or medical imaging dyes in Australia, shortages of almost every critical item necessary for the delivery of safe and effective healthcare services were experienced.

Massive disruptions to health infrastructure occurred, unprecedented in recent history.

In many countries, the resulting deaths due to both Covid-19 and interruptions to health services, had a significant impact on key health indicators such as morbidity and mortality rates, and even life expectancy in dozens of countries.

Between 2019 and 2021, global life expectancy dropped by 1.8 years to 71.4 years, reversing decades of developmental gains.

From 2020 to 2022, Covid-19 was the ultimate stress test which put health systems on the very brink of collapse to demonstrate their public health emergency preparedness, response and resiliency.

Malaysia was fortunate in this regard, having decades of experience, expertise and investments dealing with different public health issues, such as the Nipah virus and endemic dengue.

Others were not so lucky, and their health infrastructure collapsed and were devastated. Both patients and healthcare workers died. Lest we forget, in some countries, funeral pyres were lit at the sides of streets.

The Covid-19 pandemic highlighted the importance of political will to support such critical structures, and the need for long-term investment in developing, growing and future-proofing health infrastructure to respond to current challenges such as non-communicable diseases (e.g. diabetes, chronic kidney disease, and cardiovascular disease), malnutrition and ageing; as well as pandemics in the near future.

Under the harsh reality of deaths and increased morbidity, the recent pandemic also highlighted gaps and shortcomings, as well as opportunities to address them.

If these are ignored, disregarded, considered inconvenient or kicked into the long grass for another administration to address in the future, Malaysia may not be as fortunate in the next outbreak or pandemic.

There are five mission-critical areas which need urgent attention.

Ageing infrastructure and equipment

Ageing infrastructure presents a significant obstacle to providing high-quality, efficient, and equitable medical services.

Despite substantial investments in health, many of Malaysia’s public healthcare facilities, including district hospitals and community clinics, are showing signs of wear and obsolescence.

A third of the country’s public hospitals are more than 100 years old. Kajang Hospital is 138 years old. Many public hospitals and clinics, particularly those in smaller towns, rural areas and in East Malaysia, were constructed decades ago, during a time when demand and complexity of healthcare were arguably lower and different.

It is not about peeling paint or broken down furniture. Such ageing buildings may have structural issues such as cracking walls, leaking roofs, and faulty plumbing or electrical systems.

These deficiencies can compromise the safety and hygiene of healthcare environments, putting patients and staff at risk.

Not too long ago, after periods of heavy rainfall, hospitals and clinics across the country would report water leaking into their spaces, such as into an operating theatre in a Kota Kinabalu hospital.

Flooding is also a risk for community clinics, especially when they are constructed mainly out of wood and in flood prone areas. Fortunately, these are often dealt with quickly by the authorities but are symptoms of a larger concern.

Specialists and medical technicians in hospitals have reported shortages or critical equipment approaching or have gone beyond their service life, such as MRI machines, CT scanners or other advanced diagnostic tools, hampering their ability to provide timely and accurate diagnoses.

Hospital design, mould and fire safety

Older facilities are struggling to accommodate the increasing demand for healthcare services. They must cope with more patients, leading to overcrowding, longer waiting times, and strained resources.

More space is needed for new departments or specialised services. They may not have dedicated wards for elderly patients, modern intensive care units (ICUs), or facilities for palliative care.

Some hospitals may have fewer operating theatres or smaller emergency departments, struggling to handle the increased patient load.

Poor design and layout of these hospitals may lead to overcrowded waiting rooms, long queues, and treatment delays due to inefficient patient, staff, and equipment flow.

Hospitals must be designed with modern infection control measures in mind. Historically, hospitals often had open wards with limited segregation between patients.

However, the spread of highly infectious diseases, such as Covid-19, has emphasised the need for better infection control infrastructure, including isolated pressure rooms and improved ventilation systems.

Many hospitals now need these features, making it more challenging to contain outbreaks of infectious diseases within healthcare settings.

While ageing facilities of outdated hospital design may experience poor ventilation and water leakage, newer facilities have also experienced similar problems creating conditions conducive to mould growth or the spread of infections, especially in Malaysia’s tropical climate.

Newer hospitals are facing challenges which are linked to problems in hospital design. The Sultan Idris Shah Hospital Heart Centre, barely two years old, only recently reopened its operating theatres (OTs) which have been closed due to environmental control problems, linked to air conditioning, electrical problems and high humidity.

For much of its current operational life, the hospital’s OTs have been out of action. Even UITM’s brand new Hospital Al-Sultan Abdullah experienced similar issues.

The Public Works Department, which has oversight and supervisory roles over the construction of public buildings, needs to be up to the task of ensuring that these hospitals and healthcare facilities not only meet building codes or safety regulations, but are also skilled at hospital design and architecture that addresses issues such as infection control, microbial growth and sanitation.

Millions of ringgit have already been spent on costly repairs to address these issues.

The 2016 fire at Johor Bahru’s Hospital Sultanah Aminah (HSA) which claimed the lives of six people should have been a wake-up call to take fire safety seriously. This major hospital saw multiple minor fires, in 2008, 2010, 2016, 2020 and in 2023.

Nonetheless, at least a dozen major public healthcare facilities across the country, including hospitals, still have no fire certificates. Under the Fire Services Act 1988, hospitals are required to have fire certificates.

At the time of the 2016 fire, HSA did not have a FC. In 2019, the Health Minister, Dr Dzulkefly Ahmad via a Cabinet decision, declassified the report from the independent committee convened to investigate the fire which was chaired by former Court of Appeal judge Mohd Hishamudin Yunus.

However, two health ministers later and to this day, the report has not yet been made public. six people died, yet the relevant responsible officials have been promoted or retired from service. No one has been held accountable.

How can lessons be learnt and recommendations to improve fire safety be acted upon if the report is hidden from public scrutiny? A comprehensive fire safety audit of all public healthcare facilities should be done.

Health information systems

High cost, lack of skilled human resources, and inconsistent long term commitment to follow through on previous programmes, have long plagued the modernisation and digitalisation of Malaysia’s health information systems (HIS).

It is worrying to know that in some hospital departments across the country, Google Docs is currently being used as a practical stop-gap solution to share patient notes.

At the same time, paradoxically, computers are still running on Windows XP operating software and utilising legacy systems to store patients notes, investigation results, X-rays, MRIs and CT scans.

Doctors frequently use their own personal computers. The situation has sometimes been described as performing flying trapeze acts without a safety net.

Despite the fact that Malaysia began to utilise HIS in 1993 under the Sixth Malaysia Plan and was a world leader in this area in the late 1990s and early 2000s, parts of the digital healthcare system have struggled, become obsolete or are left behind.

In many community clinics and some hospitals, paper-based methods are still preferred and are seen to be reliable, never needing software patches or becoming obsolete.

Effective HIS deployment across the public healthcare system has the potential to reduce medical error, increase efficiency, cost effectiveness, and increase patient involvement in healthcare decision-making.

However, there are many challenges involved in implementing HIS system-wide including capacity and IT knowledge gaps among doctors and nurses, interoperability problems with different hardware and networks unable to communicate with one another (e.g. from the state of the art MRI scanner to the primary legacy hospital information system), increased complexity and maintenance costs.

Moving forward, it is prudent to utilise off-the-shelf HIS or electronic health record solutions rather than depend on custom software systems.

There are so many to choose from in the marketplace. These can be deployed quickly, allowing for a higher rate of modernising and streamlining of processes.

They can also be cost effective and less expensive than custom-built systems. They would have also been tested in a wide range of situations, ensuring a level of reliability and stability.

Vendors of off-the-shelf HIS also regularly update their software to comply with the latest healthcare regulations and standards, reducing the compliance burden.

Too many hospitals?

The opening of the 288-bed Cyberjaya Hospital in 2023, was seen with much trepidation and anxiety by hospital and clinic administrators in the Klang Valley.

The ongoing severe national shortage of doctors, nurses and healthcare workers of all levels, meant that staffing of this major tertiary public would be drawn and sourced from surrounding healthcare facilities which were already under tremendous stress, overstretched and undermanned.

Somehow Cyberjaya, with a population of over 100,000 and already in close proximity to Putrajaya Hospital got a hospital, while Petaling Jaya with over 620,000 people still does not have a Ministry of Health hospital.

The unequal distribution of healthcare facilities is a major issue for Malaysia. Most of the country’s well-equipped hospitals and medical centers are concentrated in urban areas such as Kuala Lumpur, Penang, and Johor Bahru.

Rural areas and the East Coast remain underserved, including large parts of Sabah and Sarawak. These areas often lack sufficient medical facilities, forcing residents to travel long distances to access even the most basic of healthcare services.

Poor transportation infrastructure in these regions often hampers timely access to healthcare services, leading to delays in treatment and higher mortality rates for conditions that might be manageable in urban centres.

Efforts to establish mobile clinics or telemedicine initiatives have been made, but the issue of inequitable access remains a significant hurdle.

Nonetheless, it might be necessary to impose a moratorium on the building of new tertiary and secondary care healthcare facilities, particularly hospitals.

It is necessary to consolidate and to improve on existing capacity and services with an emphasis on quality over quantity. Politicians will demand for hospitals and clinics to be built in their constituencies, but it is easy to order their construction but harder still to ensure that they are properly staffed and are able to deliver services.

It would be irresponsible to plunder Peter’s healthcare facility for staff, just so that Paul can cut the ribbon on a brand new hospital when it has insufficient nurses, doctors, medical assistants, and pharmacists to function properly.

Preparing for the future

Modernising health infrastructure seems like an impossible mission. By the time you have completed the job, state-of-the-art equipment at the time of its purchase, would now be close to its replacement date.

It has been estimated that it will take at least 10 years, and billions of ringgit to complete the process. Time that we do not have, and money that we certainly do not currently possess.

But the investment needs to be done. We need to consider and adopt innovative approaches to find new funds to finance the modernising of our healthcare infrastructure.

One solution could be for the government to issue social impact bonds or sukuk to raise the necessary funding. The money raised would go specifically towards financing the upgrading and modernising of healthcare facilities, procuring of equipment, and development of health infrastructure in East Malaysia.

It could also go towards aged care. The fact is that the allocations from the national federal budget will not be sufficient to do what is needed today to build up and future-proof our health infrastructure.

Many of today’s leaders currently in their late 50s and 60s will definitely need to have public health facilities and services which not only address non-communicable diseases but also aged care.

Some of these politicians probably already utilise some of those services today, but will those facilities be around 15 years from now, upgraded or diminished in capacity? It is in everyone’s interest to invest in the future of our healthcare system.

We need to prevent a Hunger Games scenario from occurring where the privileged class have access to quality and accessible healthcare because they have money and resources, while everyone else fights for whatever is being offered, told to be thankful, and looking behind as people are being left behind.

All of us need to do our part and invest in building our healthcare system.

* Azrul Mohd Khalib is Chief Executive Officer of the Galen Centre for Health and Social Policy.

Note: This article is Part 3 of a 3 part series covering healthcare financing, human resources and health infrastructure in conjunction with the upcoming National Budget 2025. You can read Part 1 here.

While Part 2 is here.