Stethoscope: Five health strategies for the new government

This article first appeared in Forum, The Edge Malaysia Weekly, on August 23, 2021 - August 29, 2021.
Stethoscope: Five health strategies for the new government
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Malaysians are looking to the new government for a more effective, fair and compassionate leadership during this triple crisis of managing the pandemic, economy and political instability. Please let me propose five health strategies for consideration.

Coordinate public administration with precision

This seems very straightforward, but Malaysia’s public administration can be better coordinated. The professional civil servants are admirable and effective, but we must support them with better coordination led by our powerful central agencies.

Here are three examples. First, there must be an effective inter-ministry collaboration and a partnership of equals. Right now, the Ministry of Health (MOH) appears to be “consulted” by the security or economic agencies as a formality or a tick-the-box exercise, without meaningful input into important decisions.

Second, we must have better coordination between the federal, state and local governments. After decades of concentrating power in Putrajaya, the federal government is at risk of making decisions that are not responsive, inclusive or well-informed enough. Therefore, we must get state and local governments to be active partners in our Covid-19 efforts, not passive recipients. One idea is to establish a meaningful Federal-State Council to coordinate all efforts, such as testing, lockdowns and vaccine distribution.

Third, all levels of government must coordinate with the private sector, civil societies and citizens. Despite declaring an Emergency between January and August 2021, there were no meaningful efforts to engage the private sector (neither through a fee-for-service nor a requisitioned-facilities model). One significant exception is the Greater Klang Valley Task Force (co-headed by a senior MOH and Armed Forces leader). In a multi-year fight against Covid-19, the federal government needs the resources of a “Team of 32 Million”, which includes civil societies, citizens and the private sector. The government cannot act like a “solo hero” and issue top-down SOPs without appropriately including these three groups.

Dramatically strengthen public health, healthcare and vaccinations

Our health strategy should have three major elements: public health (like surveillance, robust testing, contact tracing and isolation), healthcare (like intensive care units, general hospital wards, doctors and nurses) and vaccinations. Each is interdependent and cannot exist by itself. Many experts have repeatedly shared many evidence-based proposals for each of these elements. What has been missing so far is political will and a responsive MOH.

Therefore, we must provide all the necessary political, financial and organisational resources necessary to strengthen public health, healthcare and vaccinations. Here are three new angles: Use non-MOH civil service to perform contact tracing; train and empower one million community health workers, which expands on the “One Million Volunteers” programme led by the Public Health Physicians Association of Malaysia; and immediately start preparing for “mobile surge healthcare capacity”, because we must move resources to the shifting epicentres of Covid-19. We have seen that the epicentre shifted from Sabah (in late 2020) to Greater Klang Valley (in mid-2021), and it will shift again to other states.

The Special Committee on Covid-19 Vaccine Supply (JKJAV) and Ministry of Science, Technology and Innovation (MOSTI) have done very well in our vaccination programmes, although they were hampered by global vaccine shortages. The new government must consider today’s implementation needs and tomorrow’s procurement priorities. At some point, Malaysia must decide on booster shots and Round 2 vaccinations, which carry financial, procurement and logistics implications.

Shift to an endemic Covid-19 strategy

Covid-19 is already endemic, and we must accept life with Covid-19 for the next four to five years. It is useful to learn some lessons from dengue, another endemic disease in Malaysia. MOH and local governments do not conduct daily anti-dengue campaigns nationwide. Instead, a reported case of dengue triggers aggressive anti-dengue action in a specific locality, like fogging and community empowerment.

An endemic Covid-19 strategy requires three changes in national direction and public policy-making. First, we must explicitly retire our “Zero Covid-19” strategy, as the costs of lockdowns are too high to the economy and society. Our strategy should explicitly shift to “tolerable levels of Covid-19 in the community”. There is no precise level for what is considered tolerable, but these levels must not burden public hospitals and our contact tracing system. Just like dengue, in an endemic Covid-19, we can still deploy short, sharp and targeted lockdowns in small geographical areas accompanied by surge testing and contact tracing, whenever sporadic outbreaks occur.

Second, we must still maintain a multi-layer strategy against Covid-19 even as we gradually open up. The Delta, Lambda or future variants prevent us from relaxing mask restrictions, hand hygiene, social distancing or MySejahtera check-ins, even as more Malaysians are vaccinated. We must build a National Ventilation Guideline for Malaysian businesses, and add stronger enforcement, tax incentives and public pressure to get more employers and businesses to comply. This multi-layer strategy is backed by SOPs, which should be stable and predictable (not changing every day or week).

Third, our public communications must transition from “short-term campaign” to “daily routines”. In other words, all government press statements, social media posts and communications must change their tone and vocabulary to educate the public on the long-term nature of Covid-19. But actions speak louder than words, so all government leaders must comply with all SOPs and enforcement should never have double standards.

Shifting to an endemic Covid-19 strategy has many advantages. It will increase synergies with routine health services. It can reduce our overreliance on lockdowns, and their associated high costs. It will force governments to make long-term strategic decisions, instead of fire-fighting reactively. And it will manage the expectations of the rakyat, which will reduce pandemic fatigue.

Make health equal to democracy and the economy

Health is an important priority — equal to democracy, the economy and social cohesion. In other words, health is interdependent on many other priorities. For example, the Swedish-based V-Dem Institute’s Liberal Democracy Index shows that citizens live longer in countries with more democracy. In addition, poverty eradication is the single-best contributor to better population health. And social cohesion improves health by providing social, psychological and financial support systems to those who are sick.

There are several ways to strengthen our democracy during this pandemic. We must never use health as a political tool, like using Covid-19 as a convenient excuse to declare emergencies or to close parliament. Data transparency from MOH will help depoliticise our pandemic responses, which strengthens trust in our institutions.

We must also balance health with the economy, but in predictable and evidence-based ways. For example, the National Recovery Plan was announced on June 15, but one of the three metrics changed on Aug 8, just seven short weeks later. While it is true that situations evolve and government response should be “dynamic”, metrics, SOPs, regulations and reopening strategies should not change so frequently. Businesses need to plan, and the government should not waste energy repeatedly explaining all these changes. And even if metrics, SOPs or strategies change, the government must publicise the reasons, evidence and rationale for changes, not just announce the changes in a paternalistic and top-down way.

Decentralise to states and communities

The federal government is strong, powerful and well-resourced. But it cannot do everything alone. The Federal Constitution provides certain health duties to state governments, and the Local Government Act 1976, Sarawak Local Authorities Ordinance 1996 and Sabah Local Government Ordinance 1961 also provide certain health duties to city, municipal or district councils.

Together, the state and local governments can be called sub-national governments. The federal government must decentralise some health decision-making and implementation powers to sub-national governments, to truly embody an all-of-government effort to improve responsiveness and local data-gathering, and to increase accountability and relevance of sub-national governments. Creating an effective Federal-State Council could help, and place it alongside the National Council for Local Government, which was established through Article 95 (A) of the Federal Constitution.

Covid-19 starts and ends in the community. Without citizen trust and community involvement, we will never win. Malaysians have undergone decades of being treated as passive recipients of public service, without active participation or agency. Covid-19 is showing that the government alone is never enough to resolve a system-wide challenge. Therefore, the government must take specific steps to empower the community and help us care for ourselves and each other.

For a start, we must create an enabling operating environment for civil societies with helpful regulations, not “regulations for regulations’ sake”. More money should be channelled to last-mile delivery non-governmental organisations, instead of going to Members of Parliament (who are supposed to make laws, not dispense food baskets with their faces on stickers).

Dr Khor Swee Kheng is trained in medicine, public health and public policy. He specialises in health policies and global health.

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