Whither universal health coverage?
Universal health coverage is defined as ensuring access to required quality health services that do not expose the user to financial hardship.
THE Sustainable Development Goals (SDGs) adopted by the United Nations in 2015 are a universal call to action to end poverty, protect the planet, and ensure that all people enjoy peace and prosperity.
SDG 3 is to “ensure healthy lives and promote wellbeing for all at all ages”.
One of the health targets is universal health coverage (UHC), which has been defined by the World Health Organization as “ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship”.
Healthcare access and quality index
The findings from the 2015 Global Burden of Disease were used to estimate a summary measure of healthcare access and quality (the Healthcare Access and Quality [HAQ] Index) to facilitate comparisons of personal healthcare access and quality for 195 countries from 1990 to 2016.
The HAQ index is based on amenable mortality, i.e. risk-standardised mortality rates or mortality-to-incidence ratios from causes that, in the presence of quality healthcare, should not result in death.
It encompasses 32 causes of death considered to be avoidable, provided that quality healthcare is available.
These include vaccine-preventable diseases; infectious diseases; maternal and child health; non-communicable diseases, including cancers, cardiovascular diseases and diabetes; and gastrointestinal conditions from which death can easily be averted by surgery, e.g. appendicitis.
Each cause was transformed “to a scale of 0–100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best)”. (www.healthdata.org)
Singapore, Brunei, Sri Lanka and Thailand had better overall HAQ indices than Malaysia:
● Singapore ranked 22nd with a HAQ
index of 91
● Brunei ranked 53rd with a HAQ index
of 76
● Sri Lanka ranked 71st with a HAQ
index of 71
● Thailand ranked 76th with a HAQ
index of 69
● Malaysia ranked 84th with a HAQ
index of 68
● Vietnam ranked 108th with a HAQ
index of 60
● Philippines ranked 124th with a HAQ
index of 51
● Indonesia ranked 138th with a HAQ
index of 44
● Myanmar ranked 143rd with a HAQ
index of 42
● Cambodia ranked 151st with a HAQ
index of 39
● Laos ranked 155th with a HAQ index
of 37
(Source: The Lancet. Vol 391 Issue 10136 P2236-2271. June 2, 2018)
While there were no substantial differences in the HAQ indices of Sri Lanka, Thailand and Malaysia in the year 2000, both Sri Lanka and Thailand had better HAQ indices than Malaysia in 2016.
The improvements in the HAQ indices of Sri Lanka and Thailand, compared with Malaysia, cannot be ignored.
Malaysia had indices below its overall HAQ index for tuberculosis (61), lower respiratory infections (22), skin cancer (14), cervical cancer (66), uterine cancer (66), colon cancer (66), testicular cancer (59), Hodgkin’s lymphoma (53), leukaemia (50), ischaemic heart disease (36), stroke (40), peptic ulcer (53), gall bladder (53), diabetes (64), chronic kidney (44), congenital heart (59) and adverse medical treatment (47).
Disturbing reports
Malaysia’s HAQ indices are in tandem with other recent reports about its healthcare system.
The Harvard TH Chan School of Public Health’s March 2016 report stated “Malaysia demonstrates a classic case of asymmetric transition, where the rapid transitions in context have not been matched with a corresponding transition in the health system to better address the current and future needs of the population.” ( www.moh.gov.my/penerbitan/Laporan/ Vol%201_MHSR%20Contextual%20 Analysis_2016.pdf, pages 40-41)
A study of mortality reported that “among Malaysian citizens, premature mortality is concentrated among the poor for not only the Malays, but every ethnic group”. (Are the poor dying younger in Malaysia? An examination of the socioeconomic gradient in mortality. PLoS ONE 11[6]: e0158685. doi:10.1371/journal. pone.0158685. June 30, 2016)
An Asean study found that the proportion of previously solvent patients who experienced economic hardship following a cancer diagnosis was highest in Malaysia (45%) and Indonesia (42%), and lowest in Thailand (16%). (Source: Policy and priorities for national cancer control planning in low- and middle-income countries: Lessons from ASEAN Costs in oncology prospective cohort study. European Journal of Cancer. Feb 6, 2017.)
A Health Ministry and Universiti Malaya survey of primary care clinics from June 2011 to February 2012, reported that, “Within the public sector, the distribution of health services and resources was unequal and strongly favoured the urban clinics”. (Source: Chasm in primary care provision in a universal health system: Findings from a nationally representative survey of health facilities in Malaysia. PLoS One. Feb 14, 2017;12[2]:e0172229)
A study of patients at the National Heart Institute concluded that the economic impact of ischaemic heart disease (IHD) in Malaysia “was considerable and the prospect of economic hardship likely to persist over the years due to the long-standing nature of IHD.
“The findings highlight the need to evaluate the present health financing system in Malaysia and to expand its safety net coverage for vulnerable patients”. (Source: International Health, Volume 9, Issue 1, Jan 1, 2017, Pages 29–35)
A United Nations Children’s Fund study reported that “of the children under five years, 15 in 100 were underweight; 22 in 100 were stunted; 20 in 100 were wasted; and 23 in 100 were overweight or obese; malnourishment is a major concern in Malaysia – one in five is stunted and one in 10 is underweight. In terms of stunting, Malaysian children perform worse than Ghana, despite Malaysia’s GDP per capita being six times higher”. (Source: United Nations Children’s Fund [UNICEF] Malaysian Children without – A study of urban child poverty and deprivation in lowcost flats in Kuala Lumpur. February 2018, pages 9, 50 and 51)
Not only Malaysians who sustain a catastrophic illness are at increased risk of catastrophic health expenditure (CHE), the parents of children with rotavirus infection in Kuala Lumpur had also been reported to have CHE, while those in Kuala Terengganu did not. ( When health spending leaves us penniless..., Fit for life, Sept 2).
Improving the index
Excess morbidity and mortality affect the socially disadvantaged, which include the population in less developed states, the urban poor, some senior citizens, Orang Asli and people who are marginalised for various reasons.
The pertinent question is how Malaysia can improve its HAQ index when the public is unaware of specific policy and/or strategies, if any, for healthcare provision for the socially deprived or marginalised groups, senior citizens and those with CHE.
Without specific policy and/or strategies, what is the current and future status of UHC in Malaysia?
Yet, UHC is not just about nominal access. Quality is a sine qua non as stated succinctly in The Lancet’s editorial on Sept 5: “Expansion of UHC remains essential, but without quality, UHC will be an abstract and meaningless myth. People need to be central to all measures of quality.”
The immediate objective of the new government must be improvement of the HAQ indices of the various conditions to that of Malaysia’s overall HAQ index. In doing so, the overall HAQ index will improve.
The middle to long term objective has to be achieving HAQ indices about the same or better than Singapore, Sri Lanka and Thailand.
Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.