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Malaysia’s healthcare system is under pressure:—from an ageing population, rising demand for services, and uneven access across states and regions. And at the heart of it all is a critical constraint: the health workforce. A new strategic roadmap has been launched to guide long-overdue reforms in how we train, deploy, and retain healthcare professionals. But will the system move fast enough? On this episode of #ConsiderThis Melisa Idris speaks with Professor Dr Elil Renganathan, Professor of Public Health & Policy at the Jeffrey Cheah School of Medicine & Health Sciences at Monash University Malaysia, and co-chair of the Strategic Engagement Group on Health Workforce And Governance. He previously served with the WHO in Geneva for over two decades, during which he held senior positions in the organisation.
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00:00Music
00:00Hello and good evening, I'm Melissa Idris. Welcome to Consider This.
00:14This is the show where we want you to consider and then reconsider what you know of the news of the day.
00:19Malaysia's healthcare system is under pressure from an ageing population, rising demand for services and uneven access across states and regions.
00:28And at the heart of it all is a critical constraint, the health workforce.
00:34A new strategic roadmap has been launched to guide long-overdue reforms in how we train, deploy and retain healthcare professionals.
00:44The question is, will the system move fast enough?
00:48Joining me on the show to discuss this further is Professor Dr Elil Ranganathan, who is Professor of Public Health and Policy at the Jeffrey Chia School of Medicine and Health Sciences at Monash University, Malaysia.
01:01He's also the co-chair of the Strategic Engagement Group on Health, Workforce and Governance and previously was with the WHO in Geneva for over two decades, during which he's held several senior positions.
01:13Dr Elil Ranganathan, thank you so much for being on the show with me today.
01:16I am thrilled to read this roadmap because it really is very thorough.
01:22But maybe to start off our conversation, you can talk a little bit about the urgency of reforming Malaysia's health workforce.
01:30What can you describe to us as the underlying pressures that make this a critical moment for reform?
01:38Yeah, no, I think you've already addressed.
01:41Thank you very much, first of all, for inviting me.
01:44You've raised the important issue of the challenges we are facing, where we are.
01:50But I want to go back a little bit and say we are in a good position.
01:55Malaysia has got a pretty good health care system, which is a good example for many countries.
02:03And we've had very good health outcomes in the past.
02:07We have good life expectancy.
02:11And we generally are a good model for many other countries.
02:17But this obviously also comes, you know, it's like you end up being a victim of your own success.
02:24So then there's a lot more expectation of the people, the rakyat, to be able to get as good a service as they have always been getting with financial payments which are still very low.
02:43So the benchmark has been set and we want it there always.
02:46Yeah, you want it there always, yeah.
02:47So then you, as the population has been growing and as there's been changes in the demographic setup, we're becoming more and more of an aging population.
03:00The disease constellation is changing.
03:03You now have a lot more non-communicable diseases and less of communicable diseases.
03:10But then you also have emerging communicable diseases like you had with COVID and, you know, Zika and others.
03:21So coupled with that is also a general shortage of health care professional and services to support this, yes, support the health care, health service delivery.
03:36So this has prompted Malaysia to think further about reform.
03:45But Malaysia was good in terms of thinking of reform in a much more broader sense.
03:52So the Health White Paper tries to look at it in a more holistic manner, is one that attempts to future-proof health for a 15-year period.
04:04It identified four important pillars, one being service delivery, the other one prevention and promotion of health care, the third one being health care financing.
04:18And the fourth one was looking at foundational elements and governance, yeah.
04:22And within that, one of the strategic objectives that was identified was fortifying health workforce.
04:29Yeah, it was clearly identified as one of those areas that needed addressing, yeah.
04:34And the health white paper was approved and endorsed by the parliament.
04:40And then what happened is the SED was set up, yeah.
04:45So the strategic engagement worked and produced this report.
04:50And the report, a couple of key findings, key recommendations have now been taken on by the RMK 13.
05:00So this is, you know, it's been a long time coming and we needed to do it.
05:06So that's how I would say why it was urgent and why we addressed that.
05:10Okay, so that kind of leads us to this moment in time.
05:13Before we get into the strategic recommendations, can I just get you to elaborate a little bit about the shortage?
05:18You talked about a general shortage, but if we were to zoom in, what does the data tell us about, say, the current shortage and also the projected shortage?
05:27Where exactly are we seeing the shortage? Are there specific professions or skill sets that are most acutely affected?
05:36So the report and the work itself didn't go into defining numbers, yeah.
05:41But what it does emphasise or what was quite obvious was the fact that the norms, the workforce norms do not necessarily reflect the population needs.
05:57Okay, so the workforce, how they were distributed, the kind of skill sets do not necessarily respond to the population needs of a particular area.
06:08So which meant that you will find areas which are underserved, you will find places like East Malaysia, which does not have as many health workforce as you would like.
06:20So that is seen as a critical challenge, the maldistribution.
06:28You also have this urban-rural divide.
06:33You also have these issues with private and public divide.
06:38What we realised and what we thought had to be done was to look at it and see how do we address that, yeah.
06:48And addressing that is through setting up national norms, which basically says, okay, for a certain area, for a certain hospital,
06:58this is the kind of things that needs to be, to reflect and respond to certain population groups.
07:05If you ask me which areas or which professions are not as well or acutely underrepresented,
07:15I would say nursing is one of them, community-level health workers is another thing, allied health workers, yeah, mental health professionals, yeah.
07:25Those are a few which are critically, which needs more staffing.
07:31Okay, I definitely want to touch on that because I think it's important, but the report really identifies this disconnect between workforce production and workforce absorption.
07:42So I want to talk about that because it seems to be a persistent challenge with Malaysia.
07:46When we think about that, just give us an overview in terms of what the roadmap has highlighted as more effective governance.
07:56What would that look like if we were to better align our education, our training and our deployment?
08:03Okay, so governance challenges was something that we really identified.
08:10Imagine that for health workforce and training of health workforce, you have three ministries doing things.
08:21You have Ministry of Health, Ministry of Higher Education, Ministry of Defence.
08:26Yeah, yeah, because they have training, yeah, they also have staff who are doing healthcare, yeah, yeah, so you think of it as three, you know, we always think of Ministry of Health.
08:38Yes, we think everything falls under Ministry of Health, you're right.
08:40So you have these things.
08:42And then on top of that, you also have JPA, yeah, Jabatan Perkinbathan Awam, yeah, yeah, which has the responsibility and the mandate
08:55for recruitment, for recruitment, remuneration and promotion.
08:59So you have a disconnect, yeah, between, so the Minister of Health can say things and say we want to do this and so on, but then there's this dimension as well, yeah.
09:08So we propose a governance body, at least a time-limited governance body, HR governance board, which will look at these things and which has the authority also to move and make legislative changes, yeah,
09:30and bring all these different groups together and make sure that what at the end comes up as a strategic plan is addressing those things.
09:40So that strategic plan should include or this governance board should include and also provide guidance on a national framework for professional development as well.
09:57Okay. Can I just stop you there and then maybe get you to elaborate a little bit more about the HR, the Human Resource for Health Governing Board?
10:06So one kind of body to look at all the different moving parts as you laid it out to us, but what would be the primary guiding principle of this governing board?
10:17What are they trying to achieve? Paint me a vision of what the HRH governing board would look like if it were truly effective.
10:28Okay. So we think that the strategic roadmap is a good roadmap to start off with.
10:35It identifies problems and puts forward actionable recommendations with actionable phased implementation, yeah.
10:47So we would expect a governing board, a governance board to look at these things because these are the recommendations of the strategic or recommendations in the strategic roadmap and then make decisions as to how to implement those things
11:08or even make the decisions or even make the decisions as to whether it is something they want to implement or not, yeah, but at least they will then know and are able to guide the process further.
11:21Right.
11:22Yeah. So that's why we talk about a time-bound, yeah, time-bound board, which will maybe two years, yeah.
11:30And in that two years, it gets to look at the strategic roadmap, makes decisions about how do we take things forward and then identifies who will be doing that, who will be doing what, and sets in place a monitoring and evaluation process and follow.
11:49And then people are identified who are going to be stakeholders who are going to be taking that forward.
11:53Okay. So it helps to have kind of a bird's eye view of the different components, the different ministries and people, stakeholders involved.
12:05How do you think, so another idea was to think about the pathways, the career pathways that you talked about.
12:13Talk to me a little bit about that.
12:14What does the roadmap propose in terms of looking at improving career pathways or incentives, workplace supports, all of that,
12:22would that come under the governing body as well?
12:25So the roadmap or the strategic plan has got a number of elements, yeah.
12:35And there's one element that looks at professional development.
12:42There's one element that's going, that is looking at what do we do about recruitment, licensing and registration.
12:49Another element looks at deployment, development and retention, which is very important, yeah.
12:57And the final one looks at how do we strengthen community workforce, yeah.
13:02And within each of this, there is certain action items, yeah, which should lead to addressing the issues that have been raised.
13:16So as far as the training one is concerned, it's about, the professional education one is concerned.
13:24It is about moving more from time-based learning to competency-based learning, yeah.
13:30It's more about making sure that whatever you're doing, that the learning and the training fits in within the broader context, yeah,
13:39of, of, of, of, of, of a broader frame of healthcare.
13:44And then it's also about looking at continuing professional education, looking at ways to fund, yeah, education.
13:58And we're putting forward a radical idea there as well, yeah.
14:02Really?
14:02And a radical idea there is to say, okay, you know, we have a lot of people who are trained in the public sector,
14:09but end up working in the private sector.
14:11So how do we get the private sector to co-finance some of these things?
14:16So that's another thing that we feel needs to be talked about and needs to be discussed, yeah.
14:23Okay, an interesting proposition.
14:25So, so how do you, how do you get them to, to be, you know, more engaged?
14:29Generally throughout, we, we, we always try to address the, the professions in their totality.
14:36It's not just usually you hear only about the doctors, you only hear about, so, so when we talk about education,
14:42we talk about training, we talk about this framework for professional development,
14:46we are talking about doctors, nurses, pharmacists, the entire health, allied health workforce, community.
14:53And we also are keen on looking at it, both of what happens in the public sector
14:59and what also happens in the private sector, yeah.
15:02So this roadmap actually covers the private sector as well?
15:05So it's meant to be.
15:07It's meant to.
15:07It's meant to cover everything, yeah.
15:08It's meant to cover everything, yeah.
15:10Because you, you can't do one without the other.
15:15And the Minister of Health says he's the Minister of Health for health, yeah.
15:20Not for Minister of Health, for health in the public sector.
15:25Right, right.
15:26Yeah, so I think we need to be clear about that.
15:28Thank you for making that, that clear.
15:30Because I think sometimes we do look at it in such a demarcated way, in such a segregated way.
15:36Yeah.
15:37And that's why, that's why this, this higher level governance body,
15:42which will have people coming from both public and private sector.
15:46And so we move together.
15:49It's a whole of government, whole of society approach.
15:52So are you seeing any positive responses to this proposal of having a governing body oversee everything?
16:00I was very positively surprised and, as they say in English, chuffed,
16:06that it is, it has been picked up in the Rancangan Malaysia ke-13, yeah, the RMK 13.
16:15It is one of two critical recommendations that we have made.
16:20One is that the governance committee has been picked up.
16:24And the other one is the national professional, national framework of professional development, yeah?
16:31Okay.
16:31Yeah.
16:31All right.
16:32So, so there seems to be some progress, some, it seems the, the proposal,
16:37some of the strategic recommendations of this roadmap has been welcomed
16:41and has been the steps to implement it.
16:44So we're seeing the first few steps of implementation take, take place.
16:48And if I may add, the minister is also very serious about it and the Ministry of Health
16:54because we launched it at the Ministry of Health and he was there to, to basically discuss
17:03that report with his senior management, over 50 people, and the Director General of Health
17:09is also taking this further.
17:13I do have to ask you, I mean, you talked about how health workforce reforms have been
17:20long overdue, it's a long time coming.
17:22We've been talking about this for many, many years, decades even.
17:25But any kind of reform, especially one of, on this scale, will require significant investment.
17:32Yeah.
17:33In terms of, not just, I'm not just talking about financial investment and fiscal investment,
17:36but also investment of political will, investment in human investment, institutional investment.
17:45Are we in the right environment for that to happen?
17:48Because how does the roadmap make the case that these reforms are feasible
17:53and also very, very necessary and crucial at this point in time?
17:58Yeah.
18:00It's a tough one, I know.
18:01No, no, no, it's a tough one, but sometimes we have to think, if we, what does inaction mean?
18:12What happens in 10 years?
18:14Yeah.
18:14So we need to start thinking of what we are doing now in terms of reform as an investment.
18:20Yeah.
18:20It's an investment.
18:21It's an investment that says, okay, we are going to do this.
18:25If we don't do this, that's it.
18:27You know, you just, you're going to struggle with this for the future.
18:32The other thing that I think makes this a manageable roadmap is that we are proposing a phased implementation process.
18:45Okay.
18:46Yeah, we are phased implementation process.
18:48We are also clearly identifying that we need to start thinking private-public partnership as well.
18:55Yeah.
18:56So that you share some of these costs with the private sector as well.
19:01Yeah.
19:01Okay.
19:02So, so, so.
19:04Is that a novel idea?
19:05Sorry to interrupt.
19:06Is that a novel idea?
19:07Is this something new for the Ministry for Government to consider?
19:13Or has this always been a suggestion left on the table?
19:19Usually people are a bit careful about how you relate to the private sector.
19:23But I think there are many areas where private sector can play a good role and an important role.
19:30Even WHO in the regional framework for human resources, which is for the countries in our region, speaks about using private sector for the good.
19:45Yeah.
19:46Yeah.
19:46Yeah.
19:46So, so, so, you know, wherever you need to get them engaged, involve them and take advantage of what they can contribute.
19:54Because they are gaining from a lot of things that's happening.
19:57So, so historically or previously, there was a hesitation to engage the public, the private sector in public sector reform, public sector efforts.
20:06I wouldn't say there wasn't.
20:09Yeah.
20:09There was always been some.
20:11But I think talking to them about co-funding things.
20:17Okay.
20:18Yes.
20:18So, bringing them in to be funding partners.
20:21Yeah, exactly.
20:22I think when you asked me about investment, how do you deal with this?
20:25So, here it is.
20:26Yeah.
20:26Some, some, some new ideas as well.
20:28Okay.
20:29So, so the argument is to, we can afford this.
20:32We can do this if we bring in other stakeholders.
20:35Other stakeholders, you do it in a, in a, in a, in a, in a phased manner.
20:40Right.
20:40Yeah.
20:41Do the things that needs to be done first and then you slowly.
20:46You're making me very optimistic about this roadmap.
20:48But can I ask you, Dr. El, if there are risks to the implementation of these wonderful strategic recommendations?
20:58Any case, risks is, you need to do change management.
21:03Yeah.
21:04I think, I think a very critical issue whenever you're trying to do reform is there's always going to be inertia.
21:12Sure.
21:12You have to beat inertia.
21:14Yeah.
21:14And there are going to be a lot of people who would probably say, oh, you know, this has been done before.
21:20People have spoken about it.
21:22Nothing happened.
21:23Yeah.
21:24But I think this time around, there's a lot more political will.
21:30Yeah.
21:30The health white paper says that this is one strategic objective.
21:35There's a strategic roadmap now.
21:38And there's the minister who is, who is keen.
21:41There's a DG who is keen.
21:42And it's also noted in RMK 13.
21:45Yeah.
21:46It's going to be the five-year plan.
21:47Yeah.
21:47Five-year plan.
21:48And then, you know, it's going to be monitored.
21:50So, I think, like you, I'm a little, I'm optimistic.
21:54I wouldn't be pushing this if I was not optimistic.
21:56But I think we also need to be aware and constantly keep the momentum.
22:02Yeah.
22:02Because it's all with political will.
22:04But because this is such a big issue.
22:07I mean, you open any newspaper today.
22:09Yes.
22:09Every day, there's some healthcare, something about workforce.
22:14Yeah.
22:14There's some issues.
22:15So, I think this gives us an opportunity to say, okay, let's address that.
22:20So much work has gone into this strategic roadmap.
22:24Can I ask you if you had to give a single takeaway, just summarise it in one, in a nutshell, what's one takeaway that you hope stakeholders will walk away with from this roadmap?
22:39If there is one, what would it be?
22:40So, if I were to put it in one sentence, it will be if there's no health workforce, there's no healthcare, there's no reform, there's no economic development.
22:55The other thing I would say is ultimately what this roadmap is trying to reach is to have well-governed, equitably distributed and motivated health workforce so that we can be very proud and we can continue to be a healthy population government country.
23:20So, some of the recommendations in the roadmap will require long-term structural change.
23:28But is there anything in here that are short-term wins that can be that boost for, you know, to show that this can work, that this is where we're headed to?
23:40So, we have a few recommendations.
23:43I mean, like the governance board, something you can start immediately.
23:47Absolutely.
23:47Then, there are a few recommendations about how do we get registration, licensing, streamline, fast-track, make it digital.
23:59Those are things that can be done.
24:01Yes, definitely.
24:02Okay, I'm more optimistic than even more than when we started.
24:07So, thank you so much for being on the show and giving us a kind of a summary or a concise understanding of the work that's gone into this roadmap.
24:18I appreciate your time.
24:19Thank you very much.
24:20Thank you very much, Melissa, for the opportunity.
24:21That's all the time we have for you on this episode of Consider This.
24:24I'm Melissa Idris, signing off for the evening.
24:27Thank you so much for watching and good night.
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