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Malaysia’s healthcare system has long been under pressure from years of underfunding, workforce strain, and rising medical costs. But beyond these challenges lie deeper structural shifts: an ageing population, and a growing burden of chronic disease. As our healthcare system evolves and adapts, what role can external partners like the World Health Organization realistically play in supporting national priorities? On this episode of #ConsiderThis Melisa Idris speaks with Dr Rabindra Abeyasinghe, WHO Representative to Malaysia, Brunei Darussalam and Singapore.
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00:00Music
00:10Hello and good evening, I'm Melissa Idris. Welcome to Consider This.
00:14This is the show where we want you to consider and reconsider what you know of the news of the
00:19day.
00:19Now it's been much discussed that Malaysia's healthcare system is and has been under pressure.
00:25Years of underfunding, workforce strain and rising medical costs are testing the limits of our healthcare system.
00:33But beyond these challenges lie deeper structural shifts, an ageing population and the growing burden of chronic disease.
00:43So as our healthcare system evolves and adapts to these challenges,
00:47what role can external partners like the World Health Organization realistically play in supporting our national priorities?
00:56Well, joining me on the show to discuss this further, I have Dr. Rabindra Abasinghe,
01:02who is the WHO representative for Malaysia, Brunei Darussalam and Singapore.
01:08Dr. Rabi, welcome to the show. It's good of you to join me. Thank you so much for being here.
01:12Thank you, Melissa, and thank you for the opportunity.
01:14Thank you. So let's start very quickly with maybe you describing WHO's work here in Malaysia.
01:22What role do you play? What kind of work are you looking or prioritizing at the moment?
01:27Thank you. I will start by, for the sake of the audience, explaining what is WHO?
01:33Because during COVID, there were many misconceptions about WHO and sometimes we see on social media those continuing.
01:40So WHO is an affiliate organization of the UN and it's a member state organization.
01:48Meaning that our DG is elected by ministers of health.
01:53Meaning that our work programs are decided by ministers of health.
01:58So our board is the ministers of health who meet in May every year and decide our activity plans.
02:04And we function as a secretariat to the ministries.
02:09Okay.
02:09What we do is we have different kinds of support we provide for countries depending on what stage of development
02:18their health systems are and what kind of input they require.
02:21So from a Malaysia point of view, we are here largely to provide technical advice because Malaysia has quite a
02:35strong health system, quite high technical capacities.
02:38So we see our role as a technical partner to the ministry of health, we can mobilize, or we have
02:47a small office here, but we have the entire WHO behind us.
02:51So we can mobilize a lot of support in whatever areas that the country requires.
02:57We can bring the best of global evidence, we can share experiences from other countries and oftentimes ministries of health
03:07use that in countries like Malaysia to advance their health systems.
03:12Okay.
03:13May I ask a follow-up question?
03:14So you described what WHO does, but your role specifically I think is also quite interesting because providing technical advice,
03:21you're part diplomat, part public health specialist, part coordinator in a way.
03:29Yeah.
03:29Can you tell me a bit more about your specific role and how you engage with local stakeholders here?
03:34Yeah.
03:35So we play multifunctional roles as you very correctly mentioned.
03:40I am head of office, so I'm in charge of a small team, so I coordinate the work of the
03:46team.
03:47We have financial responsibilities to implement a program budget.
03:53We have to understand the challenges and the support that the government requires.
04:00We have to play a diplomatic role because we are the lead agency on health, but we also work with
04:08other UN entities.
04:09Other stakeholders, increasingly other partners, so it is a very complex role.
04:18I can only imagine.
04:19Yes, I am a public health physician.
04:24I go back a long time in public health.
04:27I've been also working for my government in Sri Lanka before I joined WHO.
04:32That was a long time ago.
04:35But yes, I've been in this role for some time in many countries.
04:40So with the work in Malaysia, can you tell me a little bit about what work you're doing?
04:46And how, so you said WHO uses the support provided by, sorry, the Ministry of Health uses the support provided
04:56by WHO.
04:57How exactly do they use that support?
04:59What kind of support are they tapping into?
05:02Well, it oftentimes depends on what kind of support the government requires.
05:07So oftentimes the request comes from the government, look, we have this challenge, how can you, what are you, what
05:20is your position on this?
05:21And we would then look at the situation, try to understand the issue and then try to find solutions from
05:31experiences in other countries with similar situations that we share.
05:36Of course, we don't implement it.
05:38It is advice that we share with the government.
05:42The government decides, I want to do this or I want to do that.
05:47So oftentimes it's not just one advice, it's complex series of things.
05:53And the government then decides, I want to do all of this.
05:56I want to do A, B and D, but not C.
06:00That's a sovereign decision and we respect that.
06:03Can you give me an example of some of the advice the government has sought?
06:07Yes, we've been talking to the government on improving universal health coverage.
06:14And one of the things that the government sought from us when the white paper was already being developed was
06:21how can we do this, right?
06:24And we've looked at the situation.
06:28We've recommended that Malaysia increase its health financing because there's so much you can do with limited financing.
06:38And we are glad that the Prime Minister in his mother and his speech acknowledged that Malaysia aims to increase
06:46its health financing up to 5% of GDP.
06:50That's the guidance given by WHO, right? Or is it 6%?
06:55Yeah, it's a minimum.
06:56A minimum, right?
06:57Yeah, and there is government buy-in for that.
07:00So we are happy that at that highest level it's been vocalised in Parliament.
07:05Okay. So universal health coverage, health financing is some of the key areas that maybe the government has said.
07:13How do you, how does WHO support us in this?
07:17Yes. So there's multiple things that we are working on the health financing.
07:21So we are working with the government, A, to see how we can better utilise the existing resources, meaning efficiency
07:30gains in the system.
07:32And secondly, of course, because there's not enough money going into the health sector, we have recommended that more money
07:40is released into health.
07:42And successive years we've seen the health budget increasing.
07:46So we are on that path.
07:48Hopefully that trajectory will, hopefully we'll see something also in this year's budget.
07:53Before you come into a country, of course you have to make an assessment and you've been here for some
07:58time, during which I'm sure you've seen the country's health system change and evolve.
08:05When you make that assessment, Dr. Rabi, what is that diagnosis, if I may use that?
08:11From the perspective of WHO, where do you see the key strengths of the Malaysian healthcare system currently?
08:19Well, we have over the years witnessed a very strong public focused healthcare system, which is built on a strong
08:28primary healthcare system.
08:32But we've seen also the system being challenged about over the last decade.
08:41Progress has been stagnant across many areas.
08:46In the early phase, Malaysia was making very significant progress in the control of communicable diseases, childhood diseases, maternal mortality.
08:56But if you look at the data for the last 10 years, there's been stagnation.
09:01And that's multifactorial.
09:03It's not just system.
09:04It's also population dynamic changes, adaptation of the system to the changes, socioeconomic development.
09:13So all of these issues are contributing to that stagnation.
09:17But it also means that we have to work and find solutions to that.
09:22We have to continue that upward trajectory of improving the health system, improving the services for people.
09:29Even though you are faced with significant challenges of aging population, increasing burden of non-communicable diseases, largely brought upon
09:40by the prosperity, economic prosperity.
09:43Can you elaborate on that, Dr. Abhi?
09:45I'm curious to know.
09:47That's quite disconcerting to know that progress has stagnated maybe in the last 10 years.
09:56What are the causes, what are the confluence of conditions that have allowed for this to happen?
10:01And is it possible to jumpstart progress again?
10:06It definitely is possible because you have the core elements which are in place.
10:10The issue is that the system hasn't robustly reacted to the changes, right?
10:17So when I said you were doing very well early on, you were making very good inroads into the control
10:24of communicable diseases.
10:27But as you made that, you suddenly saw an increase in the non-communicable diseases.
10:33And the system didn't actually adapt to that because it requires a different approach.
10:40So because non-communicable diseases are lifestyle diseases.
10:45And lifestyle diseases don't work with the way you manage an infection.
10:52It doesn't go away because you give an injection or take a course of tablets.
10:57So it requires a fundamentally different approach.
11:00And that's a discussion we've been having with the government.
11:03What approach is that?
11:04It's a lifestyle.
11:06It's talking to the population, getting population buy-in, right?
11:10It's a partnership.
11:12Malaysia is doing great because you have a subsidized health system.
11:16But that subsidized health system also needs population buy-in.
11:22If the population does not recognize that that's something that they need to protect,
11:28that they should not abuse, they need to also adapt a healthy lifestyle,
11:33that system cannot cope.
11:35Are we focusing too much on curing diseases and not enough on preventing disease?
11:42Exactly.
11:43So it's about a shift of focus, right?
11:50There's just so much that you can do by curing to cure diseases.
11:55It's far more economically profitable to have a preventative, promotive aspect.
12:03And that's what we are seeing.
12:05That is what is challenging the Malaysian system.
12:08Would that, Dr. Ravi, fall under the Ministry of Health?
12:13That speaks to me of lifestyle.
12:15It would be really, I mean, if I may use the cliche term of whole of government,
12:20it doesn't really just fall under the Ministry of Health.
12:23But the Health Ministry has to lead it.
12:25Has to lead it.
12:26Okay.
12:26That's where we're coming from.
12:28I mean, in other countries, it's the Health Ministry that leads it, right?
12:31Because it is a health issue that the whole of government is trying to partner in.
12:37It is a life course approach.
12:39You need to start from early childhood, even from the time a baby is born.
12:43Have you seen other countries who maybe have gone through a similar experience like Malaysia,
12:52stagnation or progress, that has been able to reset or refocus the healthcare system
13:01to addressing preventive medicine, to addressing lifestyle, the social determinants of health?
13:08Yes, there are countries, very good examples, that have made that shift early enough.
13:14Tell me.
13:15We, from a Malaysian perspective, we've gone further down the road and we are still adapting those changes.
13:24Right.
13:25But there's still an opportunity for us to turn it back, so to speak.
13:32The situation is also complicated by the fact that it's not only the high burden of non-communicable diseases
13:43driven by high risk factors, but it's also the mix of an aging population, right?
13:50So, your previous success in controlling communicable diseases, reducing maternal mortality,
13:55it has contributed to higher longevity.
13:59But then, if you look at it, how many healthy years have you added to life?
14:06Because if you look at the average lifespan, right now you are looking at about 10 years spent in ill
14:14health,
14:15the last 10 years.
14:1610 years, the last 10 years of life are spent in ill health.
14:21Yeah, so we need to reduce that.
14:24The projections are that the average lifespan in Malaysia will continue to increase, right?
14:31But the problem is, as that lifespan increases, we're going to see a further increase in the period spent in
14:41ill health.
14:43So, the projection is we need to change track now so that we increase the healthy lifespan
14:51and not the lifespan that is riddled with disease and problems.
14:58Is that not typical of, I guess, the lifespan, the last 10 years of life is in ill health?
15:06Is that a poor benchmark?
15:09Yeah, I think it could change.
15:11It needs to change.
15:15We know from other countries that it can change.
15:18So, that's why we are advocating for this shift for a more active lifestyle, for a more balanced nutrition.
15:27All of these issues will feed into that.
15:30But these things don't happen when you are 30, 40 years and fall ill.
15:36You need to adapt these changes already when children are in school.
15:40Talk to me about how the Ministry of Health can lead in this area.
15:46We've seen the Ministry introduce some policies like sugar taxes, healthier choice logos.
15:54They've really tried to address diabetes rates, obesity and the like.
15:58But are we, as you said earlier, you need a public buy-in, the population buy-in.
16:04So, are we overestimating what policy tools can achieve alone without behavioural change by the public?
16:13And how can the Ministry of Health lead in that specific area?
16:18That's a good question and it's a very pertinent question.
16:22And I think you are correct.
16:24The government, the Ministry of Health has recognised the importance of behaviour change.
16:29They've not only recognised it, they've actually led a global resolution on behaviour change for better health.
16:37And that was adapted at the 2023 World Health Assembly.
16:42Yeah, it's now part of the thing.
16:45I think next month we are having a national conference on behavioural insights to better health.
16:51We have been working with the MOH in strengthening those aspects, incapacitating health workers on how do you communicate.
17:00But that's not just an issue for health workers, it's beyond.
17:05As I said, you can have all the legislations but punitive action alone doesn't get you there, right?
17:11You need buy-in.
17:13You need population buy-in.
17:15And that's where the behavioural science, the health literacy comes in.
17:19The health literacy, I had a conversation recently interviewed a researcher who looked at the sugar sweetened beverage tax.
17:28And his research found that there was actually very minimal impact on consumer behaviour towards purchasing these sugary beverages.
17:36And my question is, if the government does increase the tax or adopt an absolute sugar tax, will the Malaysian
17:47public be upset with that?
17:49Because we're so used to sugar subsidies, we're so used to sugar being so sweet, so cheap and easily available,
17:56that any kind of sugar tax might feel like a punishment to the Malaysian public.
18:02That's exactly the point, right?
18:04I mean, they say Malaysians are sweet and probably because they take so much sugar.
18:08So much sugar.
18:12But the issue I'm trying to say is that it is for the welfare of the public, right?
18:17It's not, it shouldn't be viewed as a punitive action.
18:23It is for their own welfare because we are seeing the impact of diabetes on populations, right?
18:31And so we need to come to grips with how do we address this.
18:36And the tax is just one part of the solution.
18:40The wider issue is creating the public awareness that sugar is not healthy,
18:46that it needs to be taken in moderation,
18:50that you shouldn't be putting six teaspoons of sugar in your tehtarik, right?
18:56Because that already exceeds the daily limit that somebody should be taking.
19:02So if you're taking three cups of tehtarik or coffee or something and plus another sweet drink
19:09and maybe another shendol somewhere, you've exceeded your sugar quotas by many fold.
19:15And so you're running the risk of diabetes because you're also not going to the gym or going for exercise.
19:22So, and add on to that the stresses of work and all of that.
19:26So, that is why we are saying the new lifestyle requires a new approach, a new diet.
19:33We are not saying you shouldn't enjoy your sweets, but that should be done in moderation.
19:38Right.
19:38How do you balance the, or how do you advise the Malaysian government and the Ministry of Health
19:45in balancing all of this?
19:47Because, again, as I mentioned in my introduction, the healthcare system is coming under immense pressure
19:53in terms of limited funding and overstretched workforce, rising medical inflation.
19:58And there's also the current impact of the war on Iran.
20:03Shortages everywhere, costs increasing.
20:07There's so many short-term challenges.
20:09And then there's the longer-term challenges, the structural challenges, which feel far away
20:15and less pressing.
20:17How do you, when you give technical advice to governments for pandemic preparedness, crisis
20:23preparedness, how do you balance that advice with some of the more structural reform that's
20:30needed in a country?
20:31So, we take the longer-term view.
20:34We take the longer-term view.
20:35We would hope that we could close our eyes and ignore the global crises, but that doesn't
20:40happen.
20:41So, we have to be aware of that.
20:43And that brings added constraints.
20:46But then, just our assessment, which we carried out in 2022 on the impact of non-communicable
20:54diseases, that was a joint effort with MOH.
20:58We showed that just four non-communicable diseases cost the Malaysian economy almost,
21:0565 billion ringgit a year.
21:07That's more than the entire budget of the health ministry.
21:11And that's, it's not only the cost of medicines.
21:15It's also the cost of low productivity.
21:18It's the cost of what we call absenteeism, because people have to take leave to take their
21:26sick relatives to hospital.
21:28It's the cost of presentation.
21:30People who are sick are at work, but are not productive.
21:34So, all of that, when you factor in, the cost of these four NCDs at a very conservative
21:42estimate, based on 2021 figures, it's 65 billion ringgit.
21:47Now, I'm saying conservative at 2021 prices, if you use today's prices and the medical inflation, it's probably higher.
21:58And it's not the full spectrum of NCDs.
22:01So, we need to have that longer term view that this cannot continue, right?
22:08We need to find solutions.
22:10We need to change the traction so that we can, there's so much that you can invest in improving
22:18curative facilities.
22:20But the secret is in promoting preventative.
22:24That is a staggering amount, 65 billion a year.
22:29Yeah.
22:30Mind-boggling, in fact, I must say.
22:33So, where do you see this going forward?
22:36In the time that we have left, what would you say, Dr. Rabi, are the areas that you would
22:43love to focus on with the Ministry of Health in terms of collaboration?
22:47And how would you measure that progress?
22:49What would you consider progress during your tenure here?
22:53So, we are working on multiple fronts.
22:55I already mentioned the health financing, efficiency gains within the health system,
23:00looking at redistribution of the health workforce, task shifting within the health workforce,
23:06shifting to the allied health workforce rather than depending entirely on doctors and nurses.
23:12All of that will help for efficiency gains.
23:15On the preventative, promotive side, we are also advocating for better control, for better awareness.
23:22So, we are working with the Ministry on front of pack labelling.
23:26The population needs to be empowered to make the choice.
23:30You go to a supermarket, you select a drink, you select a food item, you need to be able
23:36to see on the front of the pack, how much of sugar is there, how much of fat is there,
23:41right?
23:42That's a practice that is practiced in many countries.
23:46And MOH is working on the legislation.
23:49So, that front of pack labelling is there.
23:51So, people can see, I'm buying this.
23:54This has a red traffic light for sugar, for salt.
23:59Am I going to buy all items with red or should I mix my choices, right?
24:06So, because it's important that people are empowered to make the correct decision.
24:13That means the information needs to be there.
24:15Right now, there are some packaging.
24:18The font is so small that even I can't read it.
24:21So, you can't find it.
24:23So, you're a busy housewife, you go shopping, you don't have time to be turning and looking, right?
24:30It needs to be up front there.
24:32So, we call it the traffic light signals or the front of pack labelling.
24:36Have it in big font, have it in color code, which says, this is healthy, this is not so healthy,
24:42this is absolutely dangerous.
24:43This is part of that health literacy that you talked about.
24:47Because how many people look at the label at the back of the product, right?
24:52And that's what we need to do, right?
24:55Definitely.
24:56Okay, so, I'm excited to have a better maybe ranking system, labelling system.
25:02Looking forward to that in our grocery shops in the future.
25:06Lathrabi, thank you so much for being on the show.
25:08The time has slipped away from us in this conversation.
25:11I appreciate your insights.
25:12Thank you for sharing them with us today.
25:14It's been a pleasure.
25:15That's all the time we have for you on this episode of Consider This.
25:18I'm Melissa Idris, signing off for the evening.
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