From Azrul Khalib
The Covid-19 pandemic delivered a lesson in humility to health systems around the world. Whether it was ventilators in Japan, personal protective equipment (PPE) in the US, hospital beds in Malaysia, syringes in South Africa, or medical imaging dyes in Australia, there were shortages of almost every critical item necessary for the delivery of safe and effective healthcare services.
There was massive disruption to the health infrastructure worldwide. It was 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 tested the limits of health systems. Malaysia fared better, thanks to its experience with health crises like the Nipah virus and dengue.
However, many countries struggled, with their health infrastructure collapsing. In some places, funeral pyres were set up on the streets.
The pandemic underscored the importance of political will and long-term investment in health infrastructure to respond to current challenges, such as non-communicable diseases (including diabetes, chronic kidney disease, and cardiovascular disease), malnutrition and ageing, as well as pandemics in the near future.
Malaysia must address current gaps, or it may not be as fortunate in the next crisis. There are five mission-critical areas which need urgent attention.
Ageing infrastructure and equipment
Despite substantial investments in health, many of Malaysia’s public healthcare facilities, including district hospitals and clinics, are ageing and outdated.
One-third of 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 Sabah and Sarawak, were built when healthcare demands and services were simpler.
The issue isn’t just cosmetic – old buildings often have structural problems like cracked walls, leaking roofs, and faulty plumbing or electrical systems. These pose safety and hygiene risks for both patients and staff.
After a heavy rainfall, hospitals and clinics across the country would report water leaks, even in an operating theatre in the case of a hospital in Kota Kinabalu, Sabah.
Flooding is also a risk for community clinics (K-Com), especially when they are constructed mainly out of wood and in flood-prone areas. While these issues are usually addressed quickly, they signal deeper concerns.
Hospital specialists have also reported a shortage of essential equipment, with many machines, such as MRI scanners and CT scanners, either nearing the end of their service life or already outdated, affecting timely and accurate diagnoses.
Hospital design, mould and fire safety
Older facilities are struggling with overcrowding, longer waiting times, and strained resources. Many lack space for specialised services like elderly care, modern ICUs, or palliative care.
Poor design can result in overcrowded waiting rooms, long queues, and delays in treatment due to inefficient patient, staff, and equipment flow.
Also, hospitals need modern infection control measures. Historically, open wards had limited patient segregation, but outbreaks like Covid-19 have highlighted the need for isolation rooms and improved ventilation, which many facilities still lack.
Both older and newer hospitals face problems like poor ventilation and water leakage, which can lead to mould and infections, especially in Malaysia’s tropical climate. Even newer hospitals are facing challenges which are linked to problems in hospital design.
The Sultan Idris Shah Hospital’s Heart Centre is just two years old. It recently reopened its operating theatres after being closed due to environmental control issues related to air conditioning, electrical problems, and high humidity.
The OTs were out of action for most of its first two years. Even UiTM’s brand new Hospital Al-Sultan Abdullah experienced similar issues.
The public works department (JKR) must ensure that these hospitals and healthcare facilities not only meet building codes and safety regulations, but also have the design and architecture to deal with issues such as infection control, microbial growth and sanitation.
Millions of ringgit have already been spent on repairs for the affected hospitals to overcome these issues.
The 2016 fire at Johor Bahru’s Hospital Sultanah Aminah (HSA), which killed six people, should have been a wake-up call. Despite multiple fires, several public hospitals still lack fire certificates, as required by the Fire Services Act 1988.
In 2019, the then health minister Dzulkefly Ahmad declassified the fire investigation report through a Cabinet decision. However, after two more health ministers, the report still hasn’t been made public. Six people died, yet the officials related to the matter have been promoted or have 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 costs, lack of skilled staff, and inconsistent long-term commitment have hindered the modernisation of Malaysia’s health information systems (HIS).
It is worrying to know that staff at some hospitals are resorting to Google Docs to share patient notes, while many computers still run on the defunct Windows XP operating system and rely on outdated systems for storing patient records, X-rays, MRIs, and CT scans.
Doctors frequently use their own personal computers and laptops. The situation has sometimes been described as performing flying trapeze acts without a safety net.
Although Malaysia started using HIS in 1993 and was a global leader in the late 1990s and early 2000s, parts of the system have become outdated.
Many clinics and hospitals still prefer paper records, considering them reliable and not prone to software issues.
Effective HIS deployment in public healthcare can reduce medical errors, improve efficiency, cut costs, and boost patient involvement. However, challenges include IT knowledge gaps among doctors and nurses, hardware and network compatibility issues (for example, connecting modern MRI scanners to outdated systems), and rising 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, helping to modernise processes more efficiently.
They are also more cost-effective and reliable, having been tested in various situations. Vendors regularly update these systems to meet healthcare regulations, reducing the need for manual compliance.
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.
With a severe national shortage of doctors, nurses, and healthcare workers, staffing for this new facility would be drawn from already overstretched local healthcare providers.
It’s striking that Cyberjaya, with a population of over 100,000, received a hospital while Petaling Jaya, home to over 620,000 residents, still lacks a health ministry hospital.
The unequal distribution of healthcare facilities is a major issue for Malaysia. Most well-equipped hospitals are located in urban centres like Kuala Lumpur, Penang, and Johor Bahru, leaving rural areas, particularly in Sabah and Sarawak, under-served.
These areas often lack sufficient medical facilities, forcing residents to travel long distances to access even the most basic of healthcare services. This is compounded by poor transportation infrastructure that delays treatment and increases mortality rates for manageable conditions.
While initiatives like mobile clinics and telemedicine have been introduced, access disparities remain a major challenge. 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 improve on existing capacity and services with an emphasis on quality over quantity.
Politicians may advocate for new hospitals in their constituencies but constructing them without adequate staffing will not improve healthcare delivery. 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 the upgrades are complete, the newly acquired equipment is nearing its replacement date. It’s estimated that this process will take at least 10 years and cost billions of ringgit – resources we currently lack.
But the investment needs to be done. We need to consider and adopt innovative approaches to find new funds to finance the modernisation of our healthcare infrastructure.
One solution could be for the government to issue social impact bonds or sukuk to raise the necessary funding. This funding would be specifically allocated for upgrading healthcare facilities, procuring equipment, and developing health infrastructure in Sabah and Sarawak, as well as for aged care. The fact is that current federal budget allocations are insufficient for the required improvements.
Many leaders in their late 50s and 60s will soon rely on public health services that address non-communicable diseases and 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 situation where the privileged class has access to quality and accessible healthcare while everyone else fights for whatever is being offered and are told to be thankful. All of us need to do our part and invest in building our healthcare system.
Note: This article is the final part of a three-part series covering healthcare financing, human resources and health infrastructure in conjunction with the upcoming Budget 2025.
Click here for Part 1 and Part 2 .
Azrul Khalib is the founder and CEO of the Galen Centre for Health and Social Policy.
The views expressed are those of the writer and do not necessarily reflect those of FMT.