Where is the road to realization of UHC leading for cancer in Malaysia?

SONODA Shigeto noted that the topic for the short report in the previous lecture had been set as follows: What are merits and demerits of interdisciplinary approach to promote Malaysia-Japan collaboration for cancer prevention?

  He asked students for any brief comments relating to the topic. 

A student noted that collaboration between different countries on the topic of cancer care and cancer research helps to attain a more holistic view of how cancer works and what potential solutions there are in various fields. Collaborative ventures basically assist in a acquiring a larger perspective. In terms of the demerits of an interdisciplinary approach, it could be that difference between countries could present hurdles to effective collaboration. 

A student noted that collaboration enables researchers to have more creativity or better inputs in developing solutions when they have different backgrounds and perspectives. In terms of demerits, another challenge could relate to difficulties in reaching a consensus about the priorities for solving problems and attaining goals, due to differing perspectives.

Dr. Sonoda agreed that transaction costs in arriving at a commonly held view may be very great indeed, due to differences among people and different countries, but ultimately, once a common view has been established it could reap tremendous benefits.

KAWAHARA Norie (Lecture Series Coordinator) noted that in the previous week’s lecture she had introduced the Bringing Education And Understanding To You (BEAUTY) Project being implemented in Malaysia, which is being led by MURALLITHARAN M., Managing Director of the National Cancer Society Malaysia (NCSM). 

  Dr. Kawahara noted that Dr. Murallitharan has an interesting background, having initially wanted to pursue a career in journalism before turning to science. Thanks to this background he has an extremely cross-boundary body of knowledge and experience from which to draw on and is keen to explore innovative ideas. He also believes that although challenges may be human made, they can be solved through inter-person connections.

  Another driver of health is the physical environment, including geographical distance from healthcare facilities. The kind of physical environment you live in has an impact on individual health. 

  Another driver is clinical care itself, which accounts for only 20% of the total, with healthcare for the large part being determined by factors other than clinical care. 

A case in point is that approximately 30% of healthcare is actually driven by health behavior, which is generally perceived to be an individual issue. Behavior itself is controlled by a lot of factors. One of these factors is actually your immediate environment, including whether or not you have people around you, your family members, your friends, your teachers, etc. All these people have an influence in shaping your behavior. 

Other influences include social media and the messaging on social media has a strong impact on shaping individual behavior. In simple terms, influences can be classified into cultural and political influencers, indirect environments, and immediate environments. 

This lecture will focus mainly on health behavior, and also on the social and economic environment, which will provide a social perspective on healthcare. 

As can be seen in the figure, perceived susceptibility is a key driver for action, coupled with perceived severity. These are two concepts that people need to hold in order for them to take action pertaining to health. 

Another kind of driver of health belief and subsequently behavior is health motivation. This could come from intrinsic motivation or extrinsic motivation.  Intrinsic motivation is driven from internal sources. Extrinsic motivation is driven by external deterrents or incentives. In many countries insurance companies now impose a surcharge on people who have poor health behavior, which is an example of extrinsic motivation. 

Another kind of driver for health belief is the perceived benefits, which encourages people to engage in certain actions. 

In summary, there are many external factors, including behaviors, and beliefs that lead to behaviors, and these motivate individuals or a community to actually be focused on performing tasks related to health or accessing healthcare itself.

Universal health care coverage actually means whether or not an individual living in a certain region or country can access healthcare when they need it. UHC encompasses all levels of healthcare services, from simple conditions to more complex (and expensive) diseases. Healthcare coverage itself is a very dynamic continuum ranging from traditional healers through to nurses, midwives, pharmacists, etc. “Universal” refers to access to all levels of treatment, including complex diseases, and is a goal for all countries, because even in developed countries universal coverage will vary from place to place, particularly between rural and urban areas. Income levels among the population can also impact access to UHC.

  In order to analyze the degree of UHC in a given country or region, it is important to look at coverage in the three dimensions of: i) population coverage, ii) service coverage, and iii) financial coverage/protection. In some countries, the third dimension (financial coverage) is covered by health insurance, making healthcare services low cost or free of charge. Service and population coverage can be affected by geographical barriers and challenges to coverage in rural areas. 

  The vision of healthcare professionals is to realize full population coverage for UHC and the mission of healthcare professionals is to work towards that ultimate goal. Another goal is to ensure that people do not need to pay out of pocket for healthcare services, as UHC is not really universal health care coverage if you have to pay for it. The role of healthcare professionals therefore is to work to ensure that coverage mechanisms and coverage continue to be gradually enhanced. 

  The health system in Malaysia presents a complex picture, including both the public and private sectors. The key government providers of healthcare are the Ministry of Health, the Ministry of Education, and the Ministry of Defense. The actual delivery of healthcare is via clinics, district hospitals and general hospitals. There are also private clinics, hospitals and laboratories in operation. The total picture is that there is a wide range of service available, both in the public and private sectors, with private care in particular being provided at a high level. 

  In terms of how cancer care is provided through the Malaysian healthcare system, it is necessary to look at the broader picture. In theory, Malaysia has achieved 100% UHC and people can freely go and see a doctor, with clinics being available on average every 5 kilometers. If further treatment is required, the patient can also, in theory, visit a secondary or tertiary care facility, including specialist treatment such as oncology. 

  However, the reality of the situation in the public sector in Malaysia is that many of the clinics around the country have no doctors and they have inadequate medication. This means that although in theory there is 100% population coverage through the many clinics across the country, and there is also in theory no financial cost to the patient, the reality is that the services provided are inadequate. The issue becomes even more severe when patients need to access secondary and tertiary healthcare services, because these services do not cover all the population. Only in state capital cities are tertiary healthcare services readily available.  

  In terms of private sector healthcare services in Malaysia, these are readily available from the level of clinics, but services can only be accessed through out-of-pocket payment or by holding private health insurance. Only 22% of Malaysians have private health insurance, meaning that most people who wish to access private health services need to pay out-of-pocket. 

  The reality of these disparities between the public and private systems and the inadequacy of services available publicly means that almost 40 percent of all cancer patients who undergo a diagnosis with cancer and get treatment will go bankrupt within one year. Approximately 40% of all patients incur out-of-pocket expenses due to the inadequacy of public healthcare services. The challenge for Malaysia therefore, in the absence of adequate services, and the long waits involved in receiving a cancer diagnosis and then receiving cancer treatment, is to work to promote health-seeking behavior among the general population.

Dr. Sonoda noted that Dr. Murallitharan had clearly demonstrated the gaps between the myth and reality of UHC in Malaysia and asked whether there are any discussions or momentum in Malaysia to create a new type of measurement that could go some way to closing this gap. 

  Dr. Murallitharan noted that in many countries funding for healthcare services comes from taxation, but tax revenues are decreasing as more people join the “gig” economy and do not pay tax. With a shrinking tax base many governments are being challenged and the result has been to move to insurance premium-based systems, or focus on preventive measures. 

  Dr. Sonoda referred to Dr. Murallitharan’s comments about the drivers of health, including the social and economic environment, and the physical environment as well as the healthcare environment. He asked how these drivers could be best combined with the other factors that had been mentioned in order to go some way towards solving challenges relating to UHC. He asked whether the focus is on changing people’s mindset, or on changing the political system. 

  Dr. Murallitharan responded that with almost every complex problem, there is really no one-size fits all solution. The problem with the multidimensional aspects of healthcare requires us to actually put in multidimensional solutions working all at once. In Malaysia one of the serious problems is that people wait until they are seriously sick before seeking treatment. That is why one of the ways of improving the situation relating to cancer care in Malaysia is to encourage people to consider entering into insurance. Another way is to encourage individual transformation, and push people in a direction to consider a healthier lifestyle.  

  A student referred to the slide about influencing factors on health behavior, questioning the importance of medication factors and whether they are as important as the other four influencing factors. Dr. Murallitharan responded that not all of these factors need to be given equal weighting, and indeed the weighting may change from country to country and on specific situations. Medication remains an important factor influencing health behavior, because many people actually have a fear of taking medication. In such a situation it is important therefore to also focus on how to overcome patient fears about medication. The best cancer drugs in the world will not work if people are afraid to take them, and therefore research is required on ways of diversifying medication delivery methods. Other patients may be concerned about side effects of medication, and such concerns also need addressing. It is important not to underestimate such concerns. 

  A student asked about AI and how it could play a role in solving the problem of cancer and cancer care, particularly given the lack of professional doctors in Malaysia. He suggested that AI could particularly play a role in diagnosis. 

  Dr. Murallitharan responded that already in Malaysia AI is being used to read radiology reports, thus reducing the workload of human doctors. Another example of the use of AI is in communication to patients and patient-provider relationships. A recent study has shown that a chatbot’s responses to patients’ questions were well-received by 60 to 70% of patients, in some cases even better than a human doctor, with AI being viewed as being more friendly and accessible than a real doctor. 

Dr. Murallitharan asked students to complete the following: i) Describe your own country’s health system explaining the private and public segments, and ii) describe from your own understanding, what are the challenges of UHC in your own countries, using examples.