Lecture 4
The Value of Prevention Across Borders: When Health and Healthcare Become Sources of Economic Value in Southeast Asia

Prof. Victor CW HOE

Professor of Occupational and Public Health, Universiti Malaya

Occupational Physician, Universiti Malaya Medical Centre

Victor CW HOE is a Professor of Occupational and Public Health at the Universiti Malaya (UM) and a practicing Occupational Physician at the Universiti Malaya Medical Centre (UMMC). He serves as the Head of the Department of Social and Preventive Medicine and was the Senate Representative for the Faculty of Medicine from 2022 to 2024. Dr. Hoe holds a Ph.D. in Occupational Health and Safety from Monash University, along with multiple Master’s degrees in Public Health and Occupational Safety and Health. He has received prestigious accolades, including the ILO Master Fellowship, Malaysian Medical Association (MMA) Meritorious Award and the Asia-Pacific Academic Consortium for Public Health (APACPH) Medal of Merit. His extensive experience includes industrial training with ExxonMobil, DOSH, SOCSO, and NIOSH Malaysia. He serves on the UMMC COVID-19 Task Force, where he contributed to developing Standard Operating Procedures during the pandemic, particularly in environmental control. Additionally, he is a registered consultant for Environmental Impact Assessments (EIA) with the Department of Environment Malaysia, advising on various major projects. Dr. Hoe’s research interests focus on worksite wellness, musculoskeletal disorders, ergonomics, health risk assessment, Evidence-Based Medicine, and systematic reviews. He continues to lead research initiatives and mentor students in public health.

Dr. Murallitharan Munisamy

Managing Director, National Cancer Society of Malaysia

MURALLITHARAN Munisamy is a Public Health Physician from Malaysia. He trained as a Medical Officer in the Russian Federation under a Malaysian government scholarship and completed a Master’s in Community Health Sciences at the National University of Malaysia. He earned a PhD in Public Health from Chulalongkorn University, Thailand, under the ASEAN Economic Community program. In 2015, he received the Chevening Scholarship from the UK Foreign and Commonwealth Office, completing a term as a Fellow in Health Policy, Planning, and Financing at the London School of Hygiene and Tropical Medicine and the London School of Economics and Political Science.

Before his medical career, Dr Murallitharan was an award-winning journalist for the New Straits Times, a leading English newspaper in Malaysia. In medicine, he has served in various roles, including medical officer and clinician at Hospital Kuala Lumpur and the National Blood Bank, clinical epidemiologist for the Clinical Research Centre, Ministry of Health, Malaysia, and Medical Director of MMPKV Healthcare Sdn Bhd. He is deeply involved with healthcare services for marginalized and underprivileged groups. 

Dr Murallitharan’s interests lie in public health, health systems, and health economics. He collaborates with Chulalongkorn University, the University of Tokyo, the London School of Hygiene and Tropical Medicine, and the London School of Economics. He is currently the Medical Director of the National Cancer Society of Malaysia. 

(1) Introduction to the lecture

Norie KAWAHARA opened the fourth lecture of the Spring 2026 semester of the Surviving Cancer in Asia: Cross-boundary Cancer Studies lecture series by drawing the threads of the previous three sessions into the day’s theme. Throughout the series, cancer has been approached not only as a medical issue but as a mirror reflecting the structure of society itself, and the social value of prevention has been examined through three successive layers. At the global level, Dr. Shinjiro Nozaki showed that prevention against cross-border risk is now part of the international order and also a foundation for the future of universal health coverage (UHC) in an aging Asia. 

At the community level, Dr. Zainab Shinkafi-Bagudu showed how local institutions, trust, inequalities in access, and living environments strongly shape the health choices people make. 

At the individual level, Dr. Yoshihiro Yasunaga of CYBERDYNE showed that, although behavioral change ultimately occurs at the individual level, it depends deeply on how systems and environments are designed, and people begin to move when they feel “maybe I can do this too.” The core of prevention is therefore not the diffusion of knowledge but the design that activates human behavior.

Dr. Kawahara noted that Lecture 4 now seeks to add a further layer by asking what prevention means at the very core of the economy that drives society. At this point, prevention shifts in meaning from being simply “a good thing” to becoming “a necessary investment.” In April 2026, Malaysia’s Ministry of Health launched the Malaysia Occupational Health Services for Public Sector (myOHS-PS) and the Integrated Workplace Health Programme (IWHP), reflecting a broader Malaysian direction to treat prevention not only as a healthcare policy but as an economic policy, and as economic infrastructure supporting corporate value, workforce sustainability, and national growth.

As was noted by Dr. Nozaki in his lecture, UHC systems across Asia are under growing pressure, especially in countries with limited tax revenue. Health problems do not remain individual problems: when a worker becomes sick, family income, company productivity, healthcare financing, and the regional economy are all affected simultaneously. According to the WHO Malaysia NCD Investment Case ("Prevention and Control of Noncommunicable Diseases in Malaysia: The Case for Investment"), the economic burden of non-communicable diseases (NCDs) in 2021 reached MYR 64 billion, equivalent to 4.2% of GDP, much of which came not from medical costs but from indirect losses such as absenteeism, presenteeism, and premature death. Even where UHC formally exists, healthcare often does not fully reach workers because of barriers of access, waiting times, out-of-pocket costs, employment conditions, and regional disparity, producing what may be called unreachable healthcare. In this context, the workplace becomes more than a place of employment: it becomes the first social gateway through which such people can connect to prevention, screening, and early intervention. 

This is the principal difference between Japan and many parts of Asia: in Japan, occupational health functions as an improvement within an already established system; in Asia, it often functions as an implementation pathway that fills the gaps left by the system itself.

Japan achieved UHC in 1961, with mandatory pre-employment and annual health examinations for regularly employed workers, a legal obligation for companies to appoint occupational physicians, and, more recently, the Ministry of Economy, Trade and Industry’s (METI) framework for Health and Productivity Management. Japan’s occupational health system therefore rests on a broad foundation of UHC, with the workplace providing additional layers on top. Malaysia, by contrast, is in a period of institutional transition: according to World Bank data, its UHC service coverage index reached 80 in 2023, approaching Japan’s 86, but out-of-pocket health expenditure remains far higher, at 37.09%. The workplace is therefore not simply a welfare benefit space but a practical gateway for identifying undiagnosed risk factors before disease becomes visible.

Dr. Kawahara argued that Japan can contribute three elements: i) the technology of institutionalization, embedding health screening into everyday routines rather than treating it as a one-time event; ii) the ability to translate health into the language of management, as in METI’s Health and Productivity Management model that defines employee health as a source of corporate competitiveness linked to ESG, capital markets, and long-term business sustainability; and iii) the cycle of data and continuous improvement, in which health-related outcomes are measured, visualized, corrected, and re-evaluated. 

In turn, Japan has much to learn from Malaysia: i) a sense of urgency in treating prevention as a central economic issue; ii) the integrated use of the workplace as a single gateway combining health education, mental health support, screening, and financial support; and iii) a policy design that places the return on investment of prevention at the center. What Japan should learn from Asia is the ability to redefine prevention not as a welfare add-on of a mature society but as a productive investment that moves society itself forward. 

A particularly important feature of the Malaysian case, as today’s lecturer, Dr. Hoe has previously noted, is that the problem is not the absence of regulation but the unevenness of its implementation, especially among small and medium enterprises (SMEs), subcontractors, and the informal sector.

(2) Revolutionizing Health and Safety: Psychosocial Risks, AI, Workforce Resilience and Prevention

Victor CW HOE opened by situating his lecture within the framework of World Day for Occupational Safety and Health (World OSH Day), observed annually on 28 April. The 2026 theme, “Let’s Ensure a Healthy Psychosocial Working Environment,” evolves from the 2025 theme of “Revolutionizing Health and Safety: The Role of AI and Digitalization at Work,” and frames the future of occupational safety and health (OSH) around five shared global challenges: the post-COVID era and public health integration; climate risks and environmental stressors; informal sector and gig economy vulnerabilities; economic protectionism and trade tensions; and armed conflicts and occupational hazards.

Shared global challenges

The COVID-19 pandemic underscored the critical need to integrate occupational safety with public health strategy, and workplaces must now be prepared for future crises through comprehensive protocols addressing both immediate and long-term risks; an ongoing concern at the time of the lecture was a hantavirus incident on board a cruise ship. 

Climate risks are increasing heat-related illness among outdoor workers and exacerbating exposure to extreme weather and vector-borne disease, including the emergence of dengue in Japan, which has not historically faced such risk. 

A significant share of the global workforce, particularly in low- and middle-income countries, operates in the informal and gig economy without adequate safety measures, training, protective equipment, or healthcare access, and the trajectory of the workforce may worsen these vulnerabilities. 

Economic protectionism, tariffs, and trade wars have disrupted global supply chains and increased production costs, prompting some firms to reduce investment in workplace health, safety programs, training, and equipment maintenance, with the potential consequence of higher injury and illness rates. 

Armed conflicts have a profound impact on OSH: workers in conflict zones face increased risk from infrastructure destruction, displacement, and exposure to violence, and healthcare facilities and personnel are often targeted, producing a breakdown in essential services. 

Addressing these challenges requires a collaborative approach that integrates public health principles into OSH strategy, strengthens protection for vulnerable workers, and ensures resilience against economic and geopolitical disruption.

Why workplace health matters

Workplace health is now an economic and productivity issue, not just a safety concern, and prevention is an investment rather than mere compliance. Malaysia faces a particular burden attributable to NCDs: the National Health and Morbidity Survey 2023 reported diabetes prevalence at 15.6%, hypertension at 29.2%, and overweight and obesity affecting more than 50% of adults, making Malaysia one of the most overweight nations in Southeast Asia. 

Workplace stress and burnout are rising, the workforce is aging with growing chronic disease burden, small and medium-sized enterprise (SME) and informal-sector vulnerabilities are increasing, and digitalization and long working hours are eroding workers’ ability to disconnect. 

The International Labour Organization (ILO) estimates nearly three million work-related deaths annually, while climate-related heat stress is projected to reduce global working hours by more than 2% by 2030. The rapid development of artificial intelligence (AI), including agentic AI, and AI-driven robotics is reshaping the global workforce, and reduced work opportunities drive more people into gig and informal work, fueling economic instability and workforce insecurity.

From compliance to a culture of prevention

Organizations are increasingly shifting from reactive, compliance-based approaches to proactive cultures of prevention, emphasizing anticipation and mitigation of risks before incidents occur. Key elements of preventive culture include 1) leadership commitment, with senior management actively promoting safety values and embedding them into organizational goals; 2) employee engagement, encouraging workers to participate in safety and health programs and decision-making; and 3) continuous improvement, with regular review and enhancement of protocols based on feedback and incident analysis. The adoption of advanced technologies such as AI and the Internet of Things further supports a prevention culture by enabling real-time monitoring, proactive analysis, and hazard identification. In Malaysia, a national Psychosocial Risk Assessment guideline was launched approximately one year before the lecture, requiring workplaces to incorporate psychosocial risk into their routine risk assessments.

Integration of public health and OSH

The pandemic highlighted the interdependence of occupational safety and public health, and the One Health approach — recognizing the interconnectedness of human, animal, and environmental health — is gaining traction in OSH practice. Implementing One Health enhances pandemic preparedness and workplace resilience through three mechanisms: cross-sector collaboration that fosters partnerships among public health authorities, environmental agencies, and OSH professionals; holistic risk assessment that considers a wide range of health determinants, including environmental and societal factors, in workplace safety planning; and integrated surveillance systems that monitor health indicators across sectors so that emerging threats can be detected and addressed promptly.

The rise of psychosocial risks

Psychosocial risks, encompassing  work-related stress, burnout, and harassment, are now recognized as significant occupational hazards affecting employee well-being and productivity. 

Globally, 41% of employees report feeling stressed “a lot of the day,” driven by high work intensity and unsocial hours, job insecurity, poor workplace communication, and limited control over tasks. The health implications include cardiovascular disease, mental health disorders, weakened immune function, higher absenteeism, and reduced productivity (including presenteeism). Burnout is especially pronounced among younger workers: a 2024 study found that 81% of those aged 18–24 reported experiencing burnout, with one in three having taken stress-related leave compared with one in ten among those aged 55 and above; contributing factors include unpaid overtime (48%), financial stress (46%), and job insecurity. A trust gap compounds the problem, with only 56% of workers comfortable discussing stress at work, leading to lower performance, higher turnover, and increased hiring costs.

The economic impact of poor mental health is substantial: approximately 12 billion working days are lost annually to depression and anxiety, equating to about US$1 trillion in lost productivity, with workers experiencing poor mental health recording nearly 12 days of unplanned absence per year compared with 2.5 days for those with better mental health. Mental health conditions in the United States alone are estimated to cost the economy US$282 billion annually, and the global cost could reach US$6 trillion by 2030 if unaddressed. 

Beyond traditional workplace stressors, broader contextual risks have intensified psychosocial hazards: economic protectionism and trade tensions heighten anxiety over job loss, wage reduction, and benefit erosion while companies cut costs in ways that reduce investment in safety and mental health resources; armed conflicts impose immediate physical threat and trauma in conflict zones and produce long-term consequences such as PTSD, anxiety, and depression, with healthcare and humanitarian workers in conflict zones recording PTSD rates of up to 41%, depression of 27%, and burnout of 25%.

Strategies for mitigating psychosocial risks

Dr. Hoe set out six interconnected strategies. The first is organizational commitment: leadership must foster a culture that prioritizes mental health and safety, with clear anti-harassment and anti-discrimination policies. Only 13% of employees feel comfortable discussing mental health at work, and one in three considers workplace support inadequate, yet workplaces with robust mental health programs report a 20% increase in employee retention. 

The second strategy is proactive risk management through regular, comprehensive psychosocial risk assessments tailored to workforce demographics and job roles; 52% of workplaces cite time pressure as a major psychosocial risk and 58% cite dealing with difficult clients or patients, while 84% of workers have experienced at least one mental health challenge in the past year and 71% have reported at least one symptom of stress.

The third strategy is a supportive work environment: the development and promotion of mental health programs, stress management training, and accessible psychological support such as Employee Assistance Programs (EAPs) and peer-support initiatives. Only 38% of employees feel comfortable using their company’s mental health services and more than half want more employer support, yet companies investing in mental health see an average return on investment of 4:1 through improved productivity and reduced absenteeism; EAPs and peer-support arrangements that are independent of the company increase worker confidence, retention, and return on investment. 

The fourth strategy is enhanced communication and transparency, namely open, empathetic, and inclusive communication, especially during organizational change or economic uncertainty, which helps to build the trust and psychological safety that are key drivers of well-being and empowerment. 

The fifth strategy is conflict-sensitive occupational health policy, with OSH strategies tailored to conflict-affected regions and reinforced through psychological support, trauma counseling, and additional safety protocols; this is increasingly relevant to Malaysian and other Asian seafarers who have been trapped in conflict zones for prolonged periods. 

The sixth strategy is integration and compliance: aligning workplace safety and HR policies into a unified psychosocial risk management approach and adapting to evolving regulation, including ISO 45003 and national instruments such as Malaysia’s new psychosocial risk assessment guideline. 

Best practice includes anonymous reporting systems, flexible working arrangements, leadership training for early intervention, and regular updating of OSH policy to include psychosocial risk.

The way forward

Dr. Hoe concluded that OSH is at a critical inflection point globally. Shared challenges like climate risks, informal and gig sector vulnerabilities, economic instability from protectionism and trade tensions, and armed conflicts, are all amplifying occupational risks. 

Psychosocial risks have risen sharply, with stress, burnout (especially among young workers), job insecurity, and mental health issues becoming central occupational hazards. 

Global OSH trends are moving from compliance-based models to prevention cultures, integrating public health and OSH through One Health, and treating mental health and psychosocial risks as seriously as physical risks. 

Despite progress, gaps remain in the systematic management of psychosocial risk, in the protection of vulnerable groups (informal and gig workers, women, conflict-zone workers), and in the full integration of public health perspectives into OSH frameworks.   

The way forward consists of seven complementary actions: 1) strengthening a preventive safety culture; 2) integrating public health into OSH through One Health frameworks and cross-sectoral surveillance; 3) embedding psychosocial risk management with early intervention; 4) protecting vulnerable workers through targeted, gender-responsive, and conflict-sensitive policy; 5) building organizational resilience against economic and geopolitical disruption; 6) aligning national OSH frameworks with international standards such as ISO 45003; and 7) leveraging AI, digital platforms, and real-time data to monitor risk and widen access to OSH resources for remote and underserved workforces.

In response to a question from Dr. Kawahara on whether AI is dramatically changing the mental health environment of workers, Dr. Hoe responded that AI and robotics are emerging issues whose impact will grow rapidly. While robotics will reduce traditional physical and chemical hazards as it becomes more AI-driven and autonomous, the displacement of human labor is itself a major concern: AI can improve work when used well, but also reduces the headcount required and produces fewer or qualitatively different workplace opportunities. He illustrated the point with the example of research assistants, whose work can increasingly be performed by AI, meaning that in universities such positions may be retained only for graduate students continuing their studies, with consequential effects on the pipeline of those entering research.

(3) Integrated Workplace Health Programme (IWHP): A structural blueprint for Malaysia’s economic and occupational resilience 

MURALLITHARAN Munisamy noted that his own contribution would focus on a new programmatic intervention designed to re-engage with Malaysian workplaces on NCDs and to upscale the prevention work of the workplace health sector. The model originates with Japan’s Ministry of Economy, Trade and Industry (METI), which has long promoted a comprehensive framework for workplace health prevention in Japan and has increasingly extended that framework to Japanese multinationals operating overseas. Following a visit to METI in Japan, the National Cancer Society of Malaysia (NCSM) worked with Japanese counterparts on adapting the framework to Malaysian conditions, and is now introducing it through the Ministry of Health and the Ministry of Human Resources — the two ministries that jointly regulate and control Malaysian workplaces.

The SME-dominated Malaysian workforce

Unlike many other countries, Malaysia’s workforce is driven by a very large micro, small, and medium enterprise (MSME) sector, which employs approximately eight million people and accounts for around 90% of all workplaces. For these smaller entities, day-to-day thinking is dominated by bread-and-butter concerns: business revenues, attrition, and operating costs. MSMEs comply with statutory obligations, including contributions to social security and to the human resource development fund, but rarely have the capacity to invest in extensive preventive health programs or in worker mental health. Human resource teams in MSMEs typically consist of two or three staff, so even where the need is recognized, the capacity to deliver services is limited; workplace engagement is therefore commonly restricted to health insurance, an occasional annual screening, and perhaps a single talk delivered by a local clinic, in other words a box-ticking exercise.

Yet the burden of adult obesity, hypertension, and undiagnosed diabetes affects not only the national health system but employers themselves, who lose significant productivity through absenteeism and presenteeism as chronically ill or under-functioning employees remain at their desks, with insurance and treatment costs adding a further burden. There is therefore a clear need, but very little capacity, in this segment of the economy. (Figure 1) 

The workplace as a community

A central conceptual move in the Integrated Workplace Health Programme (IWHP) is to treat the workplace itself as a community. Public health discourse has traditionally focused on geographical communities, but workers spend more than half of their waking hours, five days a week, within a workplace community, and almost all adults between the ages of 20 and 60 are locked into some kind of workplace, including those working remotely. Unlike geographical communities, workplaces possess a distinct hierarchy and organizational culture: lines of authority make it possible to direct and coordinate action for the well-being of the workforce in ways not feasible in residential settings, where a more laissez-faire attitude prevails. The workplace is therefore both a large addressable population and a structured environment that can leverage policy and behavioral insight.

From individual to institutional intervention

Healthcare has traditionally addressed individuals with motivational drive directed at personal willpower. Workplaces, by contrast, allow the use of nudging, behavioral insight, and policy-driven approaches that do not punish individuals but nudge them towards positive decisions. (Figure 2) 

 The IWHP applies this logic by re-engineering workplaces, comprising the physical environment, policies, and incentives, with the aim of to driving institution-wide change. Connecting theory to practice, the program operationalizes the Health Belief Model by lowering barriers to screening through webinars and on-site provision; the Theory of Planned Behavior by applying social norms and targeted peer pressure through official structures of work, including leadership endorsement and recognition of wellness champions; and the COM-B framework by addressing not only awareness but opportunity, motivation, and capability through skills workshops, policy redesign, and dashboards working together to produce integrated change.

Components of the IWHP

The IWHP comprises four interlocking, continuously running components. Firstly, monthly webinars and newsletters, developed with the Ministry of Health and partner knowledge agencies, drive awareness and participation and reach those who are unaware or at risk. 

Secondly, on-site screening, delivered free in collaboration with PERKESO (SOCSO) and other government agencies, removes the friction of attending an external facility and supports regular screening, with teams visiting workplaces two, three, or four times a year. 

Thirdly, skills workshops, conducted face-to-face over time, address behavior change on themes such as mental health and de-addiction, tailored to the needs of individual workplaces. 

Fourthly, workplace assessments and a gamified dashboard system give institutions their own scores, awards, and benchmarks, prompting institution-wide change. The intent is to act on all the layers that drive behavior simultaneously — “everything, everywhere, all at once” — to finally move the needle on workplace health. 

The strength of IWHP lies in ongoing implementation of the “intervention stack” of components. 

The first year of deployment of IWHP is a test year, with growth into years two, three, and four aimed at reaching the eight million-strong MSME workforce. The premise is that individuals must be supported through an “institutional exoskeleton,” and that there is an economic imperative both for individual workplaces and for the national economy. (Figure 3) 

(4) Student Assignment

Students were set the following assignment.

In your opinion, what is the most important lesson Japan can learn from Malaysia’s current approach to workplace prevention and workforce health?

(5) Discussion

Dr. Kawahara observed that Japanese observers are consistently impressed by the dynamism and speed with which Malaysia moves policy into action, and noted that, although large Japanese companies operate substantial workplace health programs, there is a concern in Japan that workplace health management has become overly checklist-driven and that the original spirit of prevention and care can be lost. Japanese companies operating in Malaysia could therefore serve as an important bridge for mutual learning from the Malaysian experience. She invited comment from Dr. Shinjiro Nozaki of the WHO, who was also attending the lecture.

Dr. Nozaki (World Health Organization) thanked the speakers for their informative presentations and reflected that Japan’s experience in improving workplace culture in the mid- to late 1980s and 1990s offers one model for the prevention of NCDs and mental health issues in aging and super-aged societies, but emphasized that Japan’s model is not the only good model. 

The time has come for mutual learning: Japan should learn from Malaysia and from other Asian models, just as Malaysia can learn from Japan and from other Asian countries. Workplace education is one of the fundamentals for tackling rising NCDs and mental health issues in aging societies, and the future of prevention lies in this exchange.

Dr. Muralli identified three challenges that frame the work ahead. 

The first is that the burden of providing organized preventive health services and a structured health education calendar to human resource officers, particularly in smaller companies with one or two HR staff, has been underestimated; this is the reason NCSM has chosen to deploy a charity-led civil society intervention into the 90% of workplaces that are MSMEs and lack such capacity. 

The second is that preventive screening ranks low in MSMEs’ financial priorities, so although some level of employer contribution is desirable, the program must be substantially supported or subsidized and offered at a manageable cost if employers are to engage systematically. 

The third is that the assumption that all workplaces are wealthy and should pay premium rates for healthcare services is incorrect; there is substantial heterogeneity in workplace income, and lower-income workplace organizations need active assistance. These three considerations together motivate the design of the IWHP intervention.

A student asked whether workplace health challenges and strategies differ between younger and older workers. Dr. Hoe replied that the question is best approached through the Health Belief Model: different groups hold different health beliefs that vary not only by age but also by culture and religion, and the design of good workplace health promotion depends on understanding the specific health beliefs of the population concerned. He added his congratulations to Dr. Muralli on the implementation of the IWHP and observed that the persistent underlying issue is whether workers actually choose to participate. It is the case that many do not, and there are clear gender differences in engagement, with women generally more concerned about their health than men.

Dr. Kawahara closed the session by drawing the day’s lesson together: what Japan can learn from Malaysia is the importance of treating prevention as part of social and economic policy itself. In Japan, workplace health management can tend toward becoming a checklist focused on examinations and compliance alone, but prevention is ultimately about people, behavior, trust, and everyday culture.