Friday 29 Mar 2024
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This article first appeared in Forum, The Edge Malaysia Weekly on March 8, 2021 - March 14, 2021

Malaysia’s first Covid-19 vaccine was administered on Feb 26, kicking off the most important vaccination programme in our history. Khairy Jamaluddin, coordinating minister for the National Covid-19 Immunisation Programme (NCIP), has plans for 80% of our resident population to be vaccinated by between December 2021 and February 2022.

The hurdles are formidable, including securing adequate supplies, ensuring smooth cold chain arrangements, increasing vaccine confidence and organising the entire logistics, database and operations of a population-wide vaccination programme. These hurdles partially explain the slow take-up in the first week of the programme, with an average of about 10,000 people being vaccinated daily (compared to the US’ current rate of between 1.5 million and 2 million daily shots).

However, newer and potentially bigger hurdles are present in the form of four crucial and over-arching policy decisions. Each decision will have an impact on the success of the vaccination programme and also the performance of the government.

This article discusses two crucial decisions: the framework to prioritise vulnerable groups and the right timing to create a private market for vaccines. A future article will discuss the non-citizen issue and the long-term vaccine sustainability decision that must be made today.

Decision 1: How to prioritise vulnerable groups

The first crucial decision for the government is “how do we prioritise vulnerable groups?” This author is less interested in the results of a prioritisation exercise and more interested in how that prioritisation takes places. In practical terms, this means that the government must disclose the decision-making framework for how and why it arrived at its priority list, and not just issue the list without an explanation or commentary.

Khairy announced on March 1 that Malaysia’s Phase 1 will be divided into Category 1 (those directly involved in healthcare, such as doctors and nurses) and Category 2 (those performing other essential services, such as police officers and teachers with concurrent diseases). In the author’s opinion, the prioritisation is broadly correct, fair and consistent with public health theory and best practices from other countries.

But although Malaysians now know which groups will be prioritised in Phase 1, we still do not know how they were selected or why they were selected earlier than other groups of people. Basically, the government has announced the “who”, but not the “how” or the “why”. Without clearly explaining the “how” and without publicising the decision-making criteria, citizens will rightly ask if these decisions were made arbitrarily, subject to interest group lobbying or influenced by insider politics.

Separately, if the government explains “why we put Group A earlier than Group B”, it will help citizens understand the trade-offs in a situation of scarce vaccines. Explaining the reasons will help reduce absolutist statements like “Group C is important”. These absolutist statements are understandable, but the real question is “why should Group C be prioritised earlier than Group A?”, not “is Group C important?”.

Answering the comparative question requires a framework. In Malaysia, the framework to compare vulnerable groups can consider three broad criteria: their actual burden of disease in the last year, their potential risk exposure, and their criticality or essentiality.

But any framework to decide on vaccine prioritisation will be imperfect because the science and evidence is limited. Human societies allocate scarce resources all the time, but the Covid-19 vaccines are a new order of urgency and importance. Subjective moral and political judgements must come into play, including a social contract-type decision on which population groups are most deserving of our initial protection. Making these decisions require clarity and courage in the moral and political sense.

Finally, Malaysia’s current phases and categories are welcome and are consistent with the nuanced vaccination phases of other countries. As an extreme case of nuance, California has divided its Phase 1 into 1a-c and then further sub-divided them into Tiers 1-3. This puts doctors in Phase 1a Tier 1 and prisoners in Phase 1b Tier 2 in California. Such nuance and precision have pros and cons, which are not discussed in this article. Instead, we look at two important comparisons between the Californian and Malaysian programmes.

One, California announced its nuanced phasing before its programme even began, while Malaysia updated ours in the first week of our programme. Two, California has issued “forward guidance”, but Malaysia has not.

An example of forward guidance is, “Beginning March 15, healthcare providers may use their clinical judgement to vaccinate individuals aged 16-64 who are deemed to be at the very highest risk to get very sick from Covid-19” if they have conditions like cancer, pregnancy or diabetes. Issuing such forward guidance will help Malaysian health professionals and citizens plan ahead.

Decision 2: When to start the private market for vaccines

On March 2, the Association of Private Hospitals Malaysia (APHM) was reported as wanting “approval to procure Covid-19 vaccines from other sources” over and above “what the government is already acquiring through its own channels”. This is intended to help achieve herd immunity quicker. Essentially, APHM wants to create a parallel and private market for Covid-19 vaccines today, by providing vaccines to anyone who can pay.

This author disagrees. Malaysia should eventually have a private market for vaccines, but only after we have adequate supplies and have protected vulnerable groups in Phases 1 and 2 of the NCIP.

In the meantime, private hospitals and general practitioner clinics should definitely participate as vaccinators in the NCIP. It is both possible and desirable for a public-private partnership to deliver vaccinations, especially if more vaccines arrive and the Ministry of Health needs more human capital and physical facilities. But vaccinating to support NCIP is very different from procuring and selling vaccines in the private market to the highest bidder.

Indeed, having a private market for vaccines today is both nearly impossible and undesirable. It is impossible for three main reasons. One, the world is currently facing a vaccine shortage. Almost every dose sold by the likes of Pfizer, Moderna, Sinovac or Gamaleya are to national governments, not private entities.

During this global shortage of vaccines, almost no private sector entity can easily or directly purchase vaccines. Governments understandably want to vaccinate the most vulnerable populations first, instead of leaving vaccines at the mercy of markets, which will likely allocate scarce vaccines to those who can pay and not those at risk.

Two, vaccine manufacturers prefer dealing with national governments, rather than thousands of private importers or hospitals around the world. In a realistic calculation, vaccine manufacturers want large purchase volumes to build long-term political capital with national governments that are large and long-term customers, and to avoid any perception of profiteering. Even if Malaysian private hospitals can purchase in the global markets today, prices will be extremely high and will be passed on to the average Malaysian consumer.

Three, it will take months for private hospitals to prepare. They must wait until more vaccines are approved by the National Pharmaceutical Regulatory Agency (NPRA), identify a qualified local Malaysian importer or distributor and then compete in the global market for scarce supplies. Then they must organise logistics, participate in vaccine confidence efforts and integrate with the national database of recipients. Selling vaccines in the private market is not a switch that can be easily flipped on and off; it takes months of preparation. For these reasons, it is impossible to create a private market for vaccines today.

But even if we can create such a market today, it would be undesirable. Firstly, during shortages, the private market allocation mechanism is extremely unfair. During vaccine shortages, every dose for a rich person is one less dose for a frontline doctor or nurse. Vaccinating someone who is able to pay instead of a frontline doctor or nurse is both unfair and dangerous to the doctor, the nurse and Malaysia’s healthcare system, compromising public health.

Secondly, it would institutionalise vaccine inequity by signalling that “those who can pay will get vaccines first”. In the last year, we have seen many examples of double standards of policies and enforcement. We cannot further entrench double standards in our vaccine policy.

A private market for vaccines today, during a period of vaccine scarcity and when our vulnerable groups are not yet vaccinated, would signal to the rakyat that businesspeople, expatriates, tourists and students going overseas are more important than doctors, nurses and senior citizens.

It is also untrue that we can achieve herd immunity earlier if private hospitals are allowed to procure vaccines today. Right now, the “speed to achieve herd immunity” is not dependent on vaccination capacity or vaccine choice.

It is dependent on increasing vaccine supplies, and vaccine confidence backed by a smooth registration system. Then, it will depend on increasing the number of vaccinators and facilities as vaccine supplies, confidence and demand increase. Then it can be followed by a free and competitive private market for vaccines.

The solution is to have a progressively larger role for the private sector, with a free market perhaps as early as August 2021 once all vulnerable groups are protected and there are adequate vaccine supplies.

Meeting these two time points will mean that we give the first doses to the vulnerable and ensure that there is enough vaccine competition to have low prices when private hospitals are finally allowed to sell freely.

There is no rush to open the private market now. Private hospitals can help strengthen the government vaccination programme first, especially by participating as vaccinators. Malaysia’s vulnerable groups depend on this, as well as a transparent framework on how to prioritise vulnerable groups.


Dr Khor Swee Kheng is a physician specialising in health systems, health policies and global health 

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