This article first appeared in Forum, The Edge Malaysia Weekly on March 22, 2021 - March 28, 2021

As the National Covid-19 Immunisation Programme continues in Malaysia, the government must make four overarching policy decisions. In my last column (Issue 1360, March 8), we examined the first two policy decisions: a framework to prioritise vulnerable groups for the vaccine and the right timing to create a private for-profit vaccine market in Malaysia. These policy decisions are directly in front of us and must be resolved immediately.

This article will examine the third and fourth policy decisions of why and how non-citizens can receive the vaccine and the long-term decisions that must be made today for the nation to achieve vaccine independence tomorrow. Although they are both important, the lack of urgency makes them invisible from the public agenda today. The government must start laying the groundwork today and not wait until it is too late.

On Feb 12, the Cabinet announced that all non-citizens residing in Malaysia would receive free vaccination. There are four main categories of non-citizens: the roughly three million documented migrants; 180,000 asylum seekers and refugees; 40,000 stateless persons and two to four million undocumented migrants, who will not be arrested when they turn up for the vaccination.

This is laudable and logical for many reasons. One, herd immunity is calculated based on 70% to 90% of “all persons residing in a country”, not “all citizens of a country”. Two, when 29% of Malaysians are below 18 years old and cannot receive the vaccine, we must vaccinate as many adults as possible — including non-citizens — to reach adequate population coverage. Three, vaccinating non-citizens is desirable not only from a public health perspective but also from moral, ethical and economic ones.

However, there are many hurdles to vaccinating non-citizens. The first is the actual delivery, including accurately estimating the doses needed, registering non-citizens in non-threatening ways and physically delivering the vaccines to inaccessible locations. The second is building trust and confidence in the vaccine itself, that non-citizens will not be given sub-standard vaccines, and that the government will truly not arrest them when they turn up for the vaccination. The third hurdle could be the biggest, which is to combine the Covid-19 vaccination drive with durable political, legal and logistical solutions for undocumented migrants, asylum seekers and refugees.

These hurdles are complicated by two systemic contradictions. The Ministry of Health issued Circular 10 in 2001, which requires all MoH staff to report undocumented migrants to the police, to fulfil the requirements of the Immigration Act. Separately, the Immigration Department continues to deport non-citizens even during Covid-19, most recently to Myanmar last month despite a court order against it.

Against this complex backdrop, three policy steps could point the way to durable solutions for Malaysia’s five to seven million non-citizens. First, the Cabinet must get more involved and not delegate this only to the MoH and Ministry of Science, Technology and Innovation (Mosti). Supra-MoH and supra-Mosti decisions are needed in non-citizen matters as these pertain to issues of sovereignty, domestic security, foreign policy and economics.

Therefore, important decisions must be made and not postponed indefinitely. These include whether there will be an amnesty, how an amnesty will be operationalised and implemented, what changes are needed to the Immigration Act and related policies, and who will implement these changes and by when.

Second, the Cabinet must resolve intra-government contradictions for a smooth vaccination programme and to truly build trust. The MoH’s Circular 10 must be revoked (or suspended, depending on what happens to the Immigration Act). All 

security agencies must operate in consistent ways, without contradicting each other or the National Committee on Immunisation Practices (NCIP). Only after there is intra-government cohesion, then partnerships with civil society organisations and the private sector can be successful to build trust, improve vaccine literacy, deliver vaccines and deliver durable solutions for non-citizens.

Third, durable solutions for non-citizens must be conceptualised and implemented starting today. Malaysia does not have durable solutions because politicians were never forced to make difficult decisions and always “kicked the issue down the road”. The Covid-19 vaccination programme provides the right timing and political cover for durable solutions.

A basket of solutions is needed for a highly complex problem. This author provides six non-mutually exclusive solutions: aggressively reforming our economy to be less reliant on foreign workers; repatriating certain non-citizens in cooperation with their embassies; implementing a time-limited amnesty for specific categories; providing (only 190,000) refugees the right to work and pathways to citizenship; providing long-term work permits for essential foreign workers while imposing civic duties like paying taxes and learning the Malay language; and peacebuilding in neighbouring countries such as Myanmar.

The issue of non-citizens in Malaysia goes well beyond Covid-19 vaccines to encompass health rights, human rights, politics, economics and security. The Migrant Industrial Complex in Malaysia was built over decades, both intentionally and unintentionally. Any act to optimise, change or dismantle it must be handled thoughtfully and must go well beyond just the Covid-19 vaccination programme.

Malaysia needs to achieve vaccine independence as quickly as possible to reduce our current overdependence on other countries for vaccine supplies. This is crucial not just for Covid-19 but for future pandemics. Consider two facts: One, at the beginning of this month, vaccine manufacturers signed agreements to supply countries with 9.6 billion doses of the Covid-19 vaccine. The vast majority of the doses are going to rich countries, with Canada purchasing nearly 10 doses for every citizen. Malaysia is much lower down the queue, given our small purchasing power.

Two, there is a very real possibility of Covid-19 being endemic (just like dengue and chicken pox) and therefore require annual vaccinations. Mutations can also reduce the effectiveness of vaccines, thus requiring new vaccines to be researched and manufactured. Putting both facts together, they indicate a possibility that Covid-19 vaccinations may become a regular occurrence, perhaps even an annual vaccination programme that goes on indefinitely.

It is important that Malaysia has its own domestic vaccine factories capable of researching and producing new vaccines quickly and at scale. In short, relying on global supplies is unpredictable, while repeated vaccine purchases will be expensive, and we may need vaccines indefinitely.

There are other benefits of having our own domestic vaccine factories, other than vaccine independence, cost savings and a long-term public health benefit. New and high-value jobs can be created, new infrastructure for research and manufacturing can be built, science can be commercialised quicker and more effectively, and we can earn goodwill and profits if we export high-quality vaccines to Southeast Asia or elsewhere.

There should be three overarching principles for the government’s decision to achieve long-term vaccine independence. First, the government must start the long-term journey today. In practical terms, this means the necessary agencies must receive the necessary funds and begin the necessary steps today.

It is also crucial to build on previous attempts at creating a national vaccine or biotechnology company, such as BiotechCorp (a part of Mosti), Ninebio Sdn Bhd (a part of MoH) and Inno Biologics Sdn Bhd (a part of the Ministry of Finance). The government cannot keep reinventing the wheel when it comes to a national vaccine strategy and must rely on previous lessons.

Second, the government must play a minimal role in the march towards vaccine independence. In practical terms, this means the government must restrict its involvement only as a funder, rather than trying to be an asset owner, researcher, competitor or manufacturer. There are several important reasons for this.

The Malaysian government has no experience or capability to play these other roles, judging from the visible failures of BiotechCorp, Ninebio and Inno Biologics. No government around the world owns or operates vaccine factories in any meaningful way, and the nominally pro-market Malaysian government should not try. We must eliminate any opportunity for corruption. These are the reasons why the government should stick to just being a strategy-setter, regulator and funder, and leave the research and manufacturing to the private sector.

Third, we will need the private sector to help Malaysia achieve vaccine independence. In practical terms, this requires the government to provide a “regulatory sandbox” for the private sector to innovate, accelerate the research-to-commercialisation process in universities and allow universities to partner with the private sector in more nimble and agile ways.

Paradoxically, competition and collaboration are simultaneously crucial to enable biotech innovation. Collaboration can happen if the government provides an open-access database of health data, while competition thrives if the government provides an intellectual and regulatory environment that encourages competition between early-stage researchers and companies.

Malaysia’s Covid-19 immunisation programme requires difficult, courageous and strategic policy decisions in four areas. This article discusses the less urgent (and therefore, less visible) policy decisions of vaccinating non-citizens and building vaccine independence. The superficial and immediate priorities are definitely important, but we must also focus on the deeper and less visible mega priorities.

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

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