7.1 Introduction
The protection and management of the natural and built environment and monitoring its relation to and impact on health are important components of any country’s health system. The ever-expanding global population and increasing urbanization place a strain on the environment and create new risks and exposures that exacerbate health problems. The first line of defence in disease prevention is controlling the physical, chemical and biological agents in the environment that have the potential to affect populations. Thus, every aspect of the environment that impacts on health falls within the scope of environmental health services (EHS). Clean water, safe disposal of solid waste and wastewater, vector and rodent control, air pollution control, food quality control and climate change are just some examples. In this chapter, we focus on providing a broad overview of the evolution of EHS in Malaysia as part of the overall health system.
7.2 Overview of EHS and Its Evolution in Malaysia
In the 1960s, after independence, 70% of the population was poor and resided in rural areas (see Chapter 3). Limited water accessibility and communicable diseases were major problems, which were addressed by the Rural Environmental Sanitation Programme (RESP), an integral component of the Rural Health Services (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). Highly effective community mobilization by allied environmental health officers and technical expertise from engineers trained in public health are credited as two success factors of the RESP, which achieved high levels of coverage and drastic reduction of the disease burden from waterborne diseases.
With increasing economic development, more than 70% of the population moved to urban areas, life expectancy increased, and there was a decline in infant mortality rates and incidence of communicable diseases (see Chapter 3) (Ministry of Health Malaysia, 1988–2017). However, population growth, increasing urbanization and industrialization introduced other environmental hazards, creating the need to address a wider range of environmental health issues such as sewerage, water quality, solid and hazardous waste, and radiation protection.
EHS in Malaysia began in an organized and structured manner with the establishment of the Environmental Health Engineering Programme in the Ministry of Health (MoH), pioneered by engineers seconded from the Public Works Department (PWD) in the 1970s. This pool of engineers, often assisted by sanitary engineers from the World Health Organization (WHO), went on to strengthen the EHS as an integral part of the MoH’s public health programme.
As the Constitution of Malaysia apportions responsibility for health to the federal government, and water supply and urban sanitation to state and local governments, the responsibility for managing EHS was split among different government agencies (see Chapter 12).
To provide leadership and the relevant authority, some public health engineers were seconded from the MoH to some of these departments. Thus EHS in Malaysia grew primarily because of the leadership and governance role the MoH took. EHS established an organizational structure and staffed it with trained personnel while at the same time empowering the organizational units with the required funding. The initial batch of public health engineers provided the leadership on the ground to support the health inspectorate and health officers. Human resources training and development were crucial to achieving success. Environmental health was introduced into postgraduate public health programmes. Engineers who had training in public health helped to upgrade the training of health inspectors and health overseers. The upgraded three-year course for health inspectors (see Chapter 8) included aspects of newer technologies in wastewater treatment, water treatment and waste disposal. Also, environmental health was included in the training of microbiologists and biochemists. Expertise was shared with other ministries and departments. The WHO contributed by establishing the Centre for the Promotion of Environmental Planning and Applied Studies (PEPAS), which conducted valuable research and training programmes that in turn led to policy and programme formulation such as the National Solid Waste Management Strategy (WHO Western Pacific Region, 1977). Introducing health impact assessment (HIA) to other agencies for development projects was a concerted effort using many existing channels available at the state and federal government levels (Reference Hashim and HashimHashim & Hashim, 2009).
7.2.1 Examples of Malaysia’s EHS Programmes
Some of the main environmental health programmes that were developed successfully are described in this section.
7.2.1.1 Rural Environmental Sanitation Programme (RESP)
Concerns about the quality of water supply and sanitation led to an environmental survey of Peninsular Malaysia in 1968. It revealed that only 3.6% of the population had piped water, while 85.3% used water from unprotected wells and 11.1% from untreated surface water (Reference Pillay, Sinha and Mohd TalhaPillay et al., n.d.). As a result, an environmental sanitation pilot project was carried out. The pilot project indicated that a national environmental health programme needed to have four basic elements to succeed: community participation, health education, appropriate technology and training. The initial efforts of EHS were directed to rural areas of the country that lacked safe water supply and sanitation and were plagued by waterborne diseases (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). The national programme was successful in increasing coverage of the rural population of safe water supply to 68.6% and sanitary latrines to 72.5% in 1987 (Ministry of Health Malaysia, 1989). This coverage reached 93.5% for safe water supply and 98.2% for sanitary latrines in 2000 (Ministry of Health Malaysia, 2002). The MoH had contributed to 22.2% of the water supply for rural communities. The MoH provided a high percentage of water supply in states such as Sarawak (62.3%), Sabah (43.5%), Kelantan (32.5%) and Terengganu (30.4%) (Reference Pillay, Sinha and Mohd TalhaPillay et al., n.d.).
This programme was not only a paradigm shift, with the MoH taking on a function that was traditionally that of state governments and the PWD, it also became an important programme under the MoH public health programmes. It complemented the other programmes, such as communicable disease control, vector hygiene, food quality control and others, and was implemented in all states (Ministry of Health Malaysia, 1988). The Environmental Health Engineering Unit grew and was later expanded with the recruitment of more public health engineers and health inspectors. The unit provided the needed policies, technical guidance and training, and it also monitored budget allocations. Initially, public health engineers were stationed in critical states such as Kedah, Perak, Pahang, Terengganu and Kelantan, but they are now present in every state nationwide. Health inspectors were trained in appropriate technologies for rural water supply and sanitation. RESP, later called the BAKAS (Bekalan Air dan Kebersihan Alam Sekeliling) or Water Supply and Environmental Sanitation Programme, clearly demonstrated the close interaction between the different levels of government. The federal government provided the funds and technical advisory services while the state governments provided the needed managerial support through the district levels right up to the village action committees (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). This was a key success factor, as was the people’s involvement through community participation (see Case Study 7.1 for more details).
One of the challenges in the application of systems thinking is that the actual system surrounding a particular problem often does not correspond to disciplinary or organizational structures. Therefore, solutions to these problems are often partial, with partial results. Indeed, while the ‘social and environmental determinants of health’ is a well-known concept, it largely remains on the periphery of health systems. A whole-system approach towards environmental health requires interfacing with non-health sectors as well as re-thinking the responsibilities and functions of the health system. The expansion of the MoH to create an engineering department and take on the task of rural water and sanitation is an excellent example of such cross-boundary work. Future advances in tackling non-communicable diseases are likely to require such re-thinking of what health services look like.
7.2.1.2 National Drinking Water Quality Surveillance Programme (NDWQSP)
Having succeeded in the BAKAS programme, the MoH engineering unit was entrusted with monitoring the quality of urban water supplies. This decision was made following a survey in 1983 that attributed the outbreak of diseases to poorly operated water supply systems. This programme, known as the National Drinking Water Quality Surveillance Programme (NDWQSP), had the objective of improving the standard of health by ensuring the safety and acceptability of public water supply systems (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). The components of the programme included monitoring, sanitary surveys, data processing and evaluation, remedial action and institutional examination such as evaluating the capacity of the water supply agency to perform its functions. Under the programme, all public water supplies were monitored, and samples were sent to the Department of Chemistry (DOC) for bacteriological and chemical analysis (Reference Pillay, Sinha and Mohd TalhaPillay & Sinha, n.d.). The relevant water authority was required to take immediate action if there were any violations of the standards set by the MoH. A quality assurance programme (QAP) was formulated in 1993 to strengthen the effectiveness of the programme (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). By 2001, the percentage of water samples that met the national standards of bacteriological quality, residual chlorine and turbidity was 98%, 96% and 96%, respectively (Reference Pillay, Sinha and Mohd TalhaPillay & Sinha, n.d.).
Significant co-operation was established between the state governments, water authorities and relevant agencies such as the DOC, the Department of Environment (DOE) and the federal Drainage and Irrigation Department as well as local authorities. The reports generated under this programme were presented at state- and federal-level meetings and critically examined by many agencies. The training of water operators and health inspectorate staff and public health engineers, coupled with inter-departmental co-operation, were key success factors of this programme. Due to the limited capacity of the DOC, the MoH also developed its water testing capabilities (Ministry of Health Malaysia, 1988) by purchasing field test kits and training the health inspectorate staff and public health engineers on their use.
The leadership and promotional role of the MoH was important in the absence of legislation. The Safe Drinking Water Act was drafted in the 1980s but never came into force for numerous reasons. However, since then, the National Water Services Commission (SPAN) has been formed to address some of the constitutional problems, such as division of responsibility and authority between federal and state government, and the Water Services Industry Act 655 was formulated and enforced in 2008 (National Water Services Commission, 2019).
7.2.1.3 Urban Sanitation
The role played by public health engineers at the state level was recognized as crucial, and over time they played a key role in advising state governments of the sad state of urban sanitation. Together with the Economic Planning Unit (EPU) of the Prime Minister’s Department, the MoH engineering unit initiated Master Plan Studies on sewerage and drainage in many towns (Economic Planning Unit, 1981). Such studies identified a grave concern: bucket latrines were widely used in urban centres. Eliminating bucket latrines became a priority, together with studies on suitable sewerage systems for larger towns.
Other than bucket latrines, individual septic tanks were the predominant disposal system. Substantial funds were needed to convert centralized sewerage systems and this would, therefore, take a long time. The MoH adopted an incremental strategy by promoting the use of centralized sewerage systems as opposed to individual septic tanks (Reference Ujang, Ujang and HenzeUjang, 2006). All new development projects were directed to follow the guidelines developed by the MoH and to instal centralized sewerage systems with treatment plants such as oxidation ponds. There was no legislation at that time; this was purely based on the MoH’s insistence and promotion through its expanded numbers of well-trained public health engineers (Reference Ujang, Ujang and HenzeUjang, 2006).
Similar efforts were made in solid waste management. All urban centres had poor waste management systems. Open burning was rampant. Crude landfills were the norm. With support from the WHO, the MoH initiated national forums to develop strategic plans for waste management. Through the environmental health engineering programme, the MoH also provided support to the Prime Minister’s Department and the Ministry of Housing and Local Government (MHLG) in matters related to sewerage, urban waste management, urban drainage and urban environmental management (Reference Ujang, Ujang and HenzeUjang, 2006; Ministry of Housing and Local Government, Malaysia, 2005).
In 1980, a special technical unit with engineers seconded from the MoH was formed to serve as the technical arm of the Local Government Department of the MHLG. This unit provided technical advisory services to all local authorities and state governments. Numerous studies were undertaken, and guidelines were developed. A major achievement was the total elimination of the bucket latrine system. Policies for urban sewerage systems became entrenched in local development plans, and efforts moved towards the formulation of laws on sewerage and waste management (Reference Ujang, Ujang and HenzeUjang, 2006). This then progressed to the privatization of both the national sewerage service and the municipal waste management services. The enactment of these laws and privatization were unprecedented moves by the federal government to take over services traditionally performed by state and local governments. It paid off handsomely, as this led to the systematic development of these two services throughout the country (Japan International Cooperation Agency (JICA), Malaysia Office, 1999).
The privatization of sewerage services was undertaken through the enactment of the Sewerage Services Act, which allowed the federal government to take over the responsibility for sewerage services, which was a traditional function of local authorities. A national sewerage company called Indah Water Konsortium (IWK) was established (Japan Sanitation Consortium, 2011). IWK took over all sewerage assets from local authorities and moved to upgrade and maintain these systems to acceptable standards by ensuring all domestic wastewater was adequately treated before discharging to surface water (Sewerage Services Department, Ministry of Housing and Local Government, 2001). Another significant move was the creation of the Sewerage Services Department (SSD) to regulate sewerage services, and this was staffed with engineers seconded from the MoH (Reference Ujang, Ujang and HenzeUjang, 2006).
7.2.1.4 Clinical Waste Management
Recognizing the hazardous nature of clinical waste generated in healthcare settings, the Engineering Division of the MoH undertook a national survey that highlighted the poor conditions in the handling, storage, transportation and disposal of clinical waste. The division went on to issue guidelines for the management of clinical and related waste in hospitals and healthcare establishments, followed by training for selected hospital personnel (Ministry of Health Malaysia, 1991). The gaps identified in the system were addressed by outsourcing clinical waste management to hospital support services. The rapid progress under this strategy was self-evident and is further outlined in Case Study 7.2 at the end of this chapter.
7.2.1.5 Air Pollution
Air pollution in Malaysia is generally at a low level except for sporadic incidents of haze during certain periods of the year. Maintaining good air quality sustainably throughout the year will drastically reduce the burden on the healthcare system. For this purpose, Malaysia built inter-departmental co-operation, involving agencies such as the DOE, the MoH, the Ministry of Transport, the Ministry of Natural Resources and Environment, the Meteorology Department and the Ministry of Foreign Affairs. The private sector was also mobilized by outsourcing air quality monitoring to a private company, Alam Sekitar Malaysian Sdn Bhd (ASMA), which has fifty-two monitoring stations throughout the country (Reference Sahani, Khan, Mahiyuddin, Latif, Ng, Yussof and ShinSahani et al., 2016).
As mentioned earlier, public health engineers were seconded from the MoH to the DOE, and they contributed to the formulation of the Environmental Quality Act 1974 (EQA) and its subsidiary regulations, which included among others the Clean Air Regulations. The MoH was a member when the Environmental Quality Council was launched in 1973, and its membership was subsequently formalized in the EQA. The council is responsible for advising the Minister of the then Ministry of Science, Technology and the Environment, now known as the Ministry of Natural Resources and Environment, regarding environmental matters, and this includes, among other things, air pollution (The Commissioner of Law Revision Malaysia, 2006).
The MoH also contributed the development of guidelines on indoor air quality (IAQ), which is under the purview of the Department of Occupational Safety and Health (DOSH), and continues to play a critical role in providing health advisory notices via news media, their website and so on. The MoH has also developed several guidelines on IAQ for healthcare settings and is training a pool of engineers to be certified by DOSH as indoor air quality assessors. To kickstart its IAQ programme, the MoH is currently focusing on sampling and monitoring air quality in its premises (Ministry of Health Malaysia, 1992).
7.2.1.6 The National Environmental Health Action Plan (NEHAP)
The NEHAP is a set of strategies jointly developed by relevant agencies and selected non-governmental organizations (NGOs) for improving environmental health in the country by specifying the roles and responsibilities of all parties. The WHO has encouraged all countries to embark on developing and implementing NEHAPs. The Malaysian Cabinet endorsed the NEHAP as a government policy in December 2012, and implementation is underway, with state governments assuming responsibility for formulating and implementing their respective State Environmental Health Action Plans (SEHAPs) (Reference Tuan MatTuan Mat, 2016). Some states, such as Sabah, Pahang, Perak and Melaka, have already started finalizing their SEHAPs, and the momentum is growing among other states (Reference Tuan MatTuan Mat, 2016). States’ adoption of the SEHAPs will be followed by the development of Local Environmental Health Action Plans (LEHAPs).
In order to be effective, NEHAP has to be given priority at all levels, including full participation and commitment from relevant agencies and NGOs, appropriate resource allocation and the enforcement of laws and regulations. The Engineering Services Division of the MoH facilitates and monitors the process by assuming the role of secretariat for the NEHAP, its steering committee, technical committee and the thematic working groups (TWGs). Eleven TWGs address various areas of concern such as vector-borne diseases, urban drainage and air quality as well as emerging issues such as climate change (National Environmental Health Action Plan, n.d.; Reference Tuan MatTuan Mat, 2016). The Division is also working with the Malaysian Space Agency (MYSA), formerly known as the Malaysian Remote Sensing Agency, to develop a geospatial risk map. This will be an invaluable tool for pre-empting adverse environmental health incidents.
Health impact assessments (HIA) have been incorporated as part of the Environmental Impact Assessment (EIA) process. The MoH undertakes the review of the components of EIA related to environmental HIA. Its importance is further emphasized by its inclusion as a TWG under NEHAP.
7.2.2 Factors Contributing to Success
The MoH rightly invested in environmental health programmes early on, which is believed to have significantly contributed to the country’s elevated health status. Other than investment, the hallmarks of the developmental process included leadership from the MoH in initiating and sustaining inter-agency collaboration and co-operation, human resource development and selective organizational strengthening, enactment of legislation and development of guidelines, and strategic involvement of the private sector while the public sector retained responsibility for policy and oversight.
Inter-departmental co-operation/organizational shift of responsibilities:
From the beginning, the MoH recognized that inter-departmental collaboration was vital, given that so many aspects of the human environment and activities have an impact on health. The MoH adopted two distinct modalities. In the case of rural water supply, the MoH took over the role that had traditionally rested with state governments and the PWD. In other cases, the MoH took the lead in spearheading the required changes and subsequently handing over authority to the relevant government departments (see Section 7.2.1.3). Spearheading change involved building technical and managerial capacity in other organizations and providing technical guidance and advice in various forms, including research, guidelines, formulation of legislation and creation of appropriate infrastructural capacity, for example, for chemical testing. However, the MoH maintained its responsibility for health by insisting that health matters be referred to it where relevant, for example, HIA in EIA for development projects. It continues to provide advice via the Environmental Quality Council (The Commissioner of Law Revision Malaysia, 2006).
Building human resource capacity:
Initially the MoH had to build its own capacity for environmental health. This was done by acquiring two engineers seconded from the PWD in the 1970s. They went on to develop a pool of public health engineers, some of whom were subsequently seconded to the DOE, MHLG, SSD, Solid Waste Department (SWD) and so on to spearhead change in those agencies and to help them recognize that their responsibilities encompassed not merely engineering perspectives but needed to expand to include environmental health perspectives. An outstanding outcome of this initiative is the formulation of the EQA and its subsidiary regulations, which provided for licensing and establishing standards for preventing, abating and controlling environmental pollution primarily from industries and shipping. Other outcomes include the enactment of the Sewerage Services Act 1993 and the Solid Waste and Public Cleansing Acts 2007.
Community participation:
In rural areas in particular, EHS succeeded by incorporating community involvement and participation in all programmes. Community participation helped to reduce the cost of projects and resulted in speedy implementation because the community leaders were motivated and wanted results quickly. There was shared ownership, and communities maintained the sanitation and water systems. The leadership structure in villages, such as the village action committee established under the government’s integrated rural development programme, helped with proper project planning and implementation. The series of health education campaigns by the district health offices also helped to mobilize the community. The support of local politicians further boosted effective community participation (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.).
Private sector involvement:
The private sector complemented the role of the public sector in several ways. In the early years, the private sector was engaged to develop plastic pour-flush latrines for the RESP and later in developing Malaysian home-grown plastic hand pumps, water tanks and other accessories. The mass production of these essential items brought the cost to affordable ranges. Later, when the national privatization policy was introduced, the private sector played greater roles (Japan International Cooperation Agency (JICA), Malaysia Office, 1999). The public sector outsourced to the private sector the programmes for national sewerage development, including the urban solid waste management programme, clinical waste management and the monitoring of air quality throughout the country. The privatization policy helped to strengthen and further develop EHS in a systematic manner, as it allowed the government to focus on its primary functions of policy and oversight while the private sector delivered services. Under the privatization policy, the required funding mechanisms were also put in place with revenue generation opportunities. Various laws and regulations were enacted to delineate responsibilities among the various agencies and to set standards for service delivery (Japan International Cooperation Agency (JICA), Malaysia Office, 1999).
With outsourcing, the oversight function for ensuring that the private sector achieved good outcomes still rested and continues to rest with the government and its agencies. For example, when the clinical waste management service was privatized, the MoH engaged specialists to monitor the performance of the private concessionaires (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.) against standards and guidelines and even introduced a fee deduction mechanism for non-performance or poor performance of the service. Similarly, when sewerage service was privatized, a new Sewerage Services Department was created to enforce the legislation. The government had to create standards, codes of practices and guidelines as well. Privatization does not absolve the government of its responsibilities.
Outsourcing has worked well in Malaysia and has fast-tracked many EHS programmes. Other countries seeking to privatize should carefully consider the selection of the privatization model and take into consideration that once a service is privatized, it is difficult to reverse it.
7.3 Key Messages from Malaysia’s Experience
7.3.1 What Went Well?
Basic rural interventions for water and human waste disposal used
◦ simple technology,
◦ strong community participation, and
◦ allied health staff delivered them effectively using established community structures.
Higher technological interventions requiring appropriate competencies were
◦ possible for concentrated urban populations (water, solid and liquid waste management);
◦ needed for complex issues (clinical waste, radiation);
◦ under the jurisdiction of authorities outside the health sector and needed inter-sectoral co-ordination.
The health sector successfully
◦ acquired and empowered staff with the appropriate competencies;
◦ provided leadership and assisted, then mentored, other agencies to develop the required competencies and exercise their powers through governance, outsourcing and oversight;
◦ mobilized private sector finance through outsourcing; and
◦ gained experience and expertise in outsourcing.
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